cms_TN
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 1 | NHC HEALTHCARE, OAKWOOD | 445002 | 244 OAKWOOD DR | LEWISBURG | TN | 37091 | 2019-05-31 | 609 | D | 1 | 1 | 4KQP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation, and interview, the facility failed to report an allegation of abuse for 1 of 3 (Resident #53) sampled residents reviewed for abuse. The findings include: The facility's Patient Protection .for Allegations/Incidents of Abuse . policy revised 12/11/17 documented, .The patient has the right to be free from abuse .5. Identification Policy .Any patient event that is reported to any partner by patient .will be considered an allegation of .abuse .if it meets any of the following criteria .patient or family complaint of physical or verbal harm, pain or mental anguish resulting from the actions of others .6. Reporting Policy .It is the policy of this facility that abuse allegations .are reported per Federal and State Law . Medical record review revealed Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 13, which indicated the resident was cognitively intact for decision making, required extensive assistance with activities of daily living, and had functional limitations in range of motion with impairment in both of her lower extremities. Review of the facility investigation of Resident #53's allegation of abuse revealed no documentation the abuse allegation was reported to the State. Interview with the Administrator on 5/29/19 at 5:09 PM in the Conference Room, the Administrator was asked when he was made aware of the allegation of abuse by Resident #53. The Administrator confirmed he was made aware of the allegation on 5/16/19, the day the allegation was made. The Administrator was asked if the allegation was reported to the State and the Administrator stated, .No. Interview with Resident #53 on 5/30/19 at 7:55 AM, in Resident #53's room, Resident #53 was asked if she had ever been abused or mistreated in the facility. Resident #53 stated, Well, uh… | 2020-09-01 |
| 2 | 2 | NHC HEALTHCARE, OAKWOOD | 445002 | 244 OAKWOOD DR | LEWISBURG | TN | 37091 | 2019-05-31 | 641 | E | 0 | 1 | 4KQP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to accurately assess residents for the use of unnecessary medications and pressure ulcers for 7 of 17 (Resident #4, #24, #27, #30, #45, #51, and #254) sampled residents reviewed. The findings include: 1. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated no cognitive impairment, and the resident received anticoagulant medications daily during the 7-day look-back period. Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. Interview with the MDS Coordinator on 5/30/19 at 12:48 PM in the Conference Room, the MDS Coordinator confirmed the MDS was inaccurate related to anticoagulant use. 2. Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed a BIMS of 14, indicating no cognitive impairment, and received anticoagulant medications 5 of the 7 days of the look-back period. Review of the (MONTH) 2019 MAR indicated [REDACTED] Interview with the MDS Coordinator on 5/30/19 at 12:50 PM in the Conference Room, the MDS Coordinator confirmed the MDS was inaccurate related to anticoagulant use. 3. Medical record review revealed Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed a BIMS of 15, which indicated no cognitive impairment, and received antianxiety medications, antidepressant medications, anticoagulant medications, and diuretic medications 5 of the 7 days of the look-back period. Review of the (MONTH) 2019 MAR indicated [REDACTED]. Interview with the MDS Coordinator on 5/30/19 at 9:59 AM in the Conference Room, the MDS Coordinator was asked if the admission MDS dated [DATE] was coded correctly… | 2020-09-01 |
| 3 | 3 | NHC HEALTHCARE, OAKWOOD | 445002 | 244 OAKWOOD DR | LEWISBURG | TN | 37091 | 2019-05-31 | 689 | D | 0 | 1 | 4KQP11 | Based on observation and interview, the facility failed to ensure the environment was free from accident hazards when 1 of 2 (Sling Lift) resident transfer lifts was not functioning properly. The findings include: Observations in Resident #36's room on 5/31/19 at 10:35 AM revealed Certified Nursing Assistant (CNA) #1 and #2 used a sling lift to transfer Resident #36 from his bed to his wheelchair. The lift malfunctioned momentarily and left Resident #36 suspended over his bed in the sling. The lift began working again, and the CNAs were able to lower Resident #36 into his wheelchair. Interview with CNA #2 outside Resident #36's room on 5/30/19 at 10:42 AM, CNA #2 was asked if there had been problems with the sling lift. CNA #2 stated, Here lately, yes. We have told maintenance. CNA #2 was asked how long the lift had been malfunctioning. CNA #2 stated, I'm not sure, maybe a week. Interview with CNA #3 on the West Hall on 5/30/19 at 10:43 AM, CNA #3 was asked if she had any problems with the sling lift. CNA #3 stated, Once in awhile it will get stuck .It's been reported to maintenance. We were just talking about it Monday. CNA #3 was asked what she was told by the maintenance staff. CNA #3 stated, He said he would look at it and try to oil it up or something. Interview with CNA #4 at the nurses station on 5/30/19 at 10:46 AM, CNA #4 was asked if she had any problems with the sling lift. CNA #4 stated, A little bit. CNA #4 was asked how long that had been going on. CNA #4 stated, It's been recent .I've noticed it usually happens more on bigger patients that it struggles with . Interview with the Director of Maintenance on 5/30/19 at 12:22 PM in the Conference Room, the Director of Maintenance was asked if he worked on the patient lifts. The Director of Maintenance stated, Not much .I just check the batteries. The Director of Maintenance was asked if he had been notified of a problem with the sling lift. The Director of Maintenance confirmed he had been notified. The Director of Maintenance was asked when he was firs… | 2020-09-01 |
| 4 | 4 | NHC HEALTHCARE, OAKWOOD | 445002 | 244 OAKWOOD DR | LEWISBURG | TN | 37091 | 2017-08-16 | 371 | D | 0 | 1 | RSCD11 | Based on observation and interview the facility failed to ensure food was properly stored in 1 of 1 (Nurses Station) nourishment refrigerators. The findings included: Observations in the medication room nourishment refrigerator on 8/15/17 at 3:20 PM, revealed 3 cans of strawberry yogurt with expiration date of 8/4/17 and 3 cans of Glucerna Therapeutic Nutrition Classic Butter Pecan with expiration date of 5/1/17. Interview with Licensed Practical Nurse (LPN) #1 on 8/15/17 at 3:20 PM, in the medication room, LPN #1 was asked should expired food be kept in the refrigerator. LPN #1 stated, No it should not. Interview with LPN #2 on 8/16/17 at 1:04 PM, at the nurses' station, LPN #2 was asked what is the process for ensuring expired foods are removed from the refrigerator in the medication room. LPN #2 stated, It is dietary's responsibility for checking and removing expired food from the refrigerator .we stand at the door and allow them to go in and check everything and if something is expired then they remove it and replace it. Interview with the Dietary Manager (DM) on 8/16/17 at 1:08 PM, in the dining room, the DM was asked what the process is for removing expired food from the refrigerator in the medication room. The DM stated, Every night they go and rotate the oldest to the front and new to the back and check the dates and that is suppose to be done nightly. The DM was asked should you expect to find expired food in the refrigerator. The Dietary Manager stated, No. Interview with the Director of Nursing (DON) on 8/16/17 at 1:11 PM, at the nurses' station, the DON was asked what is the process for ensuring the nourishment refrigerator in the medication room is free of expired food. The DON stated, Dietary comes out and checks the refrigerator .we open the door and stand there while they check it but I expect my nurses to check for expiration dates prior to administering medications or food to a resident. | 2020-09-01 |
| 5 | 5 | NHC HEALTHCARE, OAKWOOD | 445002 | 244 OAKWOOD DR | LEWISBURG | TN | 37091 | 2018-08-22 | 641 | D | 0 | 1 | X6JV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure assessments were completed to accurately reflect the resident's status for hospice and cognition for 2 of 12 (Resident #32 and 41) sampled residents reviewed. 1. Medical record review revealed Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The significant change Minimal Data Set ((MDS) dated [DATE] failed to document that hospice services had been provided during the assessment period. Interview with the MDS Coordinator on 8/22/18 at 2:26 PM, in the MDS office, the MDS Coordinator was asked if the MDS dated [DATE] should have been marked to reflect the resident was receiving hospice services. The MDS coordinator stated, Yes. 2. Medical record review revealed Resident # 41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS dated [DATE] did not have a Brief Interview for Mental Status (BIMS) which is a score that indicates the resident's cognitive function. The MDS was not completed (blank) in the cognitive assessment area. Interview with the MDS Coordinator on 8/21/18 at 2:23 PM, in the MDS office, the MDS Coordinator was asked if the BIMS score and cognitive function section of the MDS was completed. The MDS Coordinator stated, No. | 2020-09-01 |
| 6 | 6 | NHC HEALTHCARE, OAKWOOD | 445002 | 244 OAKWOOD DR | LEWISBURG | TN | 37091 | 2018-08-22 | 728 | E | 0 | 1 | X6JV11 | Based on review of the RULES OF TENNESSEE DEPARTMENT OF HEALTH BOARD FOR LICENSING HEALTH CARE FACILITIES DIVISION OF HEALTH CARE FACILITIES CHAPTER 1200-08-06 STANDARD FOR NURSING HOMES 1200- 6-.15, CNA (Certified Nursing Assistant) INSTRUCTOR job description, the Nurse Aide Training Program (NAT) sign in sheets, the Tennessee State tested Nurse Aide Exam results, the (NHC) OAKWOOD Time Schedule as Worked schedules, the Partner Time Collection Report, and interview, the facility failed to ensure 13 of 22 (Nursing Assistant (NA) #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13) NAs enrolled in the facility's Nurse Aide Training Program (NAT) were supervised by the NAT instructor when they worked in the facility. The findings included: 1. The RULES OF TENNESSEE DEPARTMENT OF HEALTH BOARD FOR LICENSING HEALTH CARE FACILITIES DIVISION OF HEALTH CARE FACILITIES CHAPTER 1200-08-06 STANDARD FOR NURSING HOMES 1200- 6-.15 documented, .The provision of direct individual care to residents by a trainee is limited to appropriately supervised clinical experiences .a program instructor must be present or readily available on-site during all clinical training hours . 2. The facility's .CNA INSTRUCTOR job description documented, .The CNA instructor is to direct and sustain the CNA Training program in the Center in order to maintain adequate CNA staffing .Arrange and provide a clinical experience for the student that insures they are prepared for the skill test . 3. Review of the NAT program sign in sheets for the facility's NAT program held in (MONTH) and (MONTH) (YEAR) revealed a total of 22 students were enrolled in the program, which included NA #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13. 4. Review of the Tennessee State tested Nurse Aide Exam (Certified Nursing Assistant Examination) results revealed NA #1, 2, 3, 4, 5, 6, and 7 failed the examination. NA #8, 9, 10, 11, 12, and 13 have not taken the Tennessee State tested Nurse Aide Exam (Certified Nursing Assistant Examination). 5. Review of the NHC (National Healthcare Co… | 2020-09-01 |
| 7 | 7 | NHC HEALTHCARE, DICKSON | 445004 | 812 CHARLOTTE ST | DICKSON | TN | 37055 | 2019-08-01 | 686 | D | 0 | 1 | 4FC811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide timely assessments and treatments for pressure ulcers for 1 of 4 (Resident #87) sampled residents reviewed for pressure ulcers. The findings include: Medical record review revealed Resident #87 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 6/4/19 documented, .has alteration in skin r/t (related to) dark and reddened areas to (R) (right) foot . The Admission assessment dated [DATE] documented, .bilat (bilateral) red heels and outer rt (right) heel dark purple area (possible SDTI) (suspected deep tissue injury) . Review of the wound assessments revealed no assessments were completed for Resident #87's sDTI from admission until 7/9/19. Review of the Treatment Administration Records dated (MONTH) and (MONTH) 2019 revealed there was no documentation of wound care treatment for [REDACTED]. Medical record review revealed the pressure ulcer to the right heel remained an unstageable pressure ulcer and had not worsened. Observations in Resident #87's room on 7/18/18 at 2:05 PM, revealed Resident #87, she had a unstageable pressure injury to the right lateral heel. Interview with the Director of Nursing (DON) on 7/31/19 at 2:38 PM, in the Education Room, the DON was asked if Resident #87 was admitted with any pressure ulcers. The DON stated, .she had a suspected deep tissue injury .outer right heel . The DON was asked if weekly skin assessments and treatments should have been done. The DON stated, Yes. The DON was asked when the wound assessments and treatments began. The DON stated, .we started (MONTH) 2nd . The facility was unable to provide documentation that wound assessments and treatments were provided for Resident #87's pressure ulcer that was identified on 6/4/19, until 7/2/19. | 2020-09-01 |
| 8 | 8 | ST BARNABAS AT SISKIN HOSPITAL | 445008 | 1 SISKEN PLAZA | CHATTANOOGA | TN | 37403 | 2019-01-16 | 842 | D | 0 | 1 | 6O2811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to ensure Physician order [REDACTED].#340 and #341) of 3 residents reviewed of 29 residents sampled. The findings include: Medical record review revealed Resident #340 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the POLST form, undated, revealed the physician had not signed and dated the resident's POLST form. Medical record review revealed Resident #341 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the POLST form dated 1/4/19 revealed the POLST form was not signed by the resident and the health care professional preparer of the form. Interview with the Director of Nursing (DON) on 1/16/19 at 8:47 AM, in the DON's office, confirmed the POLST forms were to be completed within 24 hours of admission to the facility. Continued interview confirmed the facility failed to ensure the POLST forms were complete for Resident #340 and #341. | 2020-09-01 |
| 9 | 9 | ST BARNABAS AT SISKIN HOSPITAL | 445008 | 1 SISKEN PLAZA | CHATTANOOGA | TN | 37403 | 2020-02-20 | 574 | C | 0 | 1 | UNET11 | Based on facility policy review, admission packet review, interview, and observation, the facility failed to support each resident's rights by ensuring the required State Survey Agency's contact information was made available for 3 of 3 residents (Resident #1, Resident #2, and Resident #16). Interviews obtained during the resident group meeting revealed the residents had not been given information on how to file a complaint with the State Survey Agency. This failure had the potential to affect all 43 residents of the facility who may want to exercise their right to file a complaint directly with the State Survey Agency. Findings include: Review of the facility's policy titled, Patient Rights and Responsibilities-Siskin West Subacute, undated, revealed the residents had the right to .contact the Tennessee Department of Health directly at (telephone number) to lodge any concerns you may have about your care. Review of the facility's policy titled, Resident Rights, undated, located in the facility's admission packet provided during the entrance conference, revealed at the time of admission, and periodically through their stay, the facility would inform each resident, orally and in writing, of their rights. The policy stated the resident had the right to voice grievances to the facility, or other agency or entity that hears grievances, without discrimination or reprisa,l and without fear of discrimination or reprisal. The policy also stated the resident had the right to be afforded the opportunity to contact these agencies. The policy stated the resident had the right to immediate access to any of the following: any representative of the Secretary of the U.S. Department of Health and Human Services, any representative of the State, the resident's individual physician, the State's long-term care ombudsman, and the agency responsible for the protection of, and advocacy system for, mentally or developmentally disabled individuals. Review of an untitled and undated form, located in the Admission Packet provided by the fa… | 2020-09-01 |
| 10 | 10 | ST BARNABAS AT SISKIN HOSPITAL | 445008 | 1 SISKEN PLAZA | CHATTANOOGA | TN | 37403 | 2020-02-20 | 679 | D | 0 | 1 | UNET11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, review of activity calendars, observations, and interviews, the facility failed to provide activities for 4 of 25 sampled residents (Resident #131, Resident #132, Resident #230, and Resident #232) who resided on the Sub-Acute Unit. Failure to provide residents with an activity program has the potential to affect the residents' physical, mental, and psychosocial well-being. Findings Include: Review of the St. Barnabas/Siskin West Policy Activities Department updated/revised 12/2018 indicated the definition of an activity was any activity other than activities of daily living that enhanced the resident's well-being. The policy indicated the activities would be person-centered and highlight the resident's quality of life. The procedure indicated the AD would visit the resident after admission to obtain likes and dislikes. The procedure further indicated the AD would educate the resident on happenings on the unit and she would provide an activity calendar for the resident. The policy stated, .should the patient/resident decline to attend activities .they will be provided with in-room options or 1:1 (one on one) opportunities .puzzles, books, magazines, movies and music. Resident #131 was admitted to the facility on [DATE] for occupational and physical therapy following a motor vehicle accident. Review of the Baseline Care Plan dated 2/17/2020, revealed it did not address Resident #131's activity preferences. Review of Resident #131's Resident Activities Assessment Preferences for Customary Routine Activities dated 2/19/2020, revealed it was very important for the resident to do her favorite activities; and it was somewhat important for the resident to have books, newspapers, and magazines to read, to listen to music she liked, to do things with groups of people, to go outside to get fresh air when the weather was good, and to participate in religious services or practices. Review of the a… | 2020-09-01 |
| 11 | 11 | NHC HEALTHCARE, CHATTANOOGA | 445013 | 2700 PARKWOOD AVE | CHATTANOOGA | TN | 37404 | 2020-01-02 | 580 | D | 1 | 0 | 14S411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the facility policy, medical record review, and interview, the facility failed to notify the physician in a timely manner of a malfunction of a Percutaneous Endoscopic Gastrostomy (PEG) tube (flexible feeding tube inserted through the abdominal wall and into the stomach for nutrition, fluids, and medications) for 1 resident (#2) of 3 residents reviewed for PEG tubes. The findings include: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 5/9/19 revealed Resident #2 was care-planned for Infection Potential related to Feeding Tube, and Nutritional Status, Dependent on Tube Feed with interventions including (caloric, fiber fortified nutritional tube feeding) at 60 milliliters an hour for 18 hours, assess for changes in condition and notify medical staff, and MD (medical doctor) to replace PE[NAME] Medical record review of the Resident Progress Notes dated 9/1/19 at 1:38 PM, for Resident #2 revealed .in am, previous shift .nurse reported perforation to PEG tube. Noted large hole at end of catheter. Removed without difficulty and replace with new 24F (French) 20 cc (cubic centimeters) tube .restarted without concerns per supervisor .Husband updated, left message with NP (Nurse Practitioner) . Further review revealed no documentation the physician or the NP was made aware of the PEG tube perforation and the removal and reinsertion of a new PEG tube. Medical record review of the Physician's Orders on 9/1/19 revealed no documentation of an order to reinsert the PEG tube. Medical record review of an untitled typed letter, dated 10/14/19, and signed by the Unit Supervisor RN revealed .pt. (patient) had a removable gastric tube in place that had perforated and some of the balloon was visible from tube site entrance .nurse notified house supervisor .replaced with facility gastric tube . Interview with the Compliance Registered Nurs… | 2020-09-01 |
| 12 | 12 | NHC HEALTHCARE, CHATTANOOGA | 445013 | 2700 PARKWOOD AVE | CHATTANOOGA | TN | 37404 | 2018-03-20 | 655 | D | 0 | 1 | 48GW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to develop a baseline care plan to address the care and treatment of [REDACTED].#459) of 49 sampled residents reviewed for baseline care plans. The findings included: Medical record review revealed Resident #459 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the hospital discharge orders dated 3/9/18 revealed Resident #459 was discharged with an indwelling urinary catheter. Medical record review of a baseline care plan dated 3/9/18 revealed no care plan for the care and treatment of [REDACTED]. Interview with the Director of Nursing on 3/20/18 at 7:22 AM, in the conference room, confirmed Resident #459's care plan failed to address the treatment and care of the indwelling urinary catheter. | 2020-09-01 |
| 13 | 13 | NHC HEALTHCARE, CHATTANOOGA | 445013 | 2700 PARKWOOD AVE | CHATTANOOGA | TN | 37404 | 2018-03-20 | 684 | D | 0 | 1 | 48GW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, observation, and interview the facility failed to obtain a physician's order for an indwelling urinary catheter for 1 resident (#459) of 3 residents reviewed for urinary catheters of 49 sampled residents reviewed. The findings included: Review of the facility policy, Electronic Health Record IMAR System, dated 4/24/15 revealed .admission orders [REDACTED]. Medical record review revealed Resident #459 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of hospital discharge orders dated 3/9/18 revealed .MD (Medical Doctor) order for (urinary catheter) .Catheter this admission: yes . Medical record review of Physician's Orders dated 3/9/18 revealed no order for an indwelling urinary catheter. Observation of Resident #459 on 3/18/18 at 11:00 AM and 2:00 PM, in the resident's room, revealed the resident had an indwelling urinary catheter. Observation of Resident #459 on 3/19/18 at 9:25 AM and 3:00 PM, in the resident's room, revealed the resident had an indwelling urinary catheter. Interview with Licensed Practical Nurse (LPN) #1 and LPN #2 at 3:30 PM, the 400 hall nursing station, revealed they were unaware Resident #459 had an indwelling urinary catheter and there was no physician's order. Interview with the Director of Nursing on 3/20/18 at 7:22 AM, in the conference room, confirmed the admitting nurse failed to properly reconcile admission orders [REDACTED]. Continued interview confirmed .We missed it . | 2020-09-01 |
| 14 | 14 | NHC HEALTHCARE, CHATTANOOGA | 445013 | 2700 PARKWOOD AVE | CHATTANOOGA | TN | 37404 | 2018-03-20 | 689 | D | 0 | 1 | 48GW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, observation, and interview, the facility failed to provide new interventions after a fall for 1 resident (#40) of 6 residents reviewed for falls of 49 residents reviewed. The findings included: Review of the facility's NHC FALLS PROGRAM undated revealed .Purpose: To identify patients at risk for falling and to implement the appropriate interventions .3) Implement appropriate interventions 4) Evaluate the effectiveness of the interventions . Medical record review revealed Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident was severely cognitively impaired, required extensive assistance of 1 staff to transfer, dress, toilet, complete personal hygiene, and the resident was non-ambulatory and total assistance of 1 staff for bathing. Review of the POS [REDACTED]. The new intervention was to keep the resident in high traffic areas. Review of the POS [REDACTED]. The new intervention was to educate staff to keep the resident in high traffic areas. Observation and interview with Resident #40 on 3/20/18 at 9:15 AM in the dining area revealed he was sitting in his geri chair (in the down position) at the table finishing his breakfast. States he falls because he is clumsy. I'm 96, old people fall Observation of Resident #40 on 3/20/18 at 2:30 PM, in the dining area revealed the resident sitting in the geri chair asleep, with the chair reclined. Interview with the Licensed Practical Nurse (LPN) Risk Manager on 3/20/18 at 2:45 PM, in the conference room revealed after reviewing the 9/21/17 and 10/8/17 Post Falls Investigations confirmed the new intervention for the 9/21/17 fall was to keep the resident in a high traffic area, this would include educating the staff of the new intervention, and would be added to the Certified Nurse Assistant work sheet. Continued interview confirmed … | 2020-09-01 |
| 15 | 15 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-01-18 | 602 | E | 1 | 0 | GSLM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility investigation, and interview, the facility failed to prevent misappropriation of resident's medication for 5 residents (#1, #3, #4, #5, and #6) of 9 residents reviewed for abuse. The findings included: Review of the facility policy Resident Rights - Abuse of Residents revised [DATE] revealed, .any type of resident abuse .or misappropriation of resident property is strictly prohibited .misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful (temporary or permanent) use of a resident's belonging or funds without the resident's consent . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was moderately cognitively impaired. Medical record review of Resident #1's Physicians Orders revealed an order dated [DATE] for [MEDICATION NAME] (pain medication) 0.25 milliliters (ML) sublingual (under the tongue) as needed (PRN) every 1 hour for pain. Continued review revealed the order was discontinued on [DATE]. Further review revealed an order dated [DATE] for [MEDICATION NAME] 0.5 ml sublingual PRN every 3 hours as needed for pain. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #3 was moderately cognitively impaired. Medical record review of the Physician Orders revealed an order for [REDACTED]. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed Resident #4 expired on [DATE]. Medical record review of the Quarterly MDS dated [DATE] revealed a BIMS score of 3 indicating Resident #4 was severely cognitively impaired. Medical record review of the Physician Orders revealed … | 2020-09-01 |
| 16 | 16 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2020-02-20 | 625 | D | 1 | 0 | D8DU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to provide a bed hold notice for 1 resident (Resident #1) transferred to a psychiatric facility of 3 transferred residents reviewed. The findings included: Review of the facility's policy titled, Bed Hold Policy dated 10/19/2019 showed .Residents and/or responsible parties will be fully informed of options regarding the holding or releasing of a bed when the resident is temporarily transferred from the facility or is on a therapeutic leave.Upon admission to the facility the resident and/or their representative will be notified in writing of (named facility) Bed Hold Policy.In the event that the resident is transferred out of the facility temporarily, or the resident goes out on a therapeutic leave a copy of the Bed Hold Agreement will be given to the resident or their representative.This process will be followed for all transfers, regardless of payer type. A copy of the Bed Hold Agreement will be placed in the residents Business Office File and a copy of the bed hold agreement will be provided to the resident or their representative. Resident #1 was admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. The resident was discharged on [DATE] to a psychiatric facility. Resident #1 was readmitted to the facility on [DATE], but was discharged again to the psychiatric facility on 7/24/2019 and did not return to the facility. Review of the admission Minimum Data Set ((MDS) dated [DATE] showed Resident #1 had short and long term memory loss and exhibited physical and verbal behaviors directed towards others. Review of a Physician's Telephone Order dated 6/8/2020 showed .transfer to (named psychiatric facility).psych eval (psychiatric evaluation). Review of a Physician's Telephone Order dated 7/23/2020 showed .send to (named psychiatric facility) for evaluation + (and) tx (treatment). Medical record review showed no documentation a bed hold notice was p… | 2020-09-01 |
| 17 | 17 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-04-26 | 609 | D | 1 | 0 | 6SJ411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of a facility investigation, observation, and interviews, the facility failed to report an injury of unknown origin for 1 resident (#3) of 5 residents reviewed. The findings included: Review of the facility policy Resident Rights Abuse of Residents dated 11/14/16 revealed .an injury of unknown origin .must be reported to the Executive Director .Resident Incidents must be reported immediately .not later than 24 hours if the events that cause the allegation do not involve abuse .to other officials (including law enforcement, state survey agency, and adult protective services) .in accordance with applicable law and regulations . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident had short and long term memory problems and was severely cognitively impaired for daily decision making skills. Further review revealed the resident required extensive to total assist for activities of daily living (ADL) with 1-2 person assist. Review of a facility investigation dated 3/28/18 revealed Certified Nurse Assistant (CNA) #1 noted bruising to Resident #3's left forehead, which was not present earlier in the day. Further review revealed CNA #1 reported the bruising to Licensed Practical Nurse (LPN) #5. Continued review revealed LPN #5 reported the injury to the Director of Nursing (DON). Interview with CNA #1 on 4/25/18 at 11:30 AM, in the 1 South Breakroom, revealed .I was on my way to lunch . (another CNA) was pushing her (Resident #3) out of the dining room .I brushed her (Resident #3's) hair back from her face and that is when I noticed the bruise .it was purple .reported to the nurse .got her (Resident #3) up and dressed that morning and did not see anything then . Interview with LPN #2 on 4/25/18 11:40 AM, in the 1 South Breakroom, revealed .immediately went a… | 2020-09-01 |
| 18 | 18 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-04-26 | 656 | D | 1 | 0 | 6SJ411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interviews, the facility failed to ensure the comprehensive care plan was person centered for bathing for 2 residents (#1 and #2) of 5 residents reviewed. The findings included: Review of the facility policy Bathing dated 3/7/14 revealed .All Residents complete bathing needs will be met twice weekly, or at a schedule based on resident preference . Review of the facility policy Comprehensive Resident Centered Care Plan dated 11/2/16 revealed .The care plan incorporates the resident's strengths and abilities as well as areas requiring support . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #1's care plan dated 2/5/18 revealed .provide care as needed by the resident to complete his/her daily care needs . Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had severe cognitive impairment. Further review revealed the resident required extensive assist with transfers, bathing, and dressing with 1-2 person assist. Continued review revealed the resident had a functional limitation of 1 upper and 1 lower extremity. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #2's care plan dated 3/22/18 revealed .provide care as needed by the resident to complete his/her daily care needs . Review of the admission MDS dated [DATE] revealed the resident had severe cognitive impairment. Further review revealed the resident required extensive assist for transfers, dressing with 2 person assist, and was totally dependent for personal hygiene and bathing with 1-2 person assist. Interview with Certified Nursing Assistant (CNA) #1 on 4/25/18 at 2:45 PM, on 1 South Household hallway, revealed .most residents get 2 showers a week unless they request more . Interview with Licensed Practical Nurs… | 2020-09-01 |
| 19 | 19 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2019-05-02 | 609 | D | 1 | 0 | ZMPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of a facility investigation, and interviews, the facility failed to ensure an allegation of abuse was reported immediately to the facility Administrator and to other officials (including the State Survey Agency and Adult Protective Services) for 1 resident (#1) of 4 residents reviewed for Abuse on 4 nursing units of 4 sampled residents. The findings included: Review of facility policy Resident Rights - Abuse of Residents revised 11/14/16 revealed .Reporting .1. Any witnessed or allegations of abuse .must be reported to the Executive Director, Administrator or Charge Nurse/Nurse Supervisor .a. Resident Incidents must be reported immediately .to other officials (including law enforcement, state survey agency, and adult protective services) in accordance with applicable law and regulations . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #1's quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had severe cognitive impairment. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #2's 30 day MDS dated [DATE] revealed the resident had severe cognitive impairment. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Resident #3's annual MDS dated [DATE] revealed the resident was cognitively intact. Medical record review of a Psychiatric Progress Note for Resident #3 dated 4/10/19 revealed the resident was attention seeking and inappropriate verbally with staff related to sexuality. Review of a facility investigation dated 4/25/19 revealed Resident #3 reported he witnessed Resident #2 place his hand down the front of Resident #1's pants and Resident #3 told Resident #2 to stop. Continued review reveal… | 2020-09-01 |
| 20 | 20 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2017-07-27 | 281 | D | 1 | 0 | 4611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on Lippincott Manual of Nursing Practice, facility staffing files, facility policy, medical record review, and interview, the facility employed one Licensed Practical Nurse (LPN #9) with an expired license who administered insulin to 3 diabetic residents (#5, #16, and #14) of 17 residents reviewed. The findings included: Review of Lippincott Manual of Nursing Practice, Ninth Edition, chapter 2, revealed, .Licensure is granted by an agency of state government and permits individuals accountable for the practice of professional nursing to engage in the practice of that profession, while prohibiting all others from doing so legally . Review of the facility staff certification documents on [DATE] revealed LPN #9's license to practice nursing expired on [DATE]. Review of the facility's staffing files revealed LPN was hired on [DATE]. Medical record review of the facility's Insulin Administration Policy revised (MONTH) 2010 revealed, .Procedure .check blood glucose per physician order [REDACTED]. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Physician order [REDACTED].(increase) chemsticks (blood sugar testing) to AC/HS (before meals and bedtime) . Medical record review of Physician order [REDACTED].Humalog (fast-acting insulin for diabetics) 6 (units) with lunch and supper .hold if (blood glucose) (less than) 150 . Medical record review of Resident #5's electronic Medication Administration Record [REDACTED]. Medical record review of Resident #5's eMAR dated (MONTH) (YEAR) revealed LPN #9 administered insulin without documentation of the resident's blood sugar 15 times out of 62 opportunities. Medical record review of Resident #5's eMAR dated (MONTH) (YEAR) revealed LPN #9 administered insulin without documentation of the resident's blood sugar 16 times out of 54 opportunities. Medical record review of Resident #5's eMAR dated (MONTH) (YEAR) revealed LPN… | 2020-09-01 |
| 21 | 21 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2017-07-27 | 282 | E | 1 | 0 | 4611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, review of Brunner and Suddarth's Textbook of Medical Surgical Nursing, medical record review, Review of Consultant Pharmacist Reports, and interview, the facility failed to administer insulin and follow diabetic care plans per the physicians orders for 8 residents (#1, #4, #6, #7, #13, #5, #16, #18) of 17 residents reviewed for insulin, of 24 residents reviewed. The facility's failure to follow diabetic care plans resulted in an insulin overdose and hospitalization for Resident #1. The Nursing Home Administrator (NHA), Executive Officer/Vice President of Operations, and Director of Nursing (DON) and were notified on 7/27/17 at 1:25 PM in the administrator's office, that Resident #1 received an overdose of insulin. The findings included: Review of the Facility Policy Medication Administration and Med Pass Schedule, revised (MONTH) (YEAR), revealed, .when PRN (as needed) medications are administered, the nurse must record .date and time administered .dosage .medications shall be administered as prescribed by the physician .must be administered with the written orders of the attending physician .nurses administering the medications must initial the resident's MAR .Should a drug be withheld .nurse must enter an explanatory note Review of Brunner and Suddarth's Textbook of Medical Surgical Nursing Twelfth Edition, chapter 41 revealed, .Because the insulin dose required by the individual patient is determined by the level of blood glucose in the blood, accurate monitoring of blood glucose levels is essential .[DIAGNOSES REDACTED] is defined as an episode of blood glucose concentration (less than) 45 . by the level .causes of DKA (Diabetic Ketoacidosis, a serious complication of diabetes) .missed dose of insulin . Medical record review revealed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Continued review revealed the resident was transferred to the hospital on [DATE] after receivi… | 2020-09-01 |
| 22 | 22 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2017-07-27 | 309 | E | 1 | 0 | 4611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of facility documents, review of Emergency Medical Service documents, review of hospital records and interview, the facility failed to provide insulin management and monitoring for 1 diabetic resident of 17 residents reviewed for insulin medication administration, of 24 residents reviewed. The facility's failure resulted in Resident #1 receiving an overdose of insulin, aspirating, and being sent to the hospital and placed on a ventilator (machine to assist with breathing). The facility failed to ensure insulin was administered according to correct blood sugar parameters per physician's orders [REDACTED].#6, #7, #12, #13, #14, #20, #22) of 17 residents reviewed for insulin medication administration, of 24 residents reviewed. The Nursing Home Administrator (NHA), Executive Officer/Vice President of Operations, and Director of Nursing (DON) and were notified on [DATE] at 1:25 PM in the administrator's office, that Resident #1 received an overdose of insulin. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident was transferred to the hospital on [DATE] after receiving an overdose of insulin. The resident died on [DATE]. Medical record review of a physician's orders [REDACTED].pureed diet and nectar thick liquids. Pt (patient) allowed to have mech (mechanical) soft/canned peaches, pears and jello. No straws . Medical record review of a Nurses note dated [DATE] revealed .resident having xtrem e (extreme) difficulties swallowing anything/liquids are tolerated better than food . Medical record review of a Speech Therapy note dated [DATE] revealed .Pt seen for 1:1 (one to one) skilled dysphagia (difficulty swallowing) therapy .pt recommended pureed diet and nectar thick liquids to decrease risk of aspiration . Medical record review of a Physicians Order dated [DATE] revealed Patient to be on nec… | 2020-09-01 |
| 23 | 23 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2017-07-27 | 329 | E | 1 | 0 | 4611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of Physicians' Desk Reference (PDR), Brunner & Suddarth's Textbook of Medical Surgical Nursing, medical record review, review of facility investigations, interview, and review of the Consultant Pharmacists reports, the facility administered medications unnecessarily for 9 residents (#1,#5, #7, #13, #14,#16,#18, #20, #22,) of 17 residents reviewed. The facility's failure resulted in Resident #1 receiving 100 units of insulin, instead of 4 units, and being hospitalized . The Nursing Home Administrator (NHA), Executive Officer/Vice President of Operations, and Director of Nursing (DON) and were notified on 7/27/17 at 1:25 PM in the administrator's office, that Resident #1 received an overdose of insulin. The findings included: Review of Physicians' Desk Reference (PDR) 69 Edition, (YEAR), pg 2044 - 2045, revealed, .[DIAGNOSES REDACTED] is defined as an episode of blood glucose concentration Review of Brunner and Suddarth's Textbook of Medical Surgical Nursing Twelfth Edition, chapter 41 revealed, .Because the insulin dose required by the individual patient is determined by the level of blood glucose in the blood, accurate monitoring of blood glucose levels is essential .In emergency situations, for adults who are unconscious and cannot swallow, an injection of glucogon (medication used to increase blood sugar) can be administered .[MEDICAL CONDITION] . (defined as) elevated blood glucose level .greater than 110 . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physicians Order dated 8/25/16 revealed .Humalog (fast-acting insulin) .Sliding Scale Insulin .Four Times Daily .Blood Sugar is 201.00-250.00 .(give) 4 units . Medical record review of the Electronic Medication Administration Record [REDACTED].Humalog 100 unit/ml (milliliter) .Four Times Daily .8/26/16 Sliding Scale Insulin .Blood Sugar is 201.00-250.00 - 4 units . Indicating the res… | 2020-09-01 |
| 24 | 24 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2017-07-27 | 333 | E | 1 | 0 | 4611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of Physicians' Desk Reference (PDR), Brunner & Suddarth's Textbook of Medical Surgical Nursing Twelfth Edition, facility policy review, medical record review, review of Consultant Pharmacy Reports, and interview, the facility failed to prevent significant medication errors for 12 (#1, #4, #5, #6, #7, #12, #13, #14, #16, #18, #20 and #22) of 17 residents reviewed for insulin administration. The facility's failure resulted in Resident #1 receiving 96 more units of insulin than ordered. The Nursing Home Administrator (NHA), Executive Officer/Vice President of Operations, and Director of Nursing (DON) and were notified on [DATE] at 1:25 PM in the administrator's office, that Resident #1 received an overdose of insulin. The findings included: Review of Physicians' Desk Reference (PDR) 69th Edition, (YEAR), pg 2044 - 2045, revealed, .[DIAGNOSES REDACTED] is defined as an episode of blood glucose concentration Review of Brunner and Suddarth's Textbook of Medical Surgical Nursing Twelfth Edition, chapter 41 revealed, .Because the insulin dose required by the individual patient is determined by the level of blood glucose in the blood, accurate monitoring of blood glucose levels is essential .In emergency situations, for adults who are unconscious and cannot swallow, an injection of glucogon (medication used to increase blood sugar) can be administered .[MEDICAL CONDITION] . (defined as) elevated blood glucose level .greater than 110 . Review of the Facility Policy Medication Administration and Med Pass Schedule, revised (MONTH) (YEAR), revealed, .medications shall be administered as prescribed by the physician .If a dose seems excessive .the nurse should contact the physician .the nurse should compare the drug and dosage schedule to the resident's MAR (Medication Administration Record) and with the drug label . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident di… | 2020-09-01 |
| 25 | 25 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2017-07-27 | 490 | E | 1 | 0 | 4611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of facility investigations, review of the Pharmacist Consult Reports, and interview, the facility failed to be administered in a manner to ensure there were not significant medication errors, errors in insulin administration, errors in transcribing insulin orders, and to ensure staff monitored and documented blood sugars, and followed Physicians Orders for insulin administration for 12 residents (#1, #4, #5, #6, #7, #12, #13, #14, #16, #18, #20, and #22) of 17 residents reviewed for insulin administration, of 24 residents reviewed. The facility's failure resulted in Resident #1 receiving an overdose of 96 units of insulin and being hospitalized . The Nursing Home Administrator (NHA), Executive Officer/Vice President of Operations, and Director of Nursing (DON) and were notified on [DATE] at 1:25 PM in the administrator's office, that Resident #1 received an overdose of insulin. The findings included: Medical record review, review of facility investigations, and interview, revealed on [DATE], Resident #1 had a blood sugar of 247 and 100 units of insulin was given, when only 4 units of insulin should have been administered to the resident. The resident became hypoglycemic (low blood sugar), unresponsive, was sent to the hospital, and was admitted to a Critical Care Unit on a ventilator to aid in breathing. Review of the hospital records revealed the resident had Acute [MEDICAL CONDITION] requiring mechanical ventilation and was unable to wean due to severe [MEDICAL CONDITION] (loss of brain function) and aspiration pneumonia (pneumonia caused by food or liquids in the lungs). The resident died on [DATE]. Review of the Consultant Pharmacist's Medication Regimen for January, (MONTH) and (MONTH) (YEAR) revealed documentation from the Consultant Pharmacist indicating ongoing reported insulin errors, transcription errors, and problems with documentation of blood sugar levels. Medical record review for Residen… | 2020-09-01 |
| 26 | 26 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2017-07-27 | 501 | E | 1 | 0 | 4611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the Medical Director Contract, facility policy review, review of facility investigations, review of Consultant Pharmacists Reports, medical record review, and interview, the facility failed to ensure the Medical Director participated in the development and implementation of facility policies to ensure Physicians orders were followed, insulin was administered as ordered, and blood glucose levels were monitored and documented for 12 residents (#1, #4, #5, #6, #7, #12, #13, #14, #16, #18, #20, and #22) of 17 residents reviewed for insulin administration, of 24 residents reviewed. The facility's failure resulted in Resident #1 receiving an overdose of 96 units of insulin and being hospitalized . The Nursing Home Administrator (NHA), Executive Officer/Vice President of Operations, and Director of Nursing (DON) and were notified on [DATE] at 1:25 PM in the administrator's office, that Resident #1 received an overdose of insulin. The findings included: Review of the Medical Director Contract dated [DATE] revealed .SERVICES TO BE PERFORMED BY PROVIDER .Provide medical services in accordance with accepted professional standards of practice and use only qualified duly licensed, certified or registered health care professionals in the performance of these services .Responsible for the overall coordination of medical care at the Facility .shares responsibility for assuring Facility is providing appropriate care as required which involves monitoring and ensuring implementation of resident policies and providing oversight and supervision of medical services and medical care of residents .Evaluate and take appropriate steps to correct any problems associated with any possible inadequate care Provider identifies or about which Provider receives a report . Medical record review, review of facility investigations, and interview, revealed on [DATE], Resident #1 had a blood sugar of 247 and 100 units of insulin was given, when only 4 units o… | 2020-09-01 |
| 27 | 27 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2017-07-27 | 514 | E | 1 | 0 | 4611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the facility policy, review of Brunner and Suddarth's Textbook of Medical Surgical Nursing, medical record review, and interview, the facility failed to provide sufficient documentation to determine the status or progress after the implementation of care for 4 diabetic residents (#5, #6, #16, and #18) of 17 residents reviewed for insulin, of 24 residents reviewed. The findings included: Review of the Facility Policy Medication Administration and Med Pass Schedule, revised (MONTH) (YEAR), revealed, .when PRN (as needed) medications are administered, the nurse must record .date and time administered .dosage . Review of the facility's Insulin Administration Policy revised (MONTH) 2010 revealed, .Procedure .check blood glucose per physician order .Documentation .resident's blood glucose results, as ordered . Review of Brunner and Suddarth's Textbook of Medical Surgical Nursing Twelfth Edition, chapter 41 revealed, .Because the insulin dose required by the individual patient is determined by the level of blood glucose in the blood, accurate monitoring of blood glucose levels is essential . Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #5's Care Plan Dated 8/11/17 revealed, .Potential for increased or decreased blood sugar levels .[DIAGNOSES REDACTED] (low blood sugar) .Goals .blood sugar (greater than) 70 or (less than) 110 (every) day .accuchecks (lab to monitor blood sugar levels) as ordered .insulin as ordered .see MAR (Medication Administration Record) . Medical record review of Physician Orders dated 3/21/17 revealed, .(increase) chemsticks (blood sugar testing) to AC/HS (before meals and bedtime) . Medical record review of Physician Orders dated 3/27/17 revealed, .Humalog (insulin) 6 (units) with lunch and supper .hold if (blood glucose) (less than) 150 . Medical record review of Resident #5's MAR dated (MONTH) (YEAR) reveale… | 2020-09-01 |
| 28 | 28 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2017-07-27 | 520 | E | 1 | 0 | 4611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the Monthly Pharmacist's Medication Regimen Review, review of facility investigations, medical record review, and interview, the facility failed to identify and address problems with errors in insulin administration, transcribing insulin orders, monitoring and documenting blood sugars, and following Physicians Orders for insulin administration for 12 residents (#1, #4, #5, #6, #7, #12, #13, #14, #16, #18, #20, and #22) of 17 residents reviewed for insulin administration, of 24 residents reviewed. The facility's failure resulted in Resident #1 receiving an overdose of 96 units of insulin and being hospitalized . The Nursing Home Administrator (NHA), Executive Officer/Vice President of Operations, and Director of Nursing (DON) and were notified on [DATE] at 1:25 PM in the administrator's office, that Resident #1 received an overdose of insulin. The findings included: Medical record review, review of facility investigations, and interview, revealed on [DATE], Resident #1 had a blood sugar of 247 and 100 units of insulin was given, when only 4 units of insulin should have been administered to the resident. The resident became hypoglycemic (low blood sugar), unresponsive, was sent to the hospital, and was admitted to a Critical Care Unit on a ventilator to aid in breathing. Review of the hospital records revealed the resident had Acute [MEDICAL CONDITION] requiring mechanical ventilation and was unable to wean due to severe [MEDICAL CONDITION] (loss of brain function) and aspiration pneumonia (pneumonia caused by food or liquids in the lungs). The resident died on [DATE]. Medical record review for Residents #1, #4, #5, #6, #7, #12, #13, #14, #16, #18 #20, #22 revealed significant medication errors, unnecessary medications administered, missing documentation of blood glucose monitoring, and failure to follow Physicians orders throughout medical records. Review of the Consultant Pharmacist's Medication Regimen for January, (MONT… | 2020-09-01 |
| 29 | 29 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-08-20 | 550 | G | 0 | 1 | Q9H011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, observation and interview, the facility failed to maintain dignity by not providing timely assistance with toileting for 1 resident (#89) and not providing incontinence care for 1 resident (#80) of 52 residents sampled. This failure resulted in psychosocial harm to Resident #89 and Resident #80. The findings include: Review of the facility Dignity Policy dated 1/1/17 revealed .Each resident shall be cared for in a manner that promote and enhances quality of life, dignity, respect and individuality .1. Residents shall be treated with dignity and respect at all times .11. Demeaning practices and standards of care that compromise dignity are prohibited . Medical record review revealed Resident #89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) 14 day assessment dated [DATE] revealed Resident #89 had an indwelling catheter and was frequently incontinent of bowel. Medical record review of the unscheduled MDS assessment dated [DATE] revealed the Resident's Brief Interview for Mental Status (BIMS) score was 15, indicating the resident was cognitively intact. Continued review of the MDS revealed the resident required extensive 2 person assist for bed mobility, transfers, and toileting. Interview with Resident #89 on 8/14/18 at 9:47 AM in the resident's room, confirmed .They are real short on day shift. I have called out because I need the bed pan and they did not get to me for a while and I had an accident on myself. It made me feel shamed . Interview with the Director of Nursing (DON) on 8/20/18 at 3:11 PM in the conference room, confirmed .she (Resident #89) was not treated with respect and dignity . Medical record review revealed Resident #80 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the significant change MDS dated [DATE] revealed the resident scored a 0 on the BIMS indi… | 2020-09-01 |
| 30 | 30 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-08-20 | 554 | D | 0 | 1 | Q9H011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of a facility statement, medical record review, observation, and interview, the facility failed to complete an interdisciplinary team (IDT) assessment for self-administration of medications by 1 resident (#131) of 8 residents reviewed during initial pool process, of 52 residents sampled. The findings include: Review of the facility Administering Medication Policy Statement, revised 12/12, revealed .25. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely . Review of facility policy Self-Administration of Medication dated 10/18/17 revealed .1. A resident will not self-administer his or her medications until a determination has been made by the interdisciplinary team that the resident can safely perform this task .2. The household Clinical Mentor, (nurseUnit Manager) at the request of the resident, will assess the resident to determine the resident's ability to self-administer his or her medications .findings of the assessment will be documented in the resident's clinical record . Review of a facility statement signed by the Administrator and dated 8/15/18, revealed There is no resident who self-administers medications. Medical record review revealed Resident #131 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the resident's care plan dated 5/15/18, revealed the resident was at risk for unstable blood pressure related to Hypertension, .Administer B/P (blood pressure) meds (medications) as ordered .at risk for altered tissue perfusion related to anticoagulant (blood thinner) therapy .Administer meds (Aspirin) at same time daily . Medical record review of a current physician's orders [REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #131 re… | 2020-09-01 |
| 31 | 31 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-08-20 | 656 | D | 0 | 1 | Q9H011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to develop and implement a person-centered care plan to address the resident's need for assistive devices during meal times for 1 resident (#54) of 52 sampled residents. The findings include: Medical record review revealed Resident #54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident required 1 person assistance with dressing and personal hygiene, and 2 person assistance with transfers and set up help for eating. Continued review revealed the resident was on a mechanically altered diet, had an identified weight loss, and had no oral or dental issues. Continued review revealed the resident scored 14 on the Brief Interview For Mental Status (BIMS), indicating he was cognitively intact. Medical record review of the quarterly Care Plan, undated, revealed .potential for weight loss .tremors of hands decrease his ability to self feed, dysphagia, swallowing difficulty .Staff to assist .when tremors are increased .Complete set-up and provide assistance with .eating . Continued review revealed at risk for Aspiration/Choking due to Dysphagia/Cough with intervention to .Assist .no straws .plate guard and weighted utensils with all meals . Medical record review of a clinical nurse's note dated 4/4/18 revealed .resident stated at lunch he couldn't feed himself, requested for staff to feed him . Observation of Resident #54 on 8/13/18 at 10:06 AM, in the resident's room, revealed the resident was eating a pureed breakfast provided in divided plate with no plate guard, had hand tremors and was noted to have food on clothing. Further observation revealed no weighted utensils in use. Observation of Resident #54 on 8/14/18 at 9:23 AM, in the resident's room, revealed the resident lying in bed, with the pureed breakfast meal provided in a divided plate with no plate guard… | 2020-09-01 |
| 32 | 32 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-08-20 | 657 | K | 0 | 1 | Q9H011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, review of facility documentation, observation, and interview, the facility failed to revise 7 residents' (#119, #28, #34, #39, #40, #47, and #80) care plans after falls with effective interventions to prevent further falls of 52 sampled residents, placing residents #119, #28, #34, #39, #40, #47, and #80 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The facility's failure is likely to place any resident at risk for falls in Immediate Jeopardy. The Administrator and the Director of Nursing (DON) were informed of the IJ in the conference room on 8/18/18 at 8:10 PM. The IJ was effective 11/10/17, and is ongoing. The findings include: Review of the facility policy Care Planning-Interdisciplinary Team dated 1/1/17 revealed .Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident .which includes, but is not limited to the following personnel: a. The resident's Attending Physician; b. The Registered Nurse who has responsibility for the resident; c. The Dietary Manager/Dietician; d. The Social Services Worker responsible for the resident; e. The Activity Coordinator; f. Therapists (speech, occupational, recreational, etc.), as applicable; g. Consultants (as appropriate); h. The Director of Nursing (as applicable); i. The Charge Nurse responsible for resident care; j. Nursing Assistants responsible for the resident's care; and k. Others as appropriate or necessary to meet the needs of the resident .The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan .The mechanics of how the Interdisciplinary Team … | 2020-09-01 |
| 33 | 33 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-08-20 | 677 | G | 0 | 1 | Q9H011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to provide assistance with activities of daily living for dependent residents by failure to provide bathing assistance for 1 resident (#53), and failure to provide timely incontinence care and toileting for 2 residents (#80 and #89) of 52 residents sampled. This failure resulted in Harm for Resident #80 and Resident #89. The findings include: Medical record review revealed Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly care plan updated on 5/30/18 revealed self-care deficit .Extensive assistance required with bathing .Scheduled shower days: Tuesday and Friday AM .2 Times Weekly Starting 06/23/2016 .Staff to ask (Resident #53) Every other day if she would like a bath .Active (Current) . Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Continued review revealed the resident required 2 person assistance with bed mobility and toileting and 1 person assistance with dressing, hygiene, and bathing. Medical record review of the Activities of Daily Living (ADL) Verification Worksheet revealed from 7/10/18 through 7/18/18, revealed Resident #53 received 1 shower. Interview with Resident #53 on 8/13/18 at 11:08 AM, in the resident's room, revealed the resident did not receive a shower .last week at all not Tuesday or Friday they told me they were short staffed .it has happened before .not enough of them . Continued interview revealed .I was supposed to get a shower twice a week . Interview with Certified Nursing Assistant (CNA) #3 on 8/15/18 at 9:25 AM, in the 2 South Dining room, revealed the facility did not always have enough help to take care of the residents. Further interview revealed there have been times residents have not received showers and missed a shower day that result… | 2020-09-01 |
| 34 | 34 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-08-20 | 686 | G | 0 | 1 | Q9H011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation and interview, the facility failed to prevent the development of a pressure ulcer for 1 resident (#80) wearing a medical device of 5 residents reviewed for pressure ulcers and failed to practice proper infection control prevention through hand hygiene during a dressing change for 1 resident (#119) of 2 persons observed for dressing changes of 52 residents sampled. The facility's failure resulted in the development of a pressure ulcer and Harm for Resident #80. The findings include: Review of the facility policy, Pressure Ulcers dated 5/1/11 revealed .To provide each resident the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care .All wounds, regardless of cause will be evaluated with documentation at each dressing change. A thorough wound evaluation will be completed at least weekly .Documentation will contain information regarding: Location and Staging .Size .Exudate .Pain .Wound bed .Description of wound edges .All pressure ulcers must be monitored daily .For pressure ulcers that do not have daily .dressing change ordered, the TAR (treatment record) should reflect daily monitoring .An interdisciplinary team will perform weekly wound rounds to observe and measure all pressure ulcers in the facility. Documentation of findings will be kept on the Weekly Pressure Ulcer Record .Skin/Wound Care Protocols .Relieve pressure in and out of bed . Review of the facility policy, Pressure Ulcer Prevention dated 6/2013 revealed .To assure that no pressure ulcers develop within the facility unless it is unavoidable . Review of the facility Skin Assessments/Checks Policy revised 7/24/18, revealed .A skin assessment will be conducted by the nurse on a weekly basis. Documentation will include any and all skin issues noted .Skin assessments will be done by nursin… | 2020-09-01 |
| 35 | 35 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-08-20 | 689 | K | 0 | 1 | Q9H011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, interview, facility investigation review, and observation, the facility failed to implement an effective fall prevention program for 7 residents (#119, #40, #39, #80, #28, #34, #47) of 7 residents reviewed for falls with injuries, of 40 residents in the facility with falls. The facility's failure to implement new interventions and have an effective falls prevention program resulted in injuries for 6 Residents (#119, #40, #80, #28, #34, and #47) and placed Residents (#119, #40, #39, #80, #28, #34, #47) in Immediate Jeopardy (a situation in which the provider's noncompliance has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy on 8/18/18 at 8:20 PM, in the conference room. The Immediate Jeopardy (IJ) was effective 11/10/17 and is ongoing. The facility was cited F689 at a scope and severity of K, which constitutes Substandard Quality of Care (SQC). The findings include: Review of facility policy Falls-Clinical Protocol-Assessment and Recognition, last revised 9/12, revealed .5. The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observation of the events, etc. 6. Falls should be categorized as: a. Those that occur while trying to rise from a sitting or lying to an upright position; b. Those that occur while upright and attempting to ambulate; and c. Other circumstances such as sliding out of a chair or rolling from a low bed to the floor. 7. Falls should also be identified as witnessed or unwitnessed events. Cause Identification- 1. For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. a. Causes refer to factors that are associated with or that directly result in a fall; for example, a balance problem caused by an old or … | 2020-09-01 |
| 36 | 36 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-08-20 | 690 | D | 0 | 1 | Q9H011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview the facility failed to provide catheter care for 1 resident (#89) of 4 residents reviewed with catheters, of 52 sampled residents. The findings include: Review of facility policy Catheter Care-Indwelling Catheter, dated 1/1/17, revealed .PURPOSE: to prevent infection and provide daily hygiene . Medical record review revealed Resident #89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a 14 Day Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status Score of 15, indicating the resident was cognitively intact. Continued review revealed the resident required extensive assistance with 1 staff member for bed mobility and toileting and required total assistance with 2 staff members for transfers and bathing. Further review revealed the resident required a wheelchair for mobility and was assessed as having an indwelling catheter. Medical record review of admission orders [REDACTED].FC(Foley Catheter)(indwelling urinary catheter) .chg (change) monthly .cath (catheter) care . Medical record review of readmission orders [REDACTED]. Medical record review of a Clinical Nurse Note dated 8/11/18 revealed .catheter replaced with #18 (size) catheter with 20cc (cubic centimeter) balloon (balloon to hold catheter in place) . Medical record review of a Physician order [REDACTED].Urinary Catheter Care q (every) shift .Starting 8/18/18 .Insert indwelling catheter .Every One Month Starting 8/18/18 . Interview with Resident #89 on 8/18/18 at 11:45 AM, in the resident's room, revealed .my catheter was changed just the other day .that was the first time they (facility) changed it .the nurse said she had to change the catheter because I had it since (MONTH) .they don't do catheter care everyday .they only do it on Tuesday and Thursday when I have my bath . Interview with LPN Nurse Mentor #5 on 8/18/18 at 3:56 PM, in the nursing st… | 2020-09-01 |
| 37 | 37 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-08-20 | 692 | D | 0 | 1 | Q9H011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, observation and interview, the facility failed to ensure interventions were implemented and monitored to prevent further weight loss for 2 residents (#34, #54) of 5 residents reviewed for nutrition, of 52 residents sampled. The findings include: Review of the Facility Weight Assessment and Intervention Policy revised 9/08 revealed 6 .threshold for significant unplanned weight and undesired loss will be based on the following criteria (where percentage of body weight loss = (usual weight - actual weight) / (usual weight) x 100): a. 1 month- 5% weight loss is significant; greater than 5% is severe. b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe .Continued review revealed .Individualized care plans shall address .identified causes of weight loss .Goals and benchmarks for improvement .Time frames and parameters for monitoring and reassessment . Medical record review revealed Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident scored 3 on the Brief Interview for Mental Status (BIMS) indicating the resident was severely cognitively impaired. Continued review revealed Resident #34 was independent with eating with assistance of set up only, and had no weight loss. Medical record review of the weight record from (MONTH) (YEAR) through (MONTH) (YEAR) revealed: 5/6/18 126.2 pounds 6/3/18 126 pounds 7/3/18 121.8 pounds 8/5/18 weight 111.2 pounds 8/12/18 weight 115.4 pounds Review of Nutrition Progress assessment dated [DATE] revealed Resident #34's current weight was 126 pounds, Nutrition [DIAGNOSES REDACTED].Intervention: Liberalization of diet, Evaluation .monitor weights and intake . Review of a clinical notes report dated 8/10/18 at 1:45 PM entered by Dietitian #2 revealed a significant weight loss of 8.7 percent, 10.6 pounds from 7/3/18 throug… | 2020-09-01 |
| 38 | 38 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-08-20 | 697 | G | 0 | 1 | Q9H011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview the facility failed to assess and monitor the effectiveness of an individualized Pain Management Program for 1 resident (#236) of 3 residents reviewed for pain of 52 sampled residents. The facility's failure to effectively control Resident #236's pain resulted in actual Harm to the resident. The findings include: Review of the facility policy, Pain Management, undated, revealed .Pain is always subjective; pain is whatever the person says it is .Fear of dependence, tolerance and addiction does not justify withholding opioids [MEDICATION NAME] in residents suffering with pain .Alert Communicative Resident .1. Resident identified with having pain will be asked degree of pain according to Numerical Pain Scale (0-10), with zero representing no pain and 10 representing the worst possible pain .4. Efficacy will be documented within one hour after administration of [MEDICATION NAME] .9. Physician will be notified of ineffective [MEDICATION NAME] .10. Physician will be notified immediately if pain suddenly becomes severe .18. Prevalent pain breakthrough should be reported to physician . Medical record review revealed Resident #236 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 14 day Minimum Data Set assessment dated [DATE], revealed the resident had a score of 15 on the Brief Interview For Mental Status, indicating she was cognitively intact. Medical record review of a care plan, undated, revealed .Potential for altered level of comfort-chronic pain related to .recent pressure ulcer s/p (status [REDACTED].Interventions .Notify MD (Medical Doctor) of unusual complaints of pain . Medical record review of a Nurse Practitioner's (NP) note dated 8/2/18 revealed .Discussion with patient regarding pain management had requested an increase in pain meds due to wound. Education provided re (regarding) pain management and good stewardship of use. … | 2020-09-01 |
| 39 | 39 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-08-20 | 698 | D | 0 | 1 | Q9H011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview the facility failed to assess and monitor a Central Venous Catheter (CVC) for 1 resident (#133) of 3 residents receiving [MEDICAL TREATMENT], of 52 sampled residents. The findings include: Review of the facility [MEDICAL TREATMENT] protocol, revised 5/2018 revealed .The [MEDICAL TREATMENT] organization will work with the Clinical Mentors in regards to proper care and treatment of [REDACTED]. Medical record review revealed Resident #133 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident received [MEDICAL TREATMENT]. Continued review revealed the resident scored 5 on the Brief Interview For Mental Status, indicating severe cognitive impairment. Review of a Physicians Orders dated 7/24/18 revealed the resident receives [MEDICAL TREATMENT] 3 times per week. Medical record review of a care plan undated, revealed .Has [MEDICAL CONDITION] (End Stage [MEDICAL CONDITION]) and is at risk for complications .Interventions .Monitor shunt site for any s/s (signs and symptoms) of infection, occlusion, etc . Medical record review of a [MEDICAL TREATMENT] Treatment Sheet print date 8/6/18 revealed current [MEDICAL TREATMENT] access of CVC catheter right chest. Medical record review of the Treatment Administration Record (TAR) dated 7/25/18-8/14/18, revealed no documentation the facility assessed the resident's catheter or dressing after [MEDICAL TREATMENT] treatment. Observation and interview with Resident #133 on 8/15/18 throughout the day revealed the resident had a CVC to the right upper chest for [MEDICAL TREATMENT] vascular access. Continued interview with the resident on 8/15/18 confirmed she was new to [MEDICAL TREATMENT] and didn't not know much about it. Interview with the Director of Nursing on 8/15/18 at 4:55 PM, in the conference room, confirmed there was no docume… | 2020-09-01 |
| 40 | 40 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-08-20 | 725 | K | 0 | 1 | Q9H011 | Based on review of the facility's CMS-672 Resident Census and Conditions of Residents, review of the Matrix for Providers, review of the facility's Daily Census Report, review of facility staffing schedules, observation, medical record review, review of facility incident reports, and interview, the facility failed to maintain adequate staffing levels to ensure the supervision of residents to prevent repeated falls for 7 residents (#28, #34, #39, #40, #47, #80, #119) of 40 residents reviewed for falls in the facility, and to ensure residents were provided assistance with activities of daily living (ADLs) care for 3 residents (#53, #80, and #89) of 52 residents reviewed. The facility's failure to ensure adequate staffing levels resulted in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) for 7 residents (#28, #34, #39, #40, #47 #80, #119) with serious injuries after falls. The facility's failure to provide assistance with toileting resulted in Harm to Residents #80 and #89. The Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy on 8/20/18 at 8:10 PM, in the conference room. The IJ was effective 11/10/17 and is ongoing. The findings include: Review of the facility's CMS-672 Resident Census and Conditions of Residents signed by the Administrator on 8/13/18 revealed the facility had a census of 137 residents. Further review revealed 90 residents were occasionally or frequently incontinent of bladder; 80 residents were occasionally or frequently incontinent of bowel; 25 residents ambulated with assistance or assistive devices; 92 residents had dementia; 86 residents had behavioral healthcare needs; and 8 residents had pressure ulcers. Review of the Matrix for Providers completed on 8/13/18 revealed the facility had 40 residents who had experienced falls while in the facility, with 10 residents having an injury with a fall an… | 2020-09-01 |
| 41 | 41 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-08-20 | 726 | K | 0 | 1 | Q9H011 | Based on review of the facility's Quality Assurance and Performance Improvement Plan, review of the facility's (YEAR) Assessment, and interview, the facility failed to implement a program to ensure nursing staff education and competency were completed The failure to ensure nursing staff were educated and competent placed 7 residents (#28, #34, #39, #40, #47, #80, and #119) in Immediate Jeopardy (IJ), a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator and the Director of Nursing (DON) were informed of the IJ in the conference room on 8/18/18 at 8:10 PM. The IJ was effective 11/10/17 and is ongoing. The findings include: Review of the facility Quality Assurance and Performance Improvement Plan, revised 2/27/18, revealed .The Quality Assurance (QA) Committee consists of the Director of Nursing Services, the Medical Director, the Administrator, at least two other members of the facility staff, and the Infection Preventionist .All associates including contracted staff are educated on the principles of QAPI .Associates will be trained on using QAPI process including participation on a Performance Improvement Project (PIP Team) .The QAPI program is sustained during transitions in leadership and staffing through all-associate education and involvement in the QAPI process . Facility associates and management have been trained on Root Cause Analysis .The QAPI program will be evaluated annually by the QAPI Steering Committee with input from the Leadership Team/Executive Leadership. This review will include whether goals were met, if standards of practice are being followed, any training needs will be identified and addressed . Review of the (YEAR) Facility Assessment revealed .Each job description identifies the required education .Additional competencies are determined according to the amount of resident interaction required by the job role, job specific knowledge, sk… | 2020-09-01 |
| 42 | 42 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-08-20 | 812 | E | 0 | 1 | Q9H011 | Based on facility policy review, observation and interview, the facility failed to maintain 2 of 13 resident refrigerators in a safe operating manner and failed to keep foods stored at an appropriate temperature, potentially affecting 29 residents on the Secure Unit and 33 residents on the 2 South hall. The findings include: Review of the facility policy Food Safety dated 1/2016 revealed .Refrigerators must maintain Temperature Controlled for Safety (TCS) foods at 41 (degrees) or below. Refrigeration and freezer thermometers must be accurate to at least +/- (plus or minus) 2 degrees. If temperatures are above 41 (degrees) for TCS foods, corrective actions must be implemented . Observation and interview with the Food Director on 8/13/18 at 12:20 PM, of the 2 South resident refrigerator revealed an internal thermometer at 44 degrees. Further observation revealed (1) 1/2 pint of reduced fat buttermilk with a temperature of 49 degrees. Interview with the Food Director confirmed the refrigerator was not at the appropriate temperature. Continued interview confirmed the following TSC foods stored in the refrigerator would be discarded: 12 cheese slices9-1/2 pints of chocolate milk 9- 1/2 pints of free milk 9-1/2 pints of chocolate milk 5- 1/2 pints of buttermilk 4-1/2/pints of 2% milk 2 cartons of peach yogurt 1 carton of strawberry yogurt 1 carton of cherry yogurt Observation and interview with the Food Director and Dietary Manager on 8/13/18 at 12:30 PM, of the 1 South resident refrigerator revealed an internal thermometer at 42 degrees. Further observation revealed (1) 1/2 pint of vitamin D milk and (1) 1/2 pint of chocolate milk with a temperature of 44 degrees and (1) 1/2 pint of 2% milk with a temperature of 47 degrees. Interview with the Food Director and Dietary Manager confirmed the refrigerator was not at an appropriate temperature. Continued interview confirmed the following TSC foods stored in the refrigerator would be discarded: 5- 1/2 pints of fat free milk 10- 1/2 pints of 2% milk 5- 1/2 pints of buttermi… | 2020-09-01 |
| 43 | 43 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-08-20 | 835 | K | 0 | 1 | Q9H011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, review of facility falls investigations, review of facility dailycensus and staffing, observation, and interview, the Administrator failed to ensure facility policy and procedures were implemented for falls; failed to ensure revision of care plans was completed with appropriate and individualized interventions to prevent falls; failed to prevent avoidable pressure ulcers; failed to ensure an effective falls program was implemented to prevent residents from having multiple falls and multiple injuries with falls; and failed to ensure adequate staffing to supervise residents who had falls and adequate staffing to provide activities of daily living care (ADL) care to residents. The Administrator's failure to ensure an effective falls program was implemented placed 7 residents (#28, #34, #39, #40, #47, #80, and #119) in Immediate Jeopardy (IJ), a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator's failure to ensure residents were provided assistance with toileting resulted in Harm to Residents #80 and #89. The Administrator's failure to ensure residents received pain control resuled in Harm to Resident #236. The Administrator's failure to ensure residents did not develop pressure ulcers resulted in Harm to Resident #80. The Administrator and the Director of Nursing (DON) were informed of the IJ in the conference room on 8/18/18 at 8:10 PM. The facility was cited Immediate Jeopardy at F-657, F 689, F725, F 726, F 841, F 867 and F 947. The facility was cited Substandard Quality of Care (SQC) at F-689 The IJ was effective 11/10/17 and is ongoing. The findings include: During the annual Recertification survey conducted 8/13/18 - 8/20/18, review of clinical notes, accident reports, and fall investigations revealed Resident #119 had 9 falls bet… | 2020-09-01 |
| 44 | 44 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-08-20 | 841 | K | 0 | 1 | Q9H011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Medical Director Contract, review of the Advanced Practice Nurse (APN) Protocol, review of the Facility Assessment, medical record review, review of facility falls investigations, observation, and interview, the Medical Director failed to ensure identification, development, and implementation of appropriate plans of action and ensure the effective use of its resources to maintain the highest practicable well-being of all residents, failed to ensure performance improvement was implemented and monitored, failed to provide an individualized pain management plan to avoid pain and mental anguish, failed to ensure interventions were implemented for residents with repeated occurrences with falls which placed residents at risk of harm, failed to ensure revision of care plans were done with appropriate and individualized interventions to prevent falls, failed to prevent avoidable pressure ulcers, failed to ensure an appropriate falls intervention program was implemented to prevent residents from having multiple falls and injuries, and failed to ensure a facility assessment was performed and implemented. The Medical Director's failure placed 7 residents (#119, #28, #34, #39, #40, #47, #80) in Immediate Jeopardy (IJ), a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator and the Director of Nursing (DON) were informed of the IJ in the conference room on 8/18/18 at 8:10 PM. The facility was cited Immediate Jeopardy at F-657, F725, F 726, F 835, F 841, F 867 and F 967. The facility was cited Substandard Quality of Care (SQC) at F-689 The IJ was effective 11/10/17 and is ongoing. The findings include: Review of the Medical Director Contract revealed .4. Services to be performed by provider .Responsible for the overall coordination of medical care at the Facility. Coordination of ca… | 2020-09-01 |
| 45 | 45 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-08-20 | 867 | K | 0 | 1 | Q9H011 | Based on review of the facility Quality Assurance and Performance Improvement Plan, Facility Assessment review, medical record review, observation, and interview, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to have an effective, ongoing QAPI program to ensure an effective falls program was implemented to prevent repeated falls for residents, resulting in injuries after falls. The QAPI committee's failure to ensure an appropriate falls intervention program was implemented, failure to ensure care plans were revised after falls, failure to ensure sufficient staffing to supervise residents at risk for falls, and failure to ensure competent staff, resulted in residents having multiple falls and injuries, and placed 7 residents (#119, #28, #34, #39, #40, #47, and #80) of 40 residents in the facility who had falls, in Immediate Jeopardy (IJ), a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator and the Director of Nursing (DON) were informed of the IJ in the conference room on 8/18/18 at 8:10 PM. The facility was cited Immediate Jeopardy at F-657, F725, F 726, F 841, F 867 and F 967. The facility was cited Substandard Quality of Care (SQC) at F-689 The IJ was effective 11/10/17 and is ongoing. The findings include: Review of the facility Quality Assurance and Performance Improvement Plan, revised 2/27/18, revealed .Purpose .(QAPI) Program utilizes an on-going, data driven, pro-active approach to advance the quality of life and quality of care for the residents .Quality Assurance and Performance Improvement principles drive our decision making as we endeavor to produce positive outcomes .QAPI committee consists of representatives from various departments .Performance Improvement Projects (PIPs) will be implemented when an opportunity for improvement is identified. These PIPs may apply to processes or systems throughout the comm… | 2020-09-01 |
| 46 | 46 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2018-08-20 | 947 | K | 0 | 1 | Q9H011 | Based on review of the facility's (YEAR) Assessment, review of the facility's computer based training documentation, and interview, the facility failed to implement a system to track nurse aide competency levels in order to ensure training was sufficient based on the resident population. The Administrator and the Director of Nursing (DON) were informed of the IJ in the conference room on 8/18/18 at 8:10 PM. The facility was cited Immediate Jeopardy at F657, F689, F725, F726, F841, F867 and F947. The facility was cited Substandard Quality of Care (SQC) at F-689 The IJ was effective 11/10/17 and is ongoing. The findings include: Review of the (YEAR) Facility Assessment revealed .Each job description identifies the required education .Additional competencies are determined according to the amount of resident interaction required by the job role, job specific knowledge, skills and abilities and those needed to care for the resident population. Certified nursing assistants may have additional required competencies .competencies are based on the care and services needed by the resident population .competencies are verified upon orientation, at least annually and as needed .The Staff Development Coordinator tracks and trends course completion history and performance trends, reporting those to the Administrator and Director of Nursing (DON) . Review of the facility's computer based training documentation revealed no tracking system in place to determine nurse aide competency after required annual training and in-service education, including understanding falls and skin checks. Interview with the Staff Development Coordinator on 8/18/18 at 4:30 PM, in the conference room, confirmed she was not involved in decision making of when nurse aides were competent and did not recall any specific training on falls other than the computer based Relias training assigned during orientation and annually. When asked if falls was covered in that training, the Staff Development Coordinator stated that she thought she remembered something … | 2020-09-01 |
| 47 | 47 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2019-08-28 | 695 | D | 0 | 1 | CV0B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to properly store and discard an outdated nebulizer (device used to administer medication in the form of a mist inhaled into the lungs) administration equipment (nebulizer tubing and mask) for 1 resident (#28) of 7 residents reviewed for nebulizer therapy. The findings include: Review of facility policy Administering Medication through Small Volume (Handheld) Nebulizer, revised 1/1/2017, revealed .Store equipment in plastic bag with the resident's name and date on it .Change equipment and tubing every 7 days . Medical record review revealed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum data set ((MDS) dated [DATE] revealed Resident #28 had a Brief Mental Status Interview (BIMS) score of 3, indicating severe cognitive impairment. Continued review revealed Resident #28 required limited assistance with bed mobility, transfers, personal hygiene, and dressing. Medical record review of the Physician's Recapitulation Orders dated 8/2019, revealed a nebulization solution was ordered as needed every 6 hours. Medical record review of the Medication Administration Record [REDACTED]. Observation of Resident #28 on 8/26/19 at 9:55 AM and 3:02 PM, and on 8/27/19 at 8:40 AM, in the resident's room, revealed the nebulizer at the bedside with the mask dated 3/28/19 and not stored in a plastic bag. Observation and interview with Licensed Practical Nurse (LPN) #1 on 8/26/19 at 3:35 PM, in the resident's room, confirmed the date on the nebulizer mask was 3/28/19 and the mask was not stored in a plastic bag. Further interview confirmed the nebulizer equipment had not been changed for 21 weeks. Interview with Director of Nursing (DON) on 8/26/19 at 3:47 PM, in the DON's office, confirmed the facility failed to follow their policy to properly store and discard outdated nebulizer equip… | 2020-09-01 |
| 48 | 48 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2019-08-28 | 842 | D | 0 | 1 | CV0B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to ensure Physician Orders for Scope of Treatment (POST) were completed for 3 residents (#87, #273, and #279) of 31 residents reviewed for advanced directives. The findings include: Review of the facility policy Health Care Decision Making-Advanced Directives - TN (Tennessee), revised 12/7/16, revealed The purpose of this policy and procedure is to ensure residents are informed of their rights to execute an Advanced Health Care Directive .It also provides guidelines for completion of a TN Physician Orders for Scope of Treatment (POST) form, and to facilitate the implementation of the resident's wishes so that they are carried out according to the terms of these documents and applicable law and regulation .Upon admission or as soon as possible thereafter, if the resident does not have Advance Health Care Directives, the Nurse, Nurse Practitioner, or MD (physician) will explain these documents to the resident or representative and provide forms for their review (Appointment of Health Care Agent form; POST form) .Residents wishing to create an Advance Care Plan may do so through completion of the POST form .A POST must contain: 1. Resident's name and signature .4. Physician's signature .Prior to signature, the Physician must discuss the POST form and contents with resident or the responsible party. Medical record review revealed Resident #87 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #87's POST form, undated, revealed documentation the resident was Do Not Attempt Resuscitation (DNR) status with Limited Additional Interventions. Continued review revealed Resident #87 or an appropriate resident representative had not signed the form, indicating DNR was the resident's wishes. Medical record review revealed Resident #273 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record rev… | 2020-09-01 |
| 49 | 49 | NHC HEALTHCARE, JOHNSON CITY | 445024 | 3209 BRISTOL HWY | JOHNSON CITY | TN | 37601 | 2017-05-24 | 242 | D | 0 | 1 | 2T0S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to honor individual choices for daily schedules for 2 residents (#84, #211) of 21 residents interviewed. The findings included: Medical record review revealed Resident #84 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #84 had a BIMS (Brief Interview for Mental Status) score of 10, indicating moderate cognitive impairment. Review of the medication record completed on 5/23/2017 at 3:48 PM revealed Resident #84 had a blood pressure medication ordered with parameters to hold the medication based on the resident's current blood pressure. The medication is set for an 8:00 AM administration schedule. Resident #84 also had an order for [REDACTED]. Observation and interview with Resident #84 on 5/22/2017 at 1:26 PM, in the resident's room confirmed she had not been given the opportunity to choose the time she preferred to be awakened in the morning nor the type of bathing she received. They wake me up at 5 (AM) but I don't get breakfast till 9 (AM). I would like to get up at 7 (AM) .I go (to the shower) on Tuesday and Friday. I didn't choose those days. An interview was completed with Activity Assistant (AA) #1 on 5/23/2017 at 2:10 PM. AA #1 stated, On admission, we fill out an assessment .We don't ask about what time they want to get up in the morning. On 5/23/2017 at 2:55 PM, an interview was completed with Certified Nursing Assistant #1 (CNA). CNA #1 stated she was familiar with Resident #84. I come in at 6:30 (AM). She is usually sleeping then. I go in to get her vitals (blood pressure, temperature, pulse) about 7 (AM). They get done every day. I ask if she wants to get up and she usually gets started with her day at that time. Breakfast comes out about 7:45 AM. Sometimes she says she doesn't want to get up at 7. Observation on 5/24/2017 at 7:05 AM, reveal… | 2020-09-01 |
| 50 | 50 | NHC HEALTHCARE, JOHNSON CITY | 445024 | 3209 BRISTOL HWY | JOHNSON CITY | TN | 37601 | 2017-05-24 | 371 | D | 0 | 1 | 2T0S11 | Based on facility policy review, observation, and staff interviews, the facility failed to distribute meals in a sanitary manner and failed to disinfect the hands to prevent contamination during meal service on 1 of 3 dining areas observed. The findings included: Review of policy and procedure on Handwashing, dated 10/2014, revealed, .Hands should be washed before starting to work; after break time; after using the rest room; after touching hair, face, or body .after touching anything that might contaminate hands .Sanitizing gel may ONLY be used as an added measure after washing hands to minimize bacteria, but not in place of handwashing . Observation on 05/22/17 at 11:53 AM, during meal service near the 300 hall, revealed Certified Nurse's Assistant (CNA) #5 picked up an uncovered plate of multiple food items from the hot bar (serving line), and carried it to an adjacent dining area across the hallway. Observation of CNA #6 revealed the CNA picked up an uncovered plate of multiple food items and carried the tray across the hallway into another dining area. Continued observation revealed the Dietary Aide (DA) #1 was plating food, without wearing gloves, wiping his face and adjusting his glasses, then touching the plate surfaces with bare fingers and placing resident's food on the plates to be served to the residents. Continued observation revealed DA #1 failed to wash his hands or use hand sanitizer after touching his face or glasses. Observation on 05/24/17 at 7:50 AM, during the breakfast meal service observation near the 300 hall, revealed CNA #8 picked up an uncovered breakfast plate from the tray line, walked across the hallway to the dining room and served Resident #102. Continued observation revealed CNA #9 also picked up an uncovered breakfast plate, carried the plate of food across the hallway to the dining room, and served Resident #105. On 05/24/17 at 8:04 AM, interview with the Dietary Manager (DM) #1, confirmed when staff are walking trays into another room from the serving line, the plated food shou… | 2020-09-01 |
| 51 | 51 | NHC HEALTHCARE, JOHNSON CITY | 445024 | 3209 BRISTOL HWY | JOHNSON CITY | TN | 37601 | 2018-07-25 | 641 | D | 0 | 1 | M4WC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to ensure an accurate Minimum Date Set (MDS) for one resident (#89) of 43 sampled residents. The findings include: Medical record review revealed Resident #89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a 14 day MDS dated [DATE] revealed .Section P .physical restraints .used in chair or out of bed .1 (indicating used less than daily) . Observation of the residents on 7/26/18 at 1:02 PM, in the resident's room, revealed resident alert and verbal sitting in wheelchair in room. Continued observation of the resident room revealed no restraint in place to resident or in resident room. Interview with the MDS coordinator on 7/25/18 at 8:50 AM, in the MDS office, confirmed the MDS dated [DATE] was not accurate and the resident had not used a physical restraint. | 2020-09-01 |
| 52 | 52 | NHC HEALTHCARE, JOHNSON CITY | 445024 | 3209 BRISTOL HWY | JOHNSON CITY | TN | 37601 | 2018-07-25 | 684 | D | 0 | 1 | M4WC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, review of the Lippincott Nursing Center, medical record review, facility documentation review, observation, and interview the facility failed to correctly administer medications for 1 resident (#335) of 6 residents reviewed for unnecessary medications. The findings include: Review of the undated facility policy Administering Medications revealed .3. Medications must be administered in accordance with the orders .4. The individual administering medications must verify the resident's identity before giving the resident his/her medications. Method of identifying the resident checking photograph attached to the electronic medical record .5. The individual administering the medication must check the label THREE (3) times to verify the right medication, right dosage, right time and right method (route) of administration before giving the medication .6. The following information must be check/verified for each resident prior to administering medications: [REDACTED]. Vital signs, if necessary . Review of the Lippincott Nursing Center 8 Rights of Medication Administration dated 5/27/11 revealed the 8 rights of medication administration included the right patient, right medication, right dose, right route, right time, right documentation, right reason, and right response. Medical record review revealed Resident #335 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Minimum Data Set ((MDS) dated [DATE] revealed the resident's cognitive skills for daily decision making was modified independence indicating the resident had some difficulty in new situations only. Review of facility documentation dated 7/17/18 revealed Resident #335 received the medications of another resident during the 9:00 AM medication pass. Continued review revealed the medications were administered incorrectly to Resident #335 based on mistaken identity. Medical record review of Resident #335's Electronic Medi… | 2020-09-01 |
| 53 | 53 | NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER | 445030 | 5010 TROTWOOD AVE | COLUMBIA | TN | 38401 | 2019-06-05 | 728 | D | 1 | 1 | PCFO11 | > Based on review of the facility's Nurse Aide Training (NAT) program, review of work schedules and interview, the facility failed to ensure 2 of 24 (Nurse Aide (NA) #1 and NA #2) NAs were removed from the working schedule and not allowed to perform the duties of a Certified Nursing Assistant CNA after 120 days of taking the NAT program. The findings include: Review of the facility working schedule for the months of February, March, (MONTH) and (MONTH) 2019 revealed NA #1 and NA #2 worked as NA performing the duties of a CN[NAME] Interview with the Director of Nursing (DON) on 6/5/19 at 3:00 PM in the DON's office, the DON was asked if NA #1 and NA #2 had passed the CNA certification exam. The DON stated, No . Interview with the DON on 6/5/19 at 6:03 PM in the conference room, the DON was asked when NA #1 and NA # 2 completed the Nurse Aide Training program. The DON stated .they were in the August/September (2018) class. The DON was asked if NA #1 and NA #2 worked at the facility longer than 4 months without being certified. The DON stated, .yes .they worked up until 2 weeks ago . The DON was asked what duties NA #1 and NA #1 performed. The DON stated, .CNA duties . The DON confirmed the NAs should not have worked longer than 4 months without passing the CNA certification exam. | 2020-09-01 |
| 54 | 54 | NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER | 445030 | 5010 TROTWOOD AVE | COLUMBIA | TN | 38401 | 2019-06-05 | 839 | D | 1 | 1 | PCFO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on license review and interview, the facility failed to ensure professional staff were licensed in accordance with applicable State laws for 1 of 41 (Licensed Practical Nurse (LPN) #2) nurses reviewed. The findings include: Review of the facility Personnel Action Form for LPN #2 revealed an employment date of [DATE]. Review of the State of Tennessee Department of Health Division of Health Licensure and Regulation Division of Health Related Boards on [DATE] revealed LPN #2's license number had an expired status with an expiration date of [DATE]. Review of the Department Allocation Worksheet for the pay period for [DATE] revealed LPN #2 worked at he facility through [DATE]. Interview with the Director of Nursing (DON) on [DATE] at 3:00 PM in the DON's office, the DON was asked if LPN #2 worked for the facility. The DON stated, .yes .she worked until the middle of (MONTH) (2019) .at that time we discovered her license was expired . The DON confirmed LPN #2 should not have worked on an expired license. The DON was asked who was responsible for license verification. The DON stated, .we are responsible . | 2020-09-01 |
| 55 | 55 | NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER | 445030 | 5010 TROTWOOD AVE | COLUMBIA | TN | 38401 | 2019-06-05 | 880 | D | 0 | 1 | PCFO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, the facility failed to ensure practices to prevent the potential spread of infection were followed when 3 of 8 (Certified Nursing Assistant (CNA) #1, Physical Therapist Assistant (PTA) #1, and Licensed Practical Nurse (LPN) #1) staff members failed to perform appropriate hand hygiene during contact isolation for Resident #182 and wound care for Resident #181. The findings include: 1. The facility's HANDWASHING policy with a revision date of 4/23/18 documented, .Hand hygiene has been cited frequently as the single most important practice to reduce the transmission of infectious agents in healthcare settings, and is an essential element of Standard Precautions .in the case of spore forming organisms such as[DIAGNOSES REDACTED]icile ([MEDICAL CONDITION]) .require soap and water with friction .PR[NAME]EDURE .Wash hands before and after contact with each patient .and before and after removal of gloves . 2. Medical record review revealed Resident #182 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. diff), [MEDICAL CONDITION] Stage 3, Traumatic Subdural Hemorrhage, Diabetes, [MEDICAL CONDITIONS], and Depression. The physician's orders [REDACTED].Strict Isolation-All services provided in room .for [MEDICAL CONDITION] . Observations in Resident #182's room on 6/3/19 at 12:19 PM revealed CNA #1 delivered ice to the resident, removed the gown and gloves, used hand sanitizer, and exited the room. Observations outside Resident #182's room on 6/4/19 at 8:15 AM revealed PTA #1 donned a gown, mask and gloves, and entered Resident #182's room. PTA #1 remained in the room for 37 minutes and exited the room at 8:52 AM without performing hand hygiene. Interview with PTA #1 on 6/4/19 at 8:52 AM outside Resident #182's room, PTA #1 was asked if she washed her hands before she came out of the room. PTA #1 stated, I don't like to use their bathroom . PTA #1 then used the hand… | 2020-09-01 |
| 56 | 56 | NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER | 445030 | 5010 TROTWOOD AVE | COLUMBIA | TN | 38401 | 2017-07-19 | 157 | D | 0 | 1 | 788Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to notify the Physician of a clinical complication for one resident (#168) of 3 residents reviewed for abuse. The findings included: Medical record review revealed Resident #168 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status could not be conducted because the resident was rarely/never understood. Medical record review of a nurse note by Registered Nurse (RN) #1 dated 7/18/17 at 8:50 AM revealed did not find [MEDICATION NAME] (narcotic pain medication [MEDICATION NAME]) to R (right) chest as documented. will ask on coming nurse to double-check and if none found, to place another patch. Interview with RN #1on 7/19/17 at 2:25 PM via telephone revealed she worked the 7PM to 7AM shift the night of 7/17/17 and cared for Resident #168. Further interview revealed she noticed the [MEDICATION NAME] was missing around 4 AM. Continued interview revealed RN #1 reported the missing [MEDICATION NAME] to Licensed Practical Nurse (LPN) #1 at shift change and asked her to get it replaced if it wasn't found. Interview with LPN #1 on 7/19/17 at 2:55 PM via telephone revealed she worked 7/18/17 from 7 AM to 7 PM and cared for Resident #168. Further interview revealed RN #1 told her at shift change the [MEDICATION NAME] was missing. Continued interview confirmed LPN #1 intended to notify the Physician of the missing [MEDICATION NAME] but failed to do so. | 2020-09-01 |
| 57 | 57 | NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER | 445030 | 5010 TROTWOOD AVE | COLUMBIA | TN | 38401 | 2017-07-19 | 225 | D | 1 | 1 | 788Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to investigate injuries of unknown origin for 1 resident (#379) and failed to initiate an investigation in a timely manner for a missing pain patch for 1 resident (#168) of 35 residents reviewed in Stage II. The findings included: Review of facility policy, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property, and Exploitation, revised 11/28/16 revealed .abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .An injury should be classified as an injury of unknown source when both of the following conditions are met: (a) The source of the injury was not observed by any person or the source of the injury could not be explained by the patient; and (b) The injury is suspicious because of the extent of the injury or the location of the injury or the number of injuries observed at one particular point in time or the incidence of injuries over time .All events reported as possible abuse, neglect, or misappropriation of patient property will be investigated to determine whether the alleged abuse, neglect, misappropriation of patient property, or exploitation did or did not take place .The Administrator or Director of Nurses will determine the direction of the investigation once notified of alleged incident . Review of facility policy, Miscellaneous Special Situations, Discrepancies, Loss and or Diversion of Medications, dated 6/2016 revealed .All discrepancies, suspected loss and/or diversion of medications, irrespective of drug type or class, are immediately investigated and report filed .Immediately upon the discovery or suspicion of a discrepancy, suspected loss of diversion, the Administrator, Director of Nursing (DON), Consultant Pharmacist and Director of Pharmacy are notified and an investigation co… | 2020-09-01 |
| 58 | 58 | NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER | 445030 | 5010 TROTWOOD AVE | COLUMBIA | TN | 38401 | 2017-07-19 | 514 | D | 0 | 1 | 788Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to accurately document on the Medication Administration Record [REDACTED]. The findings included: Medical record review revealed Resident #168 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical review of the Quarterly Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status could not be conducted because the resident is rarely/never understood. Medical record review of the MAR for (MONTH) (YEAR) revealed .CHECK - Patch placement every shift . (narcotic pain medication [MEDICATION NAME]). Continued review revealed documentation the patch was not found on the night shift on 7/17/17. Further review revealed documentation for patch placement on 7/18/17 as RT AC (right [MEDICATION NAME]). Interview with Licensed Practical Nurse (LPN) #1 on 7/19/17 at 2:55 PM via telephone when asked did the resident have a [MEDICATION NAME] (narcotic pain medication [MEDICATION NAME]) in place on 7/18/17 stated she could not find it. Continued interview when asked about the documentation of checking the patch placement for the [MEDICATION NAME] on 7/18/17 stated I think I put it was on but I should have put not in place. Further interview revealed LPN #1 stated didn't document it right. Interview with the Director of Nursing on 7/19/17 at 4:38 PM in the conference room when asked about LPN #1's documentation regarding the [MEDICATION NAME] placement on the 7/18/17 day shift revealed it was incorrect. Continued interview with the DON confirmed the facility failed to accurately document the [MEDICATION NAME] placement on 7/18/17 day shift for Resident #168. | 2020-09-01 |
| 59 | 59 | NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER | 445030 | 5010 TROTWOOD AVE | COLUMBIA | TN | 38401 | 2018-08-01 | 684 | D | 0 | 1 | D20911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview the facility failed to administer treatment and services to restore normal bowel function for 2 of 4 (Resident #229, and 230) residents reviewed for bowel incontinence. The findings include: 1. The facility's BM (bowel movement) Protocol policy documented, .Polyethylene [MEDICATION NAME] .17 grams by mouth as needed for constipation if no BM in 2 days .Mix in at least 4oz. (ounces) of water or juice in the morning of the 3rd day .[MEDICATION NAME] 10mg (milligram) suppository rectally as needed for constipation if no results from [MEDICATION NAME] by bedtime of the 3rd day .Fleet Enema rectally as needed for constipation if no results from [MEDICATION NAME] suppository, administer at bedtime on the 4th day .If no BM on the morning of the 5th day notify the physician . 2. Medical record review revealed Resident #229 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with Resident #229 on 7/30/18 at 5:26 PM, in her room, Resident #229 stated, .been here since Wednesday .haven't had a BM in a week . Review of the physician's orders [REDACTED].#229 was on the BM Protocol. Review of the Toileting .BM record revealed Resident #229 did not have a BM on 7/26/18, 7/27/18, 7/28/18, 7/29/18, 7/30/18, and 7/31/18. Review of the Med (medication) PRN (as needed) record dated 7/1/18 to 7/31/18 revealed Resident #229 did not receive Polyethylene [MEDICATION NAME] on 7/28/18 (the 3rd day) and did not receive the [MEDICATION NAME] rectal suppository on 7/29/18 (the 4th day) as ordered per the BM protocol. Interview with Registered Nurse (RN) #1 on 8/1/18 at 2:28 PM in the Minimum Data Set (MDS) office, RN #1 reviewed the Toileting .BM record for Resident #229, and confirmed that Resident #229 had not had a BM on 7/26/18, 7/27/18, 7/28/18, 7/29/18, 7/30/18, and 7/31/18. RN #1 reviewed the Med PRN record dated 7/1/18 to 7/31/18, and stated, She didn't get the medication . 3. Me… | 2020-09-01 |
| 60 | 60 | NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER | 445030 | 5010 TROTWOOD AVE | COLUMBIA | TN | 38401 | 2018-08-01 | 695 | D | 0 | 1 | D20911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to maintain respiratory equipment in a sanitary manner for 2 of 2 (Resident #16 and 178) sampled residents reviewed for respiratory care. The findings include: 1. The facility's RESPIRATORY MANUAL .Aerosol Therapy policy last revised 7/14, documented, .Cautions .Nebulizer can become contaminated resulting in an infection . 2. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] sulfate .1 ampul ([MEDICATION NAME]) nebulization every 2 hours As Needed SHORTNESS OF BREATH NEBULIZATION .Dx (Diagnosis) .[MEDICAL CONDITION] . The physician's orders [REDACTED].[MEDICATION NAME]-[MEDICATION NAME] .1 ampul nebulization 3 times per day NEBULIZATION .Dx .[MEDICAL CONDITION] . Observations in Resident #16's room on 7/30/18 at 5:38 PM revealed Resident #16 in bed, with a nebulizer on the bedside table. The tubing and mouthpiece were attached and dated 7/26/18. There was no cover or clean barrier for the mouthpiece. Observations in Resident #16's room on 7/31/18 at 8:30 AM revealed Resident #16 in bed with the nebulizer on the bedside table. The tubing and mouthpiece were attached and dated 7/26/18. The mouthpiece was on the floor. Observations in Resident #16's room on 7/31/18 at 5:09 PM revealed Resident #16 in bed, with a nebulizer on the bedside table. The tubing and mouthpiece were attached and dated 7/26/18. There was no cover or clean barrier for the mouthpiece. Interview with Licensed Practical Nurse (LPN) #1 on 7/31/18 at 5:13 PM on the Grove wing, LPN #1 was asked how the nebulizer tubing, masks, and mouthpieces should be stored. LPN #1 stated, .In a little baggie beside the machine. LPN confirmed the mouthpiece was not on a barrier or covered. 3. Medical record review revealed Resident #178 was admitted to the facility on [DATE] with [DIAGNOSES… | 2020-09-01 |
| 61 | 61 | NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER | 445030 | 5010 TROTWOOD AVE | COLUMBIA | TN | 38401 | 2018-08-01 | 698 | D | 0 | 1 | D20911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on worksheet review, medical record review, and interview, the facility failed to ensure there was communication between the facility and the [MEDICAL TREATMENT] clinic for 1 of 1 (Resident #3) sampled residents reviewed for [MEDICAL TREATMENT]. The findings include: The facility's [MEDICAL TREATMENT] Communication Worksheet documented, .ongoing assessment of the patient's condition and monitoring for complications before and after [MEDICAL TREATMENT] treatments received at a certified [MEDICAL TREATMENT] clinic .Center nurse complete On [MEDICAL TREATMENT] days Pre-[MEDICAL TREATMENT] section of the form prior to appointment .Send with patient to [MEDICAL TREATMENT] clinic .Request the [MEDICAL TREATMENT] clinic to complete the bottom portion of form .return it to the center with the patient . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICAL TREATMENT] every Tuesday, Thursday, Saturday (medication administration record) each [MEDICAL TREATMENT] 3 times per week (Tuesday, Thursday, Saturday) . The admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment, and the resident received [MEDICAL TREATMENT] services. Review of the Care Plan dated 1/17/18 revealed [MEDICAL CONDITION] with [MEDICAL TREATMENT] three times a week. Review of the [MEDICAL TREATMENT] communication forms revealed documentation was not completed on the forms dated 7/17/18, 7/19/18, 7/21/18 and 7/30/18. Interview with the Director of Nursing (DON) on 8/1/18 at 5:09 PM in the conference room, the DON was asked how she expected the nurses to communicate with the [MEDICAL TREATMENT] center. The DON stated, The nurse fills out the pre [MEDICAL TREATMENT] form .it goes with the patient to [MEDICAL TREATMENT] clinic .the [MEDICAL TREATMENT] clinic completes form .the form comes ba… | 2020-09-01 |
| 62 | 62 | NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER | 445030 | 5010 TROTWOOD AVE | COLUMBIA | TN | 38401 | 2018-08-01 | 880 | D | 0 | 1 | D20911 | Based on policy review, observation, and interview, 2 of 2 (Registered Nurse (RN) #2 and Certified Nursing Assistant (CNA) #1) staff failed to ensure infection control practices were maintained to prevent the potential spread of infection during wound care. The findings include: The facility's HANDWASHING policy, dated 10/1/08, documented, Hand hygiene has been cited frequently as the single most important practice to reduce the transmission of infectious agents in healthcare settings, and is an essential element of Standard Precautions .Wash hands before and after contact with each patient, after toileting, smoking or eating, and before and after removal of gloves . Observations in Resident #230's room on 7/31/18 beginning at 11:10 AM, revealed CNA #1 assisting RN #2 with wound care. RN #2 cleaned a marker with a bleach wipe and changed her gloves without performing hand hygiene. CNA #1 touched the bed covers, adjusted the bed, and changed her gloves without performing hand hygiene. RN #1 touched the wound with her gloved left hand and changed her gloves without performing hand hygiene. After applying a foam dressing to the wound, RN #1 changed her gloves without performing hand hygiene. After assisting with positioning Resident #230 during wound care, CNA #1 changed her gloves without performing hand hygiene. Interview with the Director of Nursing (DON) on 8/1/18 at 5:58 PM, in the conference room, the DON was asked what nursing staff should do between removing used gloves and donning clean gloves. The DON stated, Perform hand hygiene. | 2020-09-01 |
| 63 | 63 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2018-03-28 | 607 | D | 1 | 0 | 8HII11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility documentation, and staff interview, the facility failed to timely report an injury of unknown origin per policy to facility administration per facility policy; failed to implement facility policy related to training after an allegation of injury of unknown origin; and the facility administration failed to report the allegation of injury of unknown origin within 2 hours to the State Agency (SA) per facility policy. Failing to implement abuse policies had the potential for abuse events to reoccur and put all 176 residents residing in the facility at risk. Findings include: Review of the facility Abuse, Neglect and Misappropriation or Property, policy, revised 8/24/17, revealed the definition of an injury of unknown origin as: .means an injury that meets both of the following conditions: (1) the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and (2) the injury is suspicious because of the extent of the injury; or the location of the injury. Every Stakeholder, contractor and volunteer immediately shall report any allegation of abuse, injury of unknown source, or suspicion of crime. Directly after assuring that the resident(s) involved in the allegation or abuse event is safe and secure, the alleged perpetrator has been removed from the resident care area, and any needed medical interventions for the resident have been requested/obtained, the charge nurse will inform the Facility Administrator (the abuse coordinator), Director of Nursing (DON), physician and family or resident's representative of the allegation of abuse or suspicion of crime. The facility Administrator will determine whether the report constitutes an allegation of abuse or suspicion of crime as defined in this policy, and, if so, he or she, or the DON, will notify State agencies according to State reporting procedures within two … | 2020-09-01 |
| 64 | 64 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2018-03-28 | 609 | D | 1 | 0 | 8HII11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review,and staff interview, the facility failed to timely report an injury of unknown origin to the facility administration; and failed to notify the State Agency (SA) within 2 hours for 1 of 8 residents (Resident #10) reviewed for injury of unknown origin. Failing to report allegations of injury of unknown origin could increase the risk to all 176 residents residing in the facility. Findings include: Review of the undated facility Abuse, Neglect and Misappropriation or Property policy, revealed the definition of an injury of unknown origin as: .means an injury that meets both of the following conditions: (1) the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and (2) the injury is suspicious because of the extent of the injury; or the location of the injury. Every Stakeholder, contractor and volunteer immediately shall report any allegation of abuse, injury of unknown source, or suspicion of crime .the charge nurse will inform the Facility Administrator (the abuse coordinator), Director of Nursing (DON) .of the allegation of abuse .The facility Administrator will determine whether the report constitutes an allegation of abuse or suspicion of crime as defined in this policy, and, if so, he or she, or the DON, will notify State agencies according to State reporting procedures within two hours . Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE], revealed Resident #10 with severe cognitive impairment, no behaviors, and requiring extensive assist of 1 person for bed mobility, dressing, and eating. Resident #10 was dependent with 1 person assist for transfers, toilet needs, and bathing. Medical record review of a nursing assessment, completed by Licensed Practical Nurse (LPN) #7, dated 12/29/17 at… | 2020-09-01 |
| 65 | 65 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2018-03-28 | 880 | D | 1 | 0 | 8HII11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policies, medical record review, staff interview, and observation, the facility failed to ensure infection control measures related to the dressing change of a peripherally inserted intravenous catheter (PICC) for 1 of 3 residents (Resident #7) reviewed with PICC lines; and failed to properly utilize hand hygiene during medication administration for 1 of 4 residents (Resident #15) observed for medication administration. Failing to change PICC line dressings had the potential to affect eight residents identified with PICC lines; failing to use hand hygiene could increase the risk of infection, and had the potential to affect all 176 residents in the facility. Findings include: Review of facility Infusion Therapy Procedures dated 2011, was reviewed and revealed .PICC and Midline Catheter dressing changes must be completed at minimum every seven days. Change immediately if: loose, not occlusive, moisture accumulation, drainage, redness, or irritation. Initial dressings will be changed PRN (as needed) if saturated, and 24-48 hours post insertion of Midlines, PICC's . if there is gauze present under the dressing or drainage is noted . Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #7 was alert, oriented, and independent with all activities of daily living except assistance of 1 to be off the unit. Medical record review of the nursing admission assessment dated [DATE] revealed the resident was admitted with a right upper extremity PICC line. Medical record review of physician progress notes [REDACTED]. Medical record review of physician orders [REDACTED]. Medical record review of a Daily Skilled Nursing Note dated 12/08/17 revealed .central line dressing scheduled as per staff to be changed . Medical record review of Medication Administration Records, (MAR), dated 1… | 2020-09-01 |
| 66 | 66 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2019-04-03 | 550 | D | 1 | 1 | PJC211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based facility policy review, facility investigation review, medical record review, observation and interview, the facility failed to provide timely personal care to 1 resident (#83) of 161 residents observed. The findings include: Review of the facility policy, Resident Rights, revised 8/16/18 revealed .The facility will make every effort to support each resident in exercising his/her right to assure that the resident is always treated with respect, kindness and dignity . Review of the facility investigation dated 2/14/19 revealed Resident #83 had emesis (vomit) on his clothes and the Certified Nurse Aide (CNA) #8, failed to provide care such as changing the resident's clothes. Medical record review revealed Resident #83 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #83 was totally dependent on 2 people for dressing and mobility. Observation on 4/2/19 and 4/3/19 at 8:39 AM and 8:56 AM, respectively, in Resident #83's room revealed resident in bed, clean no signs and no symptoms of distress noted. Continued observation revealed Resident #83 had just finished eating breakfast and was assisted by staff. Record review of the facility investigation interview with the Chaplain on 2/15/19 revealed the Chaplain was in the dining room on the 4th floor at 2:00 PM and observed Resident #83 had emesis on him. Continued review revealed the Chaplain reported the observation to CNA #8. Record review of the facility investigation interview with CNA #8 on 2/14/19 revealed Resident #83 had vomited approximately 2:15 PM. Continued review revealed CNA #8 took Resident #83 to the room to provide care at 3:20 PM. Interview with the Administrator on 4/3/19 at 3:17 PM in her office revealed Resident #83 had vomited after lunch and the meal schedule for lunch on the 4th floor was from 11:30 PM to 12:30 PM. Continued interview revealed CNA #8 had remove… | 2020-09-01 |
| 67 | 67 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2019-04-03 | 641 | D | 0 | 1 | PJC211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to accurately assess 1 resident (#58) of 59 residents reviewed. The findings include: Medical record review revealed Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #58's Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 12 indicating the resident was moderately cognitively impaired. Continued review revealed the resident received insulin injections 7 of the 7 day look back period. Medical record review of Resident #58's Physician order [REDACTED]. Interview with Registered Nurse (RN) #1, responsible for the MDS, on 4/2/19 at 1:45 PM in his office confirmed Resident #58's MDS dated [DATE] was coded to reflect the resident received insulin injections for 7 of 7 days. Continued interview when asked to look at Resident #58's physicians orders, RN #1 confirmed the resident had no orders for insulin. Continued interview revealed It's my mistake, I miscoded the MDS. | 2020-09-01 |
| 68 | 68 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2019-04-03 | 695 | D | 0 | 1 | PJC211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility policy review, medical record review, observation and interview, the facility failed to provide necessary care for 3 residents (#34,#95 and #573) of 28 residents receiving respiratory services. The findings include: Review of the facility policy, Departmental (Respiratory Therapy)- Prevention of Infection, revised 2011, revealed .Store the circuit (nebulizer mask) in plastic bag, marked with date and resident's name between uses . Medical record review revealed Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician's Orders Sheet dated 2/28/19 revealed .May administer 2 liters of O2 (oxygen) per nasal cannula for SOB (shortness of breath) . Continued review revealed .may oral suction with [MEDICATION NAME] (suction device) as needed . Observation on 4/1/19 at 10:24 AM in Resident #34's room revealed the [MEDICATION NAME] was undated and unbagged and was hanging on top of the humidifier canister. Medical record review revealed Resident #95 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data set ((MDS) dated [DATE] revealed Resident #95 required oxygen therapy. Observation on 4/1/19 at 10:05 AM in Resident #95's room revealed the unbagged and undated nasal cannula and nebulizer mask were stored on top of the humidifier attached to the wall O2. Observation and interview with the House Supervisor on 4/1/19 at 5:27 PM and 5:30 PM in Residents #34 and #95 room confirmed the [MEDICATION NAME], nebulizer and nasal cannula was unbagged, undated and were stored on top of the humidifier canister. Continued interview confirmed .I see it and will change it . Medical record review revealed Resident #573 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician Orders dated 3/1/19 for Resident #573 revealed .[MEDICATION NAME] CONC (concentrate) 1.25 milligrams (MG) 0.5, 1 vial per … | 2020-09-01 |
| 69 | 69 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2019-04-03 | 741 | D | 0 | 1 | PJC211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to answer a call light in a timely manner for 1 resident (#72) of 161 residents observed. The findings include: Medical record review revealed Resident #72 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Sets ((MDS) dated [DATE] and 3/20/19 revealed Resident #72 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. Continued review revealed Resident #72 required total dependence by one person for eating. Observation on 4/1/19 at 2:16 PM on the 400 South Hall in room [ROOM NUMBER] revealed Resident #72's call light was activated at 2:16 PM and 2 staff, Licensed Practical Nurse (LPN) #3 and a Certified Nurse Aide (CNA) were on the hall. Continued observation revealed LPN #3 at the medication cart and the CNA using the Kiosk (computer on the wall). Continued observation revealed another CNA walked out of a resident room toward the two staff members, with the activated call light visible. One CNA stated .I already checked and changed 412B . Continued observation revealed a MDS Coordinator walked towards the staff talking and they all looked up and kept talking. Continued observation revealed Unit Manager #3 answered the call light at 2:32 PM. Interview with Unit Manger #3 on 4/1/19 at 2:36 PM on the 400 South Hall when asked what was expected from staff when call lights were activated stated, call lights were expected to be answered when activated. | 2020-09-01 |
| 70 | 70 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2019-04-03 | 761 | D | 0 | 1 | PJC211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, and interview, the facility failed to dispose of expired medications in 2 of 4 medication storage rooms and on 2 of 6 medication carts. The findings include: Facility policy review, Medication Administration General Guidelines, dated 9/18, revealed .Check expiration date on package/container. No expired medication will be administered to a resident .Drugs dispensed in the manufacturer's original container will be labeled with the manufacturer's expiration date .The beyond use dating, which only lists month/year, falls to the last day of that month . Observation of the 200 hall medication storage room on 4/1/19 at 1:00 PM with Licensed Practical Nurse (LPN) #7 revealed the following: 2 multiple dose bottles of Zinc Sulfate (a vitamin/mineral supplement) 220 milligrams (mg),100 count, expired 2/19 and unopened; a multiple dose bottle of [MEDICATION NAME] (a B vitamin supplement) 500mg,100 count, expired 2/19 and unopened; 2 multiple dose bottles of Centravites liquid (a vitamin supplement) 236 milliliters (ml) expired 2/19 and unopened; 3 mutiple dose bottles of [MEDICATION NAME] (a stimulant laxative) 5 mg,100 count, expired 3/19 and unopened; and 4 multiple dose bottles of Senna (a laxative) Syrup 237 ml expired 3/19 and unopened. Interview with LPN #7 on 4/1/19 at 1:16 PM in the 200 hall medication storage room confirmed .that medications should not be used if expired and should be discarded if they are . Observation of the Riberio unit medication storage room on 4/2/19 at 3:00 PM with LPN #8 revealed the following: a multiple dose bottle of Vitamin B1,100 count, expired 3/19 and unopened; 1 tube of [MEDICATION NAME] cream 1% unopened and expired 2/19; and 1 tube of [MEDICATION NAME] cream 1% unopened and expired 9/18. Interview with LPN #8 on 4/2/19 at 3:15 PM in the Riberio medication storage room confirmed .all medications should be used before their expiration date or discarded in the sharps … | 2020-09-01 |
| 71 | 71 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2019-04-03 | 812 | F | 0 | 1 | PJC211 | Based on facility policy review, observation, interview, and review of the Dish Machine Temp (Temperature) Audit, the facility dietary department failed to operate the dish machine according to the manufacturer's recommendation in 1 of 4 observations; and the facility failed to maintain 2 of 4 ice machines and 2 of 3 microwaves in a sanitary manner in 3 of 4 nourishment rooms. The findings include: Review of the facility policy, Dishmachine Procedure, revised on 1/17/19, revealed .Recording of Dishmachine Temperature .Record temperatures every shift on Dishmachine Temperature Log . Observation on 4/1/19 at 9:46 AM in the dietary department dishroom, with the Dietary Manager present, revealed the dishmachine was in operation. Further observation of the posted manufacturer's recommendation revealed the minimum wash temperature was 160 degrees Fahrenheit (F) and the minimum final rinse sanitizing temperature was 180 degrees F. Further observation revealed resident meal trays, plate covers, and plate bases were being processed through the dishmachine with the final sanitizing rinse temperatures of 171, 168, 166, and 160 degrees F. Further observation revealed the resident trays, plate covers and bases were stored after they were removed from the dishmachine. Interview with the Dietary Manager in the dietary department dishroom on 4/1/19 at 10:00 AM when asked who was responsible to take the dishmachine temperatures when it was in operation, the Dietary Manager revealed .I take the temperatures once a week and chart it . When asked who takes and records temperatures the other times, the Dietary Manager revealed the .only temperatures taken and recorded are the ones I get once a week . When asked when was the last time the temperatures were taken, the Dietary Manager revealed .I forgot to do it last week so it was the week before . Further interview revealed the Dietary Manager was not aware the temperatures were to be taken for every operation cycle, morning meal, mid-day meal, evening meal, and any other operation. R… | 2020-09-01 |
| 72 | 72 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2019-04-03 | 842 | D | 0 | 1 | PJC211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to maintain an accurate and complete record for 1 resident (#58) of 59 residents reviewed related to the Physician Orders and the Tennessee Physician Orders for Scope of Treatment (POST) form. The findings include: Medical record review revealed Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #58's Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 12 indicating the resident was moderately cognitively impaired. Medical record review of Resident #58's Physician Order Sheet dated [DATE] revealed .Full Code (meaning a person will allow all interventions needed to get their heart started) . Medical record review of Resident #58's POST form dated [DATE] revealed .Do Not Attempt Resuscitation (DNR/no CPR) (Cardiopulmonary Resuscitation) (allow natural death) . Interview with Unit Manager #1 on [DATE] at 4:20 PM in the Birmingham dining room confirmed Resident #58's POST form and physician orders did not match. Continued interview revealed .the POST form is the most up to date and should match the orders, it should have been caught before now . Interview with the Director of Nursing on [DATE] at 8:39 AM in the 2nd floor Unit Manager's office confirmed .the POST forms and physician orders for residents have to match . | 2020-09-01 |
| 73 | 73 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2019-04-03 | 921 | D | 0 | 1 | PJC211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to provide a sanitary environment for 1 resident (#152) of 33 residents reviewed receiving feeding per feeding pumps. The findings include: Medical record review revealed Resident #152 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Physician order [REDACTED].Promote (enteral formula) at 63ml/hr (milliliter per hour) for total of 1336 ml in 24 hours via PEG (percutaneous endoscopic gastrostomy)/pump . Observation on 4/1/19 at 10:43 AM, 2:30 PM and on 4/2/19 at 1:45 PM in Resident #152's room revealed the tube feeding pump, pole and floor with large amount of dried tan debris. Interview with Unit Manager #2 on 4/2/19 at 1:45 PM in Resident #152's room confirmed .that is obviously tube feeding on the pump, pole and floor . Interview with the Director of Nursing on 4/3/19 at 2:40 PM in her office confirmed tube feeding pumps and poles were to be clean. | 2020-09-01 |
| 74 | 74 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2017-06-13 | 176 | E | 0 | 1 | PJSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to determine if it was clinically appropriate for 3 of 3 (Resident #99,146 and 178) sampled residents reviewed were assessed to self-administer medications or had an order to self administer medications. The findings included: 1. The facility's Medication Administration General Guidelines policy documented, .Residents are allowed to self-administer medications when specifically authorized by the prescriber, the nursing care center's Interdisciplinary Team .and in accordance with procedures for self-administration of medications . The facility's Medication Administration Nebulizers documented, .remain with the resident for the treatment unless the resident has been assessed and authorized to self-administer . The facility's SELF-ADMINISTRATION BY RESIDENT policy documented, .Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe .The interdisciplinary team determines the resident's ability to self-administer medications by means of a skill assessment conducted as part of the care plan process . 2. Medical record review revealed Resident #99 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #99's room, on 6/13/17 at 9:45 AM, revealed LPN #7 dispensed [MEDICATION NAME] medication into a nebulizer cup. increased the oxygen level to administer the treatment, put the nebulizer mask on Resident #99, left the room and went to another hall. There was no assessment or physician order [REDACTED]. 3. Medical record review revealed Resident #146 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognit… | 2020-09-01 |
| 75 | 75 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2017-06-13 | 253 | E | 0 | 1 | PJSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview the facility failed to maintain the residents' rooms, bathrooms, furniture, and equipment in a safe and sanitary fashion for 2 of 4 (Ribeiro and 4th floor Birmingham) nursing units affecting rooms 102, 103, 104, 111, 115, 118, 119, 124 of Ribeiro unit and 402, 413, 415, 427, 429, and 430 rooms of the 4th floor Birmingham unit. The findings included: 1. The facility's Work Orders policy documented, .Maintenance work orders shall be completed in order to establish a priority of maintenance service .Procedure 1. In order to establish a priority of maintenance service, work orders must be filled out and forwarded to the maintenance director. 2. It shall be the responsibility of the department directors or any staff member identifying needed repairs to fill out and forward such work orders to the maintenance director. 3. A supply of work orders is maintained at each nurses' station 4. Work order requests should be placed in the appropriate file basket at the nurses' station. Work orders are picked up daily. Emergency requests will be given priority in making necessary repairs. The facility's Restroom Cleaning policy documented, .PURPOSE: To provide adequate guidelines for cleaning restrooms .The Environmental Services Department will clean restrooms on a daily basis, using the following procedures .X. Showers and Tubs: [NAME] Spray all surfaces with an approved germicidal detergent including walls, curtains, faucets, and shower head, Rinse completely. B. Use a brush to remove soap scrum, if necessary, and rinse . The facility's Daily Cleaning of Patient Room policy documented, .PURPOSE: To insure .proper Infection Control Policy and Procedures in the Environmental Services Department .All resident/patient rooms will be cleaned on a daily basis .Damp dust all horizontal surfaces including, but not limited to over-bed tables, beside tables, baseboard night-light, pictures on walls, top of headboard,… | 2020-09-01 |
| 76 | 76 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2017-06-13 | 279 | D | 0 | 1 | PJSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to revise the care plan for side rails and bed alarm for 3 of 23 (Resident #25, 54, and 62) residents reviewed of the 43 resident 's included in the Stage 2 review. The findings included: 1. Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed he had a severe cognitive deficit. Review of physician orders [REDACTED]. Review of the fall plan of care with an initiation date of 7/15/16 revealed the resident was identified as at risk for injury. The fall plan of care and the activities of daily living plan of care did not include the use of the side rails as ordered by the resident's physician. Observations in Resident #25's room on 6/11/17 at 2:48 PM, revealed Resident #25 lying in bed with bilateral full side rails in the raised position. Licensed Practical Nurse (LPN) #2 verified Resident #25 was only supposed to have the full side rail on the left side of the bed to assist with positioning and he was capable of sitting up on the side of the bed on his own. On 6/14/17 at 12:10 PM, LPN #1 verified the plan of care did not include the use of the side rail. 2. Medical record review revealed Resident #54 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #54's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #54 had severe cognitive deficits. The Fall Risk Evaluation dated 4/10/17 had a score of 12 indicating the resident was at risk for falls (a score of 10 or higher indicated the resident is at risk.) Review of the physician's orders [REDACTED].#54 had an order for [REDACTED].>The plan of care for falls dated 8/16/16 indicated that the resident was at risk for falls as determined by a score of 18 on the 7/19/16 fall risk screen. The goal was for the resident to not sustain a fall … | 2020-09-01 |
| 77 | 77 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2017-06-13 | 309 | D | 0 | 1 | PJSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure proper positioning for dining for 1 of 1 (Resident #44) sampled residents reviewed for positioning during dining. The findings included: Medical record review revealed Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12, indicating mild cognitive impairment, no behaviors, and required extensive to total staff assistance for activities of daily living. Observations in the Birmingham 4th floor dining room on 6/11/17 at 5:57 PM, and 6/13/17 at 12:51 PM, revealed Resident #44 was seated at the table for a meal in a low scoot chair. Resident #44's tray was on the table in front of him, and he had to reach up to the table due to poor positioning. Interview with Licensed Practical Nurse (LPN) #6 on 6/13/17 at 12:55 PM, in the 4th floor dining room, LPN #6 was asked whether it would be better for Resident #44 if he was positioned a bit higher during meals. LPN #6 stated, .it (the scoot chair) could be lifted up . LPN #6 was asked whether she thought it looked too high for the dining table. LPN #6 stated, I do . Interview with Occupational Therapist (OT) #1 on 6/13/17 at 1:05 PM, at the 4th floor nurses' station, OT #1 was asked whether the chair was too low for the table. OT #1 stated, Yes . | 2020-09-01 |
| 78 | 78 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2017-06-13 | 323 | E | 0 | 1 | PJSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure fall interventions were in place to prevent potential falls, to ensure the correct side rail type was in place for the resident and failed to assess residents for the use of the side rails for .and have the manufacturer's information for the side rails available prior to using the full side rails for 3 of 5 (Resident #25, 54, and 62) sampled residents of the 43 residents included in the Stage 2 review. The findings included: 1. Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of his annual Minimum Data Set (MDS) assessment dated [DATE] revealed he had a Brief Interview for Mental Status (BIMS) score of 99 indicating the resident was unable to complete the interview. The assessment was coded to indicate he had long and short-term memory problems, was inattentive and had an altered level of consciousness. According to the assessment he required extensive assistance with bed mobility, transfers, locomotion on the unit and was totally dependent on staff. Review of a BIMS assessment dated [DATE] revealed he had a BIMS score of 0 indicating he was severely cognitively impaired. Review of current physician orders revealed he had an order for [REDACTED]. The order had and an original order date of 11/27/15 and did not specify the type of side rail to be used. Review of the Evaluation for use of Side Rails dated 06/07/17 and signed by Licensed Practical Nurse (LPN) #2 was marked side rails not indicated at this time and the use of the side rail and risk of entrapment related to the use of the side rail was not assessed. Review of the resident's current fall plan of care with an initiation date of 7/15/16 revealed the resident was identified as at risk for injury due to having the [DIAGNOSES REDACTED].osteoporosis . The fall plan of care and the activities of daily living plan of care did not incl… | 2020-09-01 |
| 79 | 79 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2017-06-13 | 371 | F | 0 | 1 | PJSZ11 | Based on Hazard Analysis Critical Control Points (HACCP) Sanitation Manual Fifth Edition, observation and interview, the facility failed to ensure outdated and undated foods were stored in the nourishment refrigerators located on two of four (Birmingham 3rd and 4th floor ) nourishment rooms and failed to ensure the dishwasher rinse temperatures were maintained in accordance with manufacturer's specifications for 2 of 2 (6/13/17 and 6/14/17) days of observation. This had the potential to affect 171 of 187 residents in the facility. The findings included: 1. Review of the HACCP Sanitation Manual Fifth Edition page 63 revealed that .the final rinse temperature should be less than 194 degrees F (Fahrenheit). If the final (sanitizing cycle) rinse temperature is too high, the water is atomized and thus is inadequate for sanitizing . 2. Observation in the Birmingham 4th floor nourishment room on 6/11/17 at 12:20 PM, revealed there was no thermometer in the freezer, and the refrigerator in the nourishment room on the fourth floor contained one open pudding that did not have an opened date and a container of grape juice with a use by date of 6/10/17. Interview with the Licensed Practical Nurse (LPN) #2 on 6/11/17 at 12:24 PM in the Birmingham 4th floor nourishment room verified this observation. 3. Observation in the Birmingham 3rd floor nourishment room on 6/11/17 at 12:25 PM, revealed 2 containers of chocolate milk with a use by date of 5/29/17 and three containers of 2% milk with the use by dates of 6/10/17 in the refrigerator. Interview with LPN #3 on 6/11/17 at 12:30 PM in the Birmingham 3rd floor nourishment room verified the observation. 4. Review of the rinse temperature log for (MONTH) (YEAR) documented temperatures of 200 degrees F was recorded three times a day on all 13 days in (MONTH) (YEAR). Review of the dishwashers specifications revealed the dishwasher was not to exceed 194 degrees F. at the manifold. Observations in the kitchen on 6/13/17 at 2:18 PM, revealed the final rinse temperature of the high tempe… | 2020-09-01 |
| 80 | 80 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2017-06-13 | 441 | E | 0 | 1 | PJSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation and interview, the facility failed to ensure practices were followed to prevent the potential spread of infection when 1 of 1 (Licensed Practical Nurse #7) nurses observed during medication administration failed to clean nebulizer equipment after use and to clean the stethoscope between residents, and when laundry staff failed to ensure the hand-washing sink and the floors were clean in 1 of 1 laundry areas. The findings included: 1. The facility's Medication Administration Nebulizer (Updraft) policy documented, .Rinse and disinfect the nebulizer equipment . 2. Observations in Resident #99's room on 6/13/14 at 9:45 AM, revealed LPN #7 entered the room, auscultated Resident # 99's chest with a stethoscope, placed the stethoscope around her neck, and exited the room. LPN #7 went into another resident's room (Resident #160) to administer medications via a percutaneous endoscopic gastrostomy (PEG) tube, removed the stethoscope from around her neck and checked placement of the PEG tube by putting the stethoscope to the resident's abdomen, then placed stethoscope back around her neck. LPN #7 returned to Resident #99's room, turned the breathing treatment of [REDACTED]. LPN #7 then placed the stethoscope around her neck. LPN #7 did not clean the stethoscope between residents, and did not clean the nebulizer equipment after use. Interview with the Director of Nursing (DON) on 06/14/17 at 1:04 PM, in the nurse's conference room, the DON confirmed that nebulizer equipment and stethoscopes should be cleaned after each use. The facility's Care of Equipment/Laundry Department documented, .All equipment used by the Laundry Department must be maintained in a daily/regular basis . 3. The facility's Cleaning/Laundry Department policy documented, .In order to maintain the cleanliness of the laundry room, provide a clean, fresh environment for the residents, visitors and staff and to reduce the potential for infection, the fo… | 2020-09-01 |
| 81 | 81 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2017-06-13 | 520 | E | 0 | 1 | PJSZ11 | Based on medical record review, observation, and interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to have an effective ongoing quality program that identified, developed, implemented, and monitored appropriate plans of action to correct issues. The findings included: 1. The QAA Committee failed to ensure that each resident received an accurate assessment to reflect the resident's current status. The deficient practice of F 278 is a repeat deficient practice for failure to accurately assess residents. The facility was cited F 278 on the recertification survey on 8/2012, 3/2015, and 4/7/16. 2. The QAA Committee failed to ensure a comprehensive care plan was developed for a resident that reflected the resident's current status. The facility was cited F 279 on the recertification survey for failure to develop care plans that reflected the resident's current status on 8/2012, and 4/7/16. 3. The QAA Committee failed to ensure resident's environment remained as free from accident hazards as possible and is a repeat deficient practice for this,. The facility was cited F 323 on the recertification survey on 8/2012, and 3/2015. 4. The QAA Committee failed to ensure proper sanitation and food handling practices in the kitchen and is a repeat deficient practice for failure to ensure proper sanitation and food handling practices in the kitchen. The facility was cited F 371 on the recertification surveys 8/2012, 12/2013, and 4/7/16. 5. The QAA Committee failed to develop an effective Infection Control Program that provided safe and sanitary environment, and prevent the potential development and transmission of disease and infection. The facility was cited F 441 on the recertification survey on 12/2013, 3/2015, and 5/6/16. Interview with the Administrator on 6/14/17 in the Administrator's office, the Administrator was asked if the QAA Committee had identified care plans as a quality concern. The Administrator stated, .I don't know that there has been anything that we have recently had to place a… | 2020-09-01 |
| 82 | 82 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2018-07-05 | 580 | D | 1 | 0 | FKIB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to notify the Physician of a change in condition for 1 of 5 residents (Resident #1) reviewed. Findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician ordered ventilator settings for Resident #1 revealed: Mode- SIMV (synchronized intermittent mechanical vent), and Rate- 12 (minimum number of respirations per minute). Continued medical record review of a Respiratory care flow sheet revealed on 6/6/18 at 3:35 AM, 7:34 AM, 10:53 AM, 3:13 PM, and 7:00 PM the ventilator mode for Resident #1 was documented as being SIMV and the Set rate was 12. Continued review revealed at 3:13 PM the total respiratory rate had elevated to 21, and then to 28 at 7:00 PM which indicated Resident #1 was tachypnic (increased respirations). Continued review revealed at 11:05 PM on 6/6/18 Registered Respiratory Therapist (RRT) #1 changed Resident #1's ventilator mode to Assist Control which was an increase in ventilator support and also changed the respiratory set rate to 18. Continued review of the medical record revealed no documented notification to the Physician of Resident #1's change in condition. Interview with Director of Respiratory Services on 7/3/18 at 9:10 AM in the conference room confirmed Resident #1 had a change in condition on 6/6/18 which required an increase in ventilator support and RRT #1 failed to notify the Physician of the change in the resident's condition. Telephone interview with RRT #1 on 7/3/18 at 1:50 PM revealed on 6/6/18 Resident #1 trended tachypnic and he followed the respiratory algorithm to adjust the ventilator settings without first notifying the Physician of the change in the resident's condition. | 2020-09-01 |
| 83 | 83 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2018-07-05 | 684 | D | 1 | 0 | FKIB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the facility policy, medical record review, and interview, the facility failed to administer antibiotic medication per physician order and per facility policy for 1 of 3 residents (Resident #3) reviewed receiving antibiotic medication. Findings include: Review of the facility policy, Medication Administration, dated 5/16, revealed .Procedures .Medication Administrations .Medications are administered with written orders of the prescriber . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician orders for antibiotic medication revealed the following: 1. On 6/6/18 [MEDICATION NAME] 500 milligrams (mg) every 12 hours for 7 days for [DIAGNOSES REDACTED]. 2. On 6/12/18 [MEDICATION NAME] ([MEDICATION NAME]/Clavulanic Acid) 875 mg by mouth three times daily for 7 days for [DIAGNOSES REDACTED]. 3. On 6/19/18 [MEDICATION NAME] 3.375 gram infuse intravenously every 6 hours for 10 days for [DIAGNOSES REDACTED]. Medical record review of the 6/2018 Medication Administration Record [REDACTED] 1. [MEDICATION NAME] was administered for 12 of 14 doses ordered from 6/7/18 at 12:01 AM through 6/12/18 at Noon. The facility failed to administer 2 of the 14 ordered doses. 2. [MEDICATION NAME] was administered for 19 of the 21 doses ordered from 6/12/18 at 8:00 PM through 6/18/18 at 8:00 PM. The facility failed to administer 2 of the 21 ordered doses. 3. [MEDICATION NAME] was administered for 36 of 40 doses ordered from 6/20/18 at 12:01 AM through 6/28/18 at 6:00 PM. The facility failed to administer 4 of the 40 ordered doses. Interview with the Unit B2 Manager on 7/3/18 at 10:50 AM in his office, after reviewing the 6/2018 antibiotic orders and the MAR for Resident #3, confirmed the facility failed to administer the antibiotics as ordered for [MEDICATION NAME], and [MEDICATION NAME]. Interview with the Director of Nursing on 7/3/18 at 11:18 AM in her of… | 2020-09-01 |
| 84 | 84 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2018-07-25 | 550 | D | 0 | 1 | 565T11 | Based on observation and interview, the facility failed to serve meals to residents seated at the same table during 3 separate observations of the mid day meal. Findings include: Observation of the mid day meal on 7/23/18 from 11:40 AM-12:42 PM in the B3 dining room revealed 3 residents were seated at a table. 1 resident had a meal tray and the other 2 residents were not served a meal tray until 21 minutes later. Continued observation revealed 4 other residents were seated at a table and a Certified Nurse Assistant (CNA) #3 was assisting 1 resident while the other residents sat at the table. Continued observation revealed the last resident seated at the table was served his meal tray 1 hour after the 1st resident seated at the table was served. Interview with CNA #3 on 7/23/18 at 12:43 PM in the B3 dining room stated there were 3 carts delivered to the unit and not all of the trays came to the dining room residents at the same time. Further interview confirmed the last residents meal tray was on the 3rd cart and the resident had to wait to be served his meal until after the other 3 residents had received their meal. Observation of the mid day meal on 7/24/18 from 11:40 AM-12:20 PM in the B3 dining room revealed the 1st meal cart was delivered at 11:43 AM. 4 residents were seated at a table and 1 resident was served her meal tray while the other 3 residents were not served. Continued observation revealed the 2nd meal cart was delivered at 12:08 PM and the 2nd resident at the table was served his tray while the other 2 residents were dozing in their wheelchairs. Further observation revealed the 3rd meal cart was delivered at 12:22 PM and the other 2 residents received their trays. Interview with the Director of Nursing (DON) on 7/24/18 at 4:17 PM in the hall by the conference room was notified of the mid day meal dining observations on 7/23/18 and 7/24/18, and the concerns with all diners seated at a table together and not served their meal trays at the same time. The DON was asked if she was aware of the concern a… | 2020-09-01 |
| 85 | 85 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2018-07-25 | 558 | D | 0 | 1 | 565T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to keep a bathroom call light in reach for 1 of 18 bathrooms ( room [ROOM NUMBER]) observed on the R1 unit. Findings include: Observation on 7/23/18 at 3:47 PM in the bathroom in room [ROOM NUMBER] revealed the call light on the right side wall was tied to the bar of the metal shelf connected to the wall. Observation and interview with Licensed Practical Nurse (LPN) #3 also known as the Unit Manager on 7/23/18 at 3:50 PM in the bathroom in room [ROOM NUMBER] confirmed the facility failed to have a call light in reach. Further interview revealed I don't know why it is like that. Interview with the Director of Nursing on 7/25/18 at 4:55 PM in conference room revealed she expected the bathroom call light to be accessible to all residents. | 2020-09-01 |
| 86 | 86 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2018-07-25 | 584 | D | 0 | 1 | 565T11 | Based on observation and interview the facility failed to maintain clean and sanitary resident equipment for 1 of 24 sampled residents (Resident #117) reviewed. Findings include: Observation of Resident #117 on 7/23/18 at 10:48 AM in the B3 day room revealed he was seated in a wheelchair. Continued observation revealed the left side of the wheelchair had rusted areas on the lower metal bar. Continued observation revealed the wheelchair frame was dusty, dirty, and had white spotted debris over the metal frame, foot rest and handles. Observation on 7/23/18 at 11:47 AM in Resident #117's room revealed the resident had dried debris and dirt on the upper side rails. Continued observation revealed there were light blue pads attached to the side rails by Velcro tabs and had black marks and spotted brown and yellow debris on them. Observation on 7/24/18 at 9:10 AM in Resident #117's room revealed the side rails and light blue pads remained unchanged from the observation the day before. Continued observation revealed the resident's wheelchair was stored in the bathroom and the rust, dirt, and white spotted debris was still present. Observation and interview of Resident #117's bed and wheelchair on 7/24/18 at 11:30 AM with Housekeeper #3 in the resident's room revealed dried debris on the side rails, dirty blue padding to the upper side rails and the wheelchair in the bathroom with rusted areas, and it was dirty with debris and white spots on the metal frame, foot rest and handles. Interview with Housekeeper #3 when asked when resident wheelchairs were cleaned stated, I'm not sure. The Housekeeper was asked when resident beds were cleaned and stated, Everyday. Continued interview with the Housekeeper when asked when resident padding was cleaned stated, They should be wiped down every day but if the resident is in the bed, it's kind of hard. The Housekeeper was shown Resident #117's wheelchair in the bathroom and stated, It don't look too good. It could use a rag or two. It needs to be wiped down. The Housekeeper was asked … | 2020-09-01 |
| 87 | 87 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2018-07-25 | 604 | D | 0 | 1 | 565T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation and interview, the facility failed failed to obtain a physician's order, failed to assess, failed to obtain a consent, failed to monitor and failed to re-evaluate the need for restraints for 1 of 23 (Resident #117) residents reviewed; failed to obtain a medical diagnosis, failed to monitor, and failed to re-evaluate the need for a restraint for 1 of 23 (Resident #111) residents reviewed. Findings include: Review of facility policy Use of Restraints undated, revealed, .Restraints only may be used .after consideration, evaluation, and the use of all other viable alternatives. All residents have the right to be free from restraint .PHYSICAL RESTRAINTS: are defined as any manual method, or physical .device, .or equipment attached or adjacent to the resident's body that an individual cannot remove easily and which restricts the resident's freedom of movement or normal access to his/her body . Medical record review revealed Resident #117 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #117 had a Brief Interview for Mental Status (BIMS) of 3 indicating severe cognitive impairment. He was totally dependent for bed mobility and transfers with assistance of 2 or more people required. He was totally dependent for dressing, eating, toileting, personal hygiene and bathing with assistance of 1 person. The resident did not stand or ambulate and was unsteady with surface to surface transfers. He had bilateral impairments to upper and lower extremities. He used a wheelchair for mobility with assistance from 1 person. The resident did not use any physical restraints. Observation of Resident #117 on 7/23/18 10:48 AM in the B3 day room revealed he was seated in a wheelchair tilted back 30 degrees with his feet unable to reach the floor. There was a Velcro release… | 2020-09-01 |
| 88 | 88 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2018-07-25 | 609 | D | 0 | 1 | 565T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility investigation and interview the facility failed to report an allegation of abuse to the state agency within the required 2-hour time frame for 3 of 6 sampled residents in 1 of 3 allegations of abuse (Resident #118, Resident #71, and Resident #151) reviewed. Findings include: Review of facility policy Abuse, Neglect & Misappropriation or Property reviewed 11/6/17 revealed, .The Facility Administration is the Facility's designated Abuse Coordinator and any questions regarding the interpretation or implementation of the policy should be referred back to him or her .an alleged violation involving abuse .are reported immediately, but no later than 2 hours after the allegation is made . Medical record review revealed Resident #118 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9 for Resident #118 indicating moderate cognitive impairment. Continued review revealed behaviors exhibited of verbal symptoms toward others. Medical record review revealed Resident #71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a quarterly MDS dated [DATE] revealed a BIMS score of 99 for Resident #71 indicating severe cognitive impairment. Continued review revealed no moods or behaviors were exhibited. Medical record review revealed Resident #151 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed a 5-day admission MDS dated [DATE] revealed a BIMS score of 15 for Resident #151 indicating no cognitive impairment. Continued review revealed no moods or behaviors were exhibited. Review of a facility investigation involving Resident #118, Resident #71 and Resident #151 on 7/15/18 at 5:30 PM revealed an allegation of resident to resident a… | 2020-09-01 |
| 89 | 89 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2018-07-25 | 641 | D | 0 | 1 | 565T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to accurately assess the use of restraints for 1 of 2 sampled residents (Resident #117) reviewed. Findings include: Medical record review revealed resident #117 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #117 had a Brief Interview for Mental Status (BIMS) of 3 indicating severe cognitive impairment. He was totally dependent for bed mobility and transfers with assistance of 2 or more people required. He was totally dependent for dressing, eating, toileting, personal hygiene and bathing with assistance of 1 person. The resident did not stand or ambulate and was unsteady with surface to surface transfers. He had bilateral impairments to upper and lower extremities. He used a wheelchair for mobility with assistance from 1 person. The resident did not use any physical restraints. Observation of Resident #117 on 7/23/18 10:48 AM in the B3 day room revealed he was seated in a wheelchair tilted back 30 degrees with his feet unable to reach the floor. There was a Velcro release belt to his upper chest and a regular seat belt latched across his lap. Both belts were secured by a metal clasp attached to the wheelchair. Resident #117 was asked if he could release the chest belt and stated, No ma'am. Observation of Resident #117 on 7/23/18 at 12:20 PM in the B3 day room revealed he was seated in a wheelchair tilted back 30 degrees with his feet unable to reach the floor. The Velcro release belt was intact to his upper chest and the seatbelt was latched across his lap. Continued observation revealed the resident was moving his right arm up from his lap above his head and was moving his head forward and backward repeatedly causing the wheelchair to bounce slightly. Interview with the MDS Coordinator on 7/25/18 at 11:58 AM in the Unit Manager's… | 2020-09-01 |
| 90 | 90 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2018-07-25 | 656 | D | 0 | 1 | 565T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to develop a comprehensive care plan for positioning and restraints for 1 of 23 sampled residents (Resident #117) reviewed. Findings include: Medical record review revealed Resident #117 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #117 had a Brief Interview for Mental Status (BIMS) of 3 indicating severe cognitive impairment. Continued review revealed the resident did not use any physical restraints. Observation of Resident #117 on 7/23/18 10:48 AM in the B3 day room revealed he was seated in a wheelchair tilted back 30 degrees with his feet unable to reach the floor. There was a Velcro release belt to his upper chest and a regular seat belt latched across his lap. Both belts were secured by a metal clasp attached to the wheelchair. Resident #117 was asked if he could release the chest belt and stated, No ma'am. Observation of Resident #117 on 7/23/18 at 12:20 PM in the B3 day room revealed he was seated in a wheelchair tilted back 30 degrees with his feet unable to reach the floor. The Velcro release belt was intact to his upper chest and the seatbelt was latched across his lap. Continued observation revealed the resident was moving his right arm up from his lap above his head and was moving his head forward and backward repeatedly causing the wheelchair to bounce slightly. Medical record review of the comprehensive care plan for Resident #117 revised 5/26/18 revealed no identified concern related to restraints or positioning, and no related interventions. Interview with Licensed Practical Nurse (LPN) #2, Unit Manager, on 7/25/18 at 10:45 AM in his office was provided Resident #117's chart and asked where the documentation was regarding the resident's restraints and stated, They're not restraints, they use them for positioning.… | 2020-09-01 |
| 91 | 91 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2018-07-25 | 677 | E | 0 | 1 | 565T11 | Based on observation and interview, the facility failed to timely assist 5 of 7 dependent diners in the B3 dining room during 2 observations of the mid-day meal. Findings include: Observation of the mid-day meal in the B3 dining room on 7/23/18 from 11:40 AM-12:42 PM revealed 4 dependent diners were seated at the same table. 1 resident at the table was served a tray at 11:42 AM and was assisted by a Certified Nurse Aide (CNA). The other 3 dependent diners at the table did not receive a meal tray. Continued observation revealed 2 dependent diners at the table were served a meal tray at 12:01 PM and assisted by 2 CNAs. Further observation revealed the 4th dependent diner was served his meal tray at 12:40 PM and assisted by a CN[NAME] Interview with CNA #3 on 7/23/18 at 12:43 PM in the B3 dining room confirmed there were 3 residents the dining room that required cueing and 6 residents were dependent diners and required total assistance with eating. Continued interview confirmed there were 2 CNAs in the dining room available to assist the residents and 3 CNAs were passing trays on the halls at that time. CNA #3 confirmed 1 dependent diner waited 1 hour before she could assist him with his meal. Observation of the mid-day meal in the B3 dining on 7/24/18 from 11:40 AM-12:20 PM revealed 3 dependent diners and 1 resident requiring cueing were seated at a table. Another dependent diner was seated in a Geri Chair by the table. Continued observation revealed the resident in the Geri Chair and 1 resident seated at the table were served their meal at 11:43 AM and assisted by CNA #4 and CNA #5. Continued observation revealed CNA #3 served the resident that required cueing his meal at 12:08 PM and assisted with set up and cutting his food. CNA #4 sat next to him and cued him while the other 2 dependent diners dozed in their wheelchairs. Continued observation revealed the remaining 2 dependent diners were served their meals at 12:22 PM and assisted by CNA #4 and CNA #5. Interview with the Director of Nursing (DON) on 7/24/18 at… | 2020-09-01 |
| 92 | 92 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2018-07-25 | 800 | F | 0 | 1 | 565T11 | Based on observation and interview, the facility failed to serve pureed food at the appropriate consistency to 22 of 22 residents receiving pureed textured food. Findings include: Observation on 7/23/18 at 11:40 AM in the dietary department, with the Dietary Manager present, revealed the resident mid-day meal tray service was in progress. Further observation revealed the pureed textured beef, potatoes, and cauliflower all pooled together in the plate. Interview with the Dietary Manager on 7/23/18 at 11:40 AM in the dietary department confirmed the facility failed to serve pureed textured food at an appropriate consistency and appetizing manner. | 2020-09-01 |
| 93 | 93 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2018-07-25 | 812 | F | 0 | 1 | 565T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility dietary department failed to maintain refrigeration temperature at or less than 41 degrees Fahrenheit (F); failed to maintain dietary equipment in a sanitary manner; failed to thaw meat appropriately; failed to have facial hair covered during food preparation; and failed to remove expired or outdated food in 3 of 6 observations in the dietary department. Findings include: Observation on [DATE] at 8:20 AM, with the Dietary Manager present, revealed the walk-in refrigerator for produce internal temperature was 50 degrees F and a 4 inch pan of slaw was in storage on the shelf. Further observation on [DATE] at 10:20 AM revealed the walk-in refrigerator for produce was 50 degrees F and a 4 inch pan of slaw was stored on the shelf. Observation of the Dietary Manager obtaining the slaw temperature revealed 47.5 degrees F. Further observation on [DATE] at 3:50 PM revealed the walk-in refrigerator for produce was 50 degrees F and no slaw was stored in the refrigerator. Interview with the Dietary Manager on [DATE] at 8:20 AM, 10:20 AM and 3:50 PM in the walk-in refrigerator for produce in the dietary department confirmed the internal temperature was 50 degrees F and the slaw was 47.5 degrees F. Further interview confirmed the facility failed to maintain the refrigeration unit and the food in the unit at or less than 41 degrees F. Observation on [DATE] at 8:20 AM and at 3:50 PM, with the Dietary Manager present, revealed the walk-in refrigerator for dairy and the walk-in refrigerator for produce compressor unit grates, blades and ceiling area had hanging black accumulation of debris present, therefore could contaminate any exposed foods. Interview with the Dietary Manager at 8:20 AM and at 3:50 PM confirmed the compressor grates, blades and ceiling area had debris present in the walk-in refrigerators for dairy and produce. Observation on [DATE] at 10:20 AM, with the Dietary Manager present, revealed 4 sea… | 2020-09-01 |
| 94 | 94 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2018-07-25 | 880 | D | 0 | 1 | 565T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 23 residents (Resident #87 and Resident #1) reviewed related to dating of oxygen tubing for Resident #87 and Resident #1, and dating of humidified water canister for Resident #1, and storage and dating of a [MEDICATION NAME] (suctioning instrument) for Resident #1. Findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 3 indicating severe cognitive impairment. Medical record review of the physician's orders [REDACTED].oxygen at 5 liter / per minute via mask. As needed. Dx (diagnosis) lethargic, low blood pressure .3/16/18 Treatment/Procedure suction with [MEDICATION NAME] PRN (as needed) for increased secretions . Observation on 7/23/18 at 10:27 AM in Resident #1's room revealed the [MEDICATION NAME] connected to tubing hanging on the wall uncovered and undated. Further observation revealed nasal cannula uncovered and undated. Further observation revealed humdified water canister connected to oxygen port on wall dated 5/16/18. Interview and observation with Licensed Practical Nurse (LPN) #3 also known as the Unit Manager on 7/23/18 at 3:39 PM in Resident #1's room confirmed the the [MEDICATION NAME] with tubing and nasal cannula was uncovered and undated. Further observation and interview revealed the date on the humidified water canister was 5/16/18. Interview with LPN #3 on 7/25/18 at 1:23 PM at the nurse station confirmed the tubing was suppose to be dated and changed weekly by the nurses. Further interview confirmed the faci… | 2020-09-01 |
| 95 | 95 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2018-07-25 | 908 | E | 0 | 1 | 565T11 | Based on observation and interview, the facility failed to maintain equipment in the dietary department in a safe operating condition. Findings include: Observation on 7/23/18 at 10:20 AM, with the Dietary Manager (DM) present, in the dietary department revealed 17 of 17 tray delivery carts had a build-up of calcium on the interior and the tray rungs. Further observation revealed 16 of the 17 tray delivery cart interiors had rust present. Further observation revealed the interior of the dish machine had a heavy accumulation of calcium. Further observation of all the insulated plate dome lids and insulated heated plate bases interior and exterior had heavy accumulation of calcium. The calcium deposits on the insulated heated base could interfere with the base heating process and therefore could fail to maintain the food temperatures. The calcium deposits on the insulated dome lid and base could prevent a good seal to maintain the food temperature. Interview with the Dietary Manager on 7/23/18 at 10:20 AM in the dietary department confirmed the facility failed to maintain the tray delivery carts to prevent calcium build-up and to prevent rusting. Further interview confirmed the facility failed to maintain the interior of the dish machine from building up calcium. Further interview confirmed the insulated dome lids and bases had an accumulation of calcium present. Interview with the Maintenance Director on 7/23/18 at 10:50 AM in the dietary department confirmed the dietary department water left calcium deposits inside the dish machine. Further interview revealed the dish machine .is old and breaks down frequently .and needs the conveyor belt replaced . Further interview confirmed calcium deposits were present on the resident insulated plate dome lid and base making them .look unattractive . | 2020-09-01 |
| 96 | 96 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2017-09-28 | 224 | J | 1 | 0 | ONHF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of the facility investigation, and interview, the facility failed 2 of 8 residents reviewed for neglect (#1, #2). The facility staff failed to provide services in a manner to prevent neglect resulting in physical harm to two residents who were aggressive and resistive during care being provided. The facility's failure resulted in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment, or death) for Resident #1 and #2. F-224 is Substandard Quality of Care. The findings included: Review of facility policy, Abuse, Neglect, Exploitation and Misappropriation of Property, dated 5/22/17 revealed .failure to provide goods and services necessary to avoid physical harm, mental anguish or emotional distress .6. In cases of alleged resident abuse, the Director of Nursing or his/her designee will conduct interviews of interviewable residents on the resident's unit, or the entire Facility, as appropriate; and shall conduct an appropriate physical assessment of residents who are incapable of being interviewed .10. The Facility Administrator will make reasonable efforts to determine the root cause of the alleged violation, and will implement corrective action consistent with the investigation findings, and take steps to eliminate any ongoing danger to the resident or residents . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #1 required extensive assistance of 1 staff for hygiene, and Activities of Daily Living (ADL). Continued review of the MDS revealed Resident #1 scored a 3 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was severely cognitively impaired. Further review of the MDS revealed Resident #1 had not exhibited any… | 2020-09-01 |
| 97 | 97 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2017-09-28 | 225 | J | 1 | 0 | ONHF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of a facility investigation, and interview, the facility failed to conduct a thorough investigation for 1 of 4 residents reviewed for abuse. After receiving an allegation of abuse from Resident #2 the facility failed to suspend the accused employee who then worked with the resident on the same night. The facility's failure resulted in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment, or death) for Resident #2. F-225 is Substandard Quality of Care The findings included: Review of facility policy, Abuse, Neglect, Exploitation and Misappropriation of Property, dated 5/22/17 revealed .allegation of abuse as a report, complaint, grievance, statement, incident, or other facts that a reasonable person would understand to mean that abuse, as defined in this policy, is occurring, has occurred or plausibly might have occurred .neglect as failure to provide goods and services necessary to avoid physical harm, mental anguish, or emotional distress .if the suspected perpetrator is a Stakeholder, the charge nurse immediately will remove that Stakeholder from resident care areas and suspend him/her while the matter is investigated Investigation Guidelines .The Facility Administrator will investigate all allegations, reports, grievances, and incidents that potentially could constitute allegations of abuse .injuries of unknown origin source .exploitation .or suspicious crime .6. In cases of alleged resident abuse, the Director of Nursing (DON) or his/her designee will conduct interviews of interviewable residents on the resident's unit, or the entire Facility, as appropriate; and shall conduct an appropriate physical assessment of residents who are incapable of being interviewed .10. The Facility Administrator will make reasonable efforts to determine the root cause of the alleged violation, and will imple… | 2020-09-01 |
| 98 | 98 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2017-09-28 | 226 | J | 1 | 0 | ONHF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility investigation and interview, the facility failed to implement their abuse policy related to the proper identification, training and investigation of abuse/neglect. The facility failed to operationalize its abuse policy after an allegation of abuse against a resident (#2) by a Licensed Practical Nurse (LPN) #4 was reported. This failure resulted in the potential for continued abuse against residents with whom LPN #4 continued caring for as part of her work assignment. This failure resulted in an Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment, or death) for Resident #1 and #2. The facility further failed to properly identify neglect regarding Resident #1 as related to not substantiating abuse after Nurse Aide #2 (NA) intervened during resistive care of a resident by using physical force. The facility failed to ensure residents were free from abuse/neglect as per their abuse policy for 2 of 8 residents reviewed (#1, #2). F-226 is Substandard Quality of Care. The findings included: Review of facility policy, Abuse, Neglect, Exploitation and Misappropriation of Property, dated 5/22/17 revealed .willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .non-accidental or not reasonably related to the appropriate provision of ordered care and services .allegation of abuse as a report, complaint, grievance, statement, incident, or other facts that a reasonable person would understand to mean that abuse, as defined in this policy, is occurring, has occurred or plausibly might have occurred .neglect as failure to provide goods and services necessary to avoid physical harm, mental anguish, or emotional distress .if the suspected perpetrator is a Stakeholder, the charge nurse immediately will remove that Stake… | 2020-09-01 |
| 99 | 99 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2017-09-28 | 279 | J | 1 | 0 | ONHF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility investigation, and interview, the facility failed to develop a comprehensive care plan for 2 residents (#1, #8) of 8 residents reviewed. The facility's failure resulted in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment, or death) for Resident #1. The findings included: Review of facility policy, Care Plans-Comprehensive, dated 9/21/16 revealed .The nurse/Interdisciplinary Team develops and maintains a comprehensive Care Plan for each resident that identifies the highest level of functioning the resident may be expected to attain .Each resident's comprehensive Care Plan is designed to .Incorporate identified problem areas .Incorporate risk factors associated with identified problems .Aid in preventing or reducing declines in the resident's functional status and/or functional levels .Care Plan interventions are implemented after consideration of the resident's problem areas and their causes. Interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers .Care Plans are revised as information about the resident and the resident's condition change .The nurse/Interdisciplinary Team is responsible for the review and updating of Care Plans. The Care Plan should reflect the current status of the resident and be updated with changes in the residents status .When the resident has been readmitted to the facility from a hospital stay . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 required extensive assistance of 1 staff for hygiene, and scored a 3 of 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was severely cognitively impaired. Further review of … | 2020-09-01 |
| 100 | 100 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2017-09-28 | 490 | J | 1 | 0 | ONHF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy and procedure, medical record review, observation, and interview, the Administrator failed to administer the facility in an effective manner, utilizing all its resources including the proper investigation process per the abuse/neglect policy and procedure and training and education on how to handle aggressive resident interactions during care provided, resulting in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment, or death) for resident (#1, #2) of 8 residents reviewed. The findings of the abbreviated and partial extended survey found Immediate Jeopardy with Substandard Quality of Care at 483.13 (Resident Behaviors and Facility Practice). Resident #1 and Resident #2 were free from neglect. A Nurse Aide #2 (NA) and Licensed Practical Nurse #4 (LPN) physically intervened when the residents resisted care and had aggressive behaviors resulting in bodily injury and psychological trauma to the residents. Components of the facility's abuse/neglect prevention programs were not immediately implemented, including identification of the neglect, thorough investigation as well as prevention of further potential neglect by LPN #4 (Refer to F224, F225, and F226). The Administrator's failure to protect Resident #1 and Resident #2 from abuse/neglect, as well as ensure the staff were competent and trained in working with residents with combative behaviors has caused or is likely to cause acute injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 9/27/17, and determined to exist on 6/24/17. The facility's Administrator was informed of the Immediate Jeopardy on 9/27/17 at 2:30 PM in the Administrator's office. The findings included: 1. F224 - The Administrator failed to provide services necessary to avoid physical harm or mental anguish for Resident #1 and Resident #2. Resident #1 suffered a fractured arm a… | 2020-09-01 |
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CREATE TABLE [cms_TN] ( [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 );