rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
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 .an aide .she just was rough . Resident #53 confirmed she reported the incident. Resident #53 stated she reported, That I thought she was physically and verbally abusing me. Resident #53 was asked if she was satisfied with the way the investigation was handled by the facility. Resident #53 stated, Yeah, I didn't want to make a big deal about it . Resident #53 confirmed that she felt safe in the facility.",2020-09-01
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 for antianxiety, antidepressant, anticoagulant and diuretic medications. The MDS Coordinator stated, No. 4. Medical record review revealed Resident #30 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 antidepressant and anticoagulant medications 7 days, antibiotics 2 days, diuretics and opioids 6 days of the 7-day look-back period. Review of the (MONTH) 2019 MAR indicated [REDACTED]. The quarterly MDS dated [DATE] documented a BIMS of 12, which indicated moderate cognitive impairment, and received antidepressant, hypnotic, anticoagulant, and diuretic medications 5 days of the 7-day look-back period. Review of the (MONTH) 2019 MAR indicated [REDACTED]. Interview with the MDS Coordinator on 5/30/19 at 9:18 AM in the Conference Room, the MDS Coordinator was asked if the admission MDS dated [DATE] was coded correctly for anticoagulants, antibiotics, diuretics and opioids. The MDS Coordinator stated, No. The MDS Coordinator was asked if the quarterly MDS dated [DATE] was coded correctly for antidepressants, hypnotics, anticoagulants and diuretics. The MDS Coordinator stated, No. 5. Medical record review revealed Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed a BIMS of 10, which indicated moderate cognitive impairment, and received anticoagulant medications daily during the 7-day look-back period. Review of the (MONTH) 2019 and (MONTH) 2019 MARs revealed no anticoagulant medication was administered. Interview with the MDS Coordinator on 5/30/19 at 12:51 PM in the Conference Room, the MDS Coordinator confirmed the MDS was inaccurate related to anticoagulant use. 6. Medical record review revealed Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed a BIMS of 13, which indicted no cognitive impairment, and was coded for anticoagulant administration daily during the 7-day look-back period. Review of the annual MDS dated [DATE] revealed a BIMS of 14, which indicated no cognitive impairment, and was coded for anticoagulant administration daily during the 7-day look-back period. Review of the (MONTH) 2019 and (MONTH) 2019 MARs revealed anticoagulant medications were not administered. Interview with the MDS Coordinator on 5/30/19 at 10:45 AM in the Conference Room, the MDS Coordinator confirmed the MDS was coded incorrectly for anticoagulant administration. 7. Medical record review revealed Resident #254 was admitted to facility on 5/14/19 with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] documented a BIMS score of 6, which indicated severe cognitive impairment, and was not coded for Unhealed Pressure Ulcers, Other Ulcers, Wounds and Skin Problems. Review of the physician's orders [REDACTED]. Review of the Weekly Wound Assessment Record dated 5/15/19 revealed an Unstageable Pressure Ulcer to the back of the right calf. Review of the Care Plan dated 5/21/19 revealed an Unstageable Pressure Wound to the back of the right calf. Interview with the MDS Coordinator on 5/30/19 at 10:10 AM in the Conference Room, the MDS Coordinator confirmed the MDS was inaccurate related to Unstageable Pressure Ulcers and Skin Problems.",2020-09-01
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 first made aware of the problem. The Director of Maintenance stated, It's sporadic. Two or 3 months ago, we swapped the batteries. Interview with the Director of Maintenance on 5/30/19 at 1:17 PM in the Conference Room, the Director of Maintenance stated, .A service call was put in last Thursday, and then (Central Supply CNA) made a follow-up call yesterday because he hadn't come out yet. Interview with CNA #6 on 5/30/19 at 2:31 PM in the Conference Room, CNA #6 was asked if she ever had problems using the sling lift. CNA #6 stated, It's horrible. Something is wrong with the cord that connects the remote to the lift .You have to move the cord thingie around or it won't work. Sometimes it will and sometimes it won't. It has been reported . Interview with the Director of Nursing (DON) on 5/30/19 at 2:53 PM in the Conference Room , the DON was asked if the sling lift had been serviced recently. The DON stated, They are coming Tuesday. The DON was asked why the lift needed to be serviced. The DON stated, (Central Supply CNA) called them about something about it. Interview with the Administrator on 5/30/19 at 5:23 PM in the Conference Room, the Administrator was asked if he was aware the staff were having problems with the sling lift. The Administrator stated, I've heard a lot of discussion about the lift today. The Administrator was asked how often the lift was serviced. The Administrator stated, .Annually . The Administrator was asked if he was concerned the staff continued to use the sling lift even though it had not been working properly. The Administrator stated, No . Interview with the Central Supply CNA on 5/31/19 at 8:10 AM in the Conference Room, the Central Supply CNA was asked about the problem with the sling lift. The Central Supply CNA stated, The tilt wasn't working. The maintenance man looked at it. It was Tuesday (5/28/19) when I put the call (lift service call) in. They were closed on Monday (5/27/19) . The Central Supply CNA was asked if the sling lift was still being used for resident transfers. The Central Supply CNA confirmed it was still in use. The Central Supply CNA was asked how long she had known they were having problems with it. The Central Supply CNA stated, Last week one of the techs (CNAs) came to me .",2020-09-01
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,"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,"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 Corporation) OAKWOOD TIME SCHEDULE AS WORKED for the period between 6/18/18 and 8/26/18 and review of the NAT instructor's Partner Time Collection Report (clocked hours) for the period between 6/18/18 and 8/26/18 revealed the following: [NAME] NA #1 worked 25 shifts between 6/18/18 and 8/26/18. The NAT instructor was not available to provide clinical supervision for NA #1 for all or part of 25 of 25 shifts NA #1 worked. B. NA #2 worked 17 shifts between 6/18/18 and 8/26/18. The NAT instructor was not available to provide clinical supervision for NA #2 for all or part of 17 of 17 shifts NA #2 worked. C. NA #3 worked 20 shifts between 6/18/18 and 8/26/18. The NAT instructor was not available to provide clinical supervision for NA #3 for all or part of 20 of 20 shifts NA #3 worked. D. NA #4 worked 37 shifts between 6/18/18 and 8/26/18. The NAT instructor was not available to provide clinical supervision for NA #4 for all or part of 37 of 37 shifts NA #4 worked. E. NA #5 worked 27 shifts between 6/18/18 and 8/26/18. The NAT instructor was not available to provide clinical supervision for NA #5 for all or part of 27 of 27 shifts NA #5 worked. F. NA #6 worked 26 shifts between 6/18/18 and 8/26/18. The NAT instructor was not available to provide clinical supervision for NA #6 for all or part of 26 of 26 shifts NA #6 worked. [NAME] NA #7 worked 9 shifts between 6/18/18 and 8/26/18. The NAT instructor was not available to provide clinical supervision for NA #7 for all or part of 9 of 9 shifts NA #7 worked. H. NA #8 worked 5 shifts between 6/18/18 and 8/26/18. The NAT instructor was not available to provide clinical supervision for NA #8 for all or part of 5 of 5 shifts NA #8 worked. I. NA #9 worked 3 shifts between 6/18/18 and 8/26/18. The NAT instructor was not available to provide clinical supervision for NA #9 for all or part of 3 of 3 shifts NA #9 worked. [NAME] NA #10 worked 8 shifts between 6/18/18 and 8/26/18. The NAT instructor was not available to provide clinical supervision for NA #10 for all or part of 8 of 8 shifts NA #10 worked. K. NA #11 worked 11 shifts between 6/18/18 and 8/26/18. The NAT instructor was not available to provide clinical supervision for NA #11 for all or part of 11 of 11 shifts NA #11 worked. L. NA #12 worked 4 shifts between 6/18/18 and 8/26/18. The NAT instructor was not available to provide clinical supervision for NA #12 for all or part of 4 of 4 shifts NA #12 worked. M. NA #13 worked 8 shifts between 6/18/18 and 8/26/18. The NAT instructor was not available to provide clinical supervision for NA #13 for all or part of 8 of 8 shifts NA #13 worked. The facility failed to ensure the NAs received appropriate clinical supervision by the NAT instructor for all or part of the shifts they worked. 6. Interview with NA #13 on 8/21/18 at 3:50 PM, in the Conference Room, Na #13 was asked who was supervising her during that shift. NA #13 stated, (named CNA #1). NA #13 was asked who was responsible for her. NA #13 stated, I'm not sure. Na #13 was asked if she helped toilet residents and helped use the lift on residents. NA #13 stated, Yes. Phone interview with NA #12 on 8/22/18 at 10:08 AM, NA #12 confirmed she was able to change a brief on her own and independently assisted residents who needed to be fed. Phone interview with NA #9 on 8/22/18 at 10:21 AM, NA #9 stated, .I can do anything, from feeding to changing briefs to showering .help residents with anything they need .do it without supervision . He confirmed the instructor is not always in the facility when he worked and stated, my other classmates help me out . Interview with the NAT instructor on 8/22/18 at 10:57 AM, in the Conference Room, the NAT instructor was asked if the NAs are supervised by her throughout the entire shift for all the shifts NAs were scheduled. The NAT instructor stated, No, they are not .I was off from 7/6 to 7/12, so they were not supervised during that time .I was not able to supervise them from 7/16 to 7/27 because I was doing another class and at (another location) .was off some of those Saturdays and Sundays. The NAT instructor was asked if it was appropriate for NAs to care for residents independently. The NAT instructor stated, No, ma'am. Interview with CNA #1 on 8/22/18 at 11:48 AM, in the Conference Room, CNA #1 was asked if the NAT instructor supervises the NAs on the evening shift. CNA #1 stated, She's not here every evening of the week . Interview with NA #8 on 8/22/18 at 2:15 PM, in the North Hall, NA #8 confirmed she works independently with residents, and her instructor is not always in the facility on the evening shift.",2020-09-01
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,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,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 facility during the entrance conference, revealed residents could report a complaint or grievance to the Administrator, Director of Nursing, and/or Director of Quality/Grievance Officer. Residents could also report a complaint or grievance directly to the Ombudsman, CMS (Centers for Medicare & Medicaid Services), or to the State of Tennessee Department of Health. There was no contact information for the State of Tennessee Department of Health on the form. Interviews with Resident #1, Resident #2, and Resident #16 on 2/19/2020 at 10:39 AM, during the group meeting in the third-floor chapel, revealed the residents had not been given information on how to contact the State Survey Agency to formally complain about the care they received. Resident #16, who was the Resident Counsel President, stated, it would be good to know or have just in case. Observation and interview with the Administrator on 2/20/2020 at 1:00 PM, in the entry way of the first floor, revealed information about how to contact the State Survey Agency was hanging on the wall in a picture frame. Interview with the Administrator revealed the area between the parking garage and the lobby of the first-floor was not a common area where residents of the facility frequented, but visitors did. Interview with Certified Nurse Aide (CNA) #7 on 2/20/2020 at 1:29 PM, at the second-floor nurses' station, revealed to her knowledge, there was no information posted about how to contact the State Survey Agency. Interview with Licensed Practical Nurse (LPN) #5 on 2/20/2020 at 1:33 PM, at the second-floor nurses' station, revealed to her knowledge, there was no posting or information about how to contact the State Survey Agency. Interview with the Administrator on 2/20/2020 at 1:41 PM, at the second-floor nurses' station, revealed she had updated the admission packet today to include how to contact the State Survey Agency. Interview with LPN #8 on 2/20/2020 at 1:45 PM, at the third-floor nurses' station, revealed to her knowledge, there were no postings with information about the State Survey Agency. The LPN stated if a resident needed the State Survey Agency's number, they could always ask someone at the nurses' station and they would get the number for them.",2020-09-01
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 admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 2/23/2020 revealed Resident #131 was cognitively intact. Observations of Resident #131 conducted through-out the day on 2/18/2020, 2/19/2020, and 2/20/2020, in the resident's room, revealed Resident #131 had not been approached to attend activities and had not been observed in activities, either at her bedside, or in a group setting. Review of the Activity Calendar posted on the hallway by the nurses station on the 2nd floor Subacute Unit on Wednesday 2/19/20 at 8:49 AM, indicated good morning rounds were to be done at 9:00 AM; tai ji (Tai Chi) at 10:30 AM; at 2:00 PM Oliver visits; bingo was at 2:15 PM; and chili tasting was at 2:45 PM. During interview with Resident #131 on 2/19/2020 at 3:49 PM, at her bedside, Resident #131 was asked if she participated in the activities provided by the facility. The resident stated No, I didn't realize they had activities. Resident #131 was asked if anyone had come around and asked if she wanted to attend the activities, or to bring her a magazine or newspaper, and the resident stated, No. The resident was asked, if she were asked to participate in activities would she, and the resident stated, It would depend on the activities. The resident was asked if she would have attended this afternoon's bingo and chili tasting, and Resident #131 stated, I would have liked that. Resident #132 was admitted to the facility on [DATE] for occupational and physical therapy following a right total knee arthroplasty. Review of Resident #132's Baseline Care Plan dated 2/13/2020, showed it did not address the resident's activity preferences. Review of the admission MDS with an ARD of 2/19/2020 revealed Resident #132 was cognitively intact. Review of the Resident Activities Assessment, Preferences for Customary Routine Activities dated 2/19/2020, revealed it was very important to Resident #132 to listen to music he liked; and somewhat important to have books, newspapers, and magazines to read, keep up with the news, to do things with groups of people, to do his favorite activities, and to go outside to get fresh air when the weather was good. Observations conducted through-out the day on 2/18/2020, 2/19/2020, and 2/20/2020, in the resident's room, revealed Resident #132 had not been approached to attend activities and had not been observed in activities, either at his bedside, or in a group setting. During interview with Resident #132 on 2/19/2020 at 2:04 PM, the resident was asked if he had participated in any of the activities since he had been in the facility. Resident #132 stated, No. Resident #132 was asked if he was aware there were activities offered at the facility, and the resident stated, No, no one has told me anything about any activities. Resident #132 was questioned if the staff were to ask, would he participate in activities, and the resident stated, I probably would. Resident #230 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the Social History/Admission assessment dated [DATE], revealed Resident #230 had a mini mental score of 15, which indicated Resident #230 had intact cognition. Record review of Resident #230's initial Resident Activities Assessment Preferences for Customary Routine Activities dated 2/17/2020, indicated it was very important to the resident to have animals around, keep up with the news, and participate in religious services. Observation on 2/18/2020 at 9:39 AM, revealed Resident #230 was in his room. There was an activity calendar posted in the resident's room. Interview with Resident #230 on 2/18/2020 at 9:39 AM, revealed no one had informed him of any activities going on that day. Resident #230 stated Lord I did not even know that the activity calendar was posted in the room. He stated he had not read the calendar and did not think anyone had ever come to him to discuss activities. Resident #230 stated he would be interested in going to activities according to the time of day. He stated he liked working in the yard. Observation on 2/18/2020 at 2:18 PM, revealed Resident #230 was sitting up in a chair in his room. There was not an activity person in his room or on the unit, even though pet therapy was listed on the activity calendar in his room and on the big activity calendar in the hallway by the nurse's station. Interview with Resident #230 on 2/18/2020 at 2:18 PM, in his room, revealed someone had been in earlier and asked if he wanted a magazine, and that was all. Observation of Resident #230 on 2/19/2020 at 9:00 AM, revealed he was sitting up in a chair in his room and was getting ready to go to therapy at 9:45 AM. Resident #230 stated no one had been by and invited him to any activities that day, but he had a calendar that might tell what was going on. Observation on 2/19/2020 at 3:32 PM, in the dining/activity room on the 2nd floor Subacute Unit, revealed no chili tasting activity was taking place, which was listed as an activity on the calendar for 2:45 PM. Observation on 2/19/2020 at 3:35 PM, in the dining/activity room on the 3rd floor, showed a chili tasting event was occurring. Resident #230 was not in attendance. Review of the Activity Calendar posted on the hallway by the nurse's station on the 2nd floor Subacute Unit indicated on Thursday (MONTH) 20, 2020 showed there would be seven activities that day. The calendar indicated that at 8:30 AM the news would be done; 9:00 AM would be good morning rounds; 10:00 AM would be coffee activity; 11:00 AM papers were to be delivered; 11:30 AM would be bible story time; and at 2:30 PM Wheel of Fortune would be played. Interview with Registered Nurse (RN) #6 on 2/20/2020 at 12:23 PM, revealed she had not discussed any activities with Resident #230. During interview with Resident #230 on 2/20/2020 at 12:35 PM, he was in his room and his wife was at the bedside. Resident #230 stated he did not go to the chili tasting yesterday and no one had been by for morning coffee that morning. Resident #230 state he needed to get out more and socialize. Resident #230 further stated he liked chili. Resident #232 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #232's Social History/Admission assessment dated [DATE], revealed the resident had a mini mental score of 15, which indicated intact cognition. Record review of Resident #232's initial Resident Activities Assessment Preferences for Customary Routine Activities dated 2/13/2020 revealed it was very important to the resident to keep up with the news and to go to religious services. Observation and interview on 2/18/2020 at 1:04 PM, revealed Resident #232 was sitting in his room watching television. During interview, Resident #232 stated he was not aware of any activities that the facility provided. Resident #232 stated he did not think anyone had ever discussed activities with him. He stated he might go to an activity, but it depended on what time it was. He stated he liked music. Resident #232 stated he had not gone to the sing a long that was posted on the calendar for the past Saturday, and he had not been invited to go. Interview with Licensed Practical Nurse (LPN) #5 on 2/20/2020 at 11:30 AM, in the dining/activity room on the 2nd floor Subacute Unit, revealed some residents would say they were bored and they had cabin fever. LPN #5 stated she would tell the residents they were welcome to come out in the hallway and visit. LPN #5 stated she would tell the resident about the books and puzzles available on the unit and there were puzzles and activities upstairs on the 3rd floor. LPN #5 stated she would give the residents the activity calendar and told them how to get to it on the 3rd floor. Interview with the Director of Nursing (DON) on 2/20/2020 at 2:24 PM, in her office, revealed very rarely did a subacute person go to activities because they were mainly interested in getting well and going home. The DON stated the subacute stays were only two weeks and then they go home. The DON stated there was an activity calendar in each room and a big calendar in the hallway that the subacute residents passed by when going to therapy. The DON stated she was not sure if the subacute had to have documentation activities were done. The DON stated the residents in the subacute unit wanted to just go home and she felt it did not pose any risk to the residents if they did not go to activities. Interview with the AD on 2/20/2020 at 10:30 AM, in her office on the 3rd floor, revealed she had been the Activity Director for 4 years. The AD stated she used to have 3 Activity Assistants, but now it was only her. She used to have more volunteers and now she has fewer. The AD stated the nurses did the initial activity assessment, she would check over the assessment, then she would go talk to the residents and gave the residents an activity calendar, and she would go over it with the resident. She offered the residents cards, magazines, puzzles, Sudoku, and CD players. She told the residents where the books and puzzles could be located. The AD stated most of the rehab residents were more self-directed and could do their own interests. Most of the rehab residents wanted to do their rehabilitation, go home, and were not much interested in activities. The AD stated the facility has 50's singing once a month and church services on Sundays and Tuesdays. If the resident filled out that religious services or music was important to them, then she tried to get them to the services. The AD stated she did not work on the weekends and could not say if Resident #230 or Resident #232 had attended any religious services on the weekends. She did not keep track of who attended the weekend activities. Pet therapy had been cancelled because of the weather. Resident #230 and Resident #232 had not participated in the chili tasting activity yesterday and had not attended any facility activity. The AD had tried to come down to the 2nd floor yesterday to do an activity, but had only been there a few minutes and the 3rd floor paged her, and she had to go back up there to do their activity. She stated the residents on the 3rd floor liked to get her attention and looked to her for activities. The AD stated she tried to get to the 2nd floor to at least pass out books and magazines. During interview with the Administrator on 2/20/2020 at 1:30 PM, in the conference room, the Administrator was asked what her expectations were related to activities for the Sub-Acute Unit residents. The Administrator stated I expect the sub-acute residents to be asked if they want to participate in activities whenever there are activities going on, or if they want to do a bedside activity. The Administrator added the Activity Director told her she hasn't had the chance to get to the subacute residents this week.",2020-09-01
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 Nurse (RN) (former Unit House Supervisor) on 1/2/20 at 12:15 PM, in the Conference Room, confirmed she was the supervisor on duty on 9/1/19 when the Licensed Practical Nurse (LPN) (no longer employed at the facility), notified her of the perforated PEG tube. Continued interview confirmed she and the LPN removed the perforated PEG tube, reinserted a new PEG tube without notifying the physician. Interview with the Compliance RN, the Director of Nursing, and the Corporate Consulting RN on 1/2/20 at 1:50 PM, in the Conference Room, confirmed the facility did not notify the physician or NP of the PEG perforation and removal and reinsertion of the PEG tube.",2020-09-01
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,"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,"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 Resident #40 received a hematoma to his forehead with the 10/8/17 fall, and the resident was in his room, which is not in a high traffic area. Further interview confirmed the new intervention to educate staff to keep the resident in a high traffic area was not a new intervention.",2020-09-01
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 an order dated [DATE] for [MEDICATION NAME] 0.25 ML orally every 2 hours as needed for pain. Continued review revealed the order was discontinued on [DATE]. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed a BIMS score of 2, indicating Resident #5 was severely cognitively impaired. Medical record review of the Physician Orders revealed an order dated [DATE] for [MEDICATION NAME] 0.25 ML sublingual every 4 hours as needed for pain. Continued review revealed the order was discontinued on [DATE]. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed Resident #6 expired on [DATE]. Medical record review of the Quarterly MDS dated [DATE] revealed a BIMS score of 0 (zero), indicating Resident #6 was severely cognitively impaired. Medical record review of the Physician Orders revealed an order dated [DATE] for [MEDICATION NAME] 0.25 ML orally every 4 hours as need for pain. Review of a facility investigation dated [DATE] revealed the facility became aware of a possible drug diversion at approximately 11:45 PM on [DATE]. Further review revealed during the narcotic count at shift change between 2nd and 3rd shift, Licensed Practical Nurse (LPN) #3 observed a vial of [MEDICATION NAME] prescribed for Resident #1, which appeared to have the tamper resistant seal altered. Continued review revealed the vial was full as if no medication had been administered. Further review revealed LPN #3 immediately notified LPN #2, the night shift supervisor, of her concern and at that time LPN #2 immediately notified the Director of Nursing (DON). Continued review revealed the vial of [MEDICATION NAME] was delivered to the facility the afternoon of [DATE] and Resident #1's Medication Administration Record [REDACTED]. Continued review revealed on [DATE] the DON began a facility wide investigation. Further review revealed during a narcotic audit the facility identified 3 additional residents' (#4, #5, and #6) vials of [MEDICATION NAME] were altered. Further review revealed, after reviewing the staffing assignment sheets and schedules, the facility was able to identify Registered Nurse (RN) #1 provided care to, and had access to, the residents' medications. Further review revealed on [DATE], during the facility's monthly narcotic waste, the DON and the Pharmacist found a vial of [MEDICATION NAME] prescribed for Resident #3, which had been placed in the narcotic waste bin after the order was discontinued on [DATE]. Continued review revealed the vial of [MEDICATION NAME] was noted to have been altered. Further review revealed the DON reviewed the staffing assignment sheets and RN #1 provided care to Resident #3 on [DATE], the day the [MEDICATION NAME] was discontinued. Review of the police report dated [DATE] revealed .responded to (facility) in reference to a theft of medication .advised (RN #1) .had stolen liquid [MEDICATION NAME] from four different residents at the facility. (RN #1) stole the medication .While on scene I observed a bottle of [MEDICATION NAME] that had been diluted .(RN #1) was subjected to a drug screen, in which the first sample showed invalid due to the temperature of the urine at the time. (RN #1) was subjected to a second drug screen, in which she tested positive for [MEDICATION NAME] . Continued review revealed RN #1 admitted to stealing the [MEDICATION NAME]. Review of the Urine Drug Screen Laboratory Report dated [DATE] revealed RN #1 was positive for [MEDICATION NAME]. Interview with RN #1 via phone on [DATE] at 10:33 AM, confirmed she had taken [MEDICATION NAME] from various residents over a two week period in (MONTH) (YEAR). Continued interview confirmed she was unable to identify the residents specifically. Interview with the DON on [DATE] at 9:16 AM, in the conference room, confirmed she was made aware of possible drug diversion on [DATE] at approximately 11:45 PM by LPN #2. Further interview confirmed LPN #2 reported the vial of [MEDICATION NAME] ordered for Resident #1 was delivered to the facility on [DATE], the tamper resistant seal showed signs of having been tampered with, and Resident #1's MAR indicated [REDACTED]. Continued interview confirmed during the course of their investigation the facility identified 4 additional residents (Residents #3, #4, #5, and #6) whose vials of [MEDICATION NAME] were altered. Further interview confirmed after reviewing the staffing assignment sheets and schedule, the facility was able to determine RN #1 provided care to the affected residents. Continued interview confirmed initially RN #1 denied having any knowledge of the altered [MEDICATION NAME] but eventually admitted to the misappropriation of the [MEDICATION NAME]. Further interview confirmed RN #1 was suspended on [DATE] and remained on suspension until being terminated on [DATE]. Interview with the DON on [DATE] at 10:10 AM, in the conference room, confirmed through the facility's investigation they were able to identify RN #1 had taken [MEDICATION NAME] from 5 residents (Residents #1, #3, #4, #5, and #6) and the facility had failed to prevent misappropriation of resident's medication.",2020-09-01
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 provided to the resident or the resident's representative prior to the resident being transferred to the psychiatric facility on 6/8/2019 or 7/24/2019. During an interview on 2/20/2020 at 5:20 PM, the Administrator stated .I looked through the entire chart and could not find it.did not find a progress note.only thing we have is a resident agreement.does not mention bed hold.both times the resident was sent out to a psych facility.behaviors.combative.nothing for either transfer. The Administrator confirmed the facility did not give the resident or the resident representative a bed hold notification prior to the transfer on 6/8/2019 or 7/24/2019. During an interview on 2/20/2020 at 5:30 PM, the Nurse Manager confirmed a bed hold policy was not given to the family prior to transferring the resident on 6/8/2019 or 7/24/2019. During an interview on 2/20/2020 at 6:00 PM, the Social Worker confirmed a bed hold policy was not given to the resident or the resident's representative prior. During a telephone interview on 2/20/2020 at 6:30 PM, Resident #1's representative stated she was not made aware of the facility's bed hold policy either verbally or in writing.",2020-09-01
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 and assessed her (Resident #3) .she had a hematoma to the top left of her hairline .the bruising was coming down toward her eye .notified the DON .the Nurse Practitioner was in the facility and came and assessed her .notified the family . Observation on 4/25/18 at 12:00 PM revealed Resident #3 was seated in her wheelchair in the dining room. Continued observation revealed the resident had a slight purplish discoloration from her hairline down the left side of her forehead. Interview with the Administrator on 4/26/18 at 1:30 PM, in his office, confirmed the injury of unknown origin was not reported to Adult Protective Services, Law Enforcement, or the Ombudsman and the facility failed to follow facility policy.",2020-09-01
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 Nurse (LPN) #6 on 4/26/18 at 12:15 PM, in the therapy gym office, revealed . care plan should address the resident's preference and frequency of bathing . Interview with the Director of Nursing (DON) on 4/26/18 at 1:15 PM, in the DON's office, confirmed the care plans for Resident #1 and Resident #2 did not adequately reflect their bathing needs and were not person centered.",2020-09-01
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 revealed Resident #2 replied .I was just checking to see if she (Resident #1) was wet to change . Further review revealed Resident #3 changed details of the alleged incident multiple times during the facility investigation and stated he was not able to see if Resident #2 put his hand under her blanket or inside Resident #1's pants. Continued review revealed Licensed Practical Nurse (LPN) #2 reported while she was feeding Resident #3 in his room on 4/22/19 or 4/23/19, Resident #3 reported the incident to her. Further review revealed Resident #3 also reported the incident to LPN #3 on 4/24/19. Interview with LPN #2 on 5/2/19 at 1:00 PM, in the Administrator's office, confirmed Resident #3 reported the alleged incident to her on 4/22/19 or 4/23/19. Further interview revealed she did not report the allegation because .in my mind .I thought it really didn't happen . Telephone interview with LPN #3 on 5/2/19 at 2:35 PM confirmed she did not report the allegation of abuse because she thought it was .old news . Further interview with LPN #3 confirmed she was aware she should have reported the allegation immediately, but failed to do so. In summary, Resident #3 reported an allegation of abuse to facility staff on 4/22/19 or 4/23/19, but the staff did not report the allegation to the Administrator or the State Survey Agency until 4/25/19.",2020-09-01
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 #9 administered insulin without documentation of the resident's blood sugar per physician order [REDACTED]. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].[MEDICATION NAME] (fast-acting insulin insulin for diabetics) .(6 units) .two times daily .Hold if (blood sugar) (less than) 120 . Medical record review of Resident #16's eMAR dated (MONTH) (YEAR) revealed LPN #9 administered insulin without documentation of the resident's blood sugar 10 times out of 27 opportunities. Medical record review of Resident #16's eMAR dated (MONTH) (YEAR) revealed LPN #9 administered insulin without documentation of the resident's blood sugar 12 times out of 37 opportunities. Medical record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physician order [REDACTED].[MEDICATION NAME] .12 units .give extra 4 units if (blood glucose) (greater than 300)) . Medical record review of Resident #14's eMAR dated [DATE] at 1:00 PM revealed a blood sugar of 274 with documentation LPN #9 administered 10 units of insulin instead of the ordered 12 units. Continued review revealed the 5:30 PM blood sugar was 191, indicating Resident #14 continued to have high blood sugar. Interview with the DON on [DATE] at 2:35 PM, in the DON's office, confirmed nurses are to follow the physician's orders [REDACTED]. Interview with the Administrator and DON on [DATE] at 6:30 PM, confirmed, LPN #9 did not have a current license to practice nursing since the hire date in (MONTH) (YEAR). Continued interview confirmed since his employment, LPN #9 failed to follow physician's orders [REDACTED].",2020-09-01
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 receiving an overdose of insulin. Review of the eMAR dated 9/12/16 at 9:00 PM, revealed a sliding scale (based on blood sugar results) for Humalog (short acting) insulin 100 units subcutaneous four times daily starting 8/25/16. Blood sugar 415 notify MD. Blood sugar is 0-150 (give) 0 units, Blood Sugar is 151-200 (give) 2 units Blood Sugar is 201-250 (give) 4 units Blood Sugar is 251-300 (give) 6 units Blood Sugar is 301-350 (give) 8 units Blood Sugar is 351-400 (give) 10 units Blood Sugar is 401-415 (give) 12 units Continued review revealed the blood sugar on 9/11/16 at 9:00 PM was 247 and 100 units of Humalog insulin instead of 4 units, was administered to the resident. Medical record review of Resident #1's care plan with a goal date of 12/8/16, revealed .Observe and record s/sx (signs and symptoms)of elevated blood sugar levels .Administer medication as ordered for elevated blood sugars .Observe for s/sx (signs and symptoms) of decreased blood sugar levels: weakness cold clammy nervous .Resident at risk for alteration in weight due to .cancer . Medical record review revealed Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of Resident #4's care plan with a goal date of 9/28/17 revealed .Observe and record s/sx (signs and symptoms) of elevated blood sugar levels .Administer medication as ordered for elevated blood sugars .Observe for s/sx of decreased blood sugar levels: weakness cold clammy nervous . Medical record review of the eMAR dated 7/18/17 revealed .Humalog (fast acting)(sliding scale .Blood Sugar is 301-350 .8-units . Continued review revealed on 7/18/17 at 5:30 PM the resident's blood sugar was 310 and 6 units was given when 8 units should have been administered to the resident per Physician's Orders. Medical record review revealed Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of Resident #6's care plan with a goal date of 9/28/17 revealed .Insulin as ordered .Labs for blood sugars as ordered: accuchecks (blood sugar test) as ordered . Medical record review of the eMAR dated (MONTH) (YEAR) revealed .[MEDICATION NAME] R (short acting .(give) Three Times (daily) .Blood Sugar is 151-200 .(give) 4 units .Blood Sugar is 251- 300 .(give) 6 units . Continued review revealed there was no sliding scale for blood sugar results of 201-250 on the MAR. Further review revealed on 6/30/17 the blood sugar was 214 and 6 units of insulin which was an incorrect dose of insulin, according to the MAR. Medical record review of the eMAR dated (MONTH) (YEAR) revealed .[MEDICATION NAME] (insulin) .Blood Sugar is 151-200 . (give) 4 units .Blood Sugar is 251- 300 .(give) 6 units . Continued review revealed there was no sliding scale for blood sugar results of 201-250 on the eMAR. Further review revealed the following: 7/2/17 at 9:00 PM-blood sugar 215-4 units of insulin given, which was the amount for a result of 151-200 on the eMAR. 7/4/17 at 9:00 AM-blood sugar 152-2 units of insulin given (should have received 4 units) 7/5/17 at 9:00 PM-blood sugar 215-4 units of insulin given, which was the amount for a result of 151-200 on the eMAR. Telephone Interview with LPN #10 on 7/20/17 at 4:05 PM, confirmed the insulin administration could have been an error. Further interview confirmed she was not aware there was a missing range for insulin administration (201-250) on Resident #6 on 6/30/17 when she administered the insulin. Interview with LPN #11 on 7/20/17 at 1:45 PM, in the 300 nurse's station, confirmed she failed to follow the care plan for diabetic management. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #7's care plan with a goal date of 9/8/17 revealed .Insulin as ordered .Labs for blood sugars as ordered: accuchecks (blood sugar test) as ordered .medicate with .insulin as ordered . Review of the Consultant Pharmacist's Medication Regimen Review dated 1/1/17-1/17/17 revealed, .Documentation/charting issues .Humalog 6 units bid (twice daily) with hold parameter for BS Medical record review of the eMAR dated (MONTH) (YEAR) revealed .Humalog (short acting insulin) .Sliding Scale Insulin .Blood Sugar is 151-200 (give) 2 Units . Continued review revealed on 3/19/17 at 5:00 PM the Blood Sugar was 183 and 4 units of insulin was given to the resident when only 2 units should have been administered. Medical record review of the eMAR dated (MONTH) (YEAR) revealed .Humalog .Sliding Scale Insulin .Blood Sugar is 251-300 .(give) 6 units . Continued review revealed on 4/19/17 at 8:00 AM the resident's Blood Sugar was 277 and 4 units of insulin was given to the resident when the resident should have received 6 units. Medical record review of the eMAR dated (MONTH) (YEAR) revealed .Humalog .Sliding Scale Insulin .Blood Sugar is 0-150 .(give) 0 Units .Blood Sugar is 201-250 (give) 4 units . Continued review revealed on 5/7/17 at 9:00 PM the Blood Sugar was 150 and 2 units of insulin was given to the resident when the resident should not have received any insulin. Further review revealed on 5/9/17 at 5:00 PM, the blood sugar was 202 and 2 units of insulin was given to the resident when the resident should have received 4 units. Medical record review of the eMAR dated (MONTH) (YEAR) revealed .Humalog .Sliding Scale Insulin .Blood Sugar is 201-250 (give) 4 units .Blood Sugar is 251-300 (give) 6 Units . Continued review revealed the following: 6/8/17 at 9:00 PM the resident's Blood Sugar was 256 and 4 units given when the resident should have received 6 units. 6/10/17 at 12:00 PM the resident's Blood Sugar was 236 and 6 units was given when the resident should have received 4 units. 6/30/17 at 5:00 PM the resident's Blood Sugar was 217 and 2 units was given when the resident should have received 4 units. Medical record review of the eMAR dated (MONTH) (YEAR) revealed .Humalog .Sliding Scale Insulin .Blood Sugar is 201-250 (give) 4 units .Continued review revealed the following: 7/4/17 at 5:00 PM the Blood Sugar was 212 and 2 units given when the resident should have received 4 units. 7/13/17 at 5:00 PM the Blood Sugar was 243 and 2 units given when the resident should have received 4 units. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #13's care plan with a goal date of 8/23/17 revealed .Insulin as ordered .Labs for blood sugars as ordered: accuchecks (blood sugar test) as ordered . Medical record review of the MAR indicated [REDACTED].Humalog .Give 4 units .For Blood Sugar > (greater than) 200 . Continued review revealed on 4/26/17 at 12:00 PM, the blood glucose was 194 and 4 units were given to the resident when the resident should not have received any insulin. Medical record review of the MAR indicated [REDACTED]. Further review revealed on 5/3/17 at 12:00 PM, the blood glucose was 294 and 10 units were given to the resident when the resident should have received only 4 units. 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 8/11/14 revealed, .Potential for increased or decreased blood sugar levels .status .active .blood sugar (less than) 70 or (greater than) 110 .accuchecks as ordered .medicate .insulin as ordered . Medical record review of a Physician's Order dated 2/15/17 revealed, .Humalog (insulin) 4 (units) if blood sugar (greater than) 150 . Medical record review of Resident #5's eMAR dated 2/16/17 at 5 PM revealed a blood sugar of 100 with documentation indicating 4 units of insulin had been given, when no insulin should have been given. Medical record review of Resident #5's eMAR dated 2/25/17 at 8 AM revealed a blood sugar of 102 with documentation indicating 4 units of insulin had been given, when no insulin should have been given when no insulin should have been given. Medical record review of Resident #5's eMAR dated 2/26/17 at 8 AM revealed a blood sugar of 130 with documentation indicating 4 units of insulin had been given, when no insulin should have been given. Medical record review of Resident #5's eMAR dated 3/6/17 at 8 AM revealed a blood sugar of 137 with documentation indicating 4 units of insulin had been given, when no insulin should have been given. Interview with LPN #8 Nurse Manager on 7/25/17 at 3:58 PM, in the DON's office, confirmed a nurse's initials on the resident's MAR means medication was given. Further interview confirmed the care plan was not followed. Interview with the Director of Nursing (DON) on 7/26/17 at 2:35 PM, in the conference room, confirmed nurses were expected to follow the Physicians Orders. Further interview confirmed when a nurse failed to follow the insulin order it put the residents at risk for harm. Interview with LPN #2 on 7/26/17 at 5:52 PM, via telephone confirmed she did not follow physician's orders and the care plan when giving Resident #5 insulin outside of parameters. Medical Record Review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #16's Care Plan with a goal date of 10/24/17 revealed, .Potential for increased or decreased blood sugar levels .accuchecks (test to check blood sugar) as ordered .Administer medication as ordered for elevated blood sugar levels .Insulin as ordered or sliding scale . Medical record review of Physician's Orders on the (MONTH) (YEAR) eMAR revealed, .[MEDICATION NAME] (short acting insulin) .(4 units) .Hold if BG (blood glucose) (less than) 120 . Medical record review of Resident #16's eMAR dated 1/2/17 at 9:00 AM revealed a blood sugar of 88 with documentation indicating 4 units of insulin had been given when no insulin should have been given. Medical record review of Resident #16's eMAR dated 1/3/17 at 9:00 AM revealed a blood sugar of 77 with documentation indicating 4 units of insulin had been given when no insulin should have been given. Medical record review of Resident #16's eMAR dated 1/6/17 at 9 AM revealed a blood sugar of 76 with documentation indicating 4 units of insulin had been given when no insulin should have been given. Medical record review of Resident #16's eMAR dated 1/10/17 at 9:00 AM revealed a blood sugar of 115 indicating 4 units of insulin had been given. Medical record review of Physicians Orders dated 5/15/17 revealed, .[MEDICATION NAME] 6 units .Hold if (blood sugar) (less than) 120 . Medical record review of Resident #16's eMAR dated 6/26/17 at 12 PM revealed a blood sugar of 176. Further review revealed .(insulin) Not Administered (Outside Parameters) . Interview with LPN #8 Nurse Manager, on 7/25/17 at 3:58 PM, in the DON office, confirmed LPN #5 and #6 administered insulin when it was not needed and LPN #7 held insulin when it should have been administered. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #18's Care Plan with a goal date of 10/27/17 revealed, .Diabetes .potential for complications .administer medications as ordered for elevated blood sugar levels .will have (blood sugar levels) between 70-110 (every day) this 90 days .accuchecks as ordered . Medical record review of the Consultant Pharmacist's Medication Regimen Review for Resident #18 dated 4/1/17-4/11/17 revealed, .there is no space for recording (blood sugar) on EMAR with the order so unclear if this has been done consistently . Medical record review of Physician's Orders dated 4/20/17 revealed, .Humalog 8 (units) .(with) each meal .hold if (blood sugar) (less than) 110 .if (blood sugar) (greater than) 400 give 4 (additional) (units) .check (blood sugar) (3 times a day) (before meals) . Medical record review of Resident #18's eMAR dated 4/20/17 revealed, .Humalog (8 units) .Notes .hold if below 110 If greater than 400 give 4 additional units . Medical record review of Resident #18's eMAR dated (MONTH) (YEAR) revealed blood sugars over 400 on 5/2 at 4:46 PM, 5/6 at 1:10 PM, 5/6 at 5:06 PM, 5/7 at 7:39 AM, 5/7 at 4:34 PM, 5/8 at 4:40 PM, 5/23 at 9:48 AM, 5/30 at 7:52 AM, and at 5/30 at 11:30 AM. Further review revealed no documentation if additional 4 units of insulin were administered. Interview with LPN #8, Nurse Manager, on 7/26/17 at 11:10 AM, confirmed there was no way to determine if additional units of insulin were given or held. Interview with the Director of Nursing (DON) on 7/26/17 at 2:35 PM, in the conference room, confirmed nurses were expected to follow the Physicians Orders. Further interview confirmed when a nurse failed to follow the insulin order it put the residents at risk for harm. Interview with the Administrator on 7/26/17 at 6:42 PM, in the DON office confirmed not following physician orders per care plans was a .problem . Interview with the Medical Director on 7/27/17 at 8:00 AM, confirmed, .anytime there is a parameter (ordered) you check the parameter . Refer to F 333",2020-09-01
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 nectar thick liquids Medical record review of the Medication Administration Record [REDACTED].Humalog (insulin) 100 unit/ml (milliliter) .Four Times Daily XXX[DATE] Sliding Scale Insulin .Blood Sugar is 201XXX,[DATE].00 (give) 4 units . Continued review revealed on [DATE] at 9:00 PM the resident's blood sugar was 247 and 100 units of insulin was given, when only 4 units of insulin should have been administered to the resident. Review of a facility document Medication Error Report dated [DATE] revealed .based on CS ([MEDICATION NAME] blood sugar)- 247 at 9:00 PM, Agency nurse (temporary nurse from outside source) Administered 100 units of Humalog vs (versus) the ordered 6 units (should have been 4 units) .Sent to ER (emergency room ), admitted to CCU (critical care unit) on vent (ventilator to aid in breathing) . Review of a clinical note dated [DATE] at 6:39 AM, revealed Instant Glucose (sugar) given. Chocolate pudding and orange (juice) given. Review of an Emergency Medical Service (EMS) record dated [DATE] revealed at 6:00AM, .Unresponsive .Blood glucose reading/level: low comments: 30 (below 70 is considered low) .Upper Right Lung Rhonchi (abnormal breath sounds): Upper Left Lung Rhonchi; Lower Right Lung; Rhonchi: Lower Left Lung; Rhonchi .Glasco Coma Scale (scale to assess consciousness) GCS .6 (less than 8 is considered comatose) .Respiratory Effort: Labored .Narrative .Altered Mental Status and [DIAGNOSES REDACTED] .Pt (patient) was found unresponsive with low blood sugar. Nursing staff tried to feed the PT (patient) pudding and orange juice. Then activated 911. Pt found unconscious and unresponsive .Upon arrival to destination (hospital) there is no improvement in his condition . Review of a procedure note from the hospital dated [DATE] revealed .Probable aspiration, possible foreign body .No food particles were seen, but the secretions were very thick and could be consistent with the pudding that the patient had eaten earlier in the day . Review of a hospital critical care progress note, dated [DATE] revealed .Acute [MEDICAL CONDITION]: Requiring mechanical ventilation day 15. Unable to wean due to severe [MEDICAL CONDITION] (disease, damage, or malfunction of the brain) apnea .Aspiration pneumonia: Required FOB (fiber optic [MEDICATION NAME]) with mucous plug removal from R (right) main stem (an airway passage within the lung) at admission . Interview with the Administrator and Director of Nursing (DON) on [DATE] at 4:30 PM, in the DON's office, confirmed LPN #1 was an agency nurse working at the facility on [DATE] on a night shift. Further interview confirmed the LPN administered 100 units of insulin to Resident #1 in error. Interview with Licensed Practical Nurse (LPN) #1 on [DATE] at 6:55 PM, by phone, confirmed she did work at this facility for approximately 1 month through an agency. Continued interview confirmed she administered 100 units of insulin to Resident #1 in error. Continued interview confirmed .I read the dosage wrong . Continued interview confirmed the LPN gave the 100 units of insulin at around 9:00 PM. Further interview confirmed she knew something was not right because the resident was sleeping hard .couldn't waken him up .trying to give him pudding and orange juice . Continued interview confirmed the LPN noticed the resident to be breathing very deeply and he was hard to wake up. She attempted to give him [MEDICATION NAME] (medication to increase blood sugar), and also gave him thickened juice and fed him pudding to bring his sugar up. Further interview confirmed she called EMS and he was sent to the hospital. Interview with the Medical Director (MD), also Resident #1's physician, on [DATE] at 10:35 AM, in the conference room confirmed LPN #1 called the MD in the early morning of [DATE] after she had administered the 100 units of insulin. Continued interview confirmed the MD instructed the LPN to follow the [DIAGNOSES REDACTED] protocol, start an IV, and if unable to start an IV send the resident to the hospital. Continued interview confirmed the resident should not have received pudding or juice if the resident was lethargic or unconscious. Medical record review revealed Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Sliding Scale Order dated [DATE] revealed .Scale A XXX,[DATE] give 6 units . Medical record review of the Sliding Scale Insulin Order dated [DATE] revealed .[MEDICATION NAME] R .TID (three times daily) .Scale A .Blood Sugar is ,[DATE] give 4 units .Blood Sugar is ,[DATE] give 6 units . Medical record review of the MAR indicated [REDACTED].[MEDICATION NAME] R U-100 100 unit/ml .Three Times Daily Starting [DATE] .Blood Sugar is 151XXX,[DATE].00 (give) 4 units .Blood Sugar is 251.00- 300.00 (give) 6 units . Continued review revealed a missing sliding scale for blood sugar results of ,[DATE] on the MAR. Further review revealed on [DATE] the blood sugar was 214 and 6 units of insulin was given. Medical record review of the Sliding Scale Insulin Order dated [DATE] revealed .Humalog .Scale A .Blood Sugar is ,[DATE] give 4 units .Blood Sugar is ,[DATE] give 6 units . with no sliding scale for results between 201 - 250. Medical record review of the MAR indicated [REDACTED].[MEDICATION NAME] R U-100 100 unit/ml .Three Times Daily Starting [DATE] .Blood Sugar is 151XXX,[DATE].00 4 units .Blood Sugar is 251.00- 300.00 6 units . Continued review revealed no sliding scale for blood sugar results of ,[DATE] on the MAR. Further review revealed the following: [DATE] at 9:00 PM-blood sugar ,[DATE] units of insulin given [DATE] at 9:00 PM-blood sugar ,[DATE] units of insulin given [DATE] at 9:00 AM-blood sugar ,[DATE] units of insulin given Interview with LPN #11 on [DATE] at 1:45 PM, in the 300 nurse's station confirmed she failed to follow the physician's orders [REDACTED]. Interview with LPN #10 on [DATE] at 4:05 PM, by phone confirmed she was not instructed how to enter orders by order set and put the insulin order in manually. Continued interview confirmed she was not aware she made an error while entering the insulin order on Resident #6 on [DATE] when she administered the insulin. Medical record review revealed Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Sliding Scale Insulin Order dated [DATE] revealed .Humalog XXX,[DATE] give 0 units XXX,[DATE] give 2 units . Medical record review of the (MONTH) (YEAR) MAR from a Physicians order dated [DATE] revealed .Humalog .Sliding Scale Insulin .Blood Sugar is 151XXX,[DATE].00 2 Units . Continued review revealed on [DATE] at 5:00 PM the blood Sugar was 183 and 4 units of insulin was given to the resident when only 2 units should have been administered. Medical record review of the (MONTH) (YEAR) MAR indicated [REDACTED].Sliding Scale Insulin .Blood Sugar is 251XXX,[DATE].00 6 units . Continued review revealed on [DATE] at 8:00 AM the blood Sugar was 277 and 4 units of insulin was given to the resident when the resident should have received 6 units. Medical record review of the (MONTH) (YEAR) MAR indicated [REDACTED].Sliding Scale Insulin .Blood Sugar is 0XXX,[DATE].00 0 Units .Blood Sugar is 201XXX,[DATE].00 4 units . Continued review revealed on [DATE] at 9:00 PM the blood sugar was 150 and 2 units of insulin was given to the resident when the resident should not have received any insulin. Further review revealed on [DATE] at 5:00 PM, the blood sugar was 202 and 2 units of insulin was given to the resident when the resident should have received 4 units. Medical record review of the (MONTH) (YEAR) MAR indicated [REDACTED].Sliding Scale Insulin .Blood Sugar is 201XXX,[DATE].00 4 units .Blood Sugar is 251XXX,[DATE].00 6 Units . Continued review revealed on [DATE] at 9:00 PM the Blood Sugar was 256 and 4 units was given when the resident should have received 6 units; on [DATE] at 12:00 PM the Blood Sugar was 236 and 6 units was given when the resident should have received 4 units; and on [DATE] at 5:00 PM the Blood Sugar was 217 and 2 units was given when the resident should have received 4 units. Medical record review of the (MONTH) (YEAR) MAR indicated [REDACTED].Sliding Scale Insulin .Blood Sugar is 201XXX,[DATE].00 4 units . Continued review revealed on [DATE] at 5:00 PM the Blood Sugar was 212 and 2 units was given when the resident should have received 4 units, and on [DATE] at 5:00 PM the Blood Sugar was 243 and 2 units was given when the resident should have received 4 units. Medical record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Sliding Scale Order dated [DATE] revealed .Scale A XXX,[DATE] give 6 units . Medical record review of the MAR indicated [REDACTED]. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR indicated [REDACTED].Humalog .(4 units) .before meals Starting [DATE] .Give 4 units .For Blood Sugar > (greater than) 200 . Continued review revealed on [DATE] at 12:00 PM, the blood sugar was 194 and 4 units of insulin was administered to the resident when the resident should not have received any insulin. Continued review of the (MONTH) MAR indicated [REDACTED]. Medical record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the (MONTH) and (MONTH) (YEAR) MAR indicated [REDACTED].[MEDICATION NAME] (insulin) .12 units with meals give extra 4 units if BG > (greater than) 300 . Continued review revealed the following: [DATE] 1:00 PM blood sugar 345- 12 units given (should have received 16 units) [DATE] 1:00 PM blood sugar 325- 12units given (should have received 16 units) [DATE] 1:00 PM blood sugar 375- 12 units given (should have received 16) [DATE] 1:00 PM blood sugar 320- 12 units given (should have received 16) [DATE] 1:00 PM blood sugar 375- 12 units given (should have received 16) [DATE] 8:00 AM blood sugar 394- 12 units given (should have received 16) [DATE] 1:00 PM blood sugar 325- 12 units given (should have received 16) [DATE] 1:00 PM blood sugar 324- 12 units given (should have received 16) [DATE] 8:00 AM blood sugar 322- 12 units given (should have received 16) [DATE] 1:00 PM blood sugar 358- 12 units given (should have received 16) [DATE] 5:30 PM blood sugar 333- 12 units given (should have received 16) [DATE] 1:00 PM blood sugar 346- 12 units given (should have received 16) [DATE] 5:30 PM blood sugar 323- 12 units given (should have received 16) [DATE] 5:30 PM blood sugar 399- 12 units given (should have received 16) [DATE] 8:00 AM blood sugar 284- 16 units of insulin (should have received only 12) [DATE] 5:30 PM blood sugar 387- 16 units of insulin (should have received only 16) [DATE] 1:00 PM blood sugar 274- 10 units of insulin (should have received only 12) Interview with the DON on [DATE] at 2:35 PM, in the conference room, confirmed the nurses failed to follow the Physicians Orders. Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR indicated [REDACTED].[MEDICATION NAME] .sliding scale .Blood Sugar is 150XXX,[DATE].00 1 Units .Blood Sugar is 200XXX,[DATE].00 2 Units .Blood Sugar is 300XXX,[DATE].00 4 units .Blood Sugar is > 349.00 5 units . Continued review revealed on [DATE] at 5:00 PM the blood sugar was 353 and 6 units insulin was given (should have received 5 units); on [DATE] at 5:00 PM blood sugar was 216 and 1 unit insulin given (should have received 2 units); and on [DATE] at 5:00 PM blood sugar was 343 and 5 units insulin was given (should have received 4 units). Medical record review of the MAR indicated [REDACTED].Humalog .If BG > 200 at breakfast and supper give 4 units of Humalog . Continued review revealed on [DATE] at 5:00 PM blood sugar was 192 and 4 units was given (should not have received any insulin) and on [DATE] at 8:00 AM blood sugar was 204 and no insulin was given (should have received 4 units). Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR indicated [REDACTED].Humalog .(4units) .Administer 4 units .with meals if BS > 200 . Continued review revealed: [DATE] at 12:00 PM blood sugar 156- 4 units insulin given [DATE] at 8:00 AM blood sugar 88- 4 units insulin given [DATE] at 8:00 AM blood sugar 85- 4 units insulin given [DATE] at 9:00 AM blood sugar 96- 4 units insulin given [DATE] at 9:00 AM blood sugar 155- 4 units insulin given [DATE] at 9:00 AM blood sugar 170- 4 units insulin given [DATE] at 9:00 AM blood sugar 98- 4 units insulin given [DATE] at 5:00 PM blood sugar 156- 4 units insulin given [DATE] at 9:00 AM blood sugar 154- 4 units insulin given [DATE] at 5:00 PM blood sugar 145- 4 units insulin given [DATE] at 9:00 AM blood sugar 108- 4 units insulin given [DATE] at 9:00 AM blood sugar 143- 4 units insulin given [DATE] at 8:00 AM blood sugar 134- 4 units of insulin given [DATE] at 8:00 AM blood sugar 182- 4 units of insulin given Interview with the Administrator on [DATE] at 8:00 AM, in the conference room confirmed the nurses failed to follow the physician's orders [REDACTED]. Further interview confirmed this put the residents at risk for potential harm. Interview with the DON on [DATE] at 2:35 PM, in the conference room, confirmed the facility had a critical insulin administration error on [DATE] and since that time have failed to recognize and assess factors placing the diabetic residents at risk.",2020-09-01
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 resident was to receive 4 units of Humalog insulin for a blood sugar reading of 201-250. Continued review revealed on 9/11/16 at 9:00 PM, the resident's blood sugar was 247 and 100 units of insulin was administered instead of 4 units. Medical record review of the Medication Error Report dated 9/12/16 revealed .based on CS (fingerstick lab to determine blood sugar) (blood sugar)- 247 at 9 PM, Agency nurse Administered 100 units of Humalog vs (versus) the ordered 6 units (order indicated 4 units was to be given) .Sent to ER (emergency room ), admitted to CCU (critical care unit) on vent (ventilator to assist breathing) . Review of the Emergency Medical Service or Ambulance Service (EMS) record dated 9/12/16 revealed at 6:00AM, .Unresponsive .Blood glucose reading/level; low comments: 30 (blood glucose reading was 30 with any level under 70 considered low) .Upper Right Lung Rhonci (continuous rattling lung sounds caused by obstruction or secretions): Upper Left Lung Rhonci; Lower Right Lung; Rhonci: Lower Left Lung; Rhonci . At 6:15 AM, .Blood Glucose Reading/Level: 216 . and at 6:16 AM, .Medication Administration [MEDICATION NAME] 50% Syringe (intravenous solution to raise blood sugar levels) .Result after improved .Blood Glucose Reading/Level: 130 .Glasco Coma Scale GCS (neurological scale used to assess conscious state) .6 (less than 8 is considered comatose) .Respiratory Effort: Labored . Further review of the EMS record revealed, .Altered Mental Status and [DIAGNOSES REDACTED] .Pt (patient) was found unresponsive with low blood sugar .Upon arrival to destination (hospital) there is no improvement in his condition . Review of a signed statement by Licensed Practical Nurse (LPN) #1 on 9/12/16, revealed the LPN was scheduled to work at the facility on 9/11/16 from 7 PM to 7 AM. Further review revealed she checked the resident's blood sugar at approximately 8:30 PM and it was 247. Continued review revealed .I read the (insulin order) to say 100 units of Humilin R Insulin, I gave the 100 units and continued with med pass .walked the halls and noticed my male patient/resident breathing heavily around 11:30 PM, I checked his blood sugar at this time and it was 197 .went back to check on sliding scale around 5am .checked blood sugar and (blood sugar) 30. MD (Physician) was called and ordered instant glucose .start an IV (intravenous catheter in a vein to administer fluids and medications) .and if IV can't be started to send to ER .(emergency room ) . Interview with LPN #1 on 7/17/17 at 6:55 PM, via telephone, confirmed 100 units of insulin was administered to Resident #1 in error. Further interview confirmed she .read the dosage wrong .realized 1 or 2 hours later when he was sleeping .I went back and looked at the order . Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an eMAR dated (MONTH) (YEAR) with a physician's orders [REDACTED].Humalog 100 units/ml .Four Times Daily Starting 3/18/2017 Sliding Scale Insulin .Blood Sugar is 201.00-250.00 (give) 4 units . Continued review revealed on 7/10/17 at 12:00 PM, Resident #7's blood sugar was 236 and 6 units of insulin was given, 2 more units of insulin than was necessary. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an eMAR with a physician's orders [REDACTED].Humalog 100 unit/ml .before meals Starting 04/18/2017 .Give 4 units .For Blood Sugar > (greater than) 200 . Continued review revealed on 4/26/17 at 12:00 PM, Resident #13's blood glucose was 194 and 4 units were given to the resident, which was not necessary according to the physician's orders [REDACTED]. Medical record review of the eMAR with a physician's orders [REDACTED].#13's blood glucose was 181 and 4 units were given to the resident, which was not necessary according to the physician's orders [REDACTED]. Interview with the Director of Nursing (DON) on 7/26/17 at 2:35 PM, in the conference room, confirmed nurses were expected to follow the physician's orders [REDACTED]. Medical record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Consultant Pharmacist's Medication Regimen for Resident #14 dated 3/1/17-3/14/17 revealed .Med Occurrence-transcription discrepancy resulting in error .1/30/17 order to increase [MEDICATION NAME] (fast-acting insulin) to 10 u (units)w (with) / each meal if 'BG (blood glucose or blood sugar) > 300 give 4 additional units'. The order on the eMAR states to give 4 additional units if BG 300 on several occasions in (MONTH) and the additional doses should have been given)(notified nurse (name) to correct this date 3/13/17; she stated the dose was given for BS (blood surgar) > 300) . Medical record review of the MARs for the time period revealed documentation did not clearly indicate when the additional insulin was administered or not administered. Medical record review of a physician's orders [REDACTED].Increase [MEDICATION NAME] to 12 (u) units w (with) meals TID (3 times a day) + (plus) extra 4 u if BG > 300 . Medical record review of the MAR indicated [REDACTED].[MEDICATION NAME] 100 unit/ml .Three Times Daily Starting 5/3/17 .give 12 units with meals (give extra 4 units if BG > 300) . Continued review revealed on 6/2/17 the blood sugar was 284 and 16 units of insulin was given, 4 more units of insulin than was necessary. Interview with the DON on 7/26/17 at 2:35 PM, in the conference room, confirmed when a nurse failed to follow the insulin order, residents were at risk for potential harm. Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Consultant Pharmacist's Medication Regimen report dated 4/1/17-4/11/17 revealed .Documentation/charting issues .Humalog is only to be given when blood sugar is above 200. It was documented as given 5 times so far this month when it should have been held . Medical record review of the (MONTH) (YEAR) eMAR with a physician's orders [REDACTED].[MEDICATION NAME] 100 unit/ml .Four Times Daily Starting 2/20/217 .sliding scale .Blood Sugar is 150.00-199.00 (give) 1 Units .Blood Sugar is 200.00-249.00 (give) 2 Units .Blood Sugar is 300.00-349.00 (give) 4 units .Blood Sugar is > 349.00 (give) 5 units . Continued review revealed on 3/1/17 at 5:00 PM Resident #20's blood sugar was 353 and 6 units of insulin was given, 1 unit of insulin more than necessary, and on 3/12/17 at 5:00 PM, the resident's blood sugar was 343 and 5 units of insulin was given, 1 unit of insulin more than was necessary. Medical record review of the (MONTH) (YEAR) eMAR with a physician's orders [REDACTED].Humalog 100 units/ml .Two Times Daily .Starting 4/18/17 .If BG > 200 at breakfast and supper give 4 units of Humalog . Continued review revealed on 5/6/17 at 5:00 PM, Resident #20's blood sugar was 192 and 4 units of insulin was unnecessarily given (should not have received any insulin). Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the (MONTH) (YEAR) eMAR with a physician's orders [REDACTED].Humalog 100 unit/ml .Administer 4 units .with meals if BS > 200 . Continued review revealed the blood sugar on 2/18/17 at 12:00 PM, was 156 and 4 units of insulin was given to the resident, which was unnecessary according to the physician's orders [REDACTED]. Further review revealed at 5:00 PM the blood sugar level was 94. Medical record review of the (MONTH) (YEAR) eMAR revealed the blood sugar on 3/5/17 at 8:00 AM, was 85 and 4 units of insulin was administered, which was not necessary. Medical record review of the (MONTH) (YEAR) eMAR with a physician's orders [REDACTED]. Further review revealed the insulin was administered when and not necessary. Medical record review of the (MONTH) (YEAR) eMAR with a physician's orders [REDACTED]. Humalog 100 unit/ml .(4units) .Two Times Daily Starting 4/10/2017 .Administer 4 units .for BG > 200 . Continued review revealed the following unnecessary insulin administration: 4/14/17 at 9:00 AM blood sugar 96-4 units of insulin given 4/15/17 at 9:00 AM blood sugar 155- 4 units insulin given 4/16/17 at 9:00 AM blood sugar 170- 4 units insulin given 4/20/17 at 9:00 AM blood sugar 98-4 units insulin given 4/21/17 at 5:00 PM blood sugar 156-4 units insulin given 4/23/17 at 9:00 AM blood sugar 154-4 units insulin given 4/27/17 at 5:00 PM blood sugar 145- 4 units insulin given 4/29/17 at 9:00 AM blood sugar 108-4 units insulin given 4/30/17 at 9:00 AM blood sugar 143- 4 units insulin given Medical record review of the (MONTH) (YEAR) eMAR with a physician's orders [REDACTED].#22's blood sugar was 134 and 4 units of insulin was given unnecessarily, and on 5/17/17 at 8:00 AM, the resident's blood sugar was 182 and 4 units of insulin was given unnecessarily. Interview with the Administrator on 7/26/17 at 8:00 AM, in the conference room, confirmed the nurse failed to follow the physician's orders [REDACTED]. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED].Humalog (insulin) 4 (units) if blood sugar (greater than) 150 . Medical record review of Resident #5's eMAR dated 2/16/17 at 5:00 PM revealed a blood sugar of 100 with documentation LPN #2 gave 4 units of insulin when it was not needed. Review of Resident #5's eMAR dated 2/25/17 at 8:00 AM revealed a blood sugar of 102 with documentation LPN #3 gave 4 units of insulin when it was not needed. Medical record review of Resident #5's eMAR dated 2/26/17 at 8:00 AM revealed a blood sugar of 130 with documentation LPN #4 gave 4 units of insulin when it was not needed. Medical record review of Resident #5's eMAR dated 3/6/17 at 8:00 AM revealed a blood sugar of 137 with documentation LPN #2 gave 4 units of insulin when it was not needed. Interview with LPN #8 Nurse Manager on 7/25/17 at 3:58 PM, in the DON's office, confirmed a nurse's initials on the resident's MAR meant medication was given. Further interview confirmed LPNs #2, #3, and #4 administered insulin when it was not needed per the physician's orders [REDACTED]. Interview with LPN #2 on 7/26/17 at 5:52 PM, via telephone, confirmed she administered insulin outside of parameters for Resident #5. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's orders [REDACTED].(4 units) .two times daily .Hold if BG (blood glucose) (less than) 120 . Medical record review of Resident #16's eMAR dated 1/2/17 at 9:00 AM revealed a blood sugar of 88 with documentation LPN #5 gave 4 units of insulin when it was not needed. Medical record review of Resident #16's eMAR dated 1/3/17 at 9:00 AM revealed a blood sugar of 77 with documentation LPN #5 gave 4 units of insulin that was not needed. Medical record review of Resident #16's eMAR dated 1/6/17 at 9:00 AM revealed a blood sugar of 76 with documentation LPN #5 gave 4 units of insulin that was not needed. Medical record review of Resident #16's eMAR dated 1/10/17 at 9:00 AM revealed a blood sugar of 115 with documentation LPN #6 gave 4 units of insulin that was not needed. Interview with LPN #8 Nurse Manager on 7/25/17 at 3:58 PM, in the DON's office confirmed LPN #5 and LPN #6 administered insulin when it was not necessary per physician's orders [REDACTED]. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's orders [REDACTED].Humalog 8 (units) .(with) each meal .hold if (blood sugar) (less than) 110 .if (blood sugar) (greater than) 400 give 4 (additional) (units) .check (blood sugar) (3 times a day) (before meals) . Medical record review of Resident #18's eMAR dated 4/20/17 revealed, .Humalog (8 units) .Notes .hold if below 110 If greater than 400 give 4 additional units . Medical record review of Resident #18's eMAR dated 6/30/17 at 12:00 PM revealed a blood sugar of 104 with documentation RN #1 gave 4 units of insulin when it was not needed. Medical record review of Resident #18's eMAR dated 7/2/17 at 12:00 PM, revealed a blood sugar of 100 with documentation RN #1 gave 4 units of insulin when it was not needed. Interview with LPN #8, Nurse Manager, on 7/25/17 at 3:58 PM, in the DON's office, confirmed RN #1 administered insulin when it was not indicated by the physician's orders [REDACTED]. Interview with the DON on 7/26/17 at 2:35 PM, in the DON's office, confirmed if a nurse administered insulin to a resident with a blood sugar of 100, and the physician's orders [REDACTED].",2020-09-01
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 died on [DATE]. Medical record review of the Physicians Order dated [DATE] revealed .Humalog (fast acting) .Sliding Scale Insulin .Four Times Daily .Blood Sugar is 201XXX,[DATE].00 .(give) 4 units . Medical record review of the electronic Medication Administration Record [REDACTED].Humalog (insulin) 100 unit/ml (milliliter) .Four Times Daily XXX[DATE] Sliding Scale Insulin .Blood Sugar is 201XXX,[DATE]XXX,[DATE] units . Continued review revealed on [DATE] at 9:00 PM the resident's blood sugar was 247 and 100 units of insulin was given, when only 4 units of insulin should have been administered to the resident. Review of a signed statement by LPN #1 dated [DATE], revealed the LPN was scheduled to work at the facility on [DATE] from 7:00 PM to 7:00 AM. Further review revealed she checked the resident's blood sugar at approximately 8:30 PM and it was 247. Continued review revealed .I read the (insulin order) to say 100 units of Humilin R Insulin, I gave the 100 units and continued with med pass .walked the halls and noticed my male patient/resident breathing heavily around 11:30 PM, I checked his blood sugar at this time and it was 197 .went back to check on sliding scale around 5am .checked blood sugar and 30 (below 70 considered low). MD (physician) was called and ordered instant glucose .start an IV (intravenous catheter in a vein to administer fluids and medications) .and if IV can't be started to send to ER (emergency room ) Further review revealed the resident was sent to the ER. Continued review revealed the EMS (Emergency Medical Service or Ambulance) started an IV on the resident and the resident was taken to the hospital. Review of an EMS record for Resident #1 dated [DATE], revealed at 6:00 AM, .Unresponsive .Blood glucose reading/level; low comments: 30 .Upper Right Lung Rhonchi (abnormal breath sound): Upper Left Lung Rhonchi; Lower Right Lung; Rhonchi: Lower Left Lung; Rhonchi . Further review revealed at 6:15 AM, .Blood Glucose Reading/Level: 216 . and at 6:16 AM .Medication Administration [MEDICATION NAME] 50% Syringe 25 (25 ml of IV solution with [MEDICATION NAME] to increase blood sugar) .Intravenous; Result after improved .Blood Glucose Reading/Level: 130 .Glascow Coma Scale (scale to detect level of consciousness) .6 (below 8 indicates comatose) .Respiratory Effort: Labored . Further review revealed, .Altered Mental Status and [DIAGNOSES REDACTED] (low blood sugar) .Pt (patient) was found unresponsive with low blood sugar .Then activated 911. Pt found unconscious and unresponsive .Upon arrival to destination (hospital) there is no improvement in his condition . Review of a Clinical Note dated [DATE] at 6:25 AM revealed Insulin dose is listed incorrectly, 100 units were given. On call Dr (physician) was called; orders were to start IV, if IV can't be started, then send to ER .Sent to ER. Last blood sugar 215 at 5:45 am . Phone interview with LPN #1 on [DATE] at 6:55 PM, confirmed, LPN #1 did not start an IV because she was not IV certified. Further interview confirmed she did not ask for help. Review of a Clinical Note dated [DATE] at 6:39 AM, reveaIed Instant Glucose given. Chocolate pudding and orange (juice) given. Review of a Medication Error Report dated [DATE] revealed CS (blood sugar) - 247 at 9 PM, Agency nurse Administered 100 units of Humalog vs (versus) the ordered 6 units (4 units per the MAR) .Sent to ER, admitted to CCU (Critical Care Unit) on vent (ventilator to aid in breathing) . Medical record review of a critical care progress note dated [DATE], from the hospital, revealed, .Acute [MEDICAL CONDITION]: Requiring mechanical ventilation day 15. Unable to wean due to severe [MEDICAL CONDITION] (abnormal brain function), apnea (temporarily stop breathing) .Aspiration pneumonia (lung infection after inhaling food) . Medical record review of a Medicine Progress Report dated [DATE], from the hospital, revealed .Patient remains intermittently alert but totally unresponsive to voice. He opens his eyes, though he does not track movement . Interview with the Administrator and Director of Nursing (DON) on [DATE] at 4:30 PM, in the DON's office, confirmed LPN #1 was an agency nurse that was working at the facility on [DATE] night shift. Further interview confirmed the LPN administered 100 units of insulin to Resident #1 in error. Interview with the Medical Director on [DATE] at 10:35 AM, in the conference room, confirmed LPN #1 made a significant medication error. Continued interview confirmed she directed the LPN to monitor the resident closely after the insulin overdose, but at the time the blood sugar was maintained. Further interview confirmed the next call she received from LPN #1 was early morning and the blood sugar was low. The Physician instructed the LPN to follow the hypoglycemic protocol, if the resident was cooperative to administer the [MEDICATION NAME], start an IV, and if unable to start the IV, to send the resident to the ER. Continued interview confirmed the hypoglycemic episode of Resident #1 could have led to the resident becoming unstable. Interview with LPN #1 on [DATE] at 6:55 PM, by phone, revealed she worked night shift on [DATE]. Continued interview confirmed she did administer 100 units of insulin to Resident #1 by error. Continued interview confirmed .I read the dosage wrong . Continued interview confirmed the LPN gave the 100 units of insulin at around 9 (9:00) PM; the resident's blood sugar was 237 at that time. Further interview confirmed she knew something was not right because the resident was sleeping hard .couldn't wake him up .trying to give him pudding and orange juice . Continued interview confirmed she went back to check the insulin order and realized the error (unsure of what that time was). Further interview confirmed LPN #1 did not start an IV because she was not IV certified and she did not ask for help. Medical record review revealed Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the eMAR dated [DATE] revealed .Humalog .sliding scale .Four Times Daily Starting [DATE] .Blood Sugar is 301XXX,[DATE].00 (give) 8-units . Continued review revealed on [DATE] at 5:30 PM the blood sugar was 310 and 6 units was given when 8 units should have been administered to the resident. Interview with the DON on [DATE] at 2:35 PM, in the conference room, confirmed the Physician's Orders were not followed. Medical record review revealed Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Sliding Scale Insulin Order dated [DATE] revealed .[MEDICATION NAME] R .TID (three times daily) .Scale A .Blood Sugar is ,[DATE] give 4 units .Blood Sugar is ,[DATE] give 6 units . Medical record review of the eMAR dated (MONTH) (YEAR) revealed .[MEDICATION NAME] R U-100 100 unit/ml .Three Times Daily Starting [DATE] .Blood Sugar is 151XXX,[DATE].00 (give) 4 units .Blood Sugar is 251.00- 300.00 (give) 6 units . Continued review revealed no sliding scale for blood sugar results of ,[DATE] on the eMAR. Further review revealed on [DATE] the blood sugar was 214 and 6 units of insulin was given, the dosage for the ,[DATE] range on the eMAR. Medical record review of the facility's Sliding Scale A parameters dated [DATE] revealed, XXX,[DATE] give 6 units . Medical record review of the Sliding Scale Insulin Order dated [DATE] revealed .Humalog .TID .Scale A .Blood Sugar is ,[DATE] give 4 units .Blood Sugar is ,[DATE] give 6 units . Medical record review of the eMAR dated (MONTH) (YEAR) revealed .[MEDICATION NAME] R U-100 100 unit/ml .Three Times Daily Starting [DATE] .Blood Sugar is 151XXX,[DATE].00 (give) 4 units .Blood Sugar is 251.00- 300.00 (give) 6 units . Continued review revealed no sliding scale for blood sugar results of ,[DATE] on the EMAR. Further review revealed the following: [DATE] at 9:00 PM-blood sugar ,[DATE] units of insulin (range not indicated on eMAR) [DATE] at 9:00 PM-blood sugar ,[DATE] units of insulin (range not indicated on eMAR) [DATE] at 9:00 AM-blood sugar ,[DATE] units of insulin (4 units ordered) Interview with LPN #11 on [DATE] at 1:45 PM, in the 300 nurse's station, confirmed she failed to follow the Physician's Order for the sliding scale insulin. Interview with LPN #10 on [DATE] at 4:05 PM, by phone confirmed the insulin administration could have been an error. Further interview confirmed she was not instructed how to enter orders in the electronic record by order set and she put the insulin order in manually. Continued interview confirmed she was not aware she made an error while entering the insulin order on Resident #6 on [DATE] when she administered the insulin. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Consultant Pharmacist's Medication Regimen Review dated [DATE]-[DATE] revealed .Documentation/charting issues .Humalog 6 units bid (twice a day) with hold parameter for BS Medical record review of the Sliding Scale Insulin Order dated [DATE] revealed .Humalog .TID (three times a day) XXX,[DATE] give 0 units XXX,[DATE] give 2 units . Medical record review of the (MONTH) (YEAR) eMAR with a Physician's Order dated [DATE] revealed .Humalog 100 units/ml .Four Times Daily Starting [DATE] Sliding Scale Insulin .Blood Sugar is 151XXX,[DATE].00 (give) 2 Units . Continued review revealed on [DATE] at 5:00 PM the blood Sugar was 183 and 4 units of insulin was given to the resident when only 2 units should have been administered. Medical record review of the (MONTH) (YEAR) eMAR with a Physicians order dated [DATE] revealed .Humalog 100 units/ml .Four Times Daily Starting [DATE] Sliding Scale Insulin .Blood Sugar is 251XXX,[DATE].00 (give) 6 units . Continued review revealed on [DATE] at 8:00 AM the blood Sugar was 277 and 4 units of insulin was given to the resident when the resident should have received 6 units. Medical record review of the (MONTH) (YEAR) eMAR with a Physician's Order dated [DATE] revealed .Humalog 100 units/ml .Four Times Daily Starting [DATE] Sliding Scale Insulin .Blood Sugar is 0XXX,[DATE].00 0 Units .Blood Sugar is 201XXX,[DATE].00 (give) 4 units . Continued review revealed on [DATE] at 9:00 PM the blood Sugar was 150 and 2 units of insulin was given to the resident when the resident should not have received any insulin. Further review revealed on [DATE] at 5:00 PM, the blood sugar was 202 and 2 units of insulin was given to the resident when the resident should have received 4 units. Medical record review of the (MONTH) (YEAR) eMAR with a Physician's Order dated [DATE] revealed .Humalog 100 units/ml .Four Times Daily Starting [DATE] Sliding Scale Insulin .Blood Sugar is 201XXX,[DATE].00 (give) 4 units .Blood Sugar is 251XXX,[DATE].00 (give) 6 Units . Continued review revealed the following: [DATE] at 9:00 PM the Blood Sugar was 256 and 4 units given when the resident should have received 6 units. [DATE] at 12:00 PM the Blood Sugar was 236 and 6 units given when the resident should have received 4 units. [DATE] at 5:00 PM the Blood Sugar was 217 and 2 units given when the resident should have received 4 units. Medical record review of the (MONTH) (YEAR) eMAR with a Physician's Order dated [DATE] revealed .Humalog 100 units/ml .Four Times Daily Starting [DATE] Sliding Scale Insulin .Blood Sugar is 201XXX,[DATE].00 (give) 4 units . Continued review revealed the following: [DATE] at 5:00 PM the Blood Sugar was 212 and 2 units given when the resident should have received 4 units. [DATE] at 5:00 PM the Blood Sugar was 243 and 2 units given when the resident should have received 4 units. Medical record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Sliding Scale Order dated [DATE] revealed .Scale A XXX,[DATE] give 6 units . Medical record review of the eMAR dated (MONTH) (YEAR) revealed on [DATE] at 6:00 PM the resident's blood sugar was 286 and received 4 units of insulin when the resident should have received 6 units. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Consultant Pharmacist's Medication Regimen Review dated [DATE]-[DATE] revealed .Documentation/charting issues .This patient has an order to get Humalog insulin when blood sugar is above 200 before meals. It has been documented as given 8 times this month when blood sugar was below 200 . Medical record review of the eMAR with a Physicians Order dated [DATE] revealed .Humalog 100 unit/ml .(4 units) .before meals Starting [DATE] .Give 4 units .For Blood Sugar > (greater than) 200 . Continued review revealed on [DATE] at 12:00 PM, the blood glucose was 194 and 4 units were given to the resident when the resident should not have received any insulin. Medical record review of the (MONTH) (YEAR) eMAR revealed on [DATE] at 8:00 AM the blood sugar was 181 and 4 units were given to the resident when the resident should not have received any insulin. Further review revealed [DATE] at 12:00 PM, the blood glucose was 294 and 10 units were given to the resident when the resident should have received only 4 units. Medical record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Consultant Pharmacist's Medication Regimen Review dated [DATE]-[DATE] revealed XXX[DATE] order to increase [MEDICATION NAME] to 10 u/w/each meal (units with each) and if BG > 300 give additional 4 units .(numerous med errors may have occurred; I can't determine from eMAR when additional doses were given but BG has been > 300 on several occasions in (MONTH) and the additional dose should have been given) (notified nurse (name) to correct this date [DATE]; she stated the dose was given for BS > 300) . Medical record review of the (MONTH) (YEAR) eMAR revealed a Physcians order dated [DATE] .[MEDICATION NAME] .12 units with meals (give extra 4 units if BG > 300) . Continued review revealed the following: [DATE] 1:00 PM blood sugar 345- 12 units given (should have received 16 units) and at 5:30 PM the blood sugar was 397, indicating Resident #14 continued to have high blood sugar. [DATE] 1:00 PM blood sugar 325- 12 units given (should have received 16 units) and at 5:30 PM the blood sugar was 441, indicating Resident #14 continued to have high blood sugar. [DATE] 1:00 PM blood sugar 375- 12 units given (should have received 16) and at 5:30 PM the blood sugar was 347, indicating Resident #14 continued to have high blood sugar. [DATE] 1:00 PM blood sugar 320- 12 units given (should have received 16) and at 5:30 PM the blood sugar was 238, indicating Resident #14 continued to have high blood sugar. [DATE] 1:00 PM blood sugar 304- 12 units given (should have received 16). Continued review revealed no documentation for a blood sugar at 5:30 PM. [DATE] 12:00 PM the blood sugar was 325, indicating Resident #14 continued to have high blood sugar and again only received 12 units (should have received 16) and at 5:30 PM the blood sugar was 397, indicating Resident #14 continued to have high blood sugar. [DATE] 1:00 PM blood sugar 324- 12 units given (should have received 16) and at 5:30 PM the blood sugar was 429, indicating Resident #14 continued to have high blood sugar. [DATE] 8:00 AM blood sugar 322- 12 units given (should have received 16) and at 1:00 PM the blood sugar was 358, indicating Resident #14 continued to have high blood sugar and again only received 12 units (should have received 16). Continues review revealed no documentation for the 5:30 blood sugar. [DATE] 5:30 PM blood sugar 333- 12 units given (should have received 16) and at on [DATE] at 8:00 AM the blood sugar was 216, indicating Resident #14 continued to have high blood sugar. [DATE] 1:00 PM blood sugar 346- 12 units given (should have received 16) and at 5:30 PM the blood sugar was 429, indicating Resident #14 continued to have high blood sugar. [DATE] 5:30 PM blood sugar 323- 12 units given (should have received 16) and on [DATE] at 8:00 AM the blood sugar was 232, indicating Resident #14 continued to have high blood sugar. [DATE] 5:30 PM blood sugar 399- 12 units given (should have received 16) and on [DATE] at 8:00 AM the blood sugar was 328, indicating Resident #14 continued to have high blood sugar. Medical record review of the (MONTH) (YEAR) eMAR revealed the following: [DATE] 8:00 AM blood sugar-284 - 16 units of insulin given (should have received only 12) [DATE] 5:30 PM blood sugar-,[DATE] units of insulin given (should have received 16) and on [DATE] at 8:00 AM the blood sugar was 173, indicating Resident #14 continued to have high blood sugar. [DATE] 1:00 PM blood sugar-274 - 10 units of insulin given (should have received 12) and on [DATE] at 8:00 AM the blood sugar was 191, indicating Resident #14 continued to have high blood sugar. Medical record review of the (MONTH) (YEAR) eMAR revealed the following: [DATE] 1:00 PM blood sugar-330 - 12 units of insulin given (should have received 16) and at 5:30 PM the blood sugar was 169, indicating Resident #14 continued to have high blood sugar. [DATE] 1:00 PM blood sugar-307 - 12 units of insulin given (should have received 16) and at 5:30 PM the blood sugar was 205, indicating Resident #14 continued to have high blood sugar. [DATE] 1:00 PM blood sugar-327 - 12 units of insulin given (should have received 16) and at 5:30 PM the blood sugar was 187, indicating Resident #14 continued to have high blood sugar. [DATE] 5:30 PM blood sugar-316 - 12 units of insulin given (should have received 16) and on [DATE] at 8:00 AM the blood sugar was 150, indicating Resident #14 continued to have high blood sugar. Interview with the DON on [DATE] at 2:35 PM, in the conference room, confirmed the nurses failed to follow the Physicians Orders. Continued interview confirmed when a nurse failed to follow the insulin order it put the resident at risk for harm. Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the eMAR dated (MONTH) (YEAR) revealed .[MEDICATION NAME] 100 unit/ml .Four Times Daily Starting [DATE] .sliding scale .Blood Sugar is 150XXX,[DATE].00 1 Units .Blood Sugar is 200XXX,[DATE].00 2 Units .Blood Sugar is 300XXX,[DATE].00 4 units .Blood Sugar is > 349.00 5 units . Continued review revealed the following: [DATE] 5:00 PM blood sugar 353- 6 units insulin given (should have received 5 units) [DATE] 5:00 PM blood sugar ,[DATE] unit insulin given (should have received 2 units) [DATE] 5:00 PM blood sugar 343- 5 units insulin given (should have received 4 units) Review of the Consultant Pharmacist's Medication Regimen report dated [DATE]-[DATE] revealed .Documentation/charting issues .Humalog is only to be given when blood sugar is above 200. It was documented as given 5 times so far this month when it should have been held . Medical record review of the eMAR dated (MONTH) (YEAR) revealed .Humalog 100 units/ml .Two Times Daily .Starting [DATE] .If BG > 200 at breakfast and supper give 4 units of Humalog . Continued review revealed the following: [DATE] 5:00 PM blood sugar 192- 4 units given (should not have received any insulin) [DATE] 8 AM blood sugar 204- 0 units (should have received 4 units) and at 5:00 PM the blood sugar was 293 indicating resident #20 continued to have high blood sugar. Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the eMAR dated (MONTH) (YEAR) revealed .Humalog 100 unit/ml .(4units) .Before meals Starting [DATE] .Administer 4 units .with meals if BS > 200 . Continued review revealed the blood sugar on [DATE] at 12:00 PM was 156 and 4 units of insulin was given to the resident when no insulin should have been administered. Medical record review of the eMAR dated (MONTH) (YEAR) revealed the blood sugar on [DATE] at 8:00 AM was 85 and 4 units was given to the resident when no insulin should have been administered. Medical record review of the eMAR dated (MONTH) (YEAR) revealed the blood sugar on [DATE] was 149 and 4 units of insulin was given to the resident when no insulin should have been administered. Medical record review of the MAR indicated [REDACTED]. Humalog 100 unit/ml .(4units) .Two Times Daily Starting [DATE] .Administer 4 units .for BG > 200 . Continued review revealed the resident received insulin when it should not have been administered on: [DATE] at 9:00 AM blood sugar ,[DATE] units of insulin given [DATE] at 9:00 AM blood sugar ,[DATE] units insulin given [DATE] at 9:00 AM blood sugar ,[DATE] units insulin given [DATE] at 9:00 AM blood sugar ,[DATE] units insulin given [DATE] at 5:00 PM blood sugar ,[DATE] units insulin given [DATE] at 9:00 AM blood sugar ,[DATE] units insulin given [DATE] at 5:00 PM blood sugar 145- 4 units insulin given [DATE] at 9:00 AM blood sugar ,[DATE] units insulin given [DATE] at 9:00 AM blood sugar 143- 4 units insulin given Medical record review of the MAR indicated [REDACTED]. Continued review revealed on [DATE] at 8:00 AM, the blood sugar was 182 and 4 units of insulin was given when no insulin should have been administered. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physician's Order dated [DATE] revealed, .Humalog (insulin) 4 (units) if blood sugar (greater than) 150 . Medical record review of Resident #5's eMAR dated [DATE] at 5:00 PM revealed a blood sugar of 100 with documentation LPN #2 gave 4 units of insulin when it was not ordered. Review of Resident #5's eMAR dated [DATE] at 8:00 AM revealed a blood sugar of 102 with documentation LPN #3 gave 4 units of insulin when it was not ordered. Medical record review of Resident #5's eMAR dated [DATE] at 8:00 AM revealed a blood sugar of 130 with documentation of LPN #4 gave 4 units of insulin when it was not ordered. Medical record review of Resident #5's eMAR dated [DATE] at 8:00 AM revealed a blood sugar of 137 with documentation of LPN #2 gave 4 units of insulin when it was not ordered. Interview with LPN #8 Nurse Manager on [DATE] at 3:58 PM, in the DON's office, confirmed a nurse's initials on the resident's eMAR mean medication was given. Further interview confirmed LPNs #2, # 3, and #4 administered insulin when it was not needed per the physician's orders. Continued interview confirmed Resident #5's initial order had been transcribed incorrectly. Further interview confirmed RN #1 should have administered the insulin, resulting in a significant medication error. Interview with LPN #2 on [DATE] at 5:52 PM, via telephone, confirmed she administered insulin outside of parameters for Resident #5. Medical Record Review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Physician's Orders documented on the (MONTH) (YEAR) MAR, revealed, .[MEDICATION NAME] (short acting insulin) .(4 units) .two times daily .Hold if BG (blood glucose) (less than) 120 . Medical record review of Resident #16's MAR indicated [REDACTED]. Medical record review of Resident #16's MAR indicated [REDACTED]. Medical record review of Resident #16's MAR indicated [REDACTED]. Medical record review of Resident #16's MAR indicated [REDACTED]. Medical record review of Physicians Orders dated [DATE] revealed, .[MEDICATION NAME] 6 units .Hold if (blood sugar) (less than) 120 . Medical record review of Resident #16's MAR indicated [REDACTED]. Further review revealed LPN #7 did not administer 6 units of insulin. Interview with LPN #8, Nurse Manager, on [DATE] at 3:58 PM, in the DON's office, confirmed a nurse's initials on the resident's eMAR mean medication was given. Further interview confirmed not documenting a reason why a medication was held when it should have been given is considered a medication error. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Physician's Orders dated [DATE] revealed, .Humalog 8 (units) .(with) each meal .hold if (blood sugar) (less than) 100 .if (blood sugar) (greater than) 400 give 4 (additional) (units) .check (blood sugar) (3 times a day) (before meals) . Medical record review of a Consultant Pharmacist's Medication Regimen Review for Resident #18 dated [DATE]-[DATE] revealed, .The hold parameter and order for additional units if (blood sugar) (greater than) 400 were not transcribed in the MAR . Medical record review of Resident #18's MAR indicated [REDACTED]. Medical record review of Resident #18's Vital Sign documentation on ,[DATE] /17 at 8:05 AM revealed a blood sugar of 405. Medical record review of Resident #18's MAR indicated [REDACTED]. Medical record review of Resident #18's MAR indicated [REDACTED]. Interview with the Pharmacy Consultant on [DATE] at 1:00 PM, by phone, confirmed pharmacy reviews were conducted on every resident monthly. Further interview confirmed an electronic monthly audit was completed at that time. The pharmacist reviews the MAR indicated [REDACTED]. Continued interview confirmed it was not her responsibility to check for administration errors but if she notes errors or discrepancies she includes them in the monthly report. Interview with the Administrator on [DATE] at 8:00 AM, in the conference room, confirmed the nurses failed to follow the Physician's orders for sliding scale insulin. Further interview confirmed this put the residents at risk for potential harm. Interview with the DON on [DATE] at 2:35 PM, in the conference room, confirmed the facility had a critical insulin administration error on [DATE] and since that time had failed to recognize and assess factors placing the diabetic residents at risk for [DIAGNOSES REDACTED] or [MEDICAL CONDITION] continued interview confirmed, if a nurse administered insulin to a resident with a blood sugar of 100, and the physician's order stated hold for less than 120, it would be considered a medication error.",2020-09-01
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 Residents #1, #4, #5, #6, #7, #12, #13, #14, #16, #18 #20, and #22 revealed significant medication errors, unnecessary medications administered, missing documentation of blood glucose monitoring, and failure to follow Physicians orders throughout medical records. Interview with the Nursing Home Administrator on [DATE] at 7:45 AM, in the DON's office confirmed a serious insulin error involving Resident #1 occurred on [DATE] in the facility. Continued interview confirmed monthly Consultant Pharmacist Reports were sent to the Director of Nursing (DON) and the Administrator received a report through email. Further interview confirmed she did not review the reports and was not aware of the ongoing errors in transcription, documentation of blood glucose levels, or administration of insulin. Continued interview confirmed it was the Administrator's responsibility to over-see the actions of the facility staff. Refer to F282 (E), F309 (E), F329 (E), F333 (E), F501 (E), F514 (E), F520 (E)",2020-09-01
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 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. Interview with the Medical Director (MD) on [DATE] at 8:00 AM, by phone, and on [DATE] at 8:00 PM, in the Director of Nursing (DON)'s office, confirmed the facility had a critical insulin error for Resident #1 on [DATE]. Continued interview confirmed she took this error to Quality Assurance (QA). The MD stated the goal of Quality Assurance (QA) was to look for the .etiology in errors . Continued interview confirmed there were not any pharmacy reports or major trends in insulin errors discussed in the QA meetings; .I felt we were doing pretty good . Further interview confirmed the MD did not receive copies of the monthly Pharmacy Reports. Further interview revealed the MD was involved in generating protocols and procedures regarding medication administration, but did not do inservices and was not involved in hitting the floor to monitor or audit for errors. Her expectations were education occurred. Further interview confirmed the Consult Pharmacist Reports indicated ongoing transcription errors of insulin orders, errors in administration of insulin, and missing documentation of blood glucose levels occurring in the facility in January, March, April, (MONTH) and (MONTH) (YEAR). Continued interview confirmed she was not aware of the Consultant Pharmacist Reports. Further interview confirmed the Medical Director was responsible for ensuring implementation of resident policies and providing oversight and supervision of medical services and medical care of residents. Refer to F282 (E), F309 (E), F329 (E), F333 (E), F490 (E), F 514 (E), F520 (E)",2020-09-01
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) revealed 27 administrations of insulin, without documentation of the resident's blood sugar, out of 60 opportunities. Medical record review of Resident #5's MAR dated (MONTH) (YEAR) revealed 26 administrations of insulin, without documentation of the resident's blood sugar, out of 62 opportunities. Medical record review of Resident #5's MAR dated (MONTH) (YEAR) revealed 28 administrations of insulin, without documentation of the resident's blood sugar, out of 54 opportunities. Medical record review of Resident #5's MAR dated (MONTH) (YEAR) revealed, 24 administrations of insulin without documentation of the resident's blood sugar, out of 41 opportunities. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Physician's Order on Resident #16's MAR dated 5/15/17 revealed, .[MEDICATION NAME] (insulin) .(6 units) .two times daily .Hold if (blood sugar) (less than) 120 . Medical record review of Resident #16's MAR dated (MONTH) (YEAR) revealed 25 administrations of insulin, without documentation of the resident's blood sugar, out of 27 opportunities. Medical record review of Resident #16's MAR dated (MONTH) (YEAR) revealed 34 administrations of insulin, without documentation of the resident's blood sugar, out of 37 opportunities. Interview with Licensed Practical Nurse (LPN) #8, Nurse Manager, on 7/25/17 at 3:58 PM, in the Director of Nursing (DON) office, confirmed there was incomplete documentation in the medical record. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Consultant Pharmacist's Medication Regimen Review for Resident #18 dated 4/1/17-4/11/17 revealed, .there is no space for recording (blood sugar) on EMAR (Electronic Medication Administration Record) with the order so unclear if this has been done consistently . Medical record review of Resident #18's MAR dated 4/20/17 revealed, .Humalog (8 units) .Notes .hold if below 110 If greater than 400 give 4 additional units . Medical record review of Resident #18's MAR dated (MONTH) (YEAR) revealed blood sugars over 400 on 5/2 at 4:46 PM, 5/6 at 1:10 PM, 5/6 at 5:06 PM, 5/7 at 7:39 AM, 5/7 at 4:34 PM, 5/8 at 4:40 PM, 5/23 at 9:48 AM, 5/30 at 7:52 AM, and at 5/30 at 11:30 AM. Further review revealed no documentation if the additional 4 units of insulin were administered per physician order. Interview with LPN #8, Nurse Manager, on 7/26/17 at 11:10 AM, in the DON's office, confirmed if there was not a physical monitor (a space on the MAR for nurse to document the number of insulin units) placed on the MAR with the insulin order, then there was no place to document the amount of insulin given. Medical record review revealed Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MAR dated (MONTH) (YEAR) revealed .[MEDICATION NAME] R (insulin) .Three Times Daily Starting 6/28/2017 .Blood Sugar is 151.00-200.00 (give) 4 units .Blood Sugar is 251.00- 300.00 (give) 6 units . Continued review revealed no sliding scale for blood sugar results of 201-250 on the MAR. Further review revealed on 6/30/17 the blood sugar was 214 and 6 units of insulin was given. Medical record review of the MAR dated (MONTH) (YEAR) revealed the following: 7/2/17 at 9:00 PM-blood sugar 215-4 units of insulin given 7/5/17 at 9:00 PM-blood sugar 215-4 units of insulin given 7/4/17 at 9:00 AM-blood sugar 152-2 units of insulin given Interview with LPN #10 on 7/20/17 at 4:05 PM, by phone, confirmed she was not aware there was an incomplete scale order on Resident #6's MAR. Interview with LPN #7 on 7/20/17 at 5:20 PM, by phone, confirmed she entered the insulin order in the computer for Resident #6 on 6/28/17. Further interview confirmed she entered the order manually instead of picking an order set from the library and made an error during the order entry. Interview with the Administrator on 7/19/17 at 11:00 AM, in the DON's office, confirmed a 24 hour chart check was completed nightly by the night shift nurse to ensure orders and documentation was correct. Interview with the DON on 7/26/17 at 2:35 PM, in the DON's office, confirmed nurses were not entering insulin orders correctly. Further interview confirmed insulin orders were not to be put in manually unless it was a scale other than scale A or B. Continued interview confirmed transcription errors should be identified during the 24 hour chart checks. Interview with the Administrator on 7/26/17 at 6:42 PM, in the DON office, confirmed documentation was .not as good as it should be . Interview with the Administrator on 7/27/17 at 7:45 AM, in the DON office, confirmed blood sugars should be documented on the MAR. Continued interview confirmed if no blood sugars were documented, .how are we supposed to know . if the correct dose had been given. Refer to F333",2020-09-01
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, (MONTH) and (MONTH) (YEAR) revealed documentation from the Consultant Pharmacist indicating problems with insulin errors, transcription errors, and problems with documentation of blood sugar levels. Interview with the Director of Nursing (DON) on [DATE] at 2:35 PM, in the DON's office, confirmed she received the monthly Consultant Pharmacist's Medication Regimen reports, as well as the Administrator. Continued interview confirmed the Quality Assurance (QA) members met monthly and after the critical insulin error on [DATE], it was brought to QA meeting. The DON initiated insulin education for nurses and initiated medication observation audits monthly after [DATE].We probably should have done better . The Medical Director, Administrator and Director of Nursing met monthly to discuss any pertinent problems. Interview with the Medical Director (MD) on [DATE] at 8:00 AM, by phone, confirmed the goal of QA was to look for the .etiology in errors . Continued interview confirmed there were not any pharmacy reports or major trends in insulin errors discussed in the QA meetings.I felt we were doing pretty good . Further interview confirmed the MD did not receive copies of the monthly Pharmacy Reports and the QA Team failed to identify ongoing insulin administration errors, errors in transcription of insulin orders, and lack of blood sugar monitoring. Refer to F282 (E), F309 (E), F329 (E), F333 (E), F490 (E), F501 (E), F514 (E)",2020-09-01
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 indicating the resident was severely cognitively impaired. Continued review revealed Resident #80 required 1 person assist for bed mobility, locomotion on unit, eating, toileting, dressing and hygiene. Continued review revealed the resident was always incontinent of urine and bowel and was not managed on a bowel and bladder incontinence program. Medical record review of the quarterly care plan, undated, revealed the resident was always incontinent .nursing to check every 2 hours and change if wet/soiled and clean skin with mild soap and water .apply moisture barrier . Continued review revealed Bowel Continence: incontinent of bowel movement .check for incontinence .every 2 hours .clean and dry skin if wet or soiled . Further review revealed Resident #80 required extensive assistance with bathing, hygiene, dressing and grooming with goal .will be odor free . Medical record review of the ADL (Activities of Daily Living) Verification Worksheet revealed Resident #80 was provided incontinence care on 8/13/18 at 12:54 AM with the next incontinence care documented on 8/13/18 at 6:40 PM at time lapse of 17 hours and 46 minutes. Observation of Resident #80 on 8/13/18 at 10:48 AM, in the 2 South dining room, revealed the resident with front of pants and perineal area wet. Observation of Resident #80 on 8/13/18 at 11:59 AM, in the dining room, revealed the resident with front of pants and perineal area wet and had a strong urine odor. Observation of Resident #80 on 8/13/18 at 4:03 PM, in the resident's room, revealed the resident sitting in a wheelchair in his room. Continued observation revealed Resident #80's pants and the bottom front of his shirt were wet and soiled with a brown and dark yellow ring at the bottom of the shirt and had a strong urine odor. Interview with Licensed Practical Nurse (LPN) #1 on 8/13/18 at 4:06 PM, in the resident's room, confirmed the resident's pants and shirt were wet with urine and he was in need of incontinence care. Continued interview revealed the last time resident had been provided incontinence care or toileted was unknown. Further interview confirmed the resident had a strong odor of urine. Interview with the DON on 8/15/18 at 3:50 PM, in the conference room, confirmed a resident wet with urine and with a strong odor of urine, sitting in the dining room area, could be offensive to other residents and could result in feelings of embarrassment for the resident.",2020-09-01
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 required 2 person assistance with bed mobility and 1 person assistance for transfers, dressing, toileting and personal hygiene. Continued review revealed a Brief Interview for Mental Status (BIMS) Score of 3, indicating severe cognitive impairment. Observation and interview with Resident #131 on 8/13/18 at 9:36 AM, in the resident's room, revealed a cup of pills sitting on the resident's over bed table. Interview with the resident revealed the resident requested to have the medications after breakfast. Further interview revealed the resident had not participated in a care plan meeting to determine if self-administration of medication was appropriate. Interview with Licensed Practical Nurse (LPN) #1 on 8/13/18 at 9:47 AM, on the 2 South hall, confirmed LPN #1 left the medications on the over bed table .because resident likes to take her medication after she eats . Continued interview confirmed the medication was [MEDICATION NAME], SamE, a baby aspirin, and a [MEDICATION NAME]. Observation of the resident on 8/14/18 at 8:29 AM, in the resident's room, revealed a cup of pills sitting on the resident's over bed table. Interview with LPN #1 on 8/14/18 at 8:41 AM, on 2 South, revealed the resident had requested to take the medications after breakfast. Continued interview revealed LPN #1 was unaware if self-administration of medication was care planned for the resident, or if there was written documentation of an IDT assessment for the resident to self-administer medications. Interview with the Director of Nursing (DON) on 8/15/18 at 3:50 PM, in the conference room, confirmed no residents in the facility had been assessed for self-administration of medications. Continued interview confirmed medications were not to be left with residents for self-administration.",2020-09-01
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, and regular eating utensils present. Continued observation revealed the resident had difficulty feeding himself due to the shakiness/tremors of the hands related to the disease process of [MEDICAL CONDITION]. Observation of Resident #54 on 8/15/18 at 8:35 AM, in the resident's room, revealed his pureed breakfast was served in a regular plate, with regular eating utensils, and a bowl. Continued observation revealed the resident had obvious tremors of the upper extremities bilaterally. Observation of Resident #54 on 8/18/18 at 9:20 AM, in the resident's room, revealed the resident had breakfast food of pureed consistency on a regular plate with regular eating utensils, and nectar thick liquids. Continued observation revealed no plate guard and weighted utensils had been provided. Observation of Resident #54 on 8/20/18 at 9:15 AM, in the resident's room, revealed the resident had breakfast food pureed consistency in a divided plate and nectar thick liquids. Further observation revealed no plate guard or weighted utensils had been provided. Interview and observation with Resident #54 on 8/18/18 at 10:00 AM, in the resident's room, revealed the resident had never used weighted silverware and did not want to utilize. Continued interview revealed had used a plate guard and it made eating easier. Observation of resident revealed resident had a regular plate without a plate guard. Interview on 8/18/18 at 10:15 AM during the resident observation with Licensed Practical Nurse (LPN) #1 confirmed the facility had failed to provide Resident #54 with a divided plate, a plate guard, and weighted utensils to promote self-feeding at meal time.",2020-09-01
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 meets its responsibilities in the development of the interdisciplinary care plan .is at the discretion of the Care Planning Committee . Medical record review revealed Resident #119 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #119's ongoing care plan revealed the resident was at risk for falls and interventions implemented included on 12/24/15: non-slick footwear that fits and assist with transfers as needed; instruct on safety measures to reduce the risk of falls (posture, changing positions, use of handrails); keep areas free of obstructions; keep personal items within easy reach; bed to be in lowest position with wheels locked; call light within reach when in room; invite/escort to activities of choice; instruct/remind to call for assist with mobility/transfers; use of proper assistive device wheelchair/walker. On 1/8/16 a sensor alarm in chair was added; on 2/5/16 a bed sensor was added; on 4/15/16 floor mat due to resident transfers self to from wheel chair was added; on 5/9/16 posey grip in wheelchair due to increased falls was added; 10/14/16 toileting as needed and Call Before You Fall signs was added; and on 5/30/17 anti-tip bars and anti-lock brakes to wheelchair was added. Medical record review revealed Resident #119 had 9 falls from 7/1/17 - 7/10/18 with dates of falls 7/1/17, 8/20/17 (resulting in a laceration to the forehead requiring sutures), 10/15/17, 11/10/17 (resulting in a bone [MEDICAL CONDITION] leg), 11/16/17, 11/19/17, 4/13/18 (resulting in a femur fracture), 6/27/18, and 7/10/18. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #119 required extensive assistance with bed mobility, transfers, dressing, personal hygiene, and was dependent for toileting. Continued review revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating severe cognitive impairment. Medical record review of the Care Plan dated 12/24/15 and revised 7/10/18 revealed the care plan was not revised with the interventions indicated by falls investigations including to toilet every 2 hours (10/15/17 fall), toilet more frequently and utilize bean bag (11/16/17 fall), and for Velcro noodles to mattress rail (7/10/18 fall). Interview with Nurse Mentor (nurse Unit Manager) #1 on 8/18/18 at 9:25 AM in the Mentor's office, confirmed .All of us are responsible to make sure the intervention is to be implemented (revised) on the care plan .Ultimately the mentor is responsible . Interview with the Director of Nursing (DON) on 8/18/18 at 10:36 AM in the conference room, confirmed the care plan had not been revised to include new interventions for toileting interventions (10/15/17 fall and 11/16/17 fall) and Velcro noodles to the mattress (7/10/18 fall) . Medical record review revealed Resident #28 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed Resident #28 required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Continued review revealed a BIMS score of 3, indicating severe cognitive impairment. Medical record review of Resident #28's current care plan, not dated revealed, (Resident #28) is at risk for falls d/t (due to): Decreased mobility, LT (left) [MEDICAL CONDITION] s/p (status [REDACTED]. Actual Falls: 5/19/17, 6/17/17, 2/15/18 with FX (fracture) L (left) distal femur (resolve) Interventions: Assist (Resident #28) to wear non-slick footwear that fits. Attempt to engage (Resident #28) in ADL's (Activities of Daily Living) that improve strength, balance and posture. Instruct (Resident #28) on safety measures to reduce the risk of falls (posture, changing positions, use of handrails.) Keep areas free of obstructions to reduce the risk of falls or injury. Keep nurse call light within reach, Instruct (Resident #28) to use call bell or call out of assistance. Keep personal items within easy reach; bed to be in lowest position with wheels locked. Review of an Incident/Accident Report revealed Resident #28 had a fall on 2/15/18 at 9:45 AM, in the resident's room with injury. Continued review revealed, .Additional comments and/or steps taken to prevent recurrence: Ensure w/c (wheelchair) is within reach while in bed . Medical record review revealed the resident's care plan was not revised to include the intervention to keep the wheelchair within reach while the resident was in bed. Review of an Incident/Accident Report revealed Resident#28 had a fall on 6/7/18 at 2:00 PM in the dining room, CNA (Certified Nurse's Assistant) observed res. (resident) topple forward from her w/c to the floor. Res. remained alert. Skin tear noted to left forearm. Res. did hit her head on right forehead. No bruising @(at) this time . Additional comments and/or steps taken to prevent recurrence: Res. cautioned re: leaning forward in w/c . Medical record review of the resident's care plan revealed the resident's care plan was not revised to reflect the resident's fall on 6/7/18. Interview with Licensed Practical Nurse (LPN) #4 on 8/17/18 at 4:36 PM, in the secure unit, revealed the Household Nurse Mentor for each unit was responsible for updating a resident's care plan after a fall. Interview with Household Nurse Mentor #1 on 8/17/18 at 5:05 PM, in the secure unit nurse's office, revealed the Mentor was responsible for updating Resident #28's care plan with new fall interventions. Continued interview and review of the resident's care plan with the Nurse Mentor confirmed the resident's care plan had not been revised after the resident's fall on 2/15/18 to keep the resident's wheelchair within reach, and confirmed the facility failed to update the resident's care plan after the resident's fall on 6/7/18. Medical record review revealed Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed Resident #34 required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Continued review revealed a BIMS score of 3, indicating severe cognitive impairment. Medical record review of Resident #34's current care plan, not dated, revealed, (Resident #34) is at risk for falls related to Decreased Mobility, Scoliosis, Narcotic and [MEDICAL CONDITION] Medication Use . Continued review revealed the following interventions: .Assist with toileting as needed. Attempt to engage (Resident #34) in ADL's that improve strength, balance and posture. Fall risk assessment as indicated. Keep call light within reach and remind how to use as needed. Keep room free from clutter, walkways clear. Keep frequently used items within reach. Monitor medications for changes that may effect falls. Footwear will fit properly and have non-skid soles. Instruct (Resident #34 on safety measures to reduce the risk of falls (posture, changing positions, use of handrails) .Goals: Resident #34 will have no falls this review period . Review of an Incident/Accident Report revealed Resident #34 had a fall on 2/25/18 at 4:30 AM in the resident's room .Heard someone crying and found pt (patient) on the floor in her room. She states she was going to BR (bathroom) and fell . C/O (complain of) lt (left) hip pain. Skin tear to Lt elbow . Continued review revealed, Additional comments and/or steps taken to prevent recurrence: Call before you fall posted . Medical record review of the resident's care plan revealed Resident #34's care plan was not revised to reflect the resident's fall on 2/25/18 or the new intervention to post the call before you fall sign. Review of an Incident/Accident Report revealed the resident had a fall on 6/16/18 at 9:55 PM in the resident's room .I was told by CNA (Certified Nurse Assistant) that resident was on the floor in her room, went to assess resident, she had skin tear to lt. hand, bump on left side of head and was c/o lt hip pain . Further review revealed, .Additional comments and/or steps taken to prevent recurrence .Call before you fall, posey grip (rubberized mat for resident to sit on while in wheelchair to prevent sliding from chair) . Medical record review of Resident #34's care plan revealed the care plan was not revised to reflect the fall the resident had on 6/16/18 or the new intervention to add the posey grip to the wheelchair. Review of an Incident/Accident Report revealed the resident had a fall on 7/14/18 at 7:05 PM in the resident's room .Resident's roommate was calling for help (staff) and I went to the room and resident was on the floor in front of the sink and blood was pooled around her head . Further review revealed, .Additional comments and/or steps taken to prevent recurrence: Call before you fall. Encourage out of room more . Medical record review of Resident #34's care plan revealed the care plan was not revised to reflect the fall on 7/14/18 or the intervention to .encourage out of room more . Interview and review of the resident's care plan on 8/18/18 at 12:08 PM with the DON, in the conference room, revealed the Household Nurse Mentors on the units were responsible for ensuring revisions to the care plan were completed after a fall. Continued interview confirmed Resident #34's care plan had not been revised to reflect any of the resident's falls, and did not accurately reflect the fall interventions. Medical record review revealed Resident #39 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed Resident #39 required extensive assistance with bed mobility and 1 person assistance for transfers, dressing, toileting and personal hygiene. Continued review revealed a BIMS score of 7, indicating severe cognitive impairment. Medical record review of Resident #39's care plan with a goal date of 6/10/18, revealed the resident was .at risk of falls d/t (due to) weakness, Left sided weakness s/p (status [REDACTED]. Review of the facility documentation revealed the resident had a total of 9 falls between 4/3/18 and 8/11/18. Medical record review revealed Resident #39's care plan was updated to reflect 5 dates the resident had falls: 4/3/18, 4/15/18, 6/7/18, 6/27/18 (fall was actually 6/26/18 according to Icident/Accident Report) and 6/30/18. Continued review revealed the only times the resident's care plan was revised to reflect a new intervention after a fall were 6/7/17 - Call before you fall sign; 6/27/18 (for the 6/26/18 fall) - Pool noodles to bed; 6/30/18 - Frequent rounds; and 7/2/18 - Scoop mattress ordered. Interview with Household Nurse Mentor #2 on 8/15/18 at 7:40 AM, on the 400 unit confirmed the resident's care plan was not revised to reflect new or effective interventions to address Resident #39's continued falls. Interview with the DON on 8/16/18 at 9:30 AM, in the conference room confirmed the facility failed to revise the resident's care plan and failed to implement new or effective interventions to address the resident's continued falls. In summary, Resident #39 had 9 falls between 4/3/18-8/11/18. Interventions on the falls investigation were not consistently placed on the care plan. There were 6 falls with no intervention added to the care plan. Medical record review revealed Resident #40 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the admission MDS dated [DATE] revealed Resident #40 required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Continued review revealed a BIMS score of 3, indicating severe cognitive impairment. Medical record review of Resident #40's care plan dated 5/23/18, revealed Resident #40 is at risk of falls due to weakness, History of Falls, Dementia and Hypertension. Interventions including wear non-slick footwear that fits; instruct the resident on safety measures to reduce risk of falls; attempt to engage in activities of daily living (ADL's) that improve strength; balance and posture, and keep areas free of obstacles to reduce the risk of falls or injury Medical record review of facility documentation revealed the resident had a total of 4 falls between 6/27/18 and 8/2/18. Medical record review of Resident #40's care plan dated 8/6/18 revealed the care plan was not updated to reflect the resident had falls on the following dates: 6/27/18, 7/16/18, 7/30/18 and 8/2/18. Continued review revealed the resident's care plan was not revised to reflect new or effective interventions to address the resident's continued falls resulting in the resident sustaining a head injury. Observation and interview with LPN Nurse Mentor #2 on 8/17/18 at 10:00 AM, in the resident's room, confirmed the resident was in bed with the head of the bed up, fall mats to both sides of the bed were without alarms, and the call light was out of reach of the resident. Further observation revealed the Nurse Mentor took the Call Before You Fall sign off the closet door and asked the resident to read the sign. Continued observation revealed Resident #40 held the sign in her hand, smiled, and stated nice. The resident was not able to read the Call Before You Fall sign. Further interview confirmed .She doesn't use the call bell, she hollers for us . Continued interview confirmed the Call Before You Fall sign was not an appropriate intervention for Resident #40 and re-education on the use of a call light for a severely cognitively impaired resident was not an appropriate fall prevention intervention. Interview with the DON on 8/20/18 at 11:15 AM, in the conference room confirmed the resident had multiple falls without appropriate interventions put in place. In summary, Resident #40 had 4 falls between 6/27/18 and 8/2/18. Interventions on the falls investigation were not placed on the care plan. There were no new interventions added to the care plan after each fall. Medical record review revealed Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission MDS dated [DATE] revealed Resident #47 required extensive assistance of I person with bed mobility, transfers, dressing, toileting and personal hygiene. Continued review revealed a BIMS score of 3, indicating severe cognitive impairment. Medical record review of Resident #47's comprehensive care plan with an effective date of 4/5/18 revealed, .at risk for falls d/t weakness, RT (related to) acetabular fracture (a break in the socket portion of the hip joint) s/p (status/post) fall, vision impairment, [MEDICAL CONDITION], dementia, anxiety, [MEDICAL CONDITION] disorder, [DIAGNOSES REDACTED] and [MEDICAL CONDITION] med use . Continued review of the care plan revealed, .Actual falls 4/9/18, 4/10/18, 4/11/18, 4/14/18, 4/23/18, 4/25/18, 4/26/18, 4/27/18, 5/6/18 .Goals .will maintain current level of mobility with no increase in the incidence of falls/injuries .Interventions .Assist .to wear non-slick footwear that fits .attempt to engage .in ADLs that improve strength, balance, and posture .instruct .on safety measures to reduce the risk of falls (posture, changing positions, use of handrails) .keep areas free of obstructions to reduce the risk of falls or injury .keep nurse call light within easy reach .Instruct .to use call bell or call out for assistance .keep personal items within easy reach; bed to be in lowest position with wheels locked .bean bag provided to reduce the risk of falls .self-releasing lap buddy to reduce the risk for falls with injury . Continued review revealed none of the interventions documented on the care plan had been dated to illustrate when the interventions were initiated and implemented. Review of an Incident/Accident Report dated 4/5/18 and timed 7:30 PM revealed Resident #47 .crawled from his room into (another room). Multiple skin tears on bilateral elbows and L (left) knee bruise . Continued review revealed .Additional comments and/or steps taken to prevent recurrence: call before you fall, bed in low position Medical record review of Resident #47's care plan revealed the resident's care plan was not revised to reflect the resident's fall on 4/5/18 or the intervention to post call before you fall sign. Review of an Incident/Accident Report dated 4/9/18 and timed 10:30 PM revealed the resident had a fall in the resident's room without injury .called to resident room. CNA report that resident had been on floor mat by bed on knees . Further review revealed, .Additional comments and/or steps taken to prevent recurrence: call before you fall, increased rounds . Medical record review of Resident #47's care plan revealed the resident's care plan was not revised to reflect the new intervention of increased rounds. Review of an Incident/Accident Report dated 4/11/18 and timed 2:45 PM revealed, .sitting in wheelchair in day room with spouse. Leaned forward and slid out of chair. Landed on buttock . Continued review revealed, .Additional comments and/or steps to prevent recurrence: Informed spouse of need for full time sitter . Medical record review of Resident #47's care plan revealed no revision to the care plan to reflect the recommendation for the family to hire a sitter. Medical record review of a nurse note dated 4/25/18 revealed, .resident was transferred to floor (to another unit) .he has been getting out of his w/c since he arrived to floor, causing his personal alarm to go off, staff has been able to prevent resident from falling or scooting on the floor up to this point, he has wandered in the area between staff bathroom and med room and scooted himself out of his chair and onto the floor .transferred back to his chair after assessment for injury . Medical record review of the resident's care plan revealed the use of a personal emergency alarm for the resident was not included on the resident's care plan. Review of an Incident/Accident Report dated 4/25/18 and timed 11:30 PM revealed, .CNA notified this nurse that resident was lying in floor beside bed . Review of a Fall Investigation Tool dated 4/25/18 revealed, .intervention .fall mats . Medical record review of Resident #47's care plan revealed no revision to the care plan to reflect the use of fall mats for the resident. Review of an Incident/Accident Report dated 6/13/18 and timed 11:50 AM revealed, .called to room by PT (physical therapy) staff. Pt (patient) was already back in bed but was asleep on mat beside bed when physical therapy found him .he says 'I did not fall or get hurt' . Continued review revealed, .Additional comments and/or steps taken to prevent recurrence: offer rest periods, know whereabouts . Medical record review of Resident #47's care plan revealed the care plan was not revised to reflect the fall on 6/13/18 and was not revised to reflect the interventions of offering rest periods and .know whereabouts . Observation and interview on 8/18/18 at 3:50 PM, in the resident's room, with CNA #17 revealed no call before you fall sign posted. Interview with CNA #17 confirmed fall mats were located on each side of the resident's bed (not on the resident's care plan). Continued interview revealed the CNA had never known the resident to have had any alarms or seatbelts since the time the resident was moved to the secure unit (approximately 2 months ago). Continued observation in the resident's room also revealed no bean bag chair was in the resident's room as documented on the resident's care plan. Interview and review of Resident #47's care plan with the DON on 8/20/18 at 3:45 PM, in the conference room, revealed the Household Nurse Mentor was responsible for ensuring revisions to the resident's care plan after a fall. Continued interview and review of Resident #47's care plan confirmed the resident's care plan was not revised to reflect the fall on 6/13/18 or the interventions of offering rest periods and .know whereabouts . Continued interview confirmed the resident's current plan of care did not accurately reflect the actual interventions which were observed to be in place at this time. Medical record review revealed Resident #80 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the significant change MDS dated [DATE] revealed Resident #80 required extensive assistance with bed mobility and personal hygiene, and was totally dependent upon staff for dressing, eating and personal hygiene. Continued review revealed a BIMS score of 3, indicating severe cognitive impairment. Medical record review of the quarterly care plan undated revealed Resident #80 was at risk for falls. Further review revealed Resident #80's care plan was not updated with effective interventions after falls on 3/1/18, 4/20/18 and 6/19/18 nor after a fall with serious injury on 7/2/18. Medical record review of the clinical notes dated 7/2/18 revealed .returned from (hospital) .C1(cervical)-C2 Fx (Fracture) and Aspen (Rigid neck brace) collar placed around residents neck, collar is to stay in place for 3 months .laceration to forehead with stitches .will continue to monitor . Interview with MDS Coordinator #3 on 8/17/18 at 7:55 AM, in the MDS office, revealed the MDS coordinators updated the care plans quarterly with the MDS assessments. Continued interview revealed the care plans were updated all other times by the nurses on the floor. Interview with LPN #1 on 8/18/18 at 3:00 PM, on 2 South Hallway, revealed interventions were to be placed on the care plan and updated by the .care plan manager . Refer to F689",2020-09-01
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 resulted in the residents receiving only 1 shower per week .Our Kiosk that we document in does not differentiate in partial showers, bed baths, showers or whatever it just says bathing and we mark that no matter what we do but that does not mean that a .shower is done .but it looks like it . Interview with Household CNA Coordinator #1 (a CNA also) on 8/15/18 at 9:40 AM, in the 2 south dining room revealed there are .call offs and have lost some employees and do not always have enough staff to take care of the residents about 2-3 days out of the week . Further interview revealed there had been times the residents had not received showers because of staffing . Interview with CNA #4 on 8/15/18 at 9:56 AM, in the 2 south dining room, confirmed .not always enough staff to meet the needs of the residents .it upsets me .we are understaffed, I can't do my job the way I would like . Continued interview revealed .It's that way almost every day just 2 of us . Interview with LPN #2 on 8/15/18 at 10:05 AM, in the 2 south den area, revealed there was not always enough staff to meet the needs of the residents .like today the person I was working with put her notice in so there is only 1 nurse, the weekends there are not enough CNA's, last Sunday there was only 1 nurse and 2 CNA's .there have been times the residents have not received a shower due to staffing . Interview with LPN #1 on 8/18/18 at 9:12 AM, on the 2 south hallway, confirmed there .is never enough staff .recently had a set back with a CNA getting fired, a nurse quit, a CNA quit .they haven't been replaced .I have reported to the Director of Nursing (DON) and the Administrator . Medical record review revealed Resident #89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 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 # 89's BIMS score was 15, indicating the resident was cognitively intact. Continued review of the MDS revealed the resident was 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 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 was moderately cognitively impaired. Continued review revealed Resident #80 required 1 person assist for bed mobility, locomotion on unit, eating, toileting, dressing and hygiene. Continued review revealed Resident #80 was always incontinent of urine and bowel and was not managed on a bowel and bladder incontinence program. Medical record review of the quarterly care plan, undated, revealed the resident was always incontinent .nursing to check every 2 hours and change if wet/soiled and clean skin with mild soap and water .apply moisture barrier . Continued review revealed Bowel Continence: incontinent of bowel movement .check for incontinence .every 2 hours .clean and dry skin if wet or soiled . Further review revealed a self-care deficit with extensive assistance required with bathing, hygiene, dressing and grooming with goal .will be odor free . Medical record review of the ADL (Activities of Daily Living) Verification Worksheet revealed Resident #80 was provided incontinence care on 8/13/18 at 12:54 AM with the next incontinence care documented on 8/13/18 at 6:40 PM at time lapse of 17 hours and 46 minutes. Observation of Resident #80 on 8/13/18 at 10:48 AM, in the 2 South dining room, revealed the resident with front of pants and around perineal area wet. Observation of Resident #80 on 8/13/18 at 11:59 AM, in the dining room, revealed the resident with front of pants and around perineal area wet and had a strong urine odor. Observation of Resident #80 on 8/13/18 at 4:03 PM, in the resident's room, revealed the resident sitting in a wheelchair in his room. Continued observation revealed Resident #80's pants and the bottom front of his shirt were wet and soiled with a brown and dark yellow ring at the bottom of the shirt and had a strong urine odor. Interview with LPN #1 on 8/13/18 at 4:06 PM, in the resident's room, confirmed the resident's pants and shirt were wet with urine and he was in need of incontinence care. Continued interview revealed the last time resident had been provided incontinence care or toileted was unknown. Further interview confirmed the resident had a strong odor of urine. Interview with the DON on 8/15/18 at 3:50 PM, in the conference room, confirmed a resident wet with urine and with a strong odor of urine, sitting in the dining room area, could be offensive to other residents and could result in feelings of embarrassment for the resident.",2020-09-01
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 nursing assistants on bath/shower days. Any skin issues noted will be reported to the resident's nurse . Review of the facility policy, Pressure Ulcer Treatment, revised 7/18, revealed .If a resident is noted to have a pressure ulcer the nurse in charge of the resident's care should be notified. The nurse should notify the Wound Nurse and Physician .Follow standing orders for pressure ulcers including writing the order as 'per treatment guidelines' .these guidelines have been approved by the Medical Director .The Wound Nurse will evaluate the initial treatment based off the standing orders on their next working day to determine if any changes need to be made based on the condition of the ulcer . Review of the facility policy, Infection Control: Handwashing dated 1/1/17 revealed .All personnel will follow the handwashing procedure to prevent the spread of infection and disease .Employees will perform appropriate handwashing procedures using antimicrobial or non-antimicrobial soap and water under the following conditions .Before, during and after performance of normal duties such as handling dressings .Whenever doubt of contamination .Using gloves does not replace handwashing/hand hygiene . 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 had moderate impaired cognitive skills for daily decision making. Continued review revealed the resident required assistance of 1 person for bed mobility, locomotion on unit, eating, toileting, dressing, hygiene, and 2 person assistance for transfers. Medical record review of the Clinical Note dated 7/2/18, at 10:19 AM, revealed the resident suffered a fall from the bed at approximately 9:10 AM, and was sent to the emergency room for evaluation. Medical record review of the Clinical Note dated 7/2/18 at 8:30 PM, revealed the resident returned from the emergency room at 8:10 PM, with the [DIAGNOSES REDACTED]. Continued review revealed the collar was to stay in place for 3 months then have a follow-up with x-rays to monitor progress. Continued review revealed the resident was also sent with a collar for bathing. Medical record review of the Weekly Skin Assessment Form dated 7/27/18 revealed .Open area to Rt. (right) Clavicle. Medical record review of the Clinical Note dated 7/28/18 at 8:24 AM, revealed on 7/27/18 at 9:21 PM, an open area described as a skin tear was discovered on the resident's right clavicle measuring 3 centimeters (cm) in length by 0.8 cm in width. Medical record review of the Physician's Order and progress notes dated 7/30/18 revealed .Consult wound care team for evaluation and treatment of [REDACTED]. Medical record review of the Clinical Note dated 8/2/18 at 7:29 AM, revealed the resident was evaluated by the Wound Nurse Practitioner (NP). Continued review revealed the wound to the resident's right clavicle measured 3.2 cm by 2.6 cm by 0.2 cm. Continued review revealed the NP described the wound as unstageable at this time and facility acquired pressure ulcer, medical device related injury. Medical record review of the Physician's Order and progress notes dated 8/2/18 revealed .refer to (neuro surgeon) for cervical fracture follow up .Please D/C (discontinue) Hard C-collar .Place patient in soft cervical collar .D/C current wound treatment .[MEDICATION NAME] Blue .R (right) cervical wound .change every 3 days and PRN (as needed) . Medical record review of the Clinical Note dated 8/7/18, revealed the wound to the right clavicle was evaluated by the NP and measured 2.3 cm by 1.1 cm. Review of the Care Plan undated, conducted on 8/14/18 revealed no documentation or update that included C1-C2 fractures, care and use of the cervical collar, pressure ulcer development and specific treatment or interventions. Observation of the resident on 8/14/18 at 5:17 PM, in the resident's room, revealed the resident received wound care to unstageable right clavicle wound provided by Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #1. Continued observation revealed the soiled dressing to right clavicle was removed and contained a moderate amount of yellowish-brown drainage on the dressing, and the wound bed was covered with slough which indicated an unstageable wound. Interview with the Director of Nursing (DON) on 8/16/18 at 9:05 AM, in the conference room, confirmed the expectation was a daily skin assessment to be conducted on residents who wore a splint, or a Cervical Collar. Interview with Licensed Practical Nurse (LPN) #2 on 8/16/18 at 9:30 AM, on 2 South Hallway, revealed skin assessments were conducted by nursing staff weekly. Continued interview revealed the CNAs (Certified Nursing Assistant) reported skin issues that were observed during bathing or care. Further interview revealed residents who wore splints or cervical collars should have had skin checked weekly and when bathed. Interview with CNA #4 on 8/16/18 at 2:21 PM, in the 2 South living room area, revealed CNAs were not allowed to remove the C-Collar. Continued interview revealed the nurse changed the soft collar out with one used on bath days. Further interview revealed the C-collar had not been removed except for bath days. Interview with CNA Household Coordinator #1 on 8/16/18 at 2:23 PM, in the 2 South living area, revealed CNAs did not remove cervical collars. Continued interview revealed the nurse changed the cervical collar for shower days. Interview with CNA #3 on 8/16/18 at 2:42 PM, in the 2 South living room area, revealed the C-collars were exchanged for showers and that was the only time the C-collar was removed. Interview with the wound NP on 8/17/18 at 5:10 PM, in the conference room, revealed the wound to right clavicle was a preventable, avoidable, medical device induced pressure ulcer. Medical record review revealed Resident #119 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation with the Wound Care Nurse on 8/15/18 at 8:14 AM, in Resident #119's room, revealed the Wound Care Nurse prepared for wound care for 2 pressure ulcers and 1 lesion: *Stage 2 pressure ulcer located on the right heel *Lesion on the left foot *Stage 2 pressure ulcer located on the L ischial Continued observation revealed the Wound Care Nurse washed her hands, applied clean gloves, removed sock from the right heel, applied wound cleanser and applied [MEDICATION NAME] to pressure ulcer. Continued observation revealed she reapplied sock to the right foot and removed sock from left and applied wound cleaner to the left foot lesion with her contaminated glove. Further observation revealed she placed her gloved contaminated fifth digit of her hand in triad cream and placed it on the left foot lesion. Continued observation revealed the Wound Care Nurse reapplied the resident's left sock and repositioned the resident's pants to reveal the left ischium pressure ulcer. Further observation revealed she removed the dressing with her contaminated gloved hands then removed the contaminated gloves. Continued observation revealed she applied clean gloves to her uncleaned hands. Further observation revealed she measured the left ischium pressure ulcer with her contaminated gloves, applied wound cleanser to the pressure ulcer, placed the [MEDICATION NAME] Blue directly on the wound, and applied a new dressing with unclean hands. Continued observation revealed she placed the contaminated items in the bag, removed her contaminated gloves and washed her hands. Interview with the Wound Care Nurse on 8/15/18 at 8:25 AM in the conference room, confirmed, .I failed to remove my gloves and wash hands during the dressing change .I applied treatment with dirty gloves . Interview with the Director of Nursing (DON) on 8/16/18 at 9:52 AM in the conference room confirmed .She failed to wash her hands and apply clean gloves during the dressing change. She (Wound Care Nurse) did not follow infection control practices and did not follow our policy .",2020-09-01
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 recent stroke. b. Often, factors in varying degrees contribute to a falling problem .Treatment/Management - 1.Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling .If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance) .The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. a. Frail elderly individuals are often at greater risk for serious adverse consequences of falls. b. Risks of serious adverse consequences can sometimes be minimized even if falls cannot be prevented. 3. If interventions have been successful in preventing falling, the staff will continue with current approaches or reconsider whether these measures are still needed if the problem that required the intervention (for example, dizziness or musculoskeletal pain) has resolved. 4. If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will reevaluate the continued relevance of current interventions. 5. As needed, the physician will document the presence of uncorrectable risk factors, including reasons why any additional search for causes is unlikely to be helpful . Review of facility policy, Accident and Incident Report-Resident, dated 1/1/17 revealed .When an accident or incident involving a resident occurs, any person witnessing the incident will call for appropriate assistance .To assure appropriate follow-through on all accidents and incidents. To study the cause of accident and incidents and to give guidance for corrective/preventive action .Do not move the resident until a licensed nurse evaluates the condition . Medical record review revealed resident #119 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #119's Brief Interview for Mental Status (BIMS) score was 0, indicating the resident had severe cognitive impairment. Continued review of the MDS revealed the resident was extensive 2 person assist for bed mobility, transfers, and toilet use and was frequently incontinent of urine. Review of facility documentation revealed Resident #119 had 9 falls between 7/9/17 to 7/10/18 and 2 falls resulted in traumatic injury. Medical record review of Resident #119's ongoing care plan revealed the resident was at risk for falls and interventions implemented included on 12/24/15: non-slick footwear that fits and assist with transfers as needed; instruct on safety measures to reduce the risk of falls (posture, changing positions, use of handrails); keep areas free of obstructions; keep personal items within easy reach; bed to be in lowest position with wheels locked; call light within reach when in room; invite/escort to activities of choice; instruct/remind to call for assist with mobility/transfers; use of proper assistive device wheelchair/walker. On 1/8/16 a sensor alarm in chair was added; on 2/5/16 a bed sensor was added; on 4/15/16 floor mat due to resident transfers self to from wheel chair was added; on 5/9/16 posey grip in wheelchair due to increased falls was added; 10/14/16 toileting as needed and Call Before You Fall signs was added; and on 5/30/17 anti-tip bars and anti-lock brakes to wheelchair was added. Medical record review of a Clinical Notes Report dated 7/1/17 at 10:16 PM, revealed, .res (resident) alarm heard sounding at same time of a loud crash .res in bathroom, on the floor, wheelchair by sink. Brakes on wheelchair not on .no injuries .Will continue to monitor closely and respond to alarms . Interview with the DON on 8/17/18 at 10:25 AM, in the conference room, confirmed an investigation was not conducted for the fall on 7/1/17 in order to determine the cause of the fall and to implement interventions to prevent further falls. Medical record review of a Falls Risk assessment dated [DATE] revealed Resident #119 scored a 22 (high risk for potential falls). Review of a facility Incident/Accident Report dated 8/20/17 revealed on 8/20/17 at 5:00 PM the resident had a fall. Further review revealed .Resident observed lying in hallway in front of her w/c (wheelchair). Lying with face down and toward right side. Laceration to right forehead, scratch on right cheek .Additional comments and/or steps taken to prevent recurrence: Will ask PT (physical therapy) eval (evaluation) for cushion . Review of a Written Statement for the accident on 8/20/17 revealed, I just sat (Resident #119) back in her chair, she had been leaning forward. I sat down at kiosk by kitchen to chart my vitals. I also noticed before incident she was dragging rt (right) foot under chair. I told her several times from 3 - 4:30 pm to slow down and sit back in her chair so she wouldn't fall (Resident #119 had severe cognitive impairment). As I started charting .another CNA (Certified Nursing Assistant) said oh no, I turned to see (Resident #119) w/c rolling over her, she was on the floor, the w/c flipped . Review of a Written Statement for the accident on 8/20/17 revealed, This nurse was notified that resident had fallen out of her w/c in hallway. Observed lying on the floor in front of her w/c (wheelchair) .Was lying with face down on floor and toward her right side large amt (amount) of blood from laceration on right forehead . Medical record review of a physician's orders [REDACTED].#119 to the emergency room (ER) for evaluation. Medical record review of a Clinical Notes Report dated 8/20/17 at 11:13 PM, revealed, .Resident has stitches in right forehead . Review of the Interdisciplinary Team Review for the accident on 8/20/17, revealed, Interventions implemented was not completed and Probable Cause was leaning forward in w/c. Request eval for cushion . Interview with the Clinical Therapy Manager on 8/17/18 at 3:55 PM, in the therapy room, confirmed .She (Resident #119) was not evaluated for wheelchair seating and positioning after 8/20/17 .No recommendations were done, there was no eval . Medical record review of a Significant Change in Status MDS assessment dated [DATE] revealed the resident's BIMS was 0 and was occasionally incontinent of urine. Medical record review of a Falls Risk assessment dated [DATE] revealed Resident #119 scored a 23 (high risk for falls). Medical record review of a Clinical Notes Report dated 10/15/17 at 11:16 PM revealed, This nurse was informed that resident was sitting in the floor in the bathroom .Resident sitting beside commode trying to get self up. States that she slid off the commode after she went to the bathroom. No injuries found .Resident reminded by staff and family to please ask for assist when needing to go to the bathroom (Resident had severe cognitive impairment) . Review of an Incident/Accident Report dated 10/15/17 revealed the actual time of the fall was 5:15 PM. Review of the CNA's Written Statement revealed I was getting (another resident) up for supper. I heard (Resident #119) calling HELP ME. I found her on floor in .bathroom. She was trying to get in her w/c and slid into floor . Further review revealed, .steps taken to prevent recurrence: try to keep resident in sight of staff to help her go to BR (bathroom) . Review of the Interdisciplinary Team Review for the fall on 10/15/17 revealed Interventions implemented was to toilet the resident at least every 2 hours (an expected nursing intervention) and the Probable Cause was Toileting self et (and) fell . Medical record review of a Clinical Notes Report dated 11/10/17 at 8:53 AM revealed, 0805 (8:05 AM) Notified by CNA that chair alarm was activated and she entered room and observed resident sitting in the floor in the bathroom. Resident was attempting to pull herself up from a sitting position. CNA assisted resident into w/c and then notified this nurse. This nurse observed resident and noted to have deformity to right lower extremity . Further review revealed at 1:35 PM, .[DIAGNOSES REDACTED]. Review of the Incident/Accident Report for the accident on 11/10/17 revealed the steps taken to prevent recurrence was not completed. Continued review of a Written Statement by the CNA revealed The alarm was going off on the chair in (Resident #119) room and she was in the bathroom trying to get up hanging on the rail and on the floor and her right leg was around bottom of the toilet between the wall. She was hanging so help transfer her to the wheelchair and let the nurse know . Medical record review of ER (Emergency) Trauma Worksheet dated 11/10/17 revealed .unwitnessed fall .fell this morning out of her wheelchair while attempting to stand .Granddaughter states this happens quite frequently at patients nursing home and has resulted in several injuries in the past .Patient complains of right lower leg pain . Review of the Investigation Tool for the accident on 11/10/17 revealed for the Interdisciplinary Team Review, Interventions implemented was not completed and Probable Cause: Res transferring self. No safety awareness. Medical record review of the acute care Hospital Discharge Summary dated 11/14/17 revealed .Right tib-fib (tibia-fibula) fracture following a fall .suffered a fall at (facility) and sustained a right tib-fib fracture .cast was applied . Interview with Licensed Practical Nurse (LPN) #3 on 8/16/18 at 3:00 PM, in the 1 North nurses station, revealed .(on 11/10/17) CNA assisted her to the wheelchair .then came to get me .when I went in there observed a clear deformity to right lower leg .the CNA was not supposed to move her . Interview with the DON on 8/16/18 at 9:52 AM, in the conference room confirmed it did not appear an intervention to prevent falls was put in place after the fall on 11/10/17. Medical record review of a Clinical Notes Report dated 11/16/17 at 10:30 AM revealed, CNAs report that chair alarm was activated and staff went to investigate alarm and observed (Resident #119) sitting in the bathroom .This nurse entered room and observed resident sitting in the floor beside the toilet with both legs stretched out in front of her. No apparent injuries .Resident had an incontinence episode of stool and was assisted on toilet. Resident transferred to sunroom and seated in bean bag chair . Review of an Incident/Accident Report dated 11/16/17 revealed the steps taken to prevent recurrence: Res had just been toileted @ (at) 9:30 (fall occurred at 10:30). Will ask res more freq (frequently) if toilet needs. Bean bag utilized as well . Review of a CNA's Written Statement for the accident on 11/16/17 revealed, Chair alarm was going off .(Resident #119) was trying to get on the toilet alone . Review of the Interdisciplinary Team Review for the accident on 11/16/17 revealed, Interventions implemented: Toilet more freq. Utilize bean bag. Probable Cause: apparently attempting to toilet self. Medical record review of a Clinical Note Entry dated 11/19/17 at 12:45 PM revealed, .Observed resident sitting in the floor next to the bed with bilateral legs outstretched in front of her. W/C was also next to the bed and alarm had activated. When resident was asked what she was doing, she places her hands on her hand and states 'I don't know' .no apparent injuries .Daughter states that during a visit this week her mother told her she needed to go to the bathroom, and before she could get help, her mother was attempting to go to the bathroom unassisted . Review of a CNA's Written Statement for the accident on 11/19/17 revealed, Light was going off in (Resident #119) room and when I went in she was on the floor beside her bed. Review of the Incident/Accident Report for the accident on 11/19/17 revealed .steps taken to prevent recurrence .therapy picked her up . Review of the Interdisciplinary Team Review for the accident on 11/19/17 revealed no documentation a review was conducted, no interventions were implemented, and a probable cause was not indicated. Medical record review of Resident #119's ongoing care plan revealed an intervention on 11/24/17 of self-releasing safety belt in the wheelchair. Medical record review of a quarterly MDS assessment dated [DATE] revealed Resident #119's BIMS was 0 and the resident was frequently incontinent of urine. Medical record review of a Clinical Notes Report dated 4/13/18 at 2:36 PM revealed 1400 (2:00 PM) Called to sunroom by CN[NAME] CNA reports walking into dining room and observing resident laying in the floor in the sunroom. Reports that resident was previously sitting at the dining room table for meal. Upon assessment, observed resident laying on her left side in front of her w/c which was left in the sunroom during meal .Resident crying and yelling out in pain .resident does grab at her left hip and leg . Review of a Clinical Notes Report dated 4/13/18 at 11:42 PM revealed, .resident was admitted to (hospital) with a Lt. (left) femur fx. Medical record review of an acute care hospital Surgical Consultation Note dated 4/13/18 revealed .female who has profound dementia fell today injuring her left hip. X-rays in the emergency room reveal comminuted angulated intertrochanteric [MEDICAL CONDITION] hip . Review of the Incident/Accident Report for the accident on 4/13/18 revealed the .steps taken to prevent recurrence was not completed. Review of the Investigation Tool revealed under Devices .Ordered sensor, alarm in place it was written N/A (not applicable). Under Interventions, (indicating interventions that were to be in place at the time of the fall) was a self-releasing seat belt, mats, pressure sensor alarm, nonskid socks, low bed, and night light. Review of the Interdisciplinary Team Review for the accident on 4/13/18 revealed no documentation a review was conducted, no interventions were implemented, and a probable cause was not indicated. Medical record review of the acute care hospital Discharge Summary dated 4/16/18 revealed .Left proximal femur fracture postop (postoperative) 4/15 (4/15/18) ORIF (open reduction internal fixation) . Interview with LPN #3 on 8/16/18 at 3:08 PM, in the 1 north nurses station, revealed .(on 4/16/18) After lunch saw her sitting at one of the dining room tables .was in a regular chair .wheelchair was in the sunroom .was attempting to ambulate to her wheelchair .I assessed her .Complain of pain left hip area .Was grabbing and grimacing Left hip/leg area . Medical record review of Resident #119's ongoing care plan revealed an intervention on 4/19/18 of Lap Buddy (cushion placed across the lap and hooks under arms of wheel chair) while in wheel chair and on 4/21/18 sensor alarm to wheel chair (an intervention that was to be in place since 1/8/16). Medical record review of a Clinical Notes Report dated 4/19/18 at 6:00 PM revealed, Interdisciplinary Meeting held this day, in attendance: (3 family members), Administrator, Medical Director, DON, Therapy Manager, Clinical Mentor, and Social Worker. Resident family concerned regarding resident numerous falls .remain concerned with number of falls that have occurred. Family understands that resident has a dx (diagnosis) of Dementia, which is advancing. Resident has no safety awareness due to her cognitive deficits. Current interventions reviewed and will remain, with the addition of a lap buddy to apply to w/c, unfortunately the current armrests on resident w/c will not accommodate this lap buddy. Therapy to order new arm rests for w/c, then we will apply further Velcro to add another layer of protection and another step for resident to attempt to self transfer or remove these intervention devices. We will continue with current lap buddy until these new arm rests arrive. Hipsters provided to staff and instructed on use and to also leave resident in her w/c for meals . Review of an undated letter addressed to the family of Resident #119 and written by the facility Administrator revealed, .Thank you for taking time to meet regarding (Resident #119)'s care plan. More specifically, we discussed your concerns regarding the potential for (Resident #119) to suffer an injury by falling .it is important you clearly understand that (the nursing facility) cannot eliminate the potential for falls to occur .as we discussed, we will not have a staff member consistently within close proximity of (Resident #119), nor are we required to do so. Even with a staff member nearby, a resident still may accidentally fall. It is simply an unavoidable risk .you may consider hiring a private duty aide to remain with (Resident #119) . Medical record review of a Significant Change in Status MDS assessment dated [DATE] revealed Resident #119's BIMS was 0 and the resident was frequently incontinent of urine. Medical record review of a Clinical Notes Report dated 6/27/18 at 8:09 PM revealed, Residents bed sensor alarm sounded and noted that resident was partly off bed onto bedside matt. Bed was in lowest position and resident had legs and bottom on matt and upper torso on bed hanging onto side rails. Noted that resident had a skin tear on back and left arm . Review of an Incident/Accident Report dated 6/27/18 revealed .steps taken to prevent recurrence: Pool noodles . Review of the Interdisciplinary Team Review for the accident on 6/27/18 revealed, .Interventions implemented: Pool noodles. Probable Cause: Climbing out of bed, side rails are padded, has low air loss mattress w/ (with) sensor alarm, mats et low bed. Medical record review of a Clinical Notes Report dated 7/10/18 at 3:10 AM revealed, Pt (patient) alarm going off when CNA went to room, found pt half in bed and half out of bed. Head and upper body in bed and legs and feet on floor. Pt. has abrasion in middle of forehead . Review of an Incident/Accident Report dated 7/10/18 revealed .steps taken to prevent recurrence: Velcro noodles to mattress rail . Review of the Interdisciplinary Team Review for the accident on 7/10/18 revealed, Interventions implemented: Velcro noodle to mattress. Probable Cause: Unknown due to cognition. Res could not explain. Interview with Registered Nurse (RN) #2 on 8/15/18 at 7:03 AM, in the 1 north nurse's station, revealed .She (Resident #119) has fallen on numerous shifts .when up has to be in wheelchair and has a belt .she knows how to unhook .she is like a Houdini . Interview with the DON on 8/16/18 at 9:05 AM, in the conference room, confirmed . She (Resident #119) has had frequent falls. She continues to fall with all the interventions she has. We even told family they might want to consider hiring a 24 hour sitter. We have a few frequent fallers . Interview with CNA #16 on 8/16/18 at 2:42 PM, in the 1 north hallway, revealed .We don't have enough supervision for her (Resident #119) . Observation and interview with the Director of Nursing (DON) on 8/17/18 at 7:33 AM, in Resident #119's room, revealed the resident was in bed lying on her left side. Further observation revealed Velcro pads were hanging downward, on the outer upper end of the bed rails, and the pool noodles were up against the wall. Interview with the DON confirmed .the Velcro noodles are not attached to the bed correctly and the pool noodles are not in the resident's bed . Interview with Licensed Practical Nurse (LPN) House Mentor #1 on 8/17/18 at 8:10 AM, in the 1 North dining room, revealed .If she is sitting in a regular chair a staff member has to be with her. No intervention to address resident supervision .she continues to try to transfer herself and fall. She has no safety awareness .The lap buddy I just an extra measure to free herself. It is to slow her down. The lap buddy is working to certain extent. Gives us more time to get to her . Further interview confirmed no interventions were put in place to prevent further falls after Resident #119's fall on 11/10/17. Interview with House Mentor #1 on 8/18/18 at 9:25 AM, in the Mentor's office, confirmed staff were not documenting toileting. Further interview confirmed Resident #119 needed more frequent toileting than every 2 hours. The Mentor stated . All of us are responsible to make sure intervention is to be implemented . Further interview revealed when a fall occurred, .Nurse Fills out incident report .IDT (Interdisciplinary Team) comes up with new intervention . Further interview confirmed a root cause analysis was not done for the falls on 11/19/17 or 4/13/18 to determine the probable cause of the falls in order to implement interventions to prevent further falls. Further interview revealed, .(Resident #119) needs supervision within eye sight .She wanders all over unit . Further interview revealed the interventions implemented of toileting more frequently and toileting as needed were not different and not specific. Interview with the DON on 8/18/18 at 10:36 AM, in the conference room, revealed .I don't know what Velcro noodles would be exactly, maybe pool noodles . Interview with the DON on 8/18/18 at 12:39 PM, in the conference room, revealed .I've not seen a bean bag chair since I've been here .The lap buddy slows her down. We have recommended to family they do the 24 hour sitter .A lap buddy wouldn't prevent falls .You can't really prevent falls . Telephone interview with CNA #23 on 8/18/18 at 1:00 PM revealed the CNA had never seen any pool noodles with Velcro and did not know what Velcro noodles (intervention that was to be put in place after the fall on 7/10/18) were. Interview with CNA #5 on 8/18/18 at 8:59 PM, revealed the CNA did not know what Velcro pool noodles were. Medical record review revealed Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record of Resident #40's care plan dated 5/23/18 revealed the resident was at risk for falls due to weakness, history of falls, Dementia, and Hypertension. Continued review revealed interventions included wear non-slick footwear, instruct the resident on safety measures to reduce risk of falls, attempt to engage in Activities of Daily Living (ADL's) that improve strength, balance, and posture, and keep areas free of obstacles to reduce the risk of falls or injury. Medical record review of the Admission MDS dated [DATE], revealed Resident #40 had a BIMS score of 3, indicating the resident was severely cognitively impaired, and required extensive assistance of 1 for mobility, toileting, and transfers. Review of a facility Incident/Accident report dated 6/27/18, revealed Resident #40 was found on her knees in her room with 2 skin tears to the left wrist. Continued review revealed steps taken to prevent recurrence included .Call before you fall signs - visual cueing . Review of the Interdisciplinary Team Review for the accident on 6/27/18 revealed no documentation a review had been completed, no documentation of interventions implemented to prevent further falls, and no documentation of the probable cause of the fall. Medical record review of a Nursing Note dated 7/6/18, revealed .Ambulates w(with) walker w/one assist, however she frequently forgets to ask for assist and attempts to get out of chair and ambulate to/from room by herself. Frequent reminders given to call for assist. Gait is unequal and unsteady . Medical record review of a Nurses note dated 7/30/18, revealed Resident #40 was in her recliner, attempted to pick up a cup that had fallen on the floor, and slid out onto the floor. Further review revealed the resident had non slip socks on. Continued review revealed the resident was instructed to always use the call light. Review of a facility Incident/Accident report dated 7/30/18 revealed Resident #40 had a fall in her room with no injuries noted. Continued review revealed steps taken to prevent recurrence .Reinstructed & (and) demo (demonstrate) call light use . Review of the Interdisciplinary Team Review for the accident on 7/30/18 revealed no documentation a review had been completed, no documentation of interventions implemented to prevent further falls, and no documentation of the probable cause of the fall. Review of a falls assessment dated [DATE] revealed Resident #40 scored 11 (at risk for falls). Review of an Incident/Accident report dated 8/2/18 revealed Resident #40 was found lying on her back in her bathroom with her walker on top of her. Continued review revealed .Two knots were found on the back of her head with a laceration on one of them .It was determined to send her out for evaluation . Review revealed interventions in place at the time of the fall were mats and non-skid socks. Further review revealed steps taken to prevent recurrence .Reiterate use of call light .Removal of hosiery and use slipper socks . Review of CNA #15 Written Statement revealed, (CNA #14) and I were in (another resident's room) with another resident, and heard someone yelling. Ran out to see what happened next door. Went into (Resident #40) room and found her lying on bathroom floor . Review CNA #14 Written statement revealed, (CNA #15) & (and) I were in (another resident room) and heard some one yelling and went to check in each room & it was (Resident #40) laying in bathroom floor . Review of the Interdisciplinary Team Review for the accident on 8/2/18 revealed no documentation a review had been completed, no documentation of interventions implemented to prevent further falls, and no documentation of the probable cause of the fall. Further review revealed no signature from the Medical Director, Administrator or DON to indicate the fall was reviewed. Review of a falls assessment dated [DATE] revealed Resident #40 scored a 14 (at risk for falls). Medical record review revealed the resident was admitted to an acute care hospital on [DATE] for .Mechanical fall .Subdural hematoma .[MEDICAL CONDITION] .Patient was admitted after falling backwards in bathroom at (facility) . Medical record review of a Computed [NAME]ography (CT) of the Head radiology report dated 8/2/18 revealed the resident had an acute subdural hematoma (SDH). Medical record review of a Nursing Note dated 8/6/18 revealed .Resident arrived back from (named hospital) 8/6/18 .Family at bedside .daughter states she is alert at times and does not recognize her. She has severe bruising to back of head and neck, w/a (with a) small scab to back of L (left) side of head. Bruising to R (right) arm, R index finger swollen and red. Small skin tears to bilateral arms. L lower arm skin tear . Medical record review of Resident #40's care plan dated 8/6/18, revealed the resident was at risk for falls related to weakness, History of Falls, Dementia, [MEDICAL CONDITION] medication use and status [REDACTED]. Medical record review of a Nursing Note dated 8/12/18 revealed the nurse heard Resident #40 yelling out, the nurse entered the room, and found the resident lying in the corner of her room with her back against the wall. Further review revealed the resident was found to have a large bruise to the left hip and a skin tear to the right arm. Continued review of the note revealed earlier the same day, the resident was found standing in the resident's room, going to the bathroom, and other staff reported she gets up without calling for assistance. Further review revealed the resident's call light was in reach at the time of the fall and staff re-educated the resident on the use of the call light. Review of a facility Incident/Accident Report dated 8/12/18, revealed the resident was found in the corner of her room between the bed and the bathroom and the resident stated she slipped. Continued review revealed under steps taken to prevent recurrence there were no interventions implemented. Review of the Investigation Tool for the accident on 8/12/18 revealed, under the section Interventions, which indicated the interventions in place at the time of the fall, none of the interventions were marked, and handwritten in the section was Re-Educate. Review of the Interdisciplinary Team Review for the accident on 8/12/18 revealed no documentation a review had been completed, no documentation of interventions implemented to prevent further falls, and no documentation of the probable cause of the fall. Further review revealed no signature of the Medical Director, Administrator or DON to indicate they had reviewed the accident. Medical record review of a falls assessment dated [DATE] revealed the falls assessment was incomplete and no score was documented. Medical record review of a physician's orders [REDACTED].Please get floor mat that alarms @ nurses station & place beside bed . Interview with RN #3 and medical rec (TRUNCATED)",2020-09-01
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 station, confirmed when the resident was admitted to the facility the physician order [REDACTED]. Interview with the Director of Nursing on 8/18/18 at 5:00 PM, in the conference room, confirmed the catheter was to be replaced monthly and catheter care was to be reordered when the resident returned to the facility. Continued interview confirmed catheter care was to be completed daily unless ordered otherwise.",2020-09-01
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 through 8/5/18. Medical record review of physician's orders [REDACTED].RD (Registered Dietician) recommendation -Weekly wts (weights) x (for) 4 weeks r/t (related to) 8.7% wt loss x 1 month, Refer to Psychiatry (Psych) d/t (due to) wt loss . Review of Physicians Order Sheet and Progress Notes dated 8/15/18 revealed .recommendation per RD: 1) Boost Plus (nutritional supplement drink) TID (3 times per day) between meals . Review of Resident #34's care plan dated 8/16/18 revealed .therapeutic diet as ordered CCD (consistent carbohydrate diet) regular diet. Therapeutic restriction of choice .provide ques and encouragement. Feed (Resident #34) remaining food items .monitor food intake at each meal .Boost three times a day between meals . Interview with LPN #5 in nurse's office in secure unit on 8/18/18 at 3:10 PM revealed the nutritional supplement Boost was documented as given on the Medication Administration Record [REDACTED]. Review on 8/18/18 at 3:10 PM of the Psychiatry referral book in the Nurses office revealed Resident #34 was referred to Psychiatry on 8/10/18. Continued review revealed no documentation the referral had been addressed by Psychiatry. Interview with the DON on 8/18/18 at 4:55 in the conference room confirmed Resident #34 had not been seen by Psychiatry since the referral date of 8/10/18, . should have been since Psych is in the building 2 times a week . Interview on 8/20/18 at 10:19 AM with Dietary Manager and Registered Dietician #1 in the conference room confirmed the facility failed to ensure interventions were implemented to prevent further weight loss. Medical record review revealed Resident #54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed no behaviors, required 1 person assistance with hygiene, 2 person assistance with transfers, and dressing, and set up help for eating. Continued review revealed Resident #54 was on a mechanically altered diet, weighed 219 pounds, and had no oral or dental issues. Continued review revealed a BIMS Score of 14 indicating the resident was cognitively intact. Medical record review of the quarterly MDS dated [DATE] revealed no behaviors, required 1 person assistance with dressing and hygiene, 2 person assistance with transfers, and set up help for eating. Continued review revealed Resident #54 was on a mechanically altered diet, had a weight loss of 20 pounds from the previous MDS assessment, with a current weight of 199 pounds, and had no oral or dental issues. Medical record review of the quarterly care plan print date of 6/14/18 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 . Further review revealed the facility failed to develop and implement an individualized care plan to address the identified weight loss of 20 ponds. Observation of Resident #54 on 8/13/18 at 10:06 AM, in the resident's room, revealed the resident was eating breakfast provided in a 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 breakfast was provided in a divided plate with no plate guard, and regular silverware. Continued observation revealed the resident had difficulty feeding self due to tremors of hands. Observation of Resident #54 on 8/15/18 at 8:35 AM, in the resident's room, revealed breakfast was served on a regular plate, with regular silverware and bowl. Interview with RD #1 on 8/15/18 at 2:50 PM, in the conference room, revealed RD #1 was unfamiliar with this resident and was not aware of the resident's weight loss or any interventions. Further interview revealed the RD was not able to determine the interventions that were previously initiated on the care plan and if the interventions of weighted utensils and plate guard were discontinued. Interview with MDS Coordinator #3 on 8/17/18 at 7:55 AM, in the MDS office, revealed the MDS Coordinators updated the care plans quarterly with the MDS assessments. Continued interview revealed the care plans were updated all other times by the nurses on the floor. Continued interview revealed no straws, and the plate guard were active on the care plan for Resident #54. Observation of Resident #54 on 8/18/18 at 9:20 AM, in the resident's room, revealed the resident had breakfast food pureed consistency, a regular plate and regular silverware. Continued observation revealed no plate guard or weighted utensils. Interview with LPN #1 on 8/18/18 at 10:15 AM, on the 2 South Hall way revealed the resident had a plate guard but it was discontinued. Continued interview revealed the resident used a divided plate with meals. Further interview, in the resident's room, confirmed resident did not have a plate guard, a divided plate or weighted utensils. Interview with LPN #1 on 8/18/18 at 3:00 PM, on 2 South Hall, revealed the interventions were to be placed on the care plan and updated by the .care plan manager . Continued interview revealed LPN #1was unaware of Resident #54's 20 pound weight loss or any weight loss interventions except a divided plate that had been used. Interview and observation with Resident #54 on 8/18/18 at 10:00 AM, in the resident's room, revealed the resident had never used weighted silverware and did not want to utilize. Continued interview revealed Resident #54 had used a plate guard when provided and it made eating easier. Continued observation revealed the resident had a regular plate without a plate guard.",2020-09-01
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. Discussed times of administration important to better manage pain related to wound . Neurological .Patient is awake, alert and oriented x 3 . Medical record review of a nurse's note dated 8/6/18 at 3:29 PM revealed .Resident had c/o (complaints of) pain unrelieved by PRN (as needed) medication .NP notified. New orders to continue pain medication and new order for [MEDICATION NAME] (medication to treat anxiety) PRN for anxiety . Medical record review of a Physicians Order dated 8/6/18 revealed [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME]-narcotic pain medication) 10 milligrams (mg)-325 mg tablet PRN every 6 hours and [MEDICATION NAME] (medication to treat anxiety) 0.5 mg tablet PRN every 12 hours. Resident went to [MEDICAL TREATMENT] this AM .Resident did not tolerate dressing changes well . Medical record review of a nurse's note dated 8/6/18, revealed .Resident stated she did not need the [MEDICATION NAME] at this moment .Wound care done on L (left) hip this AM. Resident is now refusing to have wound care done on R (right) hip d/t (due to) pain, wound care nurse made aware. Will continue to monitor for further changes . Medical record review of a Wound Nurse note dated 8/6/18 revealed .Talked a long time for importance of changing drsgs (dressings) twice a day with reasoning .Right buttock wound was surgically had debridement done. Measured 12.8 x 9.8 .Left buttock wound measured 14 x 14 .There is another small wound noticed just below it measures 3 x 1.5 . Medical record review of a nurse's note dated 8/7/18 revealed .Resident complained of pain that is unrelieved by PRN pain medication . Wound care completed. Resident did not tolerate dressing changes well . Medical record review of a nurses note dated 8/8/18 at 4:06 PM revealed .Also discussed about the importance of accepting and managing the wound care as ordered .Ensured that pain management prior to the dressing change for the best outcome . Medical record review of a Physicians Order dated 8/9/18 revealed .medicate for pain prior dressing change . Medical record review of the Medication Administration Record [REDACTED]. Medical record review of a Nurse's Note for Resident #236 dated 8/13/18 at 1:50 PM revealed pain on a scale of 10 while dressings being changed . Interview with the Licensed Practical Nurse (LPN) #13 on 8/15/18 at 9:30 AM, on the 300 unit, confirmed the resident had complained of pain during dressing changes on 8/13/19 and 8/15/18 and had been given the medication prior to dressing change but did not report the unrelieved pain to the Physician. Interview with Certified Nursing Assistant (CNA) #23 on 8/15/18 at 9:40 AM, on the 300 hallway confirmed she had been in the resident's room during a dressing change and the Resident #236 .hollered out . when the dressing was changed and when the resident was repositioned. Observation and interview with Resident #236 on 8/15/18 at 9:55 AM, in the resident's room revealed the resident was awake and alert, resting in bed. Continued observation revealed mild facial grimacing noted with movement. Continued interview with the resident confirmed she received pain medication before the dressing change but still had severe pain during the dressing changes twice a day. Further interview confirmed she had reported the pain to the nurses and the Nurse Practitioner. Continued interview confirmed on a scale of 1 to 10 the pain is a 10, and that she has yelled out and asked the staff to stop during the dressing change. Further interview confirmed she just bears it .I don't think the pain medication is strong enough to control it . Continued interview confirmed she had refused to have dressing changes done due to the dressing changes being so painful. Interview with the Wound Nurse on 8/15/18 at 11:25 AM, in the conference room, confirmed the resident had experienced pain during dressing changes, and she required a lot of emotional support and encouragement to get through the treatment. Further interview confirmed she had not notified the Nurse Practitioner of Resident #236 having pain during the dressing changes. Continued interview confirmed .The dressing change cannot be pain free . Telephone interview with Registered Nurse (RN) #5 on 8/15/18 at 1:45 PM, confirmed the resident had extreme pain during dressing changes. Continued interview revealed she tried to give her the pain medication 20 minutes before dressing changes and she hollered out each time. Further interview revealed the nurse had not notified the Physician or Nurse Practitioner that she had pain. My thought processes were that she was being seen by the wound care team . Continued interview confirmed she asked the resident if it always hurt like this and the resident stated yes. Telephone interview with RN #3 on 8/15/18 at 2:00 PM, confirmed she had completed dressing changes on the resident and most times she has pain during the dressing changes. Further interview confirmed the nurse gave pain medication 30 minutes to an hour prior to the dressing change. Continued interview confirmed .I think it (wound) hurts because it is so deep . Further interview confirmed sometimes the resident will ask the staff to stop because of the pain and will refuse dressing changes at times. Continued interview revealed .I think the Doctor already knows about the pain. I didn't report it because it's the nurse's discretion to assess if the patient can tolerate the dressing change . Further interview confirmed pain is to be monitored every shift. Interview with the Nurse Practitioner #1 on 8/16/18 at 10:05 AM, in the conference room, confirmed she addressed the resident's complaints of pain with the resident when she was first admitted and did not want to increase the pain med at that time but discussed timing of the pain medication related to timing of the dressing changes. Continued interview confirmed she was not made aware by staff that the resident was experiencing extreme pain during the dressing changes. Interview with the Director of Nursing on 8/16/18 at 5:20 PM, in the conference room confirmed staff failed to monitor, manage and report unrelieved pain for Resident #236 and failed to follow the facility's pain management policy to use the numerical pain scale with a cognitively intact resident and reassess pain within 1 hour after administration of an [MEDICATION NAME](pain medication.",2020-09-01
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 documentation the [MEDICAL TREATMENT] CVC had been monitored. Further interview confirmed it should be documented on the TAR.",2020-09-01
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 and 7 residents having a major injury as a result of a fall. Residents who had major injuries after a fall were Residents #119, #47, #28, #34, #39, #40, and #80. Review of the facility's Daily Census Report dated 8/13/18 for the Secured Unit revealed the unit had 31 residents and 2 empty beds. Review of the facility's staffing schedule for the Secured Unit for (MONTH) (YEAR) revealed the unit was to have 1 Licensed Practical Nurse (LPN) and 4-5 Certified Nursing Assistants (CNAs) working Monday through Friday day shift; 1 LPN and 3 CNAs working weekend day shift; 1 LPN and 3-4 CNAs working Monday through Friday evening shift; 1 LPN and 2 CNAs working weekend evening shift; either 1 LPN or 1 Registered Nurse (RN) and 2-3 CNAs working Monday through Friday night shift; and 1 LPN or RN and 2 CNAs working weekend night shift. Observation on Thursday 8/16/18 at 10:50 AM, in the Secured Unit dining room, revealed residents seated in chairs and wheelchairs. Continued observation revealed no CNA or nurses were in the line of sight of the residents in the dining room and sunroom. Further observations revealed all the residents' doors were open without a staff member in line of sight. Further observation revealed the Wound Care Nurse and Wound Nurse Practitioner were in one of the resident's rooms. Medical record review and review of facility incident reports revealed Resident #119 had 9 falls between 7/1/17 and 7/10/18, with 3 falls requiring transfer to the emergency room , and 2 falls resulting in fractures of the legs. Interview with CNA #16 on 8/16/18 at 2:42 PM, in the Secured Unit hallway, revealed .We don't have enough supervision for her (Resident #119) .If we do have enough staff they pull us . Interview with Household CNA Coordinator #4 on 8/16/18 at 2:47 PM, in the Secured Unit hallway, revealed .We always have staff, but (they are) pulled .When (they) get pulled, don't have enough staff .With 3 people just can't do it . Interview with CNA #5 on 8/18/18 at 8:59 AM, on the Secured Unit hallway, revealed .Right before supper we position them (residents) (in chairs) that is how we supervise .last 3 months before it was horrible . Observation on Saturday 8/18/18 at 9:10 AM, in the secured unit sunroom, revealed Resident #119 was seated in her wheelchair. Continued observation revealed no CNAs or nurses were in line of sight of the resident. Medical record review and review of facility incidents revealed Resident #47 had 10 falls between 4/9/18 and 6/13/18 with one fall requiring sutures for a laceration. Further review revealed the resident was not safe to ambulate independently. Observation on 8/18/18 at 10:30 AM, in the Secured Unit dining room, in front of the kitchen, revealed LPN #5 was at the medication cart between the dining room and the sunroom, preparing medications for a medication pass. Continued observation revealed 16 total residents were in the dining room, sitting area, and sunroom. Further observation revealed Resident #47 ambulated into the dining room, in front of the kitchen, pushing his wheelchair towards the sunroom. Further observation revealed LPN #5 began to yell out to the homemaker/cook staff member, who was located in the kitchen, to find a staff member to help assist the resident, who was observed to be unsteady on his feet. Further observation revealed the other CNAs were in resident rooms. Further observation revealed the homemaker staff member went out on the unit and tried to find a CNA to help with Resident #47. Continued observation revealed LPN #5 assisted the resident back into a wheelchair and continued to prepare medications for medication pass while the homemaker was locating a CNA to assist. Review of the facility's Daily Census Report dated 8/13/18 for 2 South revealed the unit had 31 residents and one empty bed. Review of the facility's staffing schedule for 2 South for (MONTH) (YEAR) revealed the unit was to have 1 nurse and 3 CNAs per shift Monday through Friday and 1 nurse and 2 CNAs per shift on the weekends. Interview with Resident #61, who lived on 2 South, on 8/13/18 at 10:31 AM, in the resident's room, revealed Resident #61 did not think there was always enough staff to provide baths. Continued interview confirmed .the girls (CNAs) will come in and say there are only 2 of us (CNAs) and we can't do your bath today . Further interview revealed .sometimes there is only 1 to 2 to take care of all of us (residents) .because they have to go to the kitchen to work sometimes . Interview with Resident #96, who lived on 2 South, on 8/13/18 at 10:39 AM, in the resident's room, revealed .(the facility) short staffed .staff have quit and they haven't replaced them .a lot of times there is just 1 or 2 (CNAs) on the floor . Interview with Resident #53, who lived on 2 South, on 8/13/18 at 11:08 AM, in the resident's room, revealed .didn't get a shower last week at all .not Tuesday or Friday they told me they were short staffed .it has happened .several times .not enough of them . Interview with CNA #3 on 8/15/18 at 9:25 AM, in the 2 South dining rooms, revealed the facility did not always have enough help to take care of the residents. Continued interview revealed there had been times when residents had not received showers. Interview with Household CNA Coordinator #1 on 8/15/18 at 9:40 AM, in the 2 South dining room, revealed there had been .call offs and have lost some employees and do not always have enough staff to take care of the residents about 2 to 3 days out of the week . Continued interview revealed .pulled to the kitchen sometimes 3 to 4 times a week . Further interview confirmed there had been times the residents had not received showers because of staffing. Interview with CNA #4 on 8/15/18 at 9:56 AM, in the 2 South dining room, revealed there was not always enough staff to meet the needs of the residents .it upset me .we are understaffed. I can't do my job the way I would like . Continued interview revealed .At least once a week we try to give a shower .there have been times on the weekends that we have not been able to get some residents up out of bed because there is not enough staff . Interview with LPN #2 on 8/15/18 at 10:05 AM, in the 2 South living room area, revealed there was not always enough staff to meet the needs of the residents. Continued interview confirmed .like today the person I was working with put her notice in so there is only 1 nurse. The weekends are not enough CNAs. Last Sunday there was only 1 nurse and 2 CNAs .there have been times the residents have not received a shower due to staffing . Review of the facility's staffing schedule for 1 South for (MONTH) (YEAR) revealed the unit was to have 1-2 nurses for each shift Monday through Friday; 3-4 CNAs on day shift, 2-3 CNAs on evening shift, and 2 CNAs on night shift Monday through Friday; 1 nurse each shift on weekends; and 2 CNAs on day and evening shift and 1 CNA on night shift on the weekends. Further review revealed there were no nurses scheduled for 7:00 AM - 3:00 PM shift on 8/18/18 and 8/19/18. Interview with Nurse Mentor #5 on 8/14/18 at 7:50 AM, in the 1 South nursing station, revealed .we need the help last night .I only have 1 nurse (LPN #13) working today . Review of the staffing schedule for 8/14/18 day shift on 1 South revealed the unit was supposed to be staffed with 2 nurses. Interview with LPN #13 on 8/14/18 at 8:25 AM, in the 1 South hallway, confirmed .I am the only nurse on the floor today .I have 30 patients today .it happens all the time being the only nurse on the floor . Interview with Resident #89, who lived on 1 South, 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 RN #4 (night shift nurse on 1 South) on 8/17/18 at 6:35 AM revealed .I had 30 patients last night .I was the only nurse with 1 CNA . Review of the staffing schedule for 2 South for 8/16/17 11:00 PM - 7:00 AM shift revealed the unit was to be staffed with an RN and 2 CNAs. Interview with CNA #2 on 8/17/18 at 5:45 PM, on the 2 South hallway, revealed .just 2 of us working down here and I don't even know these patients .I work upstairs on the skilled .I was pulled from the 3rd floor and that left 1 CNA up there to take care of 17 or 18 patients . Review of the staffing schedules for 2 South and 3rd floor for the evening shift of 8/17/18 revealed 2 South was to have 2 CNAs and the 3rd Floor was to have 2 CNAs. Interview with LPN #1 on 8/18/18 at 9:12 AM, on the 2 South hallway, revealed .is never enough staff .recently had a setback with a CNA getting fired, a nurse quit, a CNA quit .they haven't been replaced .I have reported to the DON (Director of Nursing) and the Administrator . Interview with the DON on 8/20/18 at 5:30 PM, in the conference room, revealed the Nurse Mentors and Household CNA Coordinators schedule staff 6 weeks in advance and staffing is to be reviewed by each house daily. The DON stated staffing in the facility was consistent, unless a staff member needed to be pulled to another unit in the facility. Further interview revealed staffing was based upon census and acuity in each house and was determined by utilizing a computerized staffing calculator. Further interview revealed staff turnover was discussed in the leadership meetings every 2 weeks and CNA turnover was high, but nursing turnover was stable. Interview with the DON on 8/20/18 at 5:35 PM, in the conference room, revealed staff had reported to the DON there was not enough staff, but the DON stated staffing was adequate. The DON stated if someone was pulled to work on another unit or another role, then staff felt they didn't have enough adequate staff. Interview with the Medical Director on 8/20/18 at 11:14 AM, in the conference room, confirmed .greatest trend identified is the multiple changes in leadership and large turn-over in staff that are unfamiliar. Difficult to do training with mostly on the job training, and turnovers in leadership have not been helpful .Falls .We can't tie them up (restrain residents) . Telephone interview with the Chair of the Board on 8/20/18 at 3:47 PM, confirmed .the facility had staff turnover .turnover in these positions are critical . Refer to F-550, F-657, F-677, F-689, F-726, F-835, F-841, F-867, and F-947.",2020-09-01
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, skills and abilities and those needed to care for the resident population .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) . Interview with the DON on 8/18/18 at 10:36 AM, in the conference room, and review of falls investigations and interventions put in place by staff to prevent further falls, revealed and intervention for Resident #119 included Velcro noodles to the bed. The DON stated .I don't know what Velcro noodles would be exactly, maybe pool noodles . Telephone interview with Registered Nurse (RN) #5 on 8/15/18 at 1:45 PM, confirmed Resident #236 had extreme pain during dressing changes. Continued interview revealed she tried to give her the pain medication 20 minutes before dressing changes and she hollered out each time. Further interview revealed the nurse had not notified the Physician or Nurse Practitioner that she had pain. My thought processes were that she was being seen by the wound care team . Telephone interview with RN #3 on 8/15/18 at 2:00 PM, confirmed she had completed dressing changes on Resident #236 and most times she had pain during the dressing changes. Further interview confirmed the nurse gave pain medication 30 minutes to an hour prior to the dressing change. Continued interview confirmed .I think it (wound) hurts because it is so deep . Further interview confirmed sometimes the resident will ask the staff to stop because of the pain and will refuse dressing changes at times. Continued interview revealed .I think the Doctor already knows about the pain. I didn't report it because it's the nurse's discretion to assess if the patient can tolerate the dressing change . Interview with the Staff Development Coordinator on 8/18/18 at 4:30 PM, in the conference room, revealed the nursing staff has an orientation period that begins with Human Resources (HR) onboarding. The nurses have HR videos they watch and Relias (computer-based training modules) they watch. Some modules are for all staff and some are specific to nursing. The Staff Development Coordinator conducts a diabetic lab with the nurses that lasts approximately 1/2 a day with competency checked on insulin administration. When the nurses have completed the videos, the Staff Development Coordinator sends them to their nursing unit with an orientation checkoff sheet and then the House Mentor is responsible for the nurse's training. The nurses are paired with a preceptor of the House Mentor's choosing. The Staff Development Coordinator only receives the orientation checkoff sheet from the Mentors when they are done and states she is not involved in decision making of when nurses are competent. Further interview revealed she 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 on falls, like what to do if you see water in the floor. Further interview revealed she was new to the position and stated she did not have an annual plan or monthly plan for education. The Staff Development Coordinator stated she was still trying to find where deficiencies in education were, where annual trainings were due and had not been done, and was developing education month to month if someone told her there was a need. The Staff Development Coordinator stated the monthly trainings she had developed since being in her role was on the evacuation policy in (MONTH) (YEAR), then they conducted mock evacuation drills in (MONTH) and (MONTH) (YEAR) and she was currently conducting one on one training with everyone on Personal Protective Equipment (PPE) and handwashing. Interview with the Director of Nursing (DON) on 8/18/18 at 7:13 PM, in the conference room, confirmed the facility staff were responsible for investigating falls. Falls were reported to the nurse on duty and the accident report was turned into the Clinical Mentor. The Clinical Mentor checked for completeness of the report and the nurse and Clinical Mentor discussed the interventions to put in place to prevent further falls. The DON stated the current facility practice was for the nurse Clinical Mentor to decide on a fall intervention and to put it in place immediately after an incident. The nurse was to do a fall risk assessment after every fall and it was put with the investigation packet. Any interventions put in place depended on interventions already in place. The DON stated the nurses knew what options were available and they used .nursing clinical judgement (used when deciding which intervention to put in place) .no education on falls .just their (staff) clinic experience . The DON stated the nurses did not do any root cause analysis at the time of the fall and the leadership was also not doing a root cause to determine the cause of the fall in order to implement interventions to prevent further falls. The DON stated they were aware the care plans were not updated, I don't know when the care plans (were updated) .the mentor in the house should be updating the care plans .I think that there is work to be done .doing weekly meetings we will be able to get more in depth and with dementia they (residents) forget they can't get up . Interview with the DON on 8/18/18 at 7:15 PM, in the conference room, revealed, .I am not familiar with long-term care, and she (Administrator) had taught me regarding (fall) interventions . Further interview with the DON revealed the DON was familiar with Resident #47 and stated as far as she was aware the resident had not had any further falls once he was admitted to the secured unit following his return to the facility after a psychiatric hospital stay (resident had 2 falls since his return). Refer to F-657, F-689, F-725, and F-947.",2020-09-01
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 buttermilk 10 cheese slices 1 unopened package of approximately 30 cheese slices 1 unopened package of bologna slices 1 opened package of approximately 25 bologna slices 2 qts vanilla pudding and 3 qts chocolate pudding",2020-09-01
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 between 7/1/17 - 7/10/18 and sustained 3 major injuries: a right tibia fracture, left femur fracture, and left [MEDICAL CONDITION]; Resident #28 had 2 falls between 2/15/18 - 6/7/18 and sustained 1 major injury: a [MEDICAL CONDITION] femur; Resident #34 had 2 falls between 2/25/18 - 7/14/18 and sustained 2 injuries: a left [MEDICAL CONDITION] and a laceration to the back of the head requiring staples; Resident #39 had 9 falls between 4/2018 - 8/2018; Resident #47 had 8 falls between 4/5/18 - 6/13/18 and sustained 1 injury: a right eye injury requiring sutures. Resident #40 had 4 falls between 4/2018 - 8/2018 and sustained 1 injury: a subdural hematoma (a collection of blood outside the brain); and Resident #80 had 5 falls between 1/27/18 - 7/2/18 and sustained 1 major injury: a Cervical 1 - Cervical 2 fracture. During the Recertification survey, review of wound reports, Wound Nurse Practitioner documentation, and interviews, revealed Resident #80 developed 1 avoidable unstageable wound to the right clavicle. Interview with the Administrator on 8/20/18 at 12:20 PM, in the conference room, revealed the Administrator led the Quality Assurance and Performance Improvement (QAPI) meeting. During the meeting they discussed how many falls during a month looking for trends and patterns. Falls were reviewed during the morning meeting. The Administrator stated .some things I was concerned about .some of the interventions were not appropriate .after doing it that month (review of falls in AM meeting) our teams were educated .educate as we go .if nursing staff used same intervention or inappropriate intervention we would educate the mentor at that time . Further interview confirmed the facility had not used root cause analysis during falls and a resident's historical falls was not being discussed. The facility conducted the first root cause analysis in July. Further interview revealed, .saw increase in falls .increase multiple resident falls .we knew fall rate increased . Further interview revealed, .have not discussed pressure ulcers in huddle .not sure if they're talking about them in therapy .we have not done it in morning meeting yet . Interview with the Consultant, who was the facility's previous Administrator from 3/18 - 6/18, on 8/20/18 at 1:47 PM, in the conference room, revealed the falls program included household huddles daily to find interventions. The previous Administrator stated he did not attend the meetings and did not have clinical experience and relied on the nurses for interventions. Further interview revealed that approximately the 3rd week of (MONTH) he became aware falls had increased. The previous Administrator called on the Minimum Data Set (MDS) nurse to assist in decreasing falls. The previous Administrator stated there was a falls task force with in the form of huddle meetings. The previous Administrator confirmed he had no involvement in the huddles or Interdisciplinary Team (Interdisciplinary Team) meetings. He stated MDS would facilitate those meetings and .informal monitoring to ensure meetings (huddles) being held with (MDS #1) were informal .nothing formal . Refer to Refer to F-550, F-657, F-677, F-686, F-689, F-697, F-725, F-726, F-867, F-947",2020-09-01
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 care means Provider shares responsibility for assuring Facility is providing appropriate care as required which involves monitoring and ensuring implementation of resident care 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 .Participate, upon request, in personnel evaluations and other quality monitoring programs established by the Facility including attendance at the Facility's Quality Assurance Committee meetings .Provider will deliver high quality services that .Promote standards of timeliness .enhance continuity of service to all Health Center residents .conform to federal and state regulations . Review of the Advanced Practice Nurse (APN) Protocol, undated, revealed .Requiring Authority .the (APN) will provide health care services under the general supervision of (Medical Director) .F. Interpret and analyze patient data to determine patient status, care management and treatment and effectiveness of interventions . Review of the Facility Assessment (YEAR), dated 6/2/18, revealed .Community Staff .The Medical Director oversees medical practice and provides guidance in the development of clinical policies and programs at our community .Currently, there is 1 Medical Doctor and 2 Nurse Practitioners who visit the community two to three times a week to see residents . 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 between 7/1/17 - 7/10/18 and sustained 3 major injuries: a right tibia fracture, left femur fracture, and left [MEDICAL CONDITION]; Resident #28 had 2 falls between 2/15/18 - 6/7/18 and sustained 1 major injury: a [MEDICAL CONDITION] femur; Resident #34 had 2 falls between 2/25/18 - 7/14/18 and sustained 2 injuries: a left [MEDICAL CONDITION] and a laceration to the back of the head requiring staples; Resident #39 had 9 falls between 4/2018 - 8/2018; Resident #47 had 8 falls between 4/5/18 - 6/13/18 and sustained 1 injury: a right eye injury requiring sutures. Resident #40 had 4 falls between 4/2018 - 8/2018 and sustained 1 injury: a subdural hematoma; and Resident #80 had 5 falls between 1/27/18 - 7/2/18 and sustained 1 major injury: a Cervical 1 - Cervical 2 fracture. During the Recertification survey, review of wound reports, Wound Nurse Practitioner documentation, and interviews, revealed Resident #39 developed 3 avoidable wounds: 1 stage II on the right buttock, 1 stage III to left buttock, and an unstageable to the coccyx; Resident #80 developed 1 avoidable unstageable wound to the right clavicle; Resident #86 developed 1 avoidable stage IV wound to the right hip; and Resident #119 developed 2 avoidable wounds: 1 unstageable to the left ischium and 1 stage II to the right foot. Review of facility Quality Assurance and Process Improvement Meeting (QAPI) meeting minutes dated 8/29/17 - 7/24/18 revealed the Medical Director attended 11 out of 13 QAPI meetings. Interview with the Medical Director on 8/20/18 at 11:14 AM, in the conference room, confirmed she attended the QAPI meetings and falls were reviewed monthly in the meetings. Continued interview confirmed recurrent falls were reported to the Nurse Practitioners (NP) and any concerning issues went directly to the Medical Director. Further interview confirmed .I don't know how much detail is in QAPI meeting . Continued interview confirmed .involvement with pressure ulcers primarily supervisory. I use wound trained NP's and a wound Nurse . Further interview confirmed .greatest trend identified is the multiple changes in leadership and large turn-over in staff that are unfamiliar. Difficult to do training with mostly on the job training, and turnovers in leadership have not been helpful .Falls .We can't tie them up . Continued interview confirmed when the Medical Director signed the Incident/Accident reports she was agreeing with the interventions put in place. The Medical Director stated .the reports are not always timely . Refer to F 550, F657, F 677, F 686, F 689, F 697, F 725, F 726, F 835, F 867, and F 947.",2020-09-01
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 community .QAPI program is ongoing, comprehensive and addresses the services provided .data will be obtained from the following reports .Clinical reports - infection, medication error, pressure injuries, falls .The QAPI team will meet monthly, or more often as needed, to review findings and identify potential PIPs .The Nursing Home Administrator (NHA) and Board of Directors are responsible and accountable for the development, implementation and monitoring of the QAPI program .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 .The QA Committee meets at least quarterly to coordinate and evaluate the activities under the QAPI program .The QAPI Steering Committee, which includes the Medical Director as co-chair, meets monthly and is accountable for the continuous improvement in Quality of Life and Quality of Care .The QAPI Steering Committee collects data from QA sub committees (e.g., pain, falls, and weight loss) .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 .PIPS .identify areas where gaps in performance may negatively affect resident .In prioritizing activities, the team will consider: high-risk to residents .high-volume or problem prone areas .health outcomes .resident safety .resident choice .At least annually a project that focuses on high risk or problem-prone areas will be addressed through the QAPI program including PIP development .The team will utilize root cause analysis to identify the cause of the problem and any contributing factors. Plan-Do-Study-Act PDSA will also be used .Our community uses a systematic approach to determining the root cause of an issue and any contributing factors. 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 Facility Assessment (YEAR), dated 6/2/18, revealed .Community Assessment and QAPI .Information from the Community Assessment will be incorporated into the Quality Assurance Performance Improvement (QAPI) process .The identification of residents will help to drive the activities of the QAPI process. The description of care, services and resources available at our community provides both areas for monitoring of processes and outcomes as well as information for investigation of root causes of adverse events and gaps in performance .Community Staff .Our community is overseen by a Board of Directors, an Executive Director and a licensed Nursing Home Administrator. The Medical Director oversees medical practice and provides guidance in the development of clinical policies and programs at our community .Currently, there is 1 Medical Doctor and 2 Nurse Practitioners who visit the community two to three times a week to see residents . Interview with the Director of Nursing (DON) on 8/18/18 at 7:13 PM, in the conference room, confirmed the facility staff were responsible for investigating falls. Falls were reported to the nurse on duty and the accident report was turned into the Clinical Mentor. The Clinical Mentor checked for completeness of the report and the nurse and Clinical Mentor discussed the interventions to put in place to prevent further falls. The DON stated she was not familiar with Long Term Care and had a background in acute care. The DON stated the facility had plans to reinstate a weekly fall meeting that the facility used to conduct before her arrival in (MONTH) of (YEAR). The DON was not sure when weekly fall meetings had stopped, but they had reviewed the falls and ensured care plans were updated. The DON stated the current facility practice was for the nurse Clinical Mentor to decide on a fall intervention and to put it in place immediately after an incident. The accident reports were filed and tracked by the Minimum Data Set (MDS) Coordinator in an excel spread sheet that was brought to QAPI. The nurse was to do a fall risk assessment after every fall and it was put with the investigation packet. Any interventions put in place depended on interventions already in place. The DON stated the nurses knew what options were available and they used .nursing clinical judgement (used when deciding which intervention to put in place) .no education on falls .just their (staff) clinic experience . The DON stated fall investigation reports were then brought to a leadership huddle with leadership staff, to the DON, to the Administrator, and to the Medical Director for signatures. The DON stated in the leadership huddles they just reviewed the investigation completed by the unit nurses and looked at what the nurses indicated was the probable cause, interventions nursing implemented, time of fall, and any patterns. The DON stated the nurses did not do any root cause analysis at the time of the fall and the leadership was also not doing a root cause to determine the cause of the fall in order to implement interventions to prevent further falls. The DON stated they were aware the care plans were not updated, I don't know when the care plans (were updated) .the mentor in the house should be updating the care plans .I think that there is work to be done .doing weekly meetings we will be able to get more in depth and with dementia they (residents) forget they can't get up . The facility started a PIP for falls in (MONTH) after there had been 3 falls with injury and the facility needed to re-evaluate falls. The DON then stated the facility started looking at fall interventions when the new Administrator arrived in June. Interview with the Administrator on 8/20/18 at 12:20 PM, in the conference room, confirmed she led the QAPI meeting and staff discussed how many falls during a month and any trends or patterns. QAPI looked at residents with multiple falls in a month but did not look back further. The Administrator stated they didn't go back and look at every fall back in (MONTH) or last year.we haven't gotten there yet . The Administrator started a PIP plan and they reviewed falls in the morning meeting. The Administrator stated .some things I was concerned about .some of the interventions were not appropriate .after doing it that month (review of falls in morning meeting), our teams were educated .educate as we go .if nursing staff used same intervention or inappropriate intervention we would educate the mentor at that time . The Administrator stated root cause analysis during falls and related to a history of falls was not being discussed and the first root cause analysis was conducted in July. The facility saw an increase in falls and increase in multiple resident falls, and they looked at one month of falls. The Administrator stated they knew the fall rate increased. The Administrator stated .as we are starting the PIP plan we would talk .about education .have not discussed pressure ulcers in huddle .not sure if they're talking about them in therapy .we have not done it in morning meeting yet . Interview with the Consultant, who was the previous Administrator from 3/18 - 6/18, on 8/20/18 at 1:47 PM, in the conference room, revealed he did not attend the falls meetings or huddles and stated he did not have clinical experience. He stated he relied on the nurses for implementation of interventions. Further interview revealed he became aware approximately the 3rd week of (MONTH) falls had increased and he .Called on MDS (Minimum Data Set nurse) . to address. He stated, .MDS would facilitate those meetings .informal monitoring to ensure meetings (huddles) being held with (MDS #1) were informal .nothing formal . Interview with the Medical Director on 8/20/18 at 11:14 AM, in the conference room, confirmed recurrent falls were reported to the Nurse Practitioners (NPs) and any concerning issues went directly to the Medical Director. Further interview confirmed .I don't know how much detail is in QAPI meeting . (Medical Director's) involvement with pressure ulcers primarily supervisory, I use wound trained NP's and a wound Nurse . Further interview confirmed .greatest trend identified is the multiple changes in leadership and large turn-over in staff .and turnovers in leadership have not been helpful .Falls .We can't tie them up . Refer to F-550, F-657, F-677, F-686, F-689, F-697, F-725, F-726, F-835, F 841, and F-947.",2020-09-01
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 on falls, like what to do if you see water in the floor. Further interview revealed she was new to the position and stated she did not have an annual plan or monthly plan for education. She was still trying to find out where deficiencies in education were and developing an education month to month if someone told her there was a need. Interview with the Staff Development Coordinator on 8/20/18 at 2:49 PM, in the conference room confirmed .(Nurse) Mentors check (computer based training) and HR (human resources) follows that .I just started .orientation begins with me .goes on to mentor .(mentors) pick a preceptor .(nurse mentors) evaluate in 1st 90 days and if not performing .mentors talk to DON (Director of Nursing) .(nurse mentors) keep in contact with HR for Relias (computer based training) .Excel (spreadsheet) is more for me to know who is with what mentor .what household they are (on) . Interview with the Staff Development Coordinator on 8/20/18 at 4:55 PM, in the conference room, confirmed the facility did not have a system in place to track and trend the competency levels of nurse aides. Refer to F-550, F-677, F-689, F-725",2020-09-01
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 equipment for Resident #28.",2020-09-01
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 review of Resident #273's POST form, revealed the resident requested a Do Not Attempt Resuscitation status with Limited Additional Interventions. Continued review revealed the Physician had not signed or dated the form. Medical record review revealed Resident #279 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #279's POST form, undated, revealed documentation the resident was a Do Not Attempt Resuscitation status with Limited Additional Interventions. Continued review revealed Resident #279 or an appropriate resident representative had not signed the form, indicating DNR was the resident's wishes. Interview with the Director of Nursing on 8/28/19 at 1:28 PM, in the conference room, confirmed the facility .get (advanced directives) upon admission . and were to be signed by the physician and resident or resident representative. Continued interview confirmed the facility failed to ensure facility policy for Advance Directives was followed for Resident #87, #273, and #279.",2020-09-01
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, revealed staff checking vital signs. Observation on 5/24/2017 at 7:50 AM, revealed the breakfast tray was delivered to Resident #84. On 5/24/2017 at 8:05 AM an interview was completed with LPN #1. LPN #1 stated the activities staff ask residents about bedtimes, but not morning wake up times, and LPN #1 was unable to find any documentation in the record indicating Resident #84's preferred time to get up in the mornings. On 5/24/2017 at 8:05 AM, a review of the CNA Point of Care data noted no information about the time Resident #84 preferred to get up in the mornings. Medical record review revealed Resident #211 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #211 had a BIMS (Brief Interview for Mental Status) score of 14 indicating the resident was cognitively intact. On 5/22/2017 at 2:53 PM, an interview was completed with Resident #211. Resident #211 stated she was not able to choose the time she was awakened in the morning. They get me up about 8:30 (AM). I prefer 9:00 (AM) or later. On 5/23/2017 at 3:00 PM, an interview was completed with CNA #1 who stated she was familiar with Resident #211. (Resident #211) eats about 7:45 (AM). She likes to sleep in. She will say, I don't feel like it and I want to wait awhile. She gets vital signs each morning around 7:00 (AM) and she will usually say she doesn't want to get up; she wants to wait till after breakfast. Review of the medication record on 5/23/17 at 3:45 PM noted no medications that required vital sign parameters before administering the resident's prescribed medication. On 5/23/2017 at 4:09 PM, an interview was completed with LPN # 2 who stated she was familiar with Resident #211. We get everyone's vital signs every day. We would get Resident #211's vitals each shift. On day shift they would start getting vital signs at 7:00 AM. On 5/24/2017 at 7:48 AM, Resident #211's breakfast tray was noted delivered. On 5/24/2017 at 8:05 AM, a review of the Nursing Assistant Point of Care data noted no information about the time Resident #211 preferred to get up in the mornings. An interview was completed with LPN #1 on 5/24/2017 at 8:05 AM, who stated activities staff ask residents about bedtimes, but not morning wake up times, and that she couldn't find any documentation in the record indicating Resident #211's preferred time to get up in the mornings.",2020-09-01
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 should be covered. When asked if gloves are required when touching food surfaces, she confirmed that they were.",2020-09-01
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,"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 Medication Administration Record [REDACTED]. Medical record review of a nurses' note dated 7/17/18 and timed 10:30 AM revealed the resident's blood pressure was 196/87; Heart rate was 60 beats per minute; respiratory rate was 18 breaths per minute and the Oxygen saturation (amount of oxygen in the blood) was 98% (percent). Continued review revealed the resident was alert and oriented. Medical record review of a Nurse Practitioner's note dated 7/17/18 revealed .Pt (patient) was given morning meds (medications) that were prescribed to another pt. He had not received his own meds at the time. Medications were reviewed. His own morning blood pressure medication was held due to medicines he received. Pt was seen approx (approximately) 2 hours after receiving medications. He was alert and oriented. No adverse affects have occurred at this time. Discussed with patinet (patient) and daughter that he may have some drowsiness. Vital signs checked per staff and were stable . Medical record review of a nurses' note dated 7/17/18 and timed 1:45 PM revealed the resident's blood pressure was 151/76 and the resident was alert and oriented. Medical record review of nurses' notes dated 7/17/18 from 1:54 PM through 2:30 PM revealed the resident complained of nausea with some .thin watery emesis . Continued review revealed the resident remained alert, oriented and had some complaints of dizziness and sleepiness. Medical record review of a nurses' note dated 7/17/18 and timed 3:00 PM, revealed the resident had no further emesis. Continued review revealed the resident reported he was feeling .a little better . and wanted to go to his doctor's appointment. Medical record review of a nurses' note dated 7/17/18 and timed 3:30 PM, revealed the resident was out of the facility for a doctor's appointment. Medical record review of a Provider Note dated 7/18/18 revealed .patient received wrong medications including [MEDICATION NAME] (medication for [MEDICAL CONDITION]), Requip (medication for restless leg syndrome), [MEDICATION NAME] (medication for depression), Vitamin D (calcium), Risaquad (medication to balance good bacteria in the digestive system), [MEDICATION NAME] (blood pressure medication), and [MEDICATION NAME] (blood pressure medication) . Observations of Resident #335 from 7/23/18 through 7/25/18 revealed the resident was participating in physical therapy and talking with other residents in the hallway. Interview with Resident #335 and the residents' daughter on 7/23/18 at 11:30 AM, in the resident's room revealed the resident had received another resident's medication on 7/17/18. The residents' daughter reported Resident #335 received 2 blood pressure medications, an antidepressant, medication for [MEDICAL CONDITION], and a vitamin in error. Interview with Nurse Practitioner (NP) #1 on 7/24/18 at 3:05 PM, in the Station 4 Chart Room confirmed Resident #335 received another resident's medications on 7/17/18. Further interview revealed the resident complained of nausea for a couple of hours and vomited 1 time. Continued interview revealed the resident's vital signs remained stable, all of the labs were normal and there were no adverse side effects. Interview with Resident #335 on 7/24/18 at 3:41 PM, in the resident's room revealed the resident had received the medications in the hallway as the resident was going to therapy. The resident reported he had gotten sleepy while in therapy, had nausea and vomiting, and was light headed. Interview with Licensed Practical Nurse (LPN) #1 on 7/24/18 at 3:41 PM, in the Infection Control Office revealed she thought Resident #335 came out of room [ROOM NUMBER]. LPN #1 confirmed she gave Resident #335 the medication for the resident occupying room [ROOM NUMBER]. Interview with the Director of Nursing on 7/24/18 at 4:27 PM, in the Station 4 Resident Care Coordinator's Office confirmed Resident #335 received the incorrect medication on 7/17/18 and confirmed the facility failed to follow the facility policy for medication administration.",2020-09-01
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,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,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 sanitizing gel that was on the isolation kit outside the door, and then walked to the therapy gym. Interview with Registered Nurse (RN) #1 on 6/5/19 at 8:03 AM in the conference room, RN #1 was asked why Resident #182 was in isolation. RN #1 stated, [DIAGNOSES REDACTED]. RN #1 was asked what the staff were supposed to do when they entered and exited Resident #182's room. RN #1 stated, They hand wash .the hand gel stuff don't work with the [MEDICAL CONDITION]. They are supposed to wash hands with soap and water coming out of the room. Interview with the Director of Nursing (DON) on 6/5/19 at 8:42 AM in the conference room, the DON was asked if the staff should perform hand hygiene using hand sanitizing gel after they left Resident #182's room. The DON stated, It's not appropriate for the [MEDICAL CONDITION]. 3. Medical record review revealed Resident #181 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Wound Management notes dated 6/1/19 revealed Resident #181 had extensive [DIAGNOSES REDACTED] (a disease in which calcium accumulates in the small blood vessels of the fat and skin tissue) ulcers, 3 to the left upper arm, 3 to the right upper arm, 1 to the right thumb, 1 to the right hand, and 1 to the right wrist. Observations in Resident #181's room on 6/4/19 at 3:21 PM revealed the following: LPN #1 removed the soiled dressing from Resident #181's right upper arm, cleaned the posterior upper wounds with saline soaked gauze, and then used a cotton swab to apply [MEDICATION NAME] gel, using the same gloves. LPN #1 did not perform hand hygiene between cleaning the wound and applying the clean treatment. LPN #1 placed a saline soaked gauze on the wound to the anterior right upper arm, still wearing the same gloves. LPN #1 did not change gloves or wash her hands between different wounds. LPN #1 removed her gloves, and adjusted the thermostat on the wall. LPN #1 did not perform hand hygiene after removing the soiled gloves. LPN #1 cleaned the [MEDICATION NAME] gel from Resident #181's posterior upper arm wounds with saline soaked gauze, and applied [MEDICATION NAME] One (a dressing used for painful wound management that prevents the outer dressing from sticking to the wound bed) and [MEDICATION NAME] Extra (a moisture retention dressing) using the same gloves. LPN #1 did not change gloves or perform hand hygiene between cleaning the wound and applying clean dressings. LPN #1 removed her gloves, applied clean gloves, and removed the dressing from Resident #181's right lower arm. LPN #1 did not wash her hands between glove changes and between different wounds. LPN #1 cleaned the wounds to Resident #181's right posterior lower arm using saline soaked gauze and then applied [MEDICATION NAME] One, [MEDICATION NAME] Extra, (abdominal pads (ABD) used for large wounds or wounds needing high absorbency), and conforming gauze dressings using the same gloves. LPN #1 did not change gloves or perform hand hygiene between cleaning the wound and applying clean dressings. LPN #1 removed the dressings from Resident #181's right wrist and hand, cleaned the wounds with saline soaked gauze, and applied [MEDICATION NAME] One dressing. LPN #1 did not change gloves or perform hand hygiene between cleaning the wound and applying clean dressings. LPN #1 changed her gloves without performing hand hygiene, and applied [MEDICATION NAME] Extra, ABD pads, and conforming gauze to Resident #181's right wrist. LPN #1 did not perform hand hygiene between glove changes. LPN #1 removed the dressing from Resident #181's left upper arm and changed her gloves without performing hand hygiene. LPN #1 cleaned the wounds to the left upper arm with saline soaked gauze, applied [MEDICATION NAME] One, [MEDICATION NAME] Extra, and ABD pad dressings, and wrapped the right upper arm with gauze. LPN #1 did not change gloves or perform hand hygiene between cleaning the wound and applying clean dressings. Interview with the DON on 6/5/19 at 8:42 AM in the conference room, the DON was asked when staff should perform hand hygiene during wound care. The DON stated, In between clean and dirty, I want them to be washing their hands and changing their gloves. The DON was asked if they were supposed to wash their hands when they changed gloves. The DON stated, Yes.",2020-09-01
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,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 conducted. The Director of Nursing leads the investigation .Appropriate agencies, required by state regulation will be notified . Medical record review revealed Resident #379 was admitted to the facility on [DATE] and discharged [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 14 day Minimum Data Set ((MDS) dated [DATE] revealed Resident #379 scored 15/15 on the Brief Interview for Mental Status, indicating she was alert and oriented. Continued review of the MDS revealed Resident #379 required extensive assistance of 2 people for transfers and toileting; extensive assistance of 1 person for dressing and bathing; assistance of 1 person for grooming; supervision for eating; and was frequently incontinent of bowel and bladder. Medical record review of nursing notes dated 10/28/16 revealed Resident #379 had bilateral upper extremity skin tears. Continued review of nursing notes dated 11/4/16 revealed the resident had multiple skin tears to bilateral upper extremities. Review of incident reports revealed none were completed for these injuries and no investigations were completed for multiple injuries of unknown origin Interview with the Director of Nursing (DON) on 7/19/17 at 4:30 PM in the conference room, confirmed there were no incident reports for the skin tears which occurred on 10/28/17 and 11/4/17. Continued interview with the DON confirmed there was no investigation into either injury of unknown origin. Medical record review revealed Resident #168 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed a Brief Interview for Mental Status could not be conducted because the resident is rarely/never understood. Medical record review of a nurse note dated 7/18/17 at 8:50 AM by Registered Nurse (RN) #1 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 #1 on 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 checked the placement of the [MEDICATION NAME] around 4 AM and could not find it. 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 RN #3, Unit Manager on 7/19/17 at 2:45 PM in the conference room, when asked her expectation of when staff should notify her of a missing [MEDICATION NAME] on a resident revealed she would expect to be notified immediately. Continued interview revealed she was notified of the missing [MEDICATION NAME] for Resident #168 at approximately 9 AM on this date by LPN #2. Interview with the DON on 7/19/17 at 4:38 PM in the conference room revealed she did not find out about the missing [MEDICATION NAME] until this morning, and an investigation had since been initiated. Continued interview revealed RN #1 did not report the missing [MEDICATION NAME] to the unit supervisor or the DON. Further interview revealed the incident had not been reported to the state agency. Continued interview with the DON confirmed RN #1 did not report the possible misappropriation of narcotic medication in a timely manner and the facility did not report to the State Agency in the required time period.",2020-09-01
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,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. Medical record review revealed Resident #230 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].#230 was on the BM Protocol. Review of the electronic Toileting .BM record revealed Resident #229 did not have a BM on 7/21/18, 7/22/18, and 7/23/18. Review of the Med PRN record dated 7/1/18 to 7/31/18 revealed Resident #230 did not receive the Polyethylene [MEDICATION NAME] on 7/23/18 (the 3rd day). 4. Interview with the the Nurse Practitioner on 8/1/18 at 11:27 AM in the conference room, the Nurse Practitioner was asked if she had been notified about Resident #229 and 230 not having BMs. the Nurse Practitioner stated, .I was not aware .The expectation is the nurses follow the bowel protocol . Interview with RN #1 on 8/1/18 at 2:38 PM in the MDS office, RN #1 reviewed the Toileting .BM record for Resident #230, and confirmed that Resident #229 had not had a BM on 7/21/18, 7/22/18, and 7/23/18. RN #1 stated, He should have gotten the Polyethylene [MEDICATION NAME] on that third day. Interview with the Director of Nursing (DON) on 8/1/18 at 3:01 PM in the conference room, the DON confirmed that Resident #229 and #230 should have received medication after no BM for 3 days, and stated that it was not appropriate for staff to not follow the bowel protocol.",2020-09-01
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 REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME]-[MEDICATION NAME] .1 ampul nebulization every 6 hours .NEBULIZATION .Dx .shortness of breath . Observations in Resident #178's room on 7/30/18 at 12:51 PM, and on 7/31/18 at 8:44 AM, 11:36 AM, and 4:56 PM, revealed Resident #178 in bed, with a nebulizer on the bedside table. The tubing and mask were attached and dated 7/25/18. The mask and tubing were uncovered without a barrier. Interview with LPN #1 in Resident #178's room on 7/31/18 at 5:14 PM, LPN #1 confirmed the nebulizer tubing and mask were not covered or placed on a clean barrier and stated, It needs to be covered. Interview with the Director of Nursing (DON) on 7/31/18 at 5:31 PM in the conference room, the DON was asked how the nebulizer masks, mouthpieces, and tubing should be stored. The DON stated, There's a bag they are supposed to be using. and further stated it was unacceptable for them to be out on the bedside table without a cover or a clean barrier.",2020-09-01
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 back with the patient .it's scanned into the system . The DON was asked what she expected the nurses to do if the [MEDICAL TREATMENT] center did not send back the form. The DON stated, .I would think they should call the clinic to see if they can get information .keep me informed so I can know the patient is getting what they need . The facility was unable to provide documentation of communication between the [MEDICAL TREATMENT] center and the facility.",2020-09-01
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,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 hours. The Facility Administrator will investigate all allegations, reports, grievances, and incidents that potentially could constitute allegation of abuse, injuries of unknown source, exploitation, or suspicions of crime as defined in this account. 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 #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum (MDS) data set [DATE] revealed Resident #10 with severe cognitive impairment and no behaviors. Resident #10 required extensive assist of 1 person for bed mobility, dressing, and eating, and 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 1:00 AM, revealed Resident #10 complained of pain and the LPN assessed the resident with swelling and pain in the right arm. The assessment did not indicate if the Administrator, or the DON were notified. Medical record review of a radiology report for Resident #10, dated 12/30/17 and faxed at 7:14 AM, revealed an acute mildly displaced distal humerus fracture. Medical record review of a Nursing Progress Note, dated 12/30/17, written by LPN #7 revealed the night shift nurse reported an x-ray indicating a right arm fracture. The resident was transported to the emergency room at 10:15 AM. The DON and Administrator were contacted as well (first observation of pain and swelling was on 12/29/17 at 1:00 AM). Medical record review of the emergency room Progress Note, dated 12/30/17, revealed a right arm fracture that the physician documented .was not a result of abuse/neglect . Medical record review of a Nursing Progress Note, dated 12/31/17 at 12:08 AM, revealed the .resident returned from the hospital in no acute distress with a right arm splint and arm sling, family at bedside, and pain medication administered with good results . Review of the facility interventions related to the investigation included Abuse Education (MONTH) (YEAR), which included 5 questions related to when to report abuse, signs of abuse, factors increasing the risk of abuse, and common reasons for abuse. Nurses were required to sign they received a copy of the Signature Healthcare's Triage Process. Review of the sign-in sheets for the Abuse Education (YEAR), revealed 137 of 285 listed staff had signed to indicate the training was completed. Review of the facility Positioning Competency, revealed guidelines for assistance for a resident positioning in a bed and chair, and included areas to indicate completion, comments, employee signature, supervisor signature, and yes or no for successful completion. Review of the facility sign-off sheet included completed sign-off for all staff. Upon review of the individual competency sheets revealed multiple sheets were missing dates, evidence the competency was completed, and supervisor signatures. Interview with the DON on 3/28/18 at 1:00 PM in the Conference Room revealed when Certified Nurse Assistant (CNA) #9 came on shift at 11:00 PM the CNA discovered Resident #10 complaining of pain when being turned. CNA #9 reported the issue to LPN #7 and the resident was assessed with [REDACTED]. The Night Shift Supervisor/Registered Nurse (RN) #2 was notified and came to assess the resident. An x-ray was obtained with the results of a right arm fracture. Further interview confirmed the RN did not notify the DON or the Administrator per policy of the injury of unknown origin. Further interview confirmed the facility failed to report the injury of unknown origin to the SA within 2 hours as required and per policy. Interview with the Administrator on 3/28/18 at 1:35 PM in the Conference Room revealed he did not recall the time of notification of the incident. Further interview confirmed he called the DON on 12/30/17 after the x-ray results were received. Further interview revealed the facility began abuse training immediately on the day of discovery. When CNA #8 stated on 1/03/18 the injury might have occurred during positioning the facility felt the injury was caused by faulty positioning, and the facility began staff competencies for positioning. Since the emergency room physician did not think the injury was related to abuse/neglect the facility moved from an allegation of abuse to care competency. Further interview confirmed a delay in notification resulted in the facility not reporting the injury of unknown origin within 2 hours to the SA per facility policy. The Administrator confirmed the abuse training and positioning competencies for nursing were not completed by the facility after the incident. Interview with the DON on 3/28/18 at 2:00 PM in the Conference Room confirmed the abuse training of when to report abuse was not completed for all staff and the positioning competencies were not completed for all nursing staff at the time of the investigation.",2020-09-01
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 1:00 AM, revealed Resident #10 complained of pain and the LPN assessed the resident with swelling and pain in the right arm. The assessment did not indicate if the Administrator, or the DON were notified. Medical record review of a radiology report for Resident #10, dated 12/30/17 and faxed at 7:14 AM, revealed an acute mildly displaced distal humerus fracture. Medical record review of a Nursing Progress Note, dated 12/30/17, written by LPN #7 revealed the night shift nurse reported an x-ray indicating a right arm fracture. The resident was transported to the emergency room at 10:15 AM. The DON and Administrator were contacted as well (first observation of pain and swelling was on 12/29/17 at 1:00 AM). Review of the facility documentation report revealed the SA was notified on 12/30/17 at 1:35 PM, 36 1/2 hours after the event. Interview with the DON on 3/28/18 at 1:00 PM in the Conference Room revealed when CNA #9 came on duty at 11:00 PM Resident #10 complained of pain when being turned. CNA #9 reported the issue to LPN #7 and the resident was assessed with [REDACTED]. The Night Shift Supervisor/Registered Nurse (RN) #2 was notified and came to assess the resident. An x-ray was obtained with the results of a right arm fracture. Further interview confirmed the RN did not notify the DON or the Administrator per policy of the injury of unknown origin. Further interview confirmed the facility failed to report the injury of unknown origin to the SA within 2 hours as required and per policy. Interview with the Administrator on 3/28/18 at 1:35 PM in the Conference Room confirmed there was a delay in notification of the injury of unknown origin to administrative staff resulting in the facility's failure of not reporting the injury within two hours to the State Agency as required and per policy.",2020-09-01
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 11/30/17 through 12/10/17 (11 days) revealed no evidence of a dressing change to the PICC line. Medical record review of Physician order [REDACTED].#7 revealed .discontinue PICC line and reinsert new Midline catheter . Review of a procedure form for Resident #7 dated 12/10/17 revealed .the patient PICC line was out 7 centimeters and the dressing was loose on three sides. A Midline catheter was inserted into the left upper arm with a dressing applied . Medical record review of Physician order [REDACTED]. Medical record review of the MAR for Resident #7 dated from 12/11/17 through 12/26/17 (17 days) revealed no evidence of a dressing change to the Midline catheter. Medical record review of the Comprehensive Care Plan dated 12/11/17, revealed the .resident as at risk for complications related to the use of IV (intravenous) fluids and /or medications with a right upper arm PICC line . Interventions included .apply and check IV site treatment/dressings as ordered . Interview with the Director of Nursing (DON) on 3/28/18 at 2:30 PM confirmed the resident was admitted with a PICC line. Further interview revealed the PICC line became misplaced and a new Midline catheter was placed to continue the antibiotic administration. The DON confirmed the facility failed to have documentation of a dressing change to the PICC line and Midline catheter every seven days as per the facility policy. Review of the facility Medication Administration General Guidelines dated 2007 revealed, .hands are washed with soap and water and gloves applied before administration of topical, ophthalmic, otic, [MEDICATION NAME], enteral, rectal, and vaginal medications. Hand are washed with soap and water again after administration and with any resident contact. Antimicrobial sanitizer may be used in place of soap and water as allowed per state nursing regulations and facility policy . Medical record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of medication administration on 3/27/18 at 8:50 AM revealed Licensed Practical Nurse (LPN) #6 entering the isolation room for Resident #15. LPN #6 donned personal protective equipment (PPE) to include a mask, gown, and gloves. With the help of Rehab #2 the resident was repositioned to allow better access to the resident gastronomy tub ([DEVICE]). LPN #6 removed gloves, donned new gloves, and assessed the [DEVICE] for placement and residual tube feed, changed gloves and administered several medications per the [DEVICE]. LPN #6 then changed gloves and administered prescription eye drops in each eye. LPN #6 took off gloves and reached under the PPE gown and took a large bore needle from a uniform pocket, donned gloves and used the needle to puncture two fish oil capsules, and place the liquid from the capsules in a medication cup. After changing gloves, LPN #6 administered the fish oil through the [DEVICE], changed gloves and administered a subcutaneous injection into the resident's abdomen. After changing gloves, LPN #6 administered a second drop of the prescription eye drop to each of the resident's eyes. LPN #6 then removed the PPE and gloves, washed hands with soap and water before exiting the room. The hand washing prior to exit was the only time LPN #6 completed hand washing or hand hygiene for the entire medication administration. Interview with LPN #6 on 3/27/18 at 9:30 AM on the second-floor hallway confirmed hand hygiene, to include hand washing or alcohol rub, was not used during the medication administration with Resident #15. Further interview revealed LPN#6 was unsure of the facility policy for hand hygiene. Interview with the DON on 3/28/18 at 5:10 PM in the facility Conference Room revealed staff were expected to wash hands or use alcohol rub any time gloves were worn and removed, before and after injections, and before eye drops and [DEVICE] medications. Further interview confirmed nursing staff should not remove items from pockets while in an isolation room.",2020-09-01
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 removed Resident #83 from the dining room and left him in his room still covered in emesis to go down stairs to get a cupcake. Continued interview revealed the lunch trays were not late and at 2:00 PM a valentine's party was going on downstairs. Continued interview confirmed .it really bothered me about the time .",2020-09-01
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,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 nebulizer via mask 6 times a day, [DIAGNOSES REDACTED].[MEDICATION NAME] 0.5 MG/2 milliliters (ML) suspension, 1 vial per nebulizer twice a day [DIAGNOSES REDACTED]. Observation on 4/1/19 at 9:37 AM and 12:00 PM in Resident #573's room, revealed the nebulizer mask lying on the bedside table was not bagged or dated. Further observation on 4/1/19 at 2:27 PM in the resident's room revealed the unbagged and undated nebulizer mask was lying on the resident's bed. Interview with LPN #4 on 4/1/19 at 2:49 PM on 400 North Hall confirmed nebulizer masks are kept in bags when not in use. Interview with the Director of Nursing (DON) on 4/3/19 at 11:45 AM in the DON's office confirmed nebulizer masks were to be kept in a plastic bag when not in use.",2020-09-01
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,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 bin here (pointing in the medication room) . Observation of the 200 West medication cart on 4/2/19 at 5:14 PM with LPN #7 on the 200 West hallway revealed a multiple dose bottle of Vitamin B-12 100 mg,130 count, expired 6/26/18. Interview with LPN #7 on 4/2/19 at 5:30 PM on the 200 West hallway confirmed .all expired medications should not be on the cart, should not be used . Observation of the Riberio unit medication cart on 4/3/19 at 2:30 PM with LPN #9 in the Riberio unit medication storage room revealed the following: a multiple dose bottle of Elder Tonic 473 ml expired 12/18 and a multiple dose bottle of D3 (a vitamin supplement) 5000 International Units (IU),100 capsules, expired 2/19. Interview with LPN #9 on 4/3/19 at 2:40 PM in the Riberio unit medication storage room confirmed .that no medications on the cart should be expired . Interview with the Pharmacist on 4/3/19 at 8:00 PM on the telephone confirmed .she reviewed all medication carts and medication storage rooms monthly .she was there on 4/1/19 later in the day at around 5 PM .and she usually removes expired medications by using kitty litter, placing them in sharps boxes, or giving them to the unit manager for disposal .expired medications should not be on the medication carts or in the storage rooms . Interview with the Director of Nursing on 4/3/19 at 8:07 PM in her office confirmed .medication carts and medication storage rooms should not have expired medications .they should be removed and disposed of by taking them back to pharmacy .expired medications should not be used .",2020-09-01
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. Review of the Dish Machine Temp Audit form revealed the wash temperature on 1/8/19 and on 3/21/19 was158 degrees F, and on 3/26/19 was 159 degrees F. Further review revealed the final rinse sanitizing temperature on 3/21/19 was 179 degrees F. Interview with Maintenance staff #1 on 4/1/19 at 10:00 AM in the dietary department dish room revealed .over the weekend the boiler broke down and the steam it generates operates the dishwasher and it might not have recovered yet . Interview with the Administrator on 4/2/19 at 12:22 PM in the conference room confirmed the facility policy was not followed related to the failure to document the dish machine temperatures every shift. Observation in the Birmingham building Nourishment Rooms on 4/2/19, with facility staff present, revealed the following: At 3:12 PM on the 4th floor with Licensed Practical Nurse (LPN) #6 present, revealed the interior of the ice machine had pink colored debris on the ice slide. Further observation revealed the interior of the microwave had a very heavy accumulation of multi-colored dried debris and food debris. Interview with LPN #6 in the 4th floor Nourishment Room on 4/2/19 at 3:12 PM confirmed the microwave interior had debris and the ice machine interior had pink color debris. At 3:16 PM on the 3rd floor, with Medical Record staff #1 present, revealed the interior of the microwave had an accumulation of dried food debris. Interview with Medical Record staff #1 in the 3rd floor Nourishment Room on 4/2/19 at 3:16 PM confirmed the microwave interior had debris. At 3:20 PM on the 2nd floor, with Unit Manager #4 present, revealed the interior of the ice machine had pink colored debris on the ice slide. Interview with Unit Manager #4 on 4/2/19 at 3:20 PM in the Nourishment Room confirmed the interior of the ice machine had pink debris.",2020-09-01
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,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,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 cognitive impairment, and required extensive to total staff assistance for all activities of daily living. The care plan dated 3/20/17 documented, .Behavior .Problem .6/5/17 .Socially inappropriate .Resists Care .False Claims against staff .yelling out for caregivers continuously .Delusions . There was no documentation for self administration of medications. The physician's orders [REDACTED].[MEDICATION NAME] 20% (PERCENT) VIAL .One vial via nebulization four times a day .[MEDICATION NAME] .1 VIAL PER NEBULIZER FOUR TIMES DAILY . A telephone physician's orders [REDACTED].Add Dx's (diagnosis) of [MEDICAL CONDITION] . There was no assessment or physician order [REDACTED]. Observations in Resident #146's room on 6/11/17 beginning at 10:20 AM, revealed Resident #146 lying in bed holding a nebulizer medication cup in his hand containing clear liquid that was disconnected from the nebulizer. The nebulizer mask was around Resident #146's neck, and the nebulizer was turned on. The resident was yelling out for help, and was not able to state his name. There was no staff member in the room. 4. Medical record review revealed Resident #178 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented Resident #178 was severely cognitively impaired per staff assessment, and was totally dependent on staff for ADLs. The care plan dated 8/23/16, and last revised on 5/11/17, revealed there was no documentation for self administration of medications. The physician's orders [REDACTED].[MEDICATION NAME]/[MEDICATION NAME] SULFATE .1 VIAL PER NEBULIZER EVERY 6 HOURS . Observations in Resident #178's room on 6/11/17 beginning at 10:16 AM, revealed Resident #178 lying in bed with a nebulizer treatment in progress with the mask strapped to the resident's face. There were no staff member in the room. There was no assessment or physician order [REDACTED]. Interview with the Director of Nursing (DON) on 6/14/17 at 10:20 AM, in the conference room, the DON was asked whether there were any residents in the facility that could self-administer medications. The DON stated, No. The DON was asked whether it was appropriate for the nurse to start a nebulizer breathing treatment on a resident and then leave the resident alone. The DON stated, Well, the nurse is supposed to keep a frequent check on the residents.",2020-09-01
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, top of foot board, telephones, chairs, ledges, light switches, televisions, walkers, I.V. (Intravenous) poles, Geri-chairs, clean, (sic) mirror, soap and towels dispensers, and cabinets with an approved germicidal detergent. Work clockwise around the room .VIII. Clean bathroom according to procedure . 2 Observation of the Ribeiro secured nursing unit , on [DATE] beginning at 2:45 PM thru 3:45 PM, revealed: a. Room 102: A window sill was missing Formica and had missing baseboards A walker was held together with yellow tape that was peeling away from the metal bars. b. Room 103: Shower tiles had unknown black substance in the caulking c. Room 104: Window sill missing Formica d. Room 111: Baseboards missing e. Room 115: Baseboards missing f. Room 118: The lock on the clothes closet was broken which prevented the door from closing securely. g. Room 119 B: There were missing wood pieces which prevented the drawers from closing securely and the foot board on the A bed (near the door) was not securely attached to the bed frame which made it shaky and unstable. h. Room 124: Walls in the bathroom in room 124 were scuffed and in need of cleaning, repair and/or paint. Observation of the 4 th floor Birmingham nursing unit on [DATE] beginning at 4:00 PM thru 4:45 PM, revealed: a. Room 402: Window blinds were torn, bent, and not hanging straight which inhibited the blinds from closing completely, the shower tiles had large blotches of a black substance that resembled mold or mildew, the dresser was broken and in need of repair, and some of the base boards in the bathroom were missing. b. Room 413: Dresser drawer in room 413 was missing the knobs on the 3 top drawers. c. Room 415: The faucet in the sink was leaking and had a continuous line of dripping water. d. Room 427: Bed pan in room 427 was smeared with unknown brown substance and hanging in the bathroom on a metal rack. e. Room 429: A wall, located just outside room 429 was punched in which allowed a large gap between the wall and the base board. f. Room 430: Dresser was broken and the drawers could not close securely. Interview with Licensed Practical Nurse (LPN) # 2 on 4th floor Birmingham on [DATE] at 4:20 PM, LPN # 2 stated, everyone's responsibility to ensure that each resident's room and equipment was cleaned and maintained in a safe and sanitary fashion . Interview with the Facilities Management Director on [DATE] at 4:30 PM confirmed that he was responsible for maintaining each resident's equipment in a safe fashion. The Facilities Management Director stated when staff identified a piece of equipment or furnishings that were in need of repair, they were to complete a work order to ensure that it could be remedied timely. Interview with the facilities Management Director further stated that he had not received any work orders related to these concerns. The Management Director was asked what the procedure was for repairing furnishings and equipment. The Management Director, .if staff do not complete a work order, I would not be aware of the broken equipment and furnishings. Interview with the Environmental Services Supervisor, on [DATE] at 4:45 PM, the Environmental Services Director was asked whose responsibility it was to maintain the cleanliness of the resident's rooms. The Environmental Services Director stated, it was his department's responsibility to clean the residents' equipment and furnishings and his staff must have missed those concerns . Interview with the Administrator, on [DATE] at 10:30 AM, in the Administrator's office confirmed that it was the facility's policy to complete work orders for equipment and furnishings in need of repair. The Administrator stated, .it was our policy to clean and maintain the residents' rooms on a daily basis .the facility staff failed to follow the policies and procedures relative to maintaining the residents' equipment and furnishings and cleaning of the resident's rooms and their belongings on a daily basis .",2020-09-01
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 related injury by utilizing fall precautions through the next review date of 7/11/17. The plan of care did not address the use of the physician ordered bed alarm. On 6/14/17 at 12:30 PM, LPN #1 verified the plan of care did not include the use of the physician ordered bed alarm. 3. Medical record review revealed Resident #62 was last admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #62's last quarterly MDS assessment dated [DATE] indicated the Resident #62 had severe cognitive deficits. The current fall plan of care listed bilateral side rails as enabler's but did not include the type of side rails (namely full, half or quarter side rails). Resident #62 was observed in bed with bilateral full side rails up on both sides of the bed on 6/11/17 at 4:20 PM; on 6/12/17 at 3:39 PM and 3:53 PM; on 6/13/17 at 7:40 AM, 8:41 AM, and at 1:39 PM; and on 6/14/17 at 9:36 AM. During the observation on 6/12/17 at 3:39 PM, LPN #4 verified the resident always used full side rails when the resident was in bed. Interview with LPN #1 on 6/14/17 at 12:20 PM, LPN #1 stated Resident #62 was not cognitively capable of using the side rails as enabler's and stated the bilateral full side rails were put into place at the request of the resident's family.",2020-09-01
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,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 include the use of the side rail. 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. The bed was at a regular height (not low). LPN #2 verified Resident #25 was supposed to have the full side rail on the left of the bed raised to assist him with positioning. LPN #2 lowered the full side rail on the right side of the bed. Interview with LPN #2 on 6/11/17 at 2:50 PM, in Resident #25's room, LPN #2 stated, .when both side rails were up they restrained the resident from sitting up on the side of the bed . Interview with LPN #1 on 6/14/17 at 12:10 PM, verified the MDS assessment dated [DATE] was not accurate as it was coded to indicate side rails were not used .and the Evaluation for the use of the Side Rails dated 6/7/17 was not accurate as it was marked side rails not indicated at this time. LPN #2 verified the plan of care did not include the use of the side rail and there was no assessment related to the resident's risk of entrapment and verified the assessment did not include other appropriate alternatives to 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 quarterly MDS assessment dated [DATE] revealed Resident #54 had severe cognitive deficits, and required extensive assistance for bed mobility. Review of the physician's order sheets dated 5/30/17 documented orders for a bed alarm for fall prevention and bilateral safety mats next to bed. The physician's orders did not include an order for [REDACTED]. The current plan of care for falls dated of 8/16/16 documented 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 related injury by utilizing fall precautions through the next review date of 7/11/17. The interventions included the use of quarter side rails as enabler's and right and left fall mats. The plan of care did not include the use of the physician ordered bed alarm. The most current 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 indicates the resident is at risk). According to the evaluation the resident was at risk due to behavioral symptoms, being incontinent, using side rails, not able to balance without physical assistance, and the use of antipsychotic medication. Review of the most current Evaluation for Use of Side Rails form dated 4/10/17 assessed the resident as using right and left upper half side rails to assist in turning from side to side and to provide a sense of security. The evaluation did not include an assessment for the least restrictive or other alternatives to the use of the side rails. Review of a Physician's follow-up progress note dated 3/15/17 revealed the physician wrote the resident was restless. The physician's note documented the resident's behaviors were discussed with nursing. The physician wrote fall precautions in place-has a low bed/bed alarm. The progress note did not include the use of the side rails. The Facilities Management Department Work Request dated 5/25/17 documented the bed was to be replaced due to the bed control not working. The invoice documented the bed was replaced on 5/26/17. Interview with LPN #2 revealed, .when the maintenance department replaced the low bed with quarter side rails they replaced it with a regular bed with full side rails . Observation in Resident #54's room on 6/11/17 at 2:34 PM, Resident #54 was observed in bed and the bed was not in the low position and full unpadded side rails were raised. No bed alarm was present on the bed. Observations in Resident #54's room on 6/11/17 at 4:00 PM, Resident #54 was in bed with bilateral unpadded full side rails in place, the bed not in the low position and no bed alarm was in place. LPN #2 verified the observation. After looking at the plan of care, she verified the resident should have quarter side rails in place and not full side rails. Observations in Resident #54's room on 6/11/17 at 4:55 PM, Resident #54 was in a low bed with quarter side rails but there was no bed alarm in place. Observations in Resident #54's room on 6/12/17 at 7:37 AM, 6/12/17 at 2:04 PM, 6/12/17 at 3:22 PM, and 6/13/17 at 7:41 AM revealed the resident in a low bed with quarter upper bilateral side rails, and no bed alarm in place. On 6/13/17 at 7:44 AM, LPN # 2 verified the resident did not have the fall mat on the floor on the right side of the bed. On 6/13/17 at 7:58 AM, LPN #12 was informed of the resident not having the fall mat on the floor on the right side of the bed. After checking the physician's order, she went into the room obtained the fall mat form the corner of the room and placed the mat on the floor on the right side of the bed. On 6/12/17 at 3:22 pm, LPN #4 verified the resident did not have a bed alarm in place and further stated she was not sure if the resident was supposed to have a bed alarm in place . On 6/14/17 at 12:30 PM, LPN #1 verified the plan of care did not include the use of the physician ordered bed alarm. She verified the resident was supposed to have bilateral quarter side rails, a low bed, a bed alarm, and bilateral safety mats on the floor when he was in bed. She also verified the resident had no assessment for the least restrictive device or an alternative to the use of the bed rails. 3. Medical record review revealed Resident #62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #62's last quarterly MDS assessment dated [DATE] indicated the Resident #62 had severe cognitive deficits. The current fall plan of care listed bilateral side rails as enablers but did not include the type of side rails (i.e. full, half or quarter side rails). Review of the Evaluation for use of Side Rails dated 5/12/17 revealed the assessment was coded side rails not indicated at this time. The assessment did not include an evaluation of the side rails or of her risk of entrapment and did not include an assessment of appropriate alternate interventions. Interview with LPN #1 on 6/14/17 at 12:20 PM, LPN #1 stated, .the resident was not mentally capable of requesting the use of the side rails and it was the resident's family who requested them . She also verified the Evaluation for use of Side Rails dated 5/12/17 was inaccurate as documented side rails not indicated at this time and bilateral full side rails were in use at the time the assessment/evaluation was completed. She verified the assessment lacked an assessment for risk of entrapment and other appropriate interventions. Interview with the Administrator on 6/13/17 at 8:41 AM, the Administrator and Director of Nursing verified Resident #25 was in bed with bilateral full side rails up on the bed. Certified Nursing Assistant #5 stated the resident always has full side rails up on both sides of the bed.",2020-09-01
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 temperature dishwasher was 208 degrees F. Interview with the Food Service Director on 6/14/17 at 8:30 AM, the Food Service Director confirmed the dishwasher rinse temperature consistently ran over 200 degrees or greater and that a (Named Dishwasher Company) specialist checked the dishwasher and determined the gauges were inaccurate and ordered parts to repair the machine.",2020-09-01
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 following procedures are taken by the laundry staff .Use creme cleanser and green pad to scrub sink and wipe dry with a clean rag . 4. Observations in the laundry room on 6/14/17 at 9:41 PM, revealed a white 2-compartment sink covered in dirty brown/gray build-up. There was a large area of standing water on the floor in front of the dryers. Interview with Laundry Staff Member #1 on 6/14/17 at 9:45 PM, in the laundry room, Laundry Staff Member #1 was asked about the water on the floor. Laundry Staff Member #1 stated, We have been walking in water for over a year in here .we have told them about it . Laundry Staff Member #1 was asked what the dirty sink was used for. Laundry Staff Member #1 stated, Hand washing . Laundry Staff Member #1 was asked how often they cleaned the sink. Laundry Staff Member #1 stated, As often as we can. Interview with the Director of Environmental Services (DES) on 6/14/17 at 2:49 PM, the DES was asked about the water on the floor in the laundry area. The DES stated, I have reported it, and was told nothing could be done about it .may be the drain or one of the pipes in that area. The DES was asked how often he expected laundry staff to clean the hand washing sink. The DES stated, Daily. The DES was asked whether it was acceptable for the hand washing sink to be covered with the dirty build-up. The DES stated, No .",2020-09-01
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 plan in place. I understand that we were tagged last year on following the interventions and updating and following the care plans . The Administrator was asked if the QA Committee ever identified any issues with side rails. The Administrator stated, .From what I found out this week our care plans don't match the consent, the MD (Medical Doctor) orders don't match the correct side rails that we have on the beds. I'm totally shocked by the side rails that you have found. Families have been adamant that we would get sued if their loved one got hurt in the side rails. Side rails have been an issue. We report on the number of side rails and restraints in QA . The Administrator was asked if the QA Committee identified issues with the environment and accident hazards. The Administrator stated, .I was not aware that the rounding forms and work orders were not kept. The Stand up meeting minutes has a place to put environmental concerns. He (Maintenance Director) will be inserviced. I am responsible for knowing what goes on in the building . The Administrator was asked if Infection control issues are reviewed during the QAA Committee meeting. The Administrator stated, .we have QA'd infection control .",2020-09-01
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,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 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]. Further interview confirmed the facility failed to follow the facility Medication Administration policy and failed to administer antibiotics per the physician orders.",2020-09-01
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 and stated, I didn't realize it was a concern to that extent. Interview with the Administrator on 7/25/18 at 7:15 AM in the conference room stated, I think we need to ask the resident if it's OK that others are eating, or take them for a walk or something. That would take care of the dignity thing. Is that right? The Administrator was asked if he knew what the Regulations said and stated, All diners at the table are to be served at the same time. That's the answer. Further interview confirmed cognitively impaired residents may not understand why others are eating and they are not. The Administrator confirmed the facility failed to serve all residents seated at the table at the same time. Observation on 7/23/18 in the R1 dining room during the mid- day meal a at pproximately 11:40 AM revealed the lunch trays were passed. Further observation revealed Resident #111 was seated at the table with 3 residents. Further observation revealed CNA #6 was assisting another resident while Resident #111 waited at the table to be assisted. Further observation revealed Resident #111 was assisted with his meal at 12:20 PM. Interview with CNA #6 on 7/23/18 at 12:40 PM in the R1 dining room revealed 4 CNA staff were assisting with dining. Further interview revealed the dining carts were not organized to the way the residents were seated. Therefore some residents got served first while others waited to be served. Interview with the DON on 7/25/18 at 5:25 PM in her office revealed staff should serve the group at the same time. Further interview confirmed we should have staff accommodating patients as they are seated at the table.",2020-09-01
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,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 again how often resident wheelchairs were cleaned and stated, We took the wheelchairs down and hosed them down and wiped them up. When asked when that was, the Housekeeper stated, It's been quite a while. (MONTH) or (MONTH) of last year. The Housekeeper confirmed the side rails, blue pads and wheelchair should have been cleaned with a disinfectant. Interview with the Housekeeping Director on 7/24/18 at 12:12 PM in Resident #117's room when asked how often deep cleaning was performed on residents wheelchairs stated, Everywhere else it's always been the 3rd shift (Certified Nurse Aides) that are supposed to clean the wheelchairs. It's not happening here. Continued interview revealed the Housekeeping Director stated, We pressure washed every wheelchair last (MONTH) and as needed and when a resident is discharged . The Housekeeping Director was shown the dirty blue side rail pads (Housekeeper #3) had already cleaned the dried debris on the side rail) and the resident's wheelchair in the bathroom and stated, It definitely needs to be cleaned. The beds are cleaned on a daily basis and dusted underneath. We deep clean them every month, as needed and upon discharge. The pads should be cleaned daily or change them out. I do audits on rooms but beds are not included on it. I'm going to add it now though. Stated, I'm going to get with the maintenance man and see if we can get the rust off of here and clean this wheelchair up. The Housekeeping Director confirmed the facility failed to maintain Resident #117's equipment in a clean and sanitary manner.",2020-09-01
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 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 Resident #117's electronic medical record revealed no physician's orders for a restraint or positioning device. Medical record review of recapitulation Physician's Orders for (MONTH) (YEAR) revealed no orders for a restraint or positioning device. Medical record review revealed no restraint assessment, no restraint consent, no monitoring of a restraint and no re-evaluation of the restraint. There was no documentation that a lesser alternative to a restraint had been attempted prior to the use of the tilted wheelchair and belts. Interview with Licensed Practical Nurse (LPN) #2 and Unit Manager on B3 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. Those belts are for positioning and they don't prevent him from doing anything he can do without the belt. Continued interview with LPN #2 when asked why use the belts at all and stated, They are for positioning. We were told by MDS and care plan committee they weren't restraints due to his [DIAGNOSES REDACTED]. upright in the wheelchair he will flop over. (Demonstrated leaning forward over his knees). He has [DIAGNOSES REDACTED] in his legs sometimes and they go straight out, so he has the lap belt or he would slide right out of the chair. When asked where the assessment for the restraints, and documentation of their release every 2 hours, medical diagnosis, consent, and documentation of the least restrictive restraints previously used on the resident he stated, There is not any documentation for any of that, because we didn't do it, we used the chair with those belts for positioning. Interview with the MDS Coordinator on 7/25/18 at 11:58 AM in LPN #2's office with LPN #2 present stated, We were using the chair with the belts for positioning to prevent falls. When asked if the resident had had a fall LPN #2 stated,He has not. Continued interview revealed the MDS Coordinator stated, If he can't stand up then its not a restraint. Assistant Director of Nursing (ADON) #2 entered the office at 12:05 PM and all 3 staff were asked if other residents with a [DIAGNOSES REDACTED].? The staff stated they were not sure. The staff was asked if the resident could voluntarily move his head backward and forward was the chest belt preventing him from moving voluntarily and ADON #2 and LPN #2 both said Yes. The staff was asked if the resident was receiving his highest practicable well being by being restrained by tilting him back, and having a chest and lap belt if he could only move his right arm a little bit and his head? The ADON and the LPN agreed the chest belt did prevent Resident #117 from moving freely. Further interview revealed when asked if a wheelchair with a chest and lap belt was the best and least restrictive alternative for Resident #117, LPN #2 stated, It's definitely not the best chair for him. I referred him to therapy a year ago for a different chair and positioning but nothing changed. The ADON stated, The chair is not appropriate. LPN #2 stated, He is supposed to be up in the chair 3 times a week for 3 hours max (maximum) because his skin is so fragile. ADON#2, the MDS Coordinator and LPN #2 confirmed there was no physician's order or any documentation in the resident's medical record indicating the tilted wheelchair, chest belt and lap belt were to be used for positioning for Resident #117. Interview with the Occupational Therapist (OT) on 7/25/18 at 12:55 PM in the Physical Therapy Department confirmed Resident #117 was last seen by therapy on 3/29/17 per request of the nursing staff. Continued interview revealed the resident was evaluated for contracture management only. The OT was asked if they re-evaluate resident equipment like specialized wheelchairs every so often after the resident has used it for a while and stated No, we're not allowed to. We have to wait for a referral from nursing. If they need to be re-evaluated, nursing sends the request on an orange request form with the specific things they are concerned about. Continued interview revealed the OT was asked when they recommend a specific wheelchair with chest and lap belt restraints, did the physician have to approve it first, and the OT stated, We write the order for what we think is best for the resident and the physician comes behind us and signs off on it. When the OT was asked if that order was supposed to be on the active order sheet if the resident is still using it he stated, Yes, it should be in the chart. Further interview revealed when the OT was asked if he could check the electronic record to determine when and how long Resident #117 had the wheelchair and restraints, the OT looked in the computer and stated, No, I can't tell how long he's had it. When (named corporation) took over the facility in (YEAR) we didn't have access to the previous electronic records. Continued interview revealed the OT was asked if there were other residents in the facility with a [DIAGNOSES REDACTED]. Interview with the Director of Nursing (DON) on 7/25/18 at 3:50 PM in her office confirmed the facility failed to obtain a physician's [DIAGNOSES REDACTED].#117; failed to assess the resident for the use of restraints and/or positioning; failed to obtain a consent for restraints; failed to document the release of the restraints; failed to evaluate the ongoing use of restraints, and failed to document the least restrictive alternative for restraints for the resident. Continued interview with the DON confirmed there was no documentation in Resident #117's medical record regarding the use of a chest belt or lap belt for positioning purposes. Findings include: Medical record review revealed Resident #111 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed the Cognitive Skills for Daily Decision Making score 3 indicating severe impairment. Medical record review of the Quarterly MDS dated [DATE], Quarterly MDS dated [DATE] and Annual MDS dated [DATE] revealed .Section P. - Used in chair or out of bed Trunk restraint 1(Used less than daily) . Medical record review of the physician orders dated 1/6/16 revealed .Seat belt with alarm when up in wheelchair. Check Placement of seat belt with alarm every 30 minutes and release every 2 hours for toileting and repositioning. DX (diagnosis): Safety ; Frequency 0600 (6 AM),0800 (8 AM),1600 (4 PM). Medical record review of the Medication Administration Record [REDACTED].Seat belt with alarm when up in wheelchair. Check Placement of seat belt with alarm every 30 minutes and release every 2 hours for toileting and repositioning. DX (diagnosis): Safety ; Frequency 0600 (6 AM),0800 (8 AM) ,1600 (4 PM). Observation of Resident #111 on 7/23/18 at 12:20 PM in R1 dining room revealed the seat belt attached to the wheelchair and buckled around his waist. Interview with LPN #4 on 7/25/18 at 8:31 AM in the hallway near the residents room revealed the seat belt was used to prevent the resident from sliding out of his wheelchair onto the floor. Further interview confirmed LPN #4 failed to adjust his seat belt as ordered. Interview with the Nurse Practitioner on 7/25/18 at 8:40 AM at the R1 nurse station revealed if Resident #111 was in his wheelchair during the day he must have seat belt for safety. Further interview revealed the reason for the seat belt is for safety. It gives him freedom but keeps him safe. Interview with LPN #3 on 7/25/18 at 1:23 PM at the nurse station Further interview confirmed no documentaion was found for the placement and release of the safety belt. Interview with the Director of Nursing on 7/25/18 at 2:15 PM in her office revealed confirmed that there is no medical [DIAGNOSES REDACTED]. Further interview revealed there was no place for the CNA's to document on the MAR. Telephone interview with the Medical Director on 7/25/18 at 2:53 PM revealed he did not confirm the medical [DIAGNOSES REDACTED].",2020-09-01
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 abuse. Continued review revealed the facility reported the allegation of abuse on 7/16/18 at 7:43 PM. Interview with the Director of Nursing (DON) on 7/25/18 at 12:10 PM in the DON's office confirmed the facility failed to report the allegation of abuse for Resident #118, Resident #71, and Resident #151 to the state agency within the required 2-hour time frame.",2020-09-01
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 office on the 3rd floor was asked why the use of a restraint was not captured on the Quarterly MDS for Resident #117 and stated, because we were using the chair with the belts for positioning to prevent falls not as a restraint. Continued interview confirmed there was no documentation in the resident's medical record the restraints were used for positioning purposes. The facility failed to accurately assess the use of restraints for Resident #117.",2020-09-01
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. The LPN was asked to review the resident's care plan for positioning and/or restraints and interventions and stated, There is no restraint care plan because those belts were for positioning. Continued interview when the LPN was asked about care of the resident related to the chest belt, lap belt and tilted back wheelchair he stated, There should be a positioning care plan for all of that. Interview with the MDS Coordinator on 7/25/18 at 11:58 AM in the Unit Manager's office on the 3rd floor confirmed there was no positioning care plan for Resident #117, because we were using the chair with the belts for positioning to prevent falls. Interview with the Director of Nursing (DON) on 7/25/18 at 3:50 PM in her office confirmed the facility failed to create a positioning care plan with specific interventions for Resident #117, and failed to create a restraint care plan for the resident.",2020-09-01
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 4:17 PM in the hall by the conference room was notified of the dining observations on 7/23/18 and 7/24/18 and the concerns of dependent diners having to wait for assistance before they could eat their meal. The DON was asked if she realized this was a concern and stated, I didn't realize it was a concern to that extent. Interview with the Administrator on 7/25/18 at 7:15 AM in the conference room confirmed the facility failed to assist dependent diners timely.",2020-09-01
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,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 sealed vacuum packed chopped ham cubes were under running water in a sink. Further observation revealed the running water was in contact with 1 of the 4 packs. Further observation revealed 1 sealed vacuum packed chopped ham cubes was in a pan of water stored on the counter of the sink with the running water. Interview with the Dietary Manager on [DATE] at 10:20 AM in the dietary department confirmed the dietary staff failed to properly thaw meat under running water. Observation on [DATE] at 3:45 PM, with the Dietary Manager and Registered Dietitian (RD) present, revealed a male dietary staff member with facial hair and no hair covering in place was opening a bag of lettuce and pouring the lettuce into a serving container. Interview with the Dietary Manager on [DATE] at 3:45 PM in the dietary department confirmed the dietary department failed to ensure staff with facial hair wore facial covering to protect the food from contamination. Observation on [DATE] at 3:50 PM, with the RD present, revealed the interior of the ice machine had ice in contact with the bottom of the ice slide. Further observation revealed the bottom of the ice slide had pink colored residue touching the ice. Interview with the RD on [DATE] at 3:50 PM in the dietary department confirmed the facility failed to maintain the ice machine in a sanitary manner. Observation on [DATE] at 9:20 AM with the Dietary Manager present, revealed the emergency food supply was located in a separate storage area of the facility. Review of the emergency food revealed 3 cases of 41.25 pounds (lbs.) each of Corn Beef Hash and 3 cases of 39.75 lbs. of Beef Stew with the facility receiving date of [DATE]. Further review revealed nine 30 lb cases of non-fat powered milk with the pack date of [DATE] and one 30 lb case with the pack date of [DATE]. Interview with the Dietary Manager on [DATE] at 9:20 AM in the emergency food storage area confirmed the facility failed to dispose of expired food. Observation on [DATE] at 9:45 AM in the dietary department, with the Dietary Manager present, revealed the can openers in the vegetable preparation area and the cook preparation area had black sticky debris accumulated on the blade, slot, and base of the equipment. Interview with the Dietary Manager on [DATE] at 9:45 AM in the dietary department confirmed the facility failed to maintain the can openers in a sanitary manner.",2020-09-01
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 facility failed to date, and cover the respiratory equipment and replace the humidified water canister. Medical record review for Resident #87 revealed the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #87's Annual MDS dated [DATE] revealed the facility assessed the resident to have a BIMS score of 14 which indicated the resident was cognitively intact. Further review of the MDS section O revealed the resident was receiving oxygen therapy. Review of the (MONTH) (YEAR) physician's orders [REDACTED].change oxygen tubing weekly every Wednesday night . Review of the (MONTH) (YEAR) medication administration record (MAR) for Resident #87 revealed .change oxygen tubing weekly every Wednesday night . Observation of Resident #87 on 7/23/18 at 10:55 AM and 3:43 PM, and on 7/24/18 at 8:16 AM in the resident's room revealed the resident's oxygen tubing was not dated. Interview with RN #1 on 7/24/18 at 8:24 AM in Resident #87's room confirmed the oxygen tubing was not dated. RN #1 picked up the oxygen tubing and stated the tubing and canisters are changed and dated at the same time, there's usually a piece of tape on the tubing with a date on it but I don't see one on his. Further interview confirmed oxygen tubing was to be changed and dated every 7 days. Interview with the Assistant Director of Nursing (ADON) #1 on 7/24/18 at 8:30 AM in the 400 hall confirmed oxygen tubing and canisters were to be changed and dated weekly. Interview with the Director of Nursing (DON) on 7/25/18 at 8:45 AM in the conference room confirmed oxygen tubing should be dated. The DON stated there was no policy for dating oxygen tubing, it's documented on the MAR every Wednesday and the oxygen tubing should be dated.",2020-09-01
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,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 behaviors. Medical record review of General Emergency Department Discharge Instructions dated 6/24/17 revealed Resident #1 had a [MEDICAL CONDITION] (long bone of the upper arm) and was given a splint to use. Resident #1 was also written a prescription for [MEDICATION NAME] 5/325 milligrams (mg) (pain medication). Review of a Witness Statement taken by the Administrator on 6/24/17 at 1:15 PM, from NA (Nurse Assistant #1) revealed 2 NAs were assisting Resident #1 with perineal care. Continued review revealed, .NA (#1) said NA (#2) got a towel trying to clean her and (Resident #1) started swinging (and) flailing arms not making contact .NA (#2) stepped back and stated don't be hitting me .Then grabbed patient's arms (and) held (them) down on (the) bed with the towel in the other hand trying to clean her .Grabbed (her) arm too hard (and the) arm snapped .Looked like bone was going to come through (resident's) arm. Force held arm down and bone popped .Patient screamed said you broke my arm. I commented (NA #2) you broke her arm . Review of a Witness Statement dated 6/24/17 written by NA #2 revealed, .I attempted to provide morning perineal care for (Resident #1) but she wouldn't let me clean her because she was swinging her arms .I went to get the assistance of (NA #1) but the resident was still swinging her arms so hard, she almost hit my face because I was standing at the head of the bed so she can't (could not) hit me but she was swinging so hard that I proceed (ed) to hold her hand when I heard a crack . Review of a Witness Statement dated 6/24/17 written by NA #1 revealed, .(NA #2) came to get her for assistance with the Resident (#1) morning perineal care .(Resident) started swinging her arm and trying to hit staff .don't hit me, then grabbed (the) resident's arm and held it down, I heard her bone crack . Review of a Witness Statement dated 6/24/17 written by Licensed Practical Nurse #3 (LPN) revealed, .(NA #2) came and asked her to come to Resident (#1's) room quickly .She said NA (#2) had broken Resident (#1's) arm .(LPN #3) asked (NA #2) how she know (knew) she had broken her arm and (NA #2) stated the resident was swinging her arms and she put her arm up to block it and she heard it crack .(LPN #3) looked at Resident (#1's) arm and could tell it was broken . Review of a Resident Investigative Tool for Allegation of Abuse, Neglect or Misappropriation of Property dated 6/28/17 revealed Resident #1 suffered a distal humerus fracture due to physical contact with a Nurse Aide #2 (NA) #2. Continued review revealed the .resident was displaying agitation while staff were attempting to provide personal care .Alleged employee was attempting to redirect resident and prevent any further agitation while care could be completed. Further review of the Resident Investigative Tool revealed .resident was displaying agitation while providing care .She became restless and began swinging her arm at the Nursing Assistant (NA #2) .(NA #2) redirected the resident by placing residents hand down by her side .Due to her [DIAGNOSES REDACTED].This allegation was not substantiated because there was no willful intent to harm the resident. The Assistant Administrator went on to write the facility .educated all clinical staff to step away from residents when they become agitated during care. Interview with NA #1 on 9/26/17 at 9:30 AM in the conference room revealed Resident (#1) could be very feisty and did not like to be changed during perineal care. NA #1 stated Resident #1 would become aggressive at times, trying to hit or kick staff .when the resident became agitated she would reapproach, go get help from another NA or let the nurse know she could not complete personal care for the resident. Continued interview with NA (#1) revealed .on 6/24/17 (NA #2) came to get her to help provide perineal care for (Resident #1) because she was agitated and had bowel movement (BM) all over her .the resident had BM on her hands and was swinging her arms around in agitation, but she was not involved in the actual perineal care but was trying to talk to the resident and calm her down .she suggested to (NA #2) they take a break and reapproach the resident but (NA #2) continued doing care .(NA #2) blocked the resident from touching her face and held her arm down on the bed when she heard a loud popping sound .told the other (NA #2) that she broke the resident's arm and to go get the nurse .she worked with (NA #2) for a long time and did not think she intentionally hurt the resident . Further interview with NA #1 revealed NA #2 had a we're going to do it now, want to get your work done type of attitude. Interview with NA #2 on 9/26/17 at 10:00 AM, in the conference room revealed she had worked with Resident #1 for many years and Resident #1 had dementia but would be more agreeable to care if you gave her coffee. NA #2 stated on 6/24/17 .she attempted to provide perineal care for Resident #1 but she became agitated and she went to get help from (NA #1) who came into the resident's room to assist her .the resident was swinging her arms and had BM on her hands when she swung her arm towards her (NA #2's) face .reacted and it all happened so quickly but she blocked her arm and put the resident's arm down by her side when they heard a crack. Interview with Licensed Practical Nurse #1 (LPN) on 9/26/17 at 11:20 AM in the 300 Hall manager's office revealed LPN #1 served as the Unit Manager for the 300 Hall and stated Resident (#1) .was a confused, pleasant lady who, at times, was resistive to perineal care and showers. Continued interview with LPN #1 revealed Resident #1 did not have any specific triggers and that it varied from day to day whether the resident would become agitated or aggressive during personal care. Regarding the incident on 6/24/17 LPN #1 indicated he would expect staff to always back away and reapproach a resident who was resisting care and having combative behaviors. He indicated he would expect staff to back away from residents before it came to the point where they had to put their hands on them. He stated, we have a lot of psych (mental disorder) and dementia training. Interview with the Behavior Health Manager (BHM) on 9/26/17 at 2:30 PM in the conference room revealed she would expect staff to respect residents' rights without neglecting them. Continued interview revealed if a resident exhibited aggressive behaviors during care she would expect them to step away and not expect staff to physically touch the resident to intervene unless a resident was falling or about to hurt themselves. Interview with the Administrator on 9/26/17 at 3:10 PM in the conference room, revealed the facility determined NA #2 did not willfully harm Resident #1 during the incident on 6/24/17. Continued interview confirmed she was suspended and an investigation was completed. He confirmed the NAs knew they should have handled the situation differently by stepping back, letting the resident calm down and reapproaching. Interview with LPN #3 by phone on 9/26/17 at 4:10 PM revealed on .6/24/17 she was notified by (NA #2) she had broken (Resident #1's) arm during personal care. LPN #3 said she assessed the resident and called the Unit Manager. Continued interview revealed Resident #1 could be resistive to care, very fragile and if the resident was swinging her arms around she would expect the NA to step back, let her calm down, reapproach and get a nurse if needed. Interview with the Medical Director on 9/28/17 at 11:05 AM in the conference room, confirmed she reviewed the investigation regarding the incident with Resident #1 on 6/24/17 and stated if a resident had combative behaviors during care she expected the staff to call the charge nurse and not force the resident to do anything. She further confirmed in Resident #1's case a fracture can happen very easily and if (NA #2) had not touched her, her arm would not have (been) broken. Continued interview confirmed if the resident was resisting that much (NA #2) could have stopped care completely. The Medical Director confirmed NA #2 did not use common sense while providing care with Resident #1 and her actions could cause [MEDICAL CONDITIONS] type symptoms. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE], revealed Resident #2 scored a 4 out of 15 on the BIMS which indicated the resident was severely cognitively impaired. Continued review of the MDS revealed the resident had not exhibited any behaviors. Medical record review of Resident #2's Care Plan, dated 5/24/17 indicated Resident #2 had a mood Care Plan due to increased confusion and agitation as evidenced by resisting care/combative with staff when attempting to perform care. Resident #2 also had a behavior Care Plan due to being combative with staff while performing care at times, urinating in room, moving belongings from room into hallway and refuses medications at times. Two of the approaches listed on the Care Plan that staff were to use included .provide non-confrontational environment for care . and .reapproach resident later, when she becomes agitated . Medical record review of a Weekly Skin assessment dated [DATE], revealed Resident #2 had reddened intact skin on her sacrum. Continued review revealed no other skin issues were noted on the assessment. Medical record review of a Daily Skilled Nurses Note dated 6/29/17 at 11:50 PM revealed Resident #2 refused all her nighttime medications. Continued review revealed the note did not indicate Resident #2 had any aggressive behaviors or that LPN #4 had any contact with the resident during her shift. Review of a Resident Investigative Tool for Allegation of Abuse, Neglect or Misappropriation of Resident Property with an incomplete date of 7/, revealed Resident #2 made an allegation of abuse against LPN #4 on 6/30/17 stating .LPN (#4) came into her room to get her to take 7 pills and she refused because she had her own Dr.(doctor) and reported the nurse cut her arms to pieces with her claws . Continued review of the tool revealed Resident #2 had a history of [REDACTED]. Further review revealed Resident #2 had episode slapping meds (medications) out of (the) nurse hands .Nurse did hold hand to avoid being hit while getting meds off bed. The facility found there was no incident of harm and the resident bruises easily. Review of a Witness Statement dated 6/30/17, written by NA #3 indicated Resident #2 called the NA between 9:00 AM and 10:00 AM and stated, look what she did to me while showing her both of her arms. Review of a Witness Statement dated 6/30/17, written by LPN #2 who served as the Unit Manager for the 200 Hall revealed a NA came to her and reported, someone was rough. LPN #3 took Resident #2 to her room to complete a skin assessment and interview. Resident #2 stated to LPN #3 on 6/29/17, a nurse came into her room and try (tried) to get her to take 7 pills and that she refused because she had her own Dr. (doctor) and then stated the nurse cut her arms to pieces with her claws trying to get her to take meds. Review of a Witness Statement dated 6/30/17, written by LPN #4 revealed went in to give her the meds and she slapped the meds off my hand stating she didn't want it. I then held her hands and scooped up the crushed meds off her bed. Review of the C.N.[NAME] (Certified Nursing Assistant) Skin Care Alert form dated 6/30/17, completed by LPN #2 revealed Resident #2 had 4 areas on her left arm and hand and 3 areas on her right arm and hand with the following written in multiple discolorations. Medical record review of Resident #2's Care Plan dated 6/30/17, revealed Resident #2 had bruises on her bilateral forearms and top of hands Review of one of the staff interviews dated 6/30/17, written by LPN #4 with the questions Did you notice any bruising on her legs? revealed the response, her arms was what I noticed (bruises/dark spots). Review of the facility handwritten notes provided by the Assistant Administrator revealed on 6/30/17 at 2:00 PM an allegation of abuse was reported regarding Resident #2. Continued review revealed Resident #2 stated that .nurse came in last night to give medication, but she refused it. The nurse allegedly cut her arms with her claws. She didn't take her medication but then stated that she did take her medicine because it was the only way that she could stop what the nurse was doing. States she tried to call for help .does have bruising to bilateral forearms/discolorations/dark spots? The Assistant Administrator took a statement from Resident #2 that stated .she grabbed her arms when she refused her meds .Felt like she was cutting her arms with a knife .she was in bed and trying to fight her off and she finally left the room .she tried to call for help .Described the nurse as having black frizzy hair with some red .she (nurse) tried to give her 9 pills but she wasn't going to take them .she didn't tell anyone during the night because they cut her communication off. Continued review revealed the notes also describe information taken from the Psych Services provider revealed APN (#1) (Advanced Practice Nurse) reported the resident told her nurse came in and gave her 7 pills and told her that the Dr. had ordered them .the resident slapped them away and grabbed her with her claws and she tried to call for help .she grabbed and twisted her arms. Medical record review of a Social Service Note dated 6/30/17 at 5:41 PM revealed the Social Service Worker #1 (SSW) spoke with the resident as she was eating in the unit dayroom and noticed bruises on the resident's arm and asked the resident what happened. (Resident #2) began the story of how she refused medications but the nurse made her take them anyway. SSW #1 asked the resident why she did not want to take her medications and the resident responded she only takes medications from her doctor whom she trusts. Medical record review of a Behavioral Medicine/Progress Note dated 6/30/17, written by APN #1 revealed during an interview Resident #2 appeared to acknowledge her confusion as she struggled to find words and organize her thoughts. APN #1 wrote Resident #2 said last PM she had gone to her room for the evening .The black lady that checks on me came in to give me 7 pills and I refused to take them swatting her hand away .She grabbed my arm and twisted it .She pointed to open areas and said those were her claws .she struggled staying awake to watch the black lady that kept checking on her .As above, pt (patient) struggled very hard to express her words, was confused At times, appeared to want to become tearful .The last thing she told this provider was if it can happen to me then it can happen to someone else . Review of a facility Coaching & (and) Counseling session form dated 6/30/17, revealed LPN #4 was counseled regarding failure to complete proper paperwork regarding medication administration. Review of the Working Schedule for LPN #4 revealed she worked on 6/30/17 clocking in at 6:35 PM and out at 7:22 AM. LPN #4 worked on B2 which was the 200 Hall with Resident #2. Interview with LPN #2 on 9/27/17 at 8:40 AM in the Manager's office who served as the Unit Manager for the 200 Hall revealed on 6/30/17, Resident #2 had discolorations on her arms but not bruises. She stated they were purple in color but they were not bruises and she did not discuss the incident with LPN #4 who was accused of abuse by the resident. She further stated NA #4 came to her and told her Resident #2 said someone grabbed her arms. LPN #2 said she did the skin assessment and interviewed the resident and passed the information on to the administrative staff. Interview with the Assistant Administrator on 9/27/17 at 8:50 AM in the conference room, revealed she interviewed LPN #4 and she stated Resident #2 smacked the medications out of her hand. Continued interview revealed the Assistant Administrator questioned LPN #4 about her statement and she stated LPN #4 told her she put the resident's hand down in her lap and reassured her. Further interview confirmed the Assistant Administrator did not interview NA #4 who Resident #2 told first about the incident. Further interview with the Assistant Administrator revealed the resident always had discolorations and age spots on her skin. Interview with the Assistant Director of Nursing #1 (ADON) on 9/27/17 at 9:05 AM in the Manager's office, revealed she sat in on the interview between the Assistant Administrator and LPN #4. Interview revealed ADON #1 confirmed LPN #4 stated in the interview she held Resident #2's hands in her hand while she picked up the medication. Continued interview revealed ADON #1 stated when she reviewed the skin assessment and it said multiple discolorations on her arms she would think bruising, a purplish color, maybe age spots, may be old but I would need more detail. She further stated since the skin assessment from 6/29/17 and 6/30/17 do not match, it would make her want to investigate further. Further interview with ADON #1 confirmed LPN #4 could have done something differently so she would not have had physical contact with the resident. She confirmed LPN #4 could have stayed in the room but backed away from the resident so she would calm down or pulled the call light so someone would come and help her. Continued interview confirmed LPN #4 did not have to physically intervene with the resident and if Resident #2 had discoloration on her arms all the time, she would expect to see it reflected in the skin assessments. Interview by telephone with LPN #4 on 9/27/17 at 1:30 PM, revealed on 6/30/17 she went into Resident #2's room to give her medication. Continued interview revealed the resident slapped the medications out of her hand and was swinging her arms trying to hit her. Further interview revealed LPN #4 stated she held the resident's hands with one hand and picked up the medication with her other hand. Interview with LPN #4 revealed the resident always had discolorations on her hands and arms and she did not use any physical force on Resident #2. Interview with the Medical Director on 9/28/17 at 11:05 AM in the conference room, confirmed she did not review the investigation regarding the abuse allegation made by Resident #2 on 6/30/17. Continued interview revealed the Medical Director confirmed the bruises on Resident #2's arms were not documented beforehand so they were not old bruises, they were new ones. Interview with APN #1 on 9/28/17 at 1:10 PM in the conference room, confirmed after reading her documentation from 6/30/17 on Resident #2, she (resident) was clearly distraught about something that had happened. APN #1 stated she communicated this information to the Assistant Administrator and the DON (Director of Nursing) that day. Interview with the DON on 9/28/17 at 2:10 PM in the conference room revealed the DON was not employed with the facility in (MONTH) (YEAR) and stated if residents have combative behaviors she expects staff to always stop what they are doing, ensure the residents are safe and call for help, reapproach and let the nurse know. Continued interview confirmed if the staff are unable to complete care or give medication then they should document it. Further interview confirmed staff should not have unnecessary physical contact with residents.",2020-09-01
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 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 #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #2 scored a 4 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was severely cognitively impaired. The MDS revealed no documentation of Resident #2 exhibiting any behaviors. Medical record review of Resident #2's Care Plan, dated 5/24/17, revealed Resident #2 had a mood Care Plan due to increased confusion and agitation as evidenced by resisting care/combative with staff when attempting to perform care. Resident #2 also had a behavior Care Plan due to being combative with staff while performing care at times, urinating in room, moving belongings from room into hallway and refuses medications at times. Two of the approaches listed on the Care Plan that staff were to use provide non-confrontational environment for care and reapproach resident later, when she becomes agitated. Medical record review of Resident #2's Care Plan dated 6/30/17, revealed Resident #2 had bruises on her bilateral forearms and tops of hands and was initiated after the allegation of abuse was made on 6/30/17. Review of a Resident Investigative Tool for Allegation of Abuse, Neglect or Misappropriation of Resident Property with an incomplete date of 7/ revealed Resident #2 made an allegation of abuse against Licensed Pratical Nurse #4 (LPN) on 6/30/17. Resident #2 reported LPN #4 came into her room to get her to take 7 pills and she refused because she had her own Dr. (Doctor) She reported the nurse cut her arms to pieces with her claws. Continued review of the Investigative Tool revealed Resident #2 had a history of [REDACTED]. The report indicated Resident #2 had episode slapping meds out of nurse('s) hands. Nurse did hold hand to avoid being hit while getting meds off bed. The facility found there was no incident of harm and that the resident bruises easily. Review of a Witness Statement dated 6/30/17 written by LPN #4 revealed she went in to give her the meds and she slapped the meds off my hand stating she didn't want it. So, I held her hands and scooped up the crushed med off her bed. Review of the investigative documentation provided by the facility for their self-reported abuse allegation against LPN #4 on 6/30/17 revealed the administrative staff interviewed 2 residents regarding their care. Five staff members were interviewed regarding Resident #2 and her behavior on the day of the incident. LPN #4 who was the staff member named in the allegation was not suspended during the investigation per facility protocol and returned to work the same day, working the same assignment area where the resident (who had verbalized fear of the same incident happening again) resides. Review of a Coaching & (and) Counseling Session form dated 6/30/17 revealed LPN #4 was counseled regarding failure to complete proper paperwork regarding medication administration. Review of the Working Schedule for LPN #4 revealed she worked on 6/30/17 clocking in at 6:35 PM and out at 7:22 AM. LPN #4 worked the night shift on B2 which was the 200 Hall with Resident #2 the same day she made an allegation of abuse. Interview with the Administrator on 9/27/17 at 9:30 AM in the conference room confirmed the staff should have reviewed Resident #2's previous skin sheets prior to the incident on 6/30/17 as a part of their investigation and interviewed other staff regarding LPN #4. Continued interview with the Administrator confirmed he believed the investigation was complete and did not suspend LPN #4. Interview with the Administrator revealed it was more likely the skin assessment prior to the incident was inaccurate because the night shift nurse who completed it may not have seen the resident. Further interview confirmed he was under the impression the investigation had been completed and since LPN #4 did not willfully harm the resident they did not suspend her. Interview on 9/27/17 at 1:30 PM by telephone with LPN #4 confirmed she was not suspended after the allegation of abuse by Resident #2 and did not receive any education regarding residents with dementia or combative behaviors. Interview with the Medical Director on 9/28/17 at 11:05 AM in the conference room confirmed she did not review the investigation regarding the abuse allegation made by Resident #2 on 6/30/17. Continued interview with the Medical Director confirmed the bruises on Resident #2 were not documented beforehand so they were not old bruises, they were new bruises and if a resident described an incident or person as abusive, it needed to be investigated. Further interview with the Medical Director confirmed the facility failed to follow all the steps of the investigative process including suspending the accused nurse. Interview with the Assistant Administrator on 9/28/17 at 1:30 PM in the conference room, confirmed the investigation was completed on 6/30/17 and she cleared LPN #4 to come back to work that night. Continued interview confirmed she did not know if the Investigative Tool needed to be filled out and dated with the date the investigation was completed so she did not document any interview with LPN #4 during the investigation and she did not document findings from the investigation where she cleared her to work that night. Interview with the DON on 9/28/17 at 2:10 PM, in the conference room confirmed staff should not have unnecessary physical contact with residents and if staff were described in the allegation they should be suspended for the course of the investigation. Continued interview confirmed the DON stated if staff were accused of abuse and the allegation was unsubstantiated, then staff should still receive education and training regarding the issue. Refer to F-224 J",2020-09-01
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 Stakeholder from resident care areas and suspend him/her while the matter is investigated .Investigation Guidelines .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 implement corrective action consistent with the investigation findings, and take steps to eliminate any ongoing danger to the resident or residents. Medical record review for Resident #1 revealed she 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 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the resident as severely cognitively impaired. Review of the Resident Investigative Tool for Allegation of Abuse, Neglect or Misappropriation of Property form dated 6/28/17 indicated Resident #1 suffered a distal humerus (upper arm bone) fracture on 6/24/17 because of physical contact with a Nurse Aide #2 (NA). The tool indicated the resident was displaying agitation while staff were attempting to provide care. Alleged employee was attempting to redirect resident and prevent any further agitation while care could be completed. The Investigative Tool indicated the resident was displaying agitation while providing care. She became restless and began swinging her arm at the (NA #2). The NA (#2) redirected the resident by placing the resident's hand down by her side. Due to her [DIAGNOSES REDACTED]. Continued review revealed the incident was not deemed as neglect by the facility. Further review of the Investigative Tool revealed the facility determined Resident #1's combative behavior, her [DIAGNOSES REDACTED]. Continued review of the Investigative Tool revealed the Assistant Administrator documented educated all clinical staff to step away from residents when they become agitated during care. Review of the facility investigation provided by the facility for their self-reported abuse allegation against NA #2 on 6/24/17 revealed the administrative staff did not substantiate the allegation of abuse/neglect. Continued review revealed the facility did not substantiate neglect, even though NA #2 intervened with physical force acting against the facility's policy and procedure for abuse/neglect while providing personal care for Resident #1 where she exhibited aggressive and resistive behaviors toward personal care offered which caused an acute physical injury to occur. Interviews by the surveyor with the two NAs involved in the incident, the Nurse on duty, the Unit Manager and Administrator indicated the events happened in accordance with the Investigative Report filled out by the Assistant Administrator. Interview with the Administrator on 9/26/17 at 3:10 PM in the conference room revealed the facility determined NA #2 did not willfully harm Resident #1 during the incident on 6/24/17. He stated she (NA #2) was suspended and an investigation was completed. Continued interview with the Administrator revealed the facility did not determine neglect had occurred during the incident. Interview with the Medical Director on 9/28/17 at 11:05 AM in the conference room, confirmed the Medical Director reviewed the investigation regarding the incident with Resident #1 on 6/24/17 and stated if a resident had combative behaviors during care she expected the staff to call the Charge Nurse and not force the resident to do anything. Continued interview with the Medical Director confirmed in Resident #1's case a fracture can happen very easily and if NA #2 had not touched her, her arm would not have been fractured. Further interview confirmed if the resident was resisting that much she could have stopped care completely and NA #2 did not use common sense while providing care for Resident #1. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] indicated Resident #2 scored a 4 out of 15 on the BIMS which indicated the resident was severely cognitively impaired. The MDS did not indicate Resident #2 exhibited any behaviors. Medical record review of Resident #2's Care Plan, dated 5/24/17 indicated Resident #2 had a mood Care Plan due to increased confusion and agitation as evidenced by resisting care/combative with staff when attempting to perform care. Resident #2 also had a behavior Care Plan due to being combative with staff while performing care at times, urinating in room, moving belongings from room into hallway and refuses medications at times. Two of the approaches listed on the Care Plan that staff were to use included provide non-confrontational environment for care and reapproach resident later, when she becomes agitated. Review of a Resident Investigative Tool for Allegation of Abuse, Neglect or Misappropriation of Resident Property with an incomplete date of 7/ indicated Resident #2 made an allegation of abuse against LPN #4 on 6/30/17. Resident #2 reported LPN #4 came into her room to get her to take 7 pills and she refused because she had her own Dr. (doctor). She reported the nurse cut her arms to pieces with her claws. Review of the Resident Investigative Tool revealed Resident #2 had a history of [REDACTED]. Continued review revealed the report indicated Resident #2 had episode (of) slapping meds out of nurse('s) hands. Nurse did hold hand to avoid being hit while getting meds off bed. The facility found there was no incident of harm and that the resident bruises easily. Review of the investigative documentation provided by the facility for their self-reported abuse allegation against LPN #4 on 6/30/17 revealed the administrative staff interviewed 2 residents regarding their care. Five staff members were interviewed regarding Resident #2 and her behavior on the day of the incident. LPN #4 who was the staff member named in the allegation was not suspended during the investigation per facility protocol and returned to work the same day, working the same assignment area where the resident (who had verbalized fear of the same incident happening again) resides. There was no documentation LPN #4 and other staff were provided education or training after the incident. Medical record review of Resident #2's Care Plan dated 6/30/17 indicated Resident #2 had bruises on her bilateral forearms and tops of hands. This Care Plan was initiated after the allegation of abuse was made on 6/30/17. Interview with Nurse Aide (#3) on 9/28/17 at 8:05 AM in an empty resident room on the 200 Hall, confirmed NA #3 did not receive any training or education that she could recall after she reported the incident on 6/30/17 regarding alleged abuse towards Resident #2. Interviews with 6 staff members by the facility revealed Resident #2 described her interaction with LPN #4 similarly. Interviews revealed the resident reported she refused to take medications from LPN #4 and slapped the medications from her hand and reported the Nurse touched her hands and arms. Resident #2 referred to LPN #4 as cutting her arms to pieces with her claws in multiple accounts to different staff members. According to LPN #4's statement and the investigation by the Administrative staff, LPN #4 did have unnecessary physical contact with Resident #2. Interview with the Administrator on 9/27/17 at 9:30 AM in the conference room confirmed the staff should have reviewed Resident #2's previous skin sheets prior to the incident on 6/30/17 as a part of their investigation, however he could not confirm the staff received any further education or training regarding this issue. Continued interview with the Administrator confirmed they should have also interviewed other staff and additional residents regarding LPN #4 according to the facility policy. He confirmed he was under the impression the investigation had been completed and since LPN #4 did not willfully harm the resident they did not suspend her. Interview with the Medical Director on 9/28/17 at 11:05 AM in the conference room, confirmed she did not review the investigation regarding the abuse allegation made by Resident #2 on 6/30/17. Continued interview with the Medical Director confirmed the bruises on Resident #2 were not documented beforehand so they were not old bruises, they were new and if a resident described an incident or person as abusive, it needed to be investigated. Further interview confirmed the facility should have followed all the steps of the investigative process including suspending the accused nurse. Interview with the DON on 9/28/17 at 2:10 PM in the conference room revealed the DON was not employed with the facility in (MONTH) (YEAR) and stated if residents have combative behaviors she expects staff to always stop what they are doing, ensure the residents are safe and call for help, reapproach and let the nurse know. Continued interview confirmed if the staff are unable to complete care or give medication then they should document it. Further interview confirmed staff should not have unnecessary physical contact with residents. Refer to F-224 J, F-225 J",2020-09-01
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 the MDS revealed Resident #1 had not exhibited any behaviors. Medical record review of Resident #1's Care Plan dated 6/6/17 revealed no individualized interventions for agitation, aggressiveness or combative behaviors during perineal care. Review of a Resident Investigative Tool for Allegation of Abuse, Neglect or Misappropriation of Property dated 6/28/17 revealed Resident #1 suffered a distal humerus (long bone of the upper arm) fracture on 6/24/17 due to physical contact with a Nurse Aide (NA) #2. Continued review revealed the .resident was displaying agitation while staff were attempting to provide personal care and .Alleged employee was attempting to redirect resident and prevent any further agitation while care could be completed. Further review of the Resident Investigative Tool revealed .resident was displaying agitation while providing care .She became restless and began swinging her arm at Nurse Aide (NA #2) .The NA redirected the resident by placing residents hand down by her side .Due to her [DIAGNOSES REDACTED]. Interview with NA #1 on 9/26/17 at 9:30 AM in the conference room revealed Resident #1 could be very feisty, did not like to be changed during perineal care, and would become aggressive at times, trying to hit or kick staff. Continued interview with NA #1 revealed Resident #1 has had these behaviors for a long time and usually if the staff offered her black coffee she would calm down and comply with care. Further interview revealed when the resident became agitated the NA would reapproach, go get help from another NA or let the nurse know she could not complete care on the resident. Interview with NA #2 on 9/26/17 at 10:00 AM in the conference room revealed she had worked with Resident #1 for many years. Further interview revealed Resident #1 had Dementia and could be combative with care at times but would be more agreeable to care if you gave her coffee. Interview with License Practical Nurse #1 (LPN) on 9/26/17 at 11:20 AM in the 300-hall manager's office, revealed the LPN served as the Unit Manager for the 300 hall. Further interview revealed Resident #1 was a confused, pleasant lady who, at times, was resistive to perineal care and showers. Further interview revealed Resident #1 did not have any specific triggers and that it varied from day to day whether the resident would become agitated or aggressive during care. Further interview with LPN #1 revealed he was unsure if there was a Care Plan in place for Resident #1's behaviors and staff knew to offer the resident black coffee as a way of calming her down when she became agitated. Interview with the Behavior Health Manager (BHM) on 9/26/17 at 2:30 PM in the conference room revealed she did not have a Behavior Health Plan in place for Resident #1 and did not recall a time when staff approached her for suggestions or education for that particular resident. Further interview revealed the BHM was unsure if there was a Care Plan in place for Resident #1's behaviors. Interview with the Administrator on 9/26/17 at 3:10 PM in the conference room revealed there should have been a Care Plan in place to address Resident #1's combative behaviors during care and the individualized interventions the staff used when the resident displayed combative behaviors. Telephone interview with LPN #3 on 9/26/17 at 4:10 PM revealed Resident #1 could be resistive to care and was very fragile. Further interview revealed the NAs knew how to get the resident to calm down and would offer her coffee at times. Further interview revealed the LPN was unsure if there was a Care Plan in place for Resident #1's behaviors. Interview with the Medical Director on 9/28/17 at 11:05 PM in the conference room, revealed the nursing staff should ensure Care Plans were in place for the resident's problems. Further interview revealed Resident #1's combative behaviors should be care planned and interventions documented. Medical record review revealed Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] and 8/14/17 with [DIAGNOSES REDACTED]. Medical record review of Progress Notes revealed Resident #8 was sent for a Psychiatric Evaluation on 6/26/17 after an incident with Resident #4 and returned to the facility on [DATE]. Review of a Discharge Summary dated 7/12/17 revealed .The medication mgmt. (management) for this patient was aimed towards minimizing disruptive behavior both verbal and physical at her facility, however, given her chronic and persistent mental illness, periods of agitation or bizarre behavior are likely to continue to occur, and will require consistent behavioral supervision . Continued review of the Progress Notes revealed Resident #8 received another Psychiatric Evaluation from 7/17/17 until 8/14/17. Review of a Discharge Summary Psychiatry dated 8/14/17 revealed the admission was due to .behavioral issues continued to manifest themselves because of her problematic behavior after her last discharge . Continued review of Progress Notes revealed Resident #8 continued to exhibit behaviors after the second Psychiatric Evaluation. Medical record review of the Care Plan dated 8/14/17 failed to reflect the incident between Resident #8 and Resident #4. Continued review revealed the Care Plan also failed to contain information about Resident #8's behaviors. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #8 had a Brief Interview for Mental Status (BIMS) of 3, indicating she was severely cognitively impaired. Further review revealed the resident exhibited wandering behaviors 4-6 days of the review period. Medical record review of the Care Plan dated 8/14/17 revealed the Care Plan was not updated after the MDS dated [DATE] addressed wandering behaviors. Interview with the Behavioral Health Manger (BHM) on 9/26/17 at 2:35 PM in the conference room revealed Resident #8 does have behaviors that include wandering, going into other residents' rooms, spitting, and the resident required constant redirection. Further interview confirmed Resident #8 was sent for a Psychiatric Evaluation on 6/26/17 after the incident with Resident #4 and sent for a Psychiatric Evaluation again after continued behaviors following the readmission on 7/12/17. Interview with Social Services Worker #2 (SSW) on 9/26/17 at 4:05 PM in the conference room revealed SSW #2 was the assigned SSW for the unit where Resident #8 resides. Further interview confirmed Resident #8 had behaviors that included agitation, invasion of personal space of others and aggressive behaviors at times. Further interview revealed Resident #8 went for the second Psychiatric Evaluation and received electroconvulsive therapy and medication changes. Interview with the Administrator on 9/26/17 at 2:30 PM in the conference room revealed Resident #8 received a second Psychiatric Evaluation due to the facility's concern of the resident being a threat to herself and others. Further interview confirmed the facility failed to update Resident #8's Care Plan after the resident-to-resident incident with Resident #4 and after both psychiatric evaluations. Refer to F-224 J, F-225 J, F-226 J",2020-09-01
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 after NA #2 intervened with physical force during perineal care being provided. Resident #2 potentially suffered from mental anguish and bruising due to LPN #4 intervening using physical force by holding her hands or arms while the resident was being aggressive and resistive to medication administration. 2. F225 - The Administrator failed to conduct a thorough investigation for the incident regarding Resident #2. Allegedly, LPN #4 held the resident's hands or arms while the resident was exhibiting aggressive and resistive behaviors during medication administration. The facility did not suspend the LPN during the investigation, and did not interview residents or staff about their interactions with the LPN. 3. F226 - The Administrator of the facility failed to ensure their abuse/neglect policy was implemented related to identification of abuse/neglect, investigation of abuse/neglect and training and education offered. The Administrator failed to ensure a thorough investigation was conducted for an allegation of physical abuse by Resident #2. The Administrator, who served as the Abuse Coordinator, did not recognize the staff members who had used physically forced interventions with Resident #1 and Resident #2 failed to provide the necessary services to prevent physical harm or mental anguish, and did not provide education or training to staff after the incident on how to handle residents with aggressive and resistive resident behaviors. 4. F279 - The Administrator failed to ensure a comprehensive Care Plan for Resident #1 was incorporated and identified problem areas, for Resident #1 and #2, and ensured Care Plans are revised to reflect the current status and/or functional level of the resident to include resident behaviors with appropriate interventions for staff to act appropriately. Review of facility policy, Abuse, Neglect, Exploitation and Misappropriation of Property, dated 5/22/17 defined neglect as .failure to provide goods and services necessary to avoid physical harm, mental anguish or emotional distress .The Facility Administrator will investigate all allegations, reports, grievances, and incidents that potentially could constitute .allegations of abuse .injuries of unknown source .exploitation .or .suspicious crime .The Facility Administrator may delegate some or all of the investigation to the Director of Nursing, Medical Director, or other subject matter experts as appropriate but the Facility Administrator retains the ultimate responsibility to oversee and complete the investigation and to draw conclusions regarding the nature of the incident .Under the heading .Investigation Guidelines .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 capable 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. Interview with the Administrator on 9/27/17 at 9:30 AM in the conference room, confirmed the staff should have reviewed Resident #2's previous skin sheets prior to the incident on 6/30/17 as a part of their investigation; however, the Administrator did not state if the staff received education or training on this issue. Continued interview confirmed they should have also interviewed other residents and staff regarding LPN #4 according to their policy. Further interview confirmed he was under the impression the investigation had been completed and since LPN #4 did not willfully harm the resident they did not suspend her. The Administrator confirmed the facility determined NA #2 did not willfully harm Resident #1 during the incident on 6/24/17 and she was suspended and an investigation was completed. The Administrator confirmed the NAs knew they should have handled the situation differently by stepping back, letting the resident calm down and reapproaching. Interview with the Medical Director on 9/28/17 at 11:05 AM in the conference room, confirmed she did not review the investigation regarding the abuse allegation made by Resident #2 on 6/30/17. The Medical Director confirmed the bruises on Resident #2 were not documented beforehand so they were not old bruises, they were new bruises and if a resident described an incident or person as abusive, it needed to be investigated. Continued interview with the Medical Director confirmed the facility should have followed all the steps of the investigative process including suspending the accused nurse. The Medical Director confirmed she reviewed the investigation regarding the incident with Resident #1 on 6/24/17 and if a resident had aggressive/combative behaviors during care she expected the staff to call the Charge Nurse and not force the resident to do anything. She confirmed in Resident #1's case a fracture can happen very easily and if NA #2 had not touched her, her arm would not have been broken and if the resident was resisting that much she should have stopped care completely. The Medical Director confirmed NA #2 did not use common sense while providing care with Resident #1 and her actions could cause [MEDICAL CONDITION] (Post Traumatice Stress Disorder) type symptoms.",2020-09-01
101,"NHC HEALTHCARE, MILAN",445069,8017 DOGWOOD LANE P O BOX A,MILAN,TN,38358,2019-08-01,610,D,0,1,6GVS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to thoroughly investigate an allegation of abuse for 1 of 2 (Resident #84) abuse incidents reviewed. The findings include: The facility's Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation policy revised 12/11/17 documented, .INTERNAL INVESTIGATION POLICY .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 .The investigation is conducted immediately under the following circumstances .When it is identified that an alleged incident may have occurred .When there is a question as to whether to conduct an investigation, it is best to do so . Medical record review revealed Resident #84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with Resident #84 on 7/29/19 at 9:05 AM, in her room, Resident #84 stated, .I was left wet all night. They (staff) didn't do anything. She (Certified Nursing Assistant (CNA)) said I shouldn't be lying about her. The next night they (staff) got on to her (CNA). The third night she (CNA) kissed me in the mouth and said she (CNA) loved me. Resident #84 was asked if she knew the CNA's name. Resident #84 stated, (Named CNA #1). She works midnights . Review of an untitled facility timeline presented by the Assistant Director of Nursing (ADON) on 7/29/19 regarding an incident with Resident #84 documented, .7/18/19 .(Named Resident #84) reported the CNA from 11p (pm)-7am shift had not change her (Resident #84) properly. Patient (Resident #84) states that at approximately 2-3 am she (Resident #84) put her call light on because she (Resident #84) was wet and needed to be changed. Patient (Resident #84) stated (Named CNA #1) answered her call light. Only changed her (Resident #84) under pad and brief but did not change her wet bottom sheet .7/22/19---I (ADON) received a call from (Named Resident #84's daughter) .She (Named Resident #84's daughter) stated that her mother (Resident #84) had told her (Named Resident #84's daughter) about the incident of being wet and stated that .when (Named CNA #1) made her first round on 11-7 shift that she (CNA #1) asked (Resident #84) why she (Resident #84) lied on her (Resident #84) and said she (CNA #1) did not change her (Resident #84) appropriately .I (ADON) spoke with (Named Resident #84) who did state all of the above documented that occurred. She (Resident #84) also reported, that (Named CNA #1) cared for her (Resident #84) last night .stated when she (CNA #1) came in to check her (Resident #84), she (CNA #1) leaned over and kissed her (Resident #84) on the lips and stated 'I (CNA #1) still love you (Resident # 84)'. (Named Resident #84) stated that made her feel uncomfortable .and 'I (Resident #84) don't know why this has happened .I (Resident #84) did not lie on her (CNA #1)' .7/23/19 .(Named CNA #1) states she did change (Named Resident #84) properly. When I (ADON) questioned about her (CNA #1) accusing (Named Resident #84) of lying, she (CNA #1) stated, 'Yes, I did ask her why she (Resident #84) lied on me (CNA #1)' .Also questioned (CNA #1) about the kissing (Named Resident #84) on the lips. (Named CNA #1) stated, 'I (CNA #1) would never kiss my patients on the lips, but I do hug and kiss them on the cheek every night I work . The ADON confirmed that she had written this timeline and signed the document. Interview with Resident #84 on 7/31/19 at 8:32 AM, in her room, Resident #84 was asked if CNA #1 often kissed her on the cheek. Resident #84 stated, She kissed me on the mouth. Resident #84 was asked again if CNA #1 sometimes kissed her on the cheek. Resident #84 stated, No. Interview with CNA #1 on 7/30/19 at 7:35 AM, in the Conference Room, CNA #1 was asked what happened with Resident #84. CNA #1 stated, I went in the room and asked the patient, I'm trying to think what I said .asked patient why she (Resident #84) said I didn't change her and .why she (Resident #84) said I didn't change the bottom sheet. CNA #1 was asked if she kissed Resident #84. CNA #1 stated, On the cheek. CNA #1 was asked if she asked Resident #84 if she lied on her. CNA #1 stated, I don't recollect. Interview with the ADON on 7/30/19 at 1:46 PM, in the Conference Room, the ADON was asked about the incident with CNA #1 and Resident #84. The ADON stated, (Named Resident #84) said she (CNA #1) leaned down and hugged her (Resident #84) and kissed her on the lips and she (Resident #84) did not feel comfortable with that .Tuesday morning I came in and talked to her (CNA #1) about her (CNA #1 stating Resident #84) lying on her. She (CNA #1) admitted that she had said that .I then talked about the kiss .(CNA #1) said she .hug them and kiss them (residents) on the cheek . The ADON was asked when she typed up the untitled timeline. The ADON stated, .I completed it yesterday when you asked for it . The ADON was asked if any other residents were asked about CNA #1. The ADON stated, I did not. The ADON was asked if any staff were questioned about CNA #1. The ADON stated, I did not question any staff. The ADON was asked if Resident #84 had ever accused staff falsely. The ADON stated, Not that I'm aware of . The ADON was asked according to their policy, what should be done when there is an allegation of neglect or abuse. The ADON stated, An investigation should be conducted immediately. Interview with the Director of Nursing (DON) on 7/30/19 at 2:59 PM, in the Conference Room, the DON was asked if an investigation had been done about the incidents with Resident #84. The DON confirmed there was no investigation.",2020-09-01
102,"NHC HEALTHCARE, MILAN",445069,8017 DOGWOOD LANE P O BOX A,MILAN,TN,38358,2019-08-01,880,D,0,1,6GVS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, Infection Control Manual review, medical record review, observation, and interview, the facility failed to maintain infection control practices for 1 of 2 (Resident #60) sampled residents reviewed for urinary catheters and failed to provide effective [MEDICAL TREATMENT] communication for 1 of 2 (Resident #340) sampled residents reviewed for isolation. The findings include: 1. The facility's undated USE OF FOLEY CATHETER policy documented, .Follow the Physician order [REDACTED]. 2. Medical record review revealed Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].Indwelling Catheter change every month due to [MEDICAL CONDITION] Bladder/[MEDICAL CONDITION] . 3. Observations in Resident #60's room on 7/29/19 at 8:12 AM, 1:41 PM, and 5:26 PM, revealed Resident #60 was lying in the bed and his indwelling, urinary catheter bag was lying on the floor. Interview with the Director of Nursing (DON) on 7/31/19 at 2:33 PM, the DON was asked should the urinary catheter bag be lying on the floor. The DON stated, No, Ma'am. 4. The facility's Infection Control manual with a revision date of 10/1/08 documented, .It is the right of every patient in the center to receive a standard of care which includes a safe environment which prevents the transmission of infectious disease .The goals of the Infection Control Program .decrease the risk of infection to patients, partners and visitors . The facility's Nursing Home/[MEDICAL TREATMENT] agreement documented .The nursing home will inform (named clinic) of all relevant medical .information . 5. Medical record review revealed Resident #340 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Contact Precautions .RELATED [MEDICAL CONDITION] BLOOD AND WOUND .[MEDICAL TREATMENT] every Tuesday, Thursday .and Saturday . Interview with Licensed Practical Nurse (LPN) #1 on 7/30/19 at 3:24 PM, in the South Nurse's Station, LPN #1 was asked what type of communication goes with Resident #340 to [MEDICAL TREATMENT]. LPN #1 stated, We (staff) fill out a form called the [MEDICAL TREATMENT] Communication Worksheet. LPN #1 was asked did Resident #340 [MEDICAL CONDITION] which required contact isolation. LPN #1 stated, Yes. LPN #1 was asked if the information concerning [MEDICAL CONDITION] was included on the [MEDICAL TREATMENT] Communication Worksheet. LPN #1 stated No, but I guess it (MRSA information) should be . LPN #1 was asked if that information was given today in verbal report to [MEDICAL TREATMENT]. LPN #1 stated, No . Interview with the DON on 7/31/19 at 2:48 PM, in the Conference Room, the DON was asked if isolation status should be included on the [MEDICAL TREATMENT] Communication Form. The DON stated, Just because it (isolation status) is not on the form doesn't mean they ([MEDICAL TREATMENT] staff) don't know. The DON was asked how can isolation status be communicated and not overlooked. The DON stated, I will have to add it (isolation status) to this form. Interview with LPN #2 on 8/1/19 at 9:50 AM, in the Conference Room, LPN #2 was asked if she was over Infection Control. LPN #2 stated, Yes. LPN #2 was asked should the [MEDICAL TREATMENT] Communication Worksheet reflect that the patient is in Isolation. LPN #2 stated, Yes .",2020-09-01
103,"NHC HEALTHCARE, MILAN",445069,8017 DOGWOOD LANE P O BOX A,MILAN,TN,38358,2017-12-14,659,D,0,1,82QH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure care plan interventions were followed for provision of activities of daily living (ADLs)/incontinence care and fall prevention for 2 of 23 (Resident #67 and 76) sampled residents reviewed. The findings included: 1. Medical record review revealed Resident #67 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 10/20/17 documented, .Requires extensive to total assist with most ADL's .frequently incontinent of bowel .APPROACHES .Check for incontinence q (every) 2 hrs (hours) and PRN (as needed), provide care . Observations in Resident #67's room on 12/11/17 at 12:06 PM, revealed Resident #67 lying in bed. Certified Nursing Technician (CNT) #1 delivered Resident #67's lunch tray to her. Resident #67 told CNT #1 she needed to be cleaned up, and CNT #1 stated, OK. I'll tell (Named CNT). CNT #1 then left the room and continued serving trays. Interview with Resident #67 on 12/11/17 at 12:52 PM, in her room, Resident #67 was asked whether staff had come to help her get cleaned up yet. Resident #67 stated, No . Resident #67 confirmed she had an episode of bowel incontinence. Observations in Resident #67's room on 12/11/17 at 1:00 PM, revealed Resident #67 was lying in bed, with 2 staff members providing incontinence care. The brief was removed, revealing fecal incontinence. Interview with CNT #1 on 12/11/17 at 1:01 PM, on the 300 hall, CNT #1 was asked what they normally do if a resident needed incontinence care provided during a meal pass. CNT #1 stated, We usually go in and change them. CNT #1 was asked whether it was appropriate to leave a resident waiting for incontinence care after an episode of bowel incontinence during an entire meal. CNT #1 stated, No. Interview with the Director of Nursing (DON) on 12/12/17 at 3:56 PM, in the conference room, the DON was asked when she expected staff to provide incontinence care to residents. The DON stated, Every 2 hours and PRN. The DON was asked what she expected staff to do if someone needed incontinence care during a meal. The DON stated, They would provide incontinence care. The DON was asked if it was acceptable for a resident to wait through a whole meal after a request for care after an episode of bowel incontinence. The DON stated, No. 2. Medical record review revealed Resident #76 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 10/6/17 revealed Resident #76 had falls noted since admission, and fall prevention interventions included placing 2 fall mats at bedside when Resident #76 was in bed. Observations in Resident #76's room on 12/11/17 at 2:37 PM and 3:11 PM, and on 12/13/17 at 7:50 AM, revealed Resident #76 lying in her bed. There were no fall mats at the bedside. Interview with Licensed Practical Nurse (LPN) #1 on 12/13/17 at 7:55 AM, in Resident #76's room, LPN #1 confirmed there were no fall mats at the bedside for Resident #76. LPN #1 went to the nurses' station, reviewed the care plan, and confirmed there should be fall mats at the bedside.",2020-09-01
104,"NHC HEALTHCARE, MILAN",445069,8017 DOGWOOD LANE P O BOX A,MILAN,TN,38358,2017-12-14,677,D,0,1,82QH11,"**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 incontinence care was provided for 1 of 1 (Resident #67) sampled resident reviewed for activities of daily living (ADL) care. The findings included: 1. The facility's INCONTINENT CARE policy documented, .PURPOSE .Designated partners to giveincontinent (give incontinent) care for those patients incontinent of bowel and/or bladder .OBJECTIVE .Prevent Infections .Prevent Odors .Provide comfort to perineal area caused by irritation, infection, or incisions .Prevent skin irritation . 2. Medical record review revealed Resident #67 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum (MDS) data set [DATE] documented a Brief Interview for Mental Status score of 15, which indicated no cognitive impairment, required extensive assistance with toilet use and personal hygiene, and was frequently incontinent of bowel. Review of the care plan dated 10/20/17 revealed, Resident #67 required extensive to total assist with most ADLs and was frequently incontinent of bowel. Interventions included to check for incontinence every 2 hours and as needed and provide care. Observations in Resident #67's room on 12/11/17 at 12:06 PM, revealed Resident #67 lying in bed. Certified Nursing Technician (CNT) #1 delivered Resident #67's lunch tray to her. Resident #67 told CNT #1 she needed to be cleaned up, and CNT #1 stated, OK. I'll tell (Named CNT). CNT #1 then left the room and continued serving trays. Interview with Resident #67 on 12/11/17 at 12:52 PM, in her room, Resident #67 was asked whether staff had come to help her get cleaned up. Resident #67 stated, No . Resident #67 confirmed she had an episode of bowel incontinence. Observations in Resident #67's room on 12/11/17 at 1:00 PM, revealed Resident #67 lying in bed, with 2 staff members providing incontinence care. The brief was removed, revealing fecal incontinence. Interview with CNT #1 on 12/11/17 at 1:01 PM, on the 300 hall, CNT #1 was asked what they normally do if a resident needed incontinence care provided during a meal pass. CNT #1 stated, We usually go in and change them. CNT #1 was asked whether it was appropriate to leave a resident waiting for incontinence care after an episode of bowel incontinence during an entire meal. CNT #1 stated, No. Interview with the Director of Nursing (DON) on 12/12/17 at 3:56 PM, in the conference room, the DON was asked when she expected staff to provide incontinence care to residents. The DON stated, Every 2 hours and PRN. The DON was asked what she expected staff to do if someone needed incontinence care during a meal. The DON stated, They would provide incontinence care. The DON was asked if it was acceptable for a resident to wait through a whole meal after a request for care after an episode of bowel incontinence. The DON stated, No.",2020-09-01
105,"NHC HEALTHCARE, MILAN",445069,8017 DOGWOOD LANE P O BOX A,MILAN,TN,38358,2017-12-14,689,E,0,1,82QH11,"**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 fall prevention measures were followed for 2 of 4 (Resident #18 and 76) sampled residents reviewed for falls. The findings included: 1. The facility's undated GAIT BELTS policy documented, .Designated partner will use a gait belt during ambulation or movement of the patient who needs security and assistance .Objective .Provide increased security for the patient and staff .Prevent injury during movement of patient .Use the belt during walking to stabilize the patient .If patient begins to fall, use the gait belt to .Draw patient close to your body with the belt .Gently and slowly lower patient to the floor by allowing the patient to slide down your leg . 2. Medical record review revealed Resident #18 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 11, which indicated moderate cognitive impairment, required extensive staff assistance with transfers, walking did not occur, and Resident #18 had 1 fall in the month prior to admission. The Post Falls Nursing assessment dated [DATE] documented, .Fall in room ambulating to bathroom . The Fall Scene Investigation Report dated 10/2/17 documented, .(Certified Nursing Technician (CNT) #4) (with) pt (patient) (and) lowered to floor .root cause of the fall .Became weak . The SCREENING FORM PAGE 2 documented, .S/P (status [REDACTED].Pt was ambulating to bathroom (with) CNT and went to floor. Was using rw (rolling walker) and CNT reports pt was trying to amb (ambulate) too quickly (and) did not slow (with) verbal cues .followed up personally (with) this CNT. Educated her on how use of gait belt could have given her more control (with) pt to both slow her down (and) slow fall . Review of a hospital history and physical dated 10/31/17 revealed a [DIAGNOSES REDACTED]. Observations of Resident #18 in her room on 12/11/17 at 9:23 AM, revealed her lying in bed with an aircast to the left ankle. Interview with CNT #5 on 12/13/17 at 11:10 AM, outside the dining room, CNT #5 was asked when staff should use gait belts. CNT #5 stated, When we are transferring residents . CNT #5 was asked if staff should use gait belts when assisting residents to ambulate to the bathroom. CNT #5 stated, Yes. Telephone interview with Licensed Practical Nurse (LPN) #2 on 12/13/17 at 2:04 PM, LPN #2 was asked if she knew if the CNT was using a gait belt when she was assisting Resident #18 to the bathroom at the time of her fall. LPN #2 stated, I'm not for sure . LPN #2 was asked whether the CNT should have been using a gait belt. LPN #2 stated, Yes, for sure. Interview with the Rehabilitation (Rehab) Director on 12/13/17 at 4:55 PM, in the therapy gym, the Rehab Director was asked if she knew whether or not the CNT was using a gait belt at the time of the fall. The Rehab Director confirmed the CNT was not using the gait belt at the time of Resident #18's fall. The Rehab Director confirmed the CNT should have been using the gait belt. 3. Medical record review revealed Resident #76 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The significant change MDS dated [DATE] documented a BIMS score of 14, which indicated no cognitive impairment, and required extensive assistance for transfers and ambulation. The care plan dated 10/6/17 documented Resident #76 had falls noted since admission, and fall prevention interventions included placing 2 fall mats at bedside when Resident #76 was in bed. Observations in Resident #76's room on 12/11/17 at 2:37 PM and 3:11 PM, and on 12/13/17 at 7:50 AM, revealed Resident #76 lying in her bed. There were no fall mats at the bedside. Interview with Licensed Practical Nurse (LPN) #1 on 12/13/17 at 7:55 AM, in Resident #76's room, LPN #1 confirmed there were no fall mats at the bedside for Resident #76. LPN #1 went to the nurses' station, reviewed the care plan, and confirmed there should be fall mats at the bedside.",2020-09-01
106,CLAIBORNE HEALTH AND REHABILITATION CENTER,445071,1850 OLD KNOXVILLE ROAD,TAZEWELL,TN,37879,2019-01-07,609,D,1,0,Y9FF11,"**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 allegations of abuse were reported timely to the facility's Administrator and to the state survey agency for 4 residents (#1, #2, #3, and #4) of 8 residents reviewed for abuse on 1 of 4 nursing units. The findings included: Review of facility policy titled Reporting Allegations of Abuse/Neglect/Exploitation, last reviewed 6/2018, revealed .policy of this facility to report all allegations of abuse/neglect/exploitation to appropriate agencies in accordance with current state and federal regulations . 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 scored 3/15 (severely cognitive impaired) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident exhibited physical and verbal behaviors directed toward others and required total care for bed mobility, transfer, toilet use, and personal hygiene. Medical record review of Resident #1's care plan dated 11/16/18 revealed the resident was care planned for episodes of combativeness during care. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed Resident #2 was assessed as severely cognitive impaired and was unable to complete the BIMS. Further review revealed the resident required total assistance for bed mobility, toilet use, dressing, and personal hygiene. Medical record review of Resident #2's care plan dated 9/19/18 revealed the resident would smack at staff during care received for Activities of Daily Living (ADL). 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 severely cognitive impaired and required extensive assistance for bed mobility, transfer, toilet use, and personal hygiene. Medical record review of Resident #3's care plan dated 10/17/18 revealed the resident was care planned for resistance to care during ADLs and smacks and yells out when care was provided. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the annual MDS dated [DATE] revealed Resident #4 was severely cognitive impaired and was unable to complete the BIMS. Further review revealed the resident had episode of physical behavioral directed toward others. Continued review revealed the resident required total assistance for bed mobility, transfer, toilet use, and personal hygiene. Medical record review of Resident #4's care plan revealed the resident was at risk for episodes of [MEDICAL CONDITION] and changes in behaviors and moods. Review of a facility investigation dated 12/14/18 revealed Certified Nursing Assistant (CNA) #1 notified Licensed Practical Nurse (LPN) #1 the morning of 12/14/18 of an allegation of abuse, which occurred on the day shift of 12/13/18 (prior day). Further review revealed CNA #1 alleged she witnessed CNA #2 abuse 4 residents during care. Continued review revealed CNA #1 alleged CNA #2 held her hands over the mouth of Resident #2 and #4 and hit Resident #1 in the head with a pillow because he called the CNAs the B word. Further review revealed CNA #1 stated, during ADL care for Resident #3, CNA #2 was holding the resident's hands tightly because the resident was trying to put her hands in the incontinent episode and when Resident #3 started to cry CNA #2 put her hand over the resident's mouth and told her to be quiet. Continued review revealed CNA #1 stated she was afraid to report the incidents, but after she thought about it over night she reported the incidents to LPN #1. Further review revealed CNA #2 denied the incidents, but she was terminated on 12/18/18 due to .recent investigation has determined that on Thursday, (MONTH) 13th while performing her CNA assignments (CNA #2) provided care and assistance which did not meet an acceptable standard of care . Continued review revealed . a recent investigation determined (CNA #1) observed a number of inappropriate interactions demonstrated by a fell ow coworker (CNA#2). Standard practices were not followed as there was a delay in reporting these events . Interview with CNA #1 on 1/7/19 at 1:30 PM, in the Director of Nursing's (DON) office, confirmed the CNA was aware she was required to report any allegation of abuse immediately. Telephone interview with CNA #2 on 1/7/19 at 1:45 PM revealed the CNA denied the abuse occurred. Interview with the Administrator on 1/7/19 at 3:15 PM, in the Administrator's office, confirmed CNA #1 was aware she should have reported the allegation of abuse immediately, but failed to do so.",2020-09-01
107,CLAIBORNE HEALTH AND REHABILITATION CENTER,445071,1850 OLD KNOXVILLE ROAD,TAZEWELL,TN,37879,2017-02-08,309,D,0,1,F38S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to follow physician orders [REDACTED].#27) of 5 residents reviewed for unnecessary medication of 35 sampled residents. The findings included: Medical record review revealed Resident #27 was admitted to the facility with [DIAGNOSES REDACTED]. Medical record review of Resident #27's Care Plan dated 11/23/16 revealed .The resident uses [MEDICAL CONDITION] Medications .[MEDICATION NAME] .Administer [MEDICAL CONDITION] medications as ordered by physician .monitor for side effects and effectiveness q (every) shift . Medical record review of a Psychiatric Consult dated 1/13/17 revealed .suggest .1. D/C (discontinue) [MEDICATION NAME] to eval (evaluate) for need . Medical record review of Physician order [REDACTED].[MEDICATION NAME] (antidepressant medication) Tablet 10mg (milligram) Give 1 tablet by mouth one time a day related to Anxiety Disorder . Medical record review of Physicians Orders dated 1/17/17 revealed .TO (telephone order) .D/C [MEDICATION NAME] . Medical record review of the Medication Administration Record [REDACTED]. Interview with Registered Nurse (RN) #1 on 2/7/17 at 1:35PM, at the 2nd floor Nurses station confirmed [MEDICATION NAME] had been discontinued on 1/17/17 but Resident #27 continued to receive the medication until 1/30/17, 13 days after the medication was discontinued.",2020-09-01
108,CLAIBORNE HEALTH AND REHABILITATION CENTER,445071,1850 OLD KNOXVILLE ROAD,TAZEWELL,TN,37879,2017-02-08,371,F,0,1,F38S11,"Based on the facility policy, observation, and interview, the facility failed to dispose of left overs in 1 of 3 refrigerator/coolers by the use by date (UBD), failed to properly store pans and failed to ensure kitchen equipment and non-food contact surfaces were clean and maintained in a sanitary manner, affecting 62 of 74 residents. The findings included: Review of the facility policy Infection Control Sanitation and Storage dated/revised 1/2010 revealed .Any prepared refrigerated foods that are to be used for leftovers are to be covered and dated. And discarded after the (3) third day and not to be used .provide clean .storage and work areas .General Responsibilities: the highest level of sanitation in the areas of food, equipment, work surfaces .maintaining a safe and sanitary work area .equipment cleanliness .Pots and pan are to be air dried . Observation with the Certified Dietary Manager (CDM) on 2/6/17 at 10:00 AM in the kitchen, revealed: a). A can opener with debris on the blade. b). A Commercial mixer with dried debris on the beater shaft and outside rim. Observation with the CDM on 2/6/17 at 10:10 AM, in the kitchen, revealed the following pans stored wet and available for use: a). 2 of 11 four inch 1/2 steamtable pans b). 1 of 12 four inch 1/4 steamtable pans c). 1 of 6 two inch full steamtable pans d). 1 of 6 two inch full steamtable pans with dried debris on the inside of the pan. Observation with the CDM on 2/6/17 at 10:15 AM, in the kitchen, revealed the hood vents with dusty debris. Observation with the CDM on 2/6/17 at 10:20 AM, of the walk-in cooler, in the kitchen revealed these items stored after the UBD and available for resident consumption: a). One 4 inch 1/8 pan 1/2 full of chopped chicken b). One 2 pound container full of refried beans c). One 4 inch 1/8 pan full of taco meat d). One 6 inch 1/8 pan full of rice e). One 4 inch 1/4 pan full cream of chicken soup f). One 1 quart container 1/4 full of ketchup g). One 4 inch 1/6 pan 1/3 full of pasta salad. Observation with the CDM on 2/7/17 at 1:45 PM, in the second floor nourishment room revealed an ice maker with a white plastic shield (to guard the ice from falling out of the bin) with a build-up of black debris. Interview with the CDM on 2/6/17 at 10:30 AM, in the dry stock room confirmed the facility failed to properly dispose of left overs in 1 of 3 refrigerator/coolers, failed to properly store pans, and failed to maintain food and non-food contact surfaces in a sanitary manner. Interview with the CDM on 2/7/17 at 1:50 PM, in the second floor nourishment room confirmed the facility failed to maintain the ice machine in a sanitary manner.",2020-09-01
109,CLAIBORNE HEALTH AND REHABILITATION CENTER,445071,1850 OLD KNOXVILLE ROAD,TAZEWELL,TN,37879,2018-03-08,641,D,0,1,WN2T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to complete an accurate assessment for 1 resident (Resident #50) of 32 residents reviewed. The findings included: Medical record review revealed Resident #50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #50 received an anticoagulant (a blood thinning medication used to treat, prevent, and reduce the risk of blood clots). Medical record review of the electronic physician's orders [REDACTED].#50 was prescribed an anticoagulant. Interview with the MDS nurse on 03/07/18 at 9:50 AM, in the conference room, confirmed Resident #50 did not receive an anticoagulant and the MDS assessment dated [DATE] was inaccurate.",2020-09-01
110,CLAIBORNE HEALTH AND REHABILITATION CENTER,445071,1850 OLD KNOXVILLE ROAD,TAZEWELL,TN,37879,2018-03-08,656,D,0,1,WN2T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medial record and interview, the facility failed to follow the comprehensive care plan for 1 resident (Resident #44), of 4 residents reviewed for constipation, of 32 residents reviewed. The findings included: Medical record review revealed Resident #44 was admitted to the facility on [DATE], with a readmitted [DATE], with [DIAGNOSES REDACTED]. Medical record review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was severely cognitively impaired. Further review revealed the resident was always incontinent of bowel and required extensive assist with bed mobility, transfer, dressing, eating, and personal hygiene. Continued review revealed the resident was total dependence for toilet use. Medical record review of Resident #44's care plan dated 10/12/16 revealed .presence of constipation.Monitor/document bowel sounds (decreased or absent bowel sounds may indicate constipation) and frequency of BM (bowel movement): provide laxative of choice per facility protocol (to include suppository (a medication inserted into the rectum used to treat constipation), enema (injection of fluid into the bowel to stimulate stool evacuation), MOM (Milk of Magnesium to treat constipation), [MEDICATION NAME] (stimulate laxative), [MEDICATION NAME] (stool softener), and Prune juice if no BM for more than 48 hrs (hours). Medical record review of Resident #44's daily Bowel Program flow sheets (a documentation tool for tracking daily bowel habits and medications administered for bowels) dated 9/1/17 to 3/6/18 revealed the following: September 2017 - 10 consecutive days, from 9/10/17-9/19/17, without documentation of a BM and no stool softener or laxative intervention. October 2017 - 7 consecutive days, from 9/28/17-10/4/17, without documentation of a BM and with no stool softener or laxative intervention, resulting in Resident #44 requiring disimpaction (manual removal of hard stool from the rectal cavity) on 10/22/17. November 2017 - 5 consecutive days, from 11/11/17 - 11/15/17, without documentation of a BM and 2 [MEDICATION NAME] (stimulant laxative) given on 11/15/17; and 7 consecutive days, from 11/22/17-11/28/17, without documentation of a BM and no stool softener or laxative intervention until documentation of 3 [MEDICATION NAME] on 11/29/17. December 2017 - 11 consecutive days, from 12/28/17 - 1/7/18, without documentation of a BM and no stool softener or laxative intervention. January 2018 - 9 consecutive days, from 1/18/18-1/26/18, without documentation of a BM and no stool softener or laxative intervention. February 2018 - 9 consecutive days, from 2/3/18-2/11/18, and an additional 6 days, from 2/16/18-2/21/18, without documentation of a BM and no stool softener or laxative intervention, which resulted in Resident #44 requiring disimpaction on 2/22/18. March 2018 - 8 consecutive days, from 2/26/18-3/5/18, without documentation of a BM and no stool softener or laxative intervention. Telephone interview with Resident #44's Physician on 3/7/18 at 1:50 PM, confirmed he had standing orders in place to address constipation. The physician stated he had a standing order for laxative of choice, which would include [MEDICATION NAME] 100 MG (milligram) or [MEDICATION NAME] 17 GM (gram). Further interview confirmed [MEDICATION NAME] and [MEDICATION NAME] had not actually been documented on the routine orders for Resident #44 and the nurses would have had to contact him for further orders. Interview with the Director of Nursing (DON) on 3/8/18 at 10:45 AM, in the conference room, confirmed the facility failed to follow Resident #44's plan of care for bowel management. Refer to F690.",2020-09-01
111,CLAIBORNE HEALTH AND REHABILITATION CENTER,445071,1850 OLD KNOXVILLE ROAD,TAZEWELL,TN,37879,2018-03-08,690,D,0,1,WN2T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to implement a bowel protocol for 1 resident (Resident #44) of 4 residents reviewed for constipation. The findings included: Medical record review revealed Resident #44 was admitted to the facility on [DATE], with a readmitted [DATE], with [DIAGNOSES REDACTED]. Medical record review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was severely cognitively impaired. Further review revealed the resident was always incontinent of bowel and required extensive assist with bed mobility, transfer, dressing, eating, and personal hygiene. Continued review revealed the resident was total dependence for toilet use. Medical record review of Resident #44's Physician orders [REDACTED]. Medical record review of the Physician's Routine Orders dated 6/1/16 revealed, .laxative of choice. Continued review revealed no administration instructions to include what medication, dosage, frequency, and route. Medical record review of Resident #44's care plan dated 10/12/16 revealed .presence of constipation as defined by 2 or fewer bowel movements during look back period.Monitor/document bowel sounds and frequency of BM (bowel movement): provide laxative of choice per facility protocol if no BM for more than 48 hrs (hours). Medical record review of the facility's Bowel Program sheet, undated, revealed the following bowel management interventions: suppository (medication inserted into the rectum used to treat constipation), enema (injection of fluid into the lower bowel by way of the rectum to stimulate stool evacuation), Milk of Magnesia (MOM) (medication used to treat constipation), [MEDICATION NAME] (stimulant laxative), [MEDICATION NAME] (stool softener), and prune juice. Continued review revealed no administration instructions to include type of suppository and/or enema to administer. Further review revealed no administration instructions to include dosage, frequency, and/or route for the MOM, [MEDICATION NAME], and [MEDICATION NAME]. Medical record review of Resident #44's daily Bowel Program flow sheets (a documentation tool for tracking daily bowel habits and medications administered for bowels) dated 9/1/17 - 3/6/18 revealed the following: September 2017 - 10 consecutive days, from 9/10/17-9/19/17, without documentation of a BM and no stool softener or laxative intervention. October 2017 - 7 consecutive days, from 9/28/17-10/4/17, without documentation of a BM and with no stool softener or laxative intervention, resulting in Resident #44 requiring disimpaction (manual removal of hard stool from the rectal cavity) on 10/22/17. November 2017 - 5 consecutive days, from 11/11/17 - 11/15/17, without documentation of a BM and 2 [MEDICATION NAME] (stimulant laxative) given on 11/15/17; and 7 consecutive days, from 11/22/17-11/28/17, without documentation of a BM and no stool softener or laxative intervention until documentation of 3 [MEDICATION NAME] on 11/29/17. December 2017 - 11 consecutive days, from 12/28/17 - 1/7/18, without documentation of a BM and no stool softener or laxative intervention. January 2018 - 9 consecutive days, from 1/18/18-1/26/18, without documentation of a BM and no stool softener or laxative intervention. February 2018 - 9 consecutive days, from 2/3/18-2/11/18, and an additional 6 days, from 2/16/18-2/21/18, without documentation of a BM and no stool softener or laxative intervention, which resulted in Resident #44 requiring disimpaction on 2/22/18. March 2018 - 8 consecutive days, from 2/26/18-3/5/18, without documentation of a BM and no stool softener or laxative intervention. Medical record review of a nurse's Progress Note dated 10/22/17 by Licensed Practical Nurse (LPN) #4 revealed .patient has noted BM but unable to pass due to impaction. Patient states it is hurting me get it out. Nurse at this time does impaction removal noted very dry hard stool. Medical record review of a nurse's Progress Note dated 2/22/18 by LPN #1 revealed .Resident refused all AM meds (medications) x (times) 3 attempts. Kicking, punching, and cursing at staff for no apparent reason. Impaction removed at approximately 1 PM. Blood noted in stool related to anal tearing from stool being so large and hard. Interview with LPN #1 on 3/7/18 at 11:00 AM, in the unit one medication storage room, confirmed she had manually removed a very large hard stool from Resident #44 on 2/22/18. Continued interview confirmed the resident had a small tear to the rectum due to the size of the bowel movement. Further interview revealed the Certified Nurse Assistants (CNAs) had informed her it was normal for Resident #44 to have hard stool requiring staff assistance for removal. Further interview revealed LPN #1 had no knowledge of a facility bowel protocol or any standing orders to treat constipation. Interview with CNA #1 on 3/7/18 at 11:14 AM, at the unit 1 nurse's station, revealed she was one of the regular care givers for Resident #44. Further interview confirmed Resident #44 did have constipation and required manual assistance from staff to remove the stool. Interview with Registered Nurse (RN) #1, Unit 1 Manager, on 3/7/18 at 12:19 PM, at the unit 1 nurse's station, revealed the nurse was not aware of any standing orders from Resident #44's Physician for constipation, but there was a facility bowel protocol the nurses followed. Further interview revealed the protocol was if no BM in 2 days a stool softener would be administered, if no BM in 3 days a laxative would be administered, if no results, an enema would be administered, and if no results from the enema the Physician would be notified for further orders. Interview with RN #2, Unit 2 Manager, on 3/7/18 at 12:25 PM, at the unit 1 nurse's station, revealed the nurse stated the facility currently had no bowel management protocol. Interview with Resident #44's Physician by phone on 3/7/18 at 1:50 PM, revealed he had standing orders in place to address constipation. Further interview confirmed he had a standing order of laxative of choice which would include [MEDICATION NAME] 100 MG (milligram) or [MEDICATION NAME] 17 GM (gram). Medical record review of Resident #44's Physician orders [REDACTED]. Interview with Resident #44's Physician on 3/7/18 at 3:00 PM, in the conference room, revealed after 7 consecutive days without a BM, Resident #44 would require a laxative. Continued interview confirmed Resident #44 had no order to administer a laxative after 7 days without a BM. Further interview confirmed Resident #44 had the potential for pain and discomfort from constipation. Interview with LPN #3 by phone on 3/7/18 at 6:15 PM, confirmed the LPN had to manually remove stool from Resident #44's rectum. Continued interview confirmed she had no knowledge of physician standing orders to address constipation. Further interview confirmed if a resident had not had a BM in 2 days, night shift would administer MOM or [MEDICATION NAME]; if no results, day shift would administer an enema, and if no results the Physician would be notified. Continued interview confirmed the LPN was not aware of a facility bowel protocol. Interview with RN #3, Night Shift Supervisor, on 3/7/18 at 6:37 PM, at the unit 1 nurse's station, revealed the facility followed the bowel program sheet for the bowel protocol. Continued interview revealed if a resident had not had a BM in 3 days a suppository would be administered, if no results from the suppository, an enema would be administered, if no results from the enema, MOM would be administered. Further interview revealed the bowel program sheet was not clear on when to administer medications or what dosage was to be administered. Interview with LPN #4 on 3/8/18 at 8:34 AM, in the conference room, confirmed on 10/21/17, Resident #44 had hard visible stool in her rectum and was unable to push the stool out without the nurse's assistance. Further interview confirmed LPN #4 was not aware of a facility bowel protocol. Interview with RN #1 on 3/8/18 at 9:23 AM, in the conference room, revealed the facility's bowel protocol sheet did not have administration instructions to include dosage, frequency, and route. Further interview revealed there were no standing orders on the resident charts for nurses to review. Interview with the Director of Nursing (DON) on 3/8/18 at 10:45 AM, in the conference room, confirmed nursing staff were to follow the facility's bowel protocol. Continued interview confirmed the nursing staff had not followed the facility's bowel protocol.",2020-09-01
112,CLAIBORNE HEALTH AND REHABILITATION CENTER,445071,1850 OLD KNOXVILLE ROAD,TAZEWELL,TN,37879,2018-03-08,695,D,0,1,WN2T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility in-service, observation, and interview, the facility failed to implement [MEDICAL CONDITION] (a tube inserted in the neck to allow air to enter the lungs) suctioning equipment to care for 1 resident (Resident #34) of 1 reviewed for a [MEDICAL CONDITION], of 32 residents reviewed. The findings included: Medical record review revealed Resident #34 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a facility in-service (education) dated 2/7/18 revealed .In Service on Oxygen and Suction Equipment.All tubing (Nebulizer (a breathing machine used to administer inhaled medications into the lungs), Oxygen, Suction) will be changed once per week and dated.All suction cans will be changed when soiled and replaced with a new one, and dated. Observation with Registered Nurse (RN #1) on 3/6/18 at 7:22 AM in the resident's room, revealed a suction canister (un-dated), on Resident #34's end table, with secretions approximately 1/4 full, and the suction tubing was dated 2/19/18. Interview with RN #1 on 3/6/18 at 7:30 AM, at the unit 1 nurse's station, confirmed the suction tubing was out dated and should be changed every 7 days. The facility failed to implement the facility inservice education.",2020-09-01
113,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2019-01-15,623,E,0,1,W7UH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to send notification of transfer to the hospital to the Ombudsman for 4 residents (#9, #11,#22, and #30) of 39 residents reviewed. The findings include: Review of the facility policy, Transfer/Discharge Notice, dated 12/6/16 revealed .The facility will send a copy of the transfer or discharge notice to a representative of the Office of the State Long-Term Care Ombudsman . Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Discharge Minimum Data Set ((MDS) dated [DATE] revealed Resident #9 was transferred to the hospital. Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Nursing Home To Hospital Transfer Form revealed Resident #11 was transferred to the hospital on [DATE]. Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Nursing Home To Hospital Transfer Form revealed Resident #22 was transferred to the hospital on [DATE]. Medical record review revealed Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Nursing Home To Hospital Transfer Form revealed Resident #30 was transferred to the hospital on [DATE]. Interview with the Social Worker on 1/15/19 at 1:50 PM in her office revealed she did not know she had to contact the Ombudsman when a resident was transferred or discharged from the facility. Further interview revealed the transfer and discharge notification to the Ombudsman had not been done since (MONTH) (YEAR). Interview with the Administrator and Director of Nursing (DON) on 1/15/19 at 1:57 PM in the Administrator's office confirmed the facility had not notified the Ombudsman when a resident transferred or discharged from the facility. Further interview with the DON revealed .nobody is doing it right now, it is on the list . Further interview with the Administrator stated .the one person responsible (to notify the Ombudsman of resident transfer or discharge) would have been the social worker .",2020-09-01
114,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2019-01-15,690,D,1,1,W7UH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to obtain physician orders [REDACTED].#25) of 39 residents reviewed. The findings include: Review of the undated facility policy, Physician Orders, revealed .orders given by Physician/Medical Practitioner .notification to family/POA (Power of Attorney) via telephone .New order documented in nursing notes that order was received and family notified . Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #25's physician's orders [REDACTED]. Medical record review of an Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #25 had a Brief Interview of Mental Status score of 15 indicating the resident was cognitively intact. Medical record review of Resident #25's Daily Skilled Nurse's Notes for 12/1/18 thru 12/10/18 revealed no documentation regarding an order for [REDACTED].>Interview with Resident #25 on 1/13/19 at 9:24 AM in her room revealed she stated The head nurse (the former Director of Nursing (DON)) came to help put a catheter in one evening, not sure if there was an order or not. Continued interview revealed she reports there were several people in the room trying to help place the catheter. She stated the nurse, the one not here because she was fired, asked her if she could place the catheter to get a urine sample because she was sick. She stated the nurse told me she was worried about me. I told her she could go ahead and put the catheter in. Continued interview revealed she stated I asked her if she had an order and she said yes. Interview with the Nurse Practitioner on 1/13/19 at 11:29 AM in the West dining room confirmed an order was not obtained for Resident #25 to be catheterized. Interview with Registered Nurse (RN) #4 on 1/14/19 at 3:49 PM at the North hall nursing station revealed she assisted the former DON in performing an intermittent catheterization for Resident #25. She stated the event happened in (MONTH) (YEAR). Continued interview revealed she stated the former DON had told RN #4 that she had obtained an order for [REDACTED].#25 gave consent for the former DON to perform the catheterization. Interview with Licensed Practical Nurse (LPN) #2 on 1/14/19 at 4:06 PM at the South hall nurse station revealed she was asked by the former DON to assist in placing an intermittent catheter for Resident #25. She stated this happened sometime in (MONTH) (YEAR). She stated there were 5 people including the former DON in the room with the resident. Continued interview revealed Resident #25 gave the former DON permission to place the catheter. She stated I didn't know there wasn't an order for [REDACTED]. Interview with the Administrator and Director of Nursing on 1/15/19 at 2:43 PM in the Administrator's office confirmed an order was not obtained for the former DON to catheterize Resident #25. Continued interview revealed the former DON was suspended, terminated, and reported to the Tennessee Board of Nursing.",2020-09-01
115,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2019-01-15,695,D,0,1,W7UH11,"**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 obtain a physician order for [REDACTED]. The findings include: Review of the facility policy, Physician Orders, reviewed 6/1/15, revealed an order given by the Physician/Medical Practitioner .Nurse receiving order is responsible for complete order documentation . Medical record review revealed Resident #108 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum (MDS) data set [DATE] revealed Resident #108 had received oxygen while not a resident in the facility and received oxygen while a resident at the facility. Medical record review of the physician orders revealed no orders for oxygen administration. Observation on 1/13/19 at 8:50 AM, 11:25 AM, 11:45 AM, 11:56 AM, 2:47 PM, and 3:32 PM revealed Resident #108 was in the room, in bed, nasal cannula in use, and the oxygen concentrator in operation set at 2 liter per minute (lpm). Observation on 1/14/19 at various times during the day revealed Resident #108 in the room, in bed, nasal cannula in place, and oxygen concentrator set at 2 lpm. Observation on 1/15/19 at 10:13 AM in Resident #108's room, with the Director of Nursing (DON) present, revealed the resident in bed with the nasal cannula in place and the oxygen concentrator operating at 2 lpm. Interview with Certified Nurse Aide (CNA) #5 on 1/15/19 at 10:13 AM at the South nursing station revealed she had cared for Resident #108 since the resident's admission. When asked how long the resident had been using oxygen the CNA stated .since admission . Interview with the DON on 1/15/19 at 10:20 AM at the North/East nursing station confirmed Resident #108's admission orders [REDACTED]. The DON confirmed the medical record for Resident #108 did not have oxygen orders. The DON stated she expected nurses to have orders for the oxygen. Interview with Licensed Practical Nurse (LPN) #2 on 1/15/19 at 10:30 AM by the South nursing station revealed the LPN had provided care since the day after Resident #108 was admitted . The LPN stated the resident had been on oxygen since the LPN had been providing the resident care. The LPN confirmed the medical record did not have an order for [REDACTED].>",2020-09-01
116,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2019-01-15,812,F,0,1,W7UH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility staff failed to handle food in a sanitary manner when assisting residents with meals for 1 resident of 15 residents in the dining room. The facility dietary department failed to maintain dietary equipment in a sanitary manner; failed to maintain sanitizer in the sanitizer container used to sanitize work surfaces; and failed to operate the dish machine with sanitizer in 1 of 6 observations of the dietary department. The findings include: Review of the facility policy, Assistance with Meals, revised 6/27/18 revealed, .Employees who provide resident assistance with meals shall demonstrate competency in prevention of foodborne illness, including personal hygiene practices and safe food handling . Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum (MDS) data set [DATE] revealed Resident #5 required total one person assist with eating. Observation on 1/13/19 at 12:15 PM in the East dining room at the noon meal revealed Registered Nurse (RN) #1 picked up a roll from Resident #5's plate with her bare hands and attempted to give Resident #5 a bite of the roll and also attempted to put the roll in the residents hand. Interview with RN #1 on 1/13/19 at 12:16 PM in the East dining room revealed, RN #1 stated I have been feeding people like that for [AGE] years. I need to get a glove when handling residents food. Interview with the Director of Nursing on 1/14/19 at 8:50 AM in her office confirmed staff should never touch any resident's food with their bare hands. Observation on 1/13/19 at 9:02 AM in the dietary department walk-in refrigerator revealed a build-up of blackened debris and white debris on the condenser grate. Observation on 1/14/19 at 10:45 AM in the dietary department, with the Certified Dietary Manager (CDM) present, revealed the can opener blade tip and where the blade attached to the handle, had dried sticky blackened debris. Further observation of the can opener base slot revealed dried sticky blackened debris. Further observation of 3 storage bins containing flour, food thickening agent, and sugar revealed the lids had a heavy accumulation of dried food debris and multi colored dried splatters. The 3 bins exterior front and area in direct contact with the bin lid had a heavy accumulation of dried food debris and multi colored dried splatters. Further review of the range top back splash revealed a heavy accumulation of blackened debris. Further observation revealed 1 ice scoop stored in direct contact with the top of the ice machine. Observation of the other ice scoop revealed the scoop was stored in a container located on top of the ice machine. The container was on its side and the water draining could pool on the top of the ice machine. Interview with the CDM on 1/14/19 at 10:45 AM in the dietary department confirmed the dietary equipment was not maintained in a sanitary manner. Observation and interview on 1/14/19 at 2:10 PM in the dietary department, with the CDM present, confirmed the walk-in refrigerator grate had an accumulation of blackened debris. Further interview confirmed the grate had an area on the lower right side with white debris. Further observation revealed fresh eggs stored in an egg crate were exposed and could possible have been contaminated. Observation on 1/14/19 at 1:30 PM in the dietary department revealed the CDM obtaining the sanitizer level of 2 sanitizer containers used to sanitize work surfaces. Further observation and interview with the CDM confirmed the sanitizer test strip failed to register the sanitizer level in 2 attempts. Further observation revealed the dish machine was in operation. The dietary staff operating the dish machine stated the dining room trays and 1 of 2 tray delivery carts contents had been processed through the dish machine. Further observation revealed the dietary staff member, with the CDM present, using a sanitizer test strip to determine the sanitizer level in the dish machine. Observation of 4 separate test strip attempts revealed no change in the test strip indicating no sanitizer in the dish machine. Interview with the dietary staff member revealed the dietary staff member failed to test the sanitizer level prior to starting the dish machine operation. Interview with the CDM confirmed the dish machine was in operation with no sanitizer.",2020-09-01
117,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2019-01-15,919,D,0,1,W7UH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide a call light for 1 resident (#37) of 59 residents. The findings include: Medical record review revealed Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 1/13/19 at 9:54 AM, 11:52 AM and 2:50 PM in Resident #37's room revealed no call light available for the resident. Interview with Registered Nurse (RN) #2 on 1/13/19 at 2:52 PM in Resident #37's room confirmed she did not have call light. Interview with the Director of Nursing (DON) on 1/13/19 at 9:01 AM in her office when questioned about who was responsible for ensuring residents have a call light, the DON stated, .Everyone, anybody assigned to the room is . The DON confirmed all residents should have a call light available.",2020-09-01
118,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2018-02-22,725,E,1,0,BOIT11,"> Based on review of the facility nurse staffing schedules and interviews the facility failed to have sufficient nursing staff to provide nursing and related services and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by the staffing schedule for 2/10/18. The findings included: Review of the facility nurse staffing for 2/10/18 revealed 3 CNAs were scheduled for the 3:00 PM to 11:00 PM shift. 1 of 3 scheduled CNAs was present to work the evening shift. CNA #3 worked the 7:00 AM to 3:00 PM shift and stayed over to help cover the evening shift. Interview with Resident #2 on 2/20/18 at 12:15 PM in the resident's room revealed he was cognitively intact and stated the facility was understaffed for the evening shift on 2/10/18 with only 1 of the scheduled CNAs showing up to work. Further interview with Resident #2 revealed CNA #3 worked a double to help cover the evening shift on 2/10/18. Continued interview with Resident #2 revealed the medications were administered .about an hour late . on evening shift for 2/10/18. Interview with Resident #4 on 2/22/18 at 1:40 PM in the resident's room revealed he was cognitively intact. He stated the facility staffing is frequently short. He also stated he required assistance to get in and out of the bed. He further stated he prefers to be in bed by 8:30 PM and on the evening shift of 2/10/18 he was not assisted into bed until between 10:00 PM and 11:00 PM. Interview with CNA #1 on 2/21/18 at 8:40 AM in the north hall revealed she worked the day shift on 12/31/17. Continued interview revealed CNA #1 stated only 1 CNA was in attendance to work the 3:00 PM to 11:00 PM shift. Interview with RN #4 on 2/21/18 at 8:45 AM in the north hall revealed she worked the evening shift for 2/10/18. Continued interview revealed she stated the medications were given approximately 1 hour late. Further interview revealed some residents were not assisted into bed at their usual preferred times. Interview with CNA #5 on 2/21/18 at 10:50 AM in the east hall revealed she worked the day shift on 2/10/18. Continued interview revealed she noticed only 1 CNA had arrived to work the evening shift for 2/10/18. Interview with the Director of Nursing (DON) on 2/21/18 at 1:03 PM in the conference room confirmed staffing was short on 2/10/18. Continued interview revealed the DON offered incentive pay to the nursing staff to attempt coverage of the evening shifts. Interview with CNA #3 on 2/22/18 at 2:45 PM in the conference room confirmed she was scheduled and worked the 7:00 AM to 3:00 PM shift on 2/10/18. Continued interview confirmed CNA #3 also worked the 3:00 PM to 11:00 PM shift on 2/10/18. Further interview revealed CNA #3 was assigned resident rooms 1 to 24 and CNA #4 was assigned resident rooms 25 to 48. CNA #3 stated all the work got done .the meds were about an hour late and the residents got checked and turned about twice that shift but some did not get to bed at their usual times.",2020-09-01
119,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2019-05-15,921,E,1,0,2DLD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, observation, and interview the facility failed to maintain the physical environment in a safe and sanitary manner for 22 bathrooms out of 31 bathrooms observed. The findings included: Review of facility policy, Infection Control, revised 10/2018, revealed .The facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of disease and infection .The QAPI Committee through the Infection Control; Committee, shall establish, review, and revise infections control policies and practices, and help department heads and managers ensure they are implemented and followed . Observation of the facility during tours on 5/14/19 and 5/15/19 revealed the following: room [ROOM NUMBER] - loose faucet; missing toilet seat room [ROOM NUMBER] - room trash can overflowing; urine odor room [ROOM NUMBER] - diaper on bathroom floor; dirty water in commode room [ROOM NUMBER] - brown debris in toilet bowl; basin on floor with used gloves and cleansers in it Rooms 8 & 10 share bathroom - unflushed toilet room [ROOM NUMBER] - clothes on bedside table and floor room [ROOM NUMBER] - strong urine odor; dirty linen in sink Rooms 12 & 14 - strong smell of urine in bathroom Rooms 15 & 17 - bathroom trash can overflowing Rooms 16 & 18 - dirty water in commode with brown particles in bowl Shower room - drain without cover room [ROOM NUMBER] - powder on toilet seat and floor; strong urine odor; colored water in toilet room [ROOM NUMBER] - urine in toilet room [ROOM NUMBER] - diaper and pitcher on overbed table; lift sling on bedside table; brown material on toilet bowl; soiled linen on floor, in sink, and on toilet tank room [ROOM NUMBER] - dirty streaks in toilet; trash can full room [ROOM NUMBER] - 1 unlabeled bedpan on floor and 1 unlabeled bedpan on bathroom rail room [ROOM NUMBER] - diaper in chair and clothes as well room [ROOM NUMBER] - trash can overflowing; urine in commode; commode dirty room [ROOM NUMBER] - stains on toilet seat; hair, urine in commode Rooms 40 & 42 - brown debris in toilet bowl and on commode; soiled linens on floor and toilet tank room [ROOM NUMBER] - commode not flushed room [ROOM NUMBER] - dirty water in commode; sink dirty with tan ring around bowl room [ROOM NUMBER] - toilet bowl with brown residue room [ROOM NUMBER] - O2 mask and tubing on empty bed room [ROOM NUMBER] - unlabeled bedpan and urinal on floor; unlabeled basin with wet towels in it on floor Interview with the DON on 5/15/19 at 12:30 PM while touring the facility confirmed the 22 bathrooms were not clean with dirty water in the commodes; soiled linen on the floors; and trash cans overflowing. The DON also confirmed it was the responsibility of Housekeeping to keep the bathrooms clean.",2020-09-01
120,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2017-06-23,282,G,1,0,Q80711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, manufacturer's instructions review, observation, medical record review and interview the facility failed to follow the resident's care plan to ensure safe transfer techniques were implemented for 1 resident (#1) of 9 residents reviewed for abuse of 11 residents sampled. The facility's failure resulted in harm to Resident #1. The findings included: Review of the facility's policy, Resident Lift, undated, revealed, .Residents who are unable to transfer themselves independently or with minimal assistance shall be transferred safely with a lift .Guideline .2. At least two (2) trained staff are needed to transfer a resident when using a lift .7. In order to lift safely, follow manufactures operational guidelines for lifting, positioning, and transfer .Note: Make sure to pull appropriate make and model manufacturer guidelines for the lift used and follow manufacturer's instructions. Review of the manufacturer's Safety Instructions for Intended use revealed, (Product name) is a mobile raising aid .intended to be used on a horizontal surface for raising to a standing position and short transfer of residents .where the resident has been clinically assessed to correspond to the following categories .Sits in a wheelchair - Is able to partially bear weight on at least one leg - Has some trunk stability - Dependent on carer in most situations - Physically demanding for carer . Review of facility's assessment, Mechanical Lifts - Function Flow Chart dated [DATE], revealed .Can the resident bear weight on at least one leg? No .Total lift required for transfer . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 3 out of 15 indicating the resident's cognition was severely impaired. Continued review revealed the resident required extensive assistance of 2 persons for bed mobility, transfers, and used a wheelchair for mobility. Medical record review of Resident #1's Care Plan dated [DATE] revealed problem of .[MEDICAL CONDITION] with Cognitive Deficits and Impaired Mobility .Two person assist and hoyer (total lift transfer device) lift required during transfers . Medical record review of Progress Note dated [DATE] revealed .Musculoskeletal: No joint deformity .Nonambulatory . Medical record review of the CNA (certified nurse assistant) Care Kardex, undated, revealed .Transfers .Assist 2 .hoyer (total lift) . Medical record review of Physical Therapy (PT) PT Evaluation & Plan of Treatment dated [DATE] revealed .Standing Balance .Unable (total dependence) . Medical Record review of Physician order [REDACTED].X-ray (L) hip 4 views STAT hip pain .May give [MEDICATION NAME] ,[DATE] mg (pain medication) by mouth every 8 hours as needed for hip pain . Medical Record review of Clinical page dated [DATE] 8:38 PM revealed .assisted to bed .had intense pain in left leg during the transfer .noted the inward rotation of her left leg and swelling in left upper thigh at hip area. NP was notified and order received. Family is aware . Medical record of Physician order [REDACTED].please transfer to ED (emergency department) for eval (evaluation) + Hx (history) L (left) hip pain, (decrease) ROM (range of motion) and acute swelling . Medical Record review of the hospital Ortho-Trauma Consult Note dated [DATE] revealed Angulated spiral [MEDICAL CONDITION] left femoral shaft . Medical Record review of the hospital discharge summary dated [DATE] revealed Resident #1 had an ORIF (open reduction internal fixation) to left femur on [DATE] and returned to the facility on [DATE]. Observation of Resident #1 on [DATE] at 1:40 PM revealed the head of the bed elevated 35 degrees, over-bed table in front of her, and currently eating lunch. Continued observation revealed the quarter upper rails were in the raised position on the bed. The daughter is sitting in a chair beside Resident #1's bed. Interview with the Therapy Director in the physical therapy department on [DATE] at 2:40 PM revealed they (Therapy Department) provide recommendations on transfer methods. (Resident #1) would not be appropriate for a sit to stand lift because she is unable to stand; a total lift transfer would be appropriate because she cannot stand. Interview with CNA #2 (7 AM-3 PM shift) on [DATE] at 1:55 PM revealed CNA #2 had provided care for Resident #1 on Wednesday, (MONTH) 7th. Continued interview revealed .we're supposed to use the Hoyer lift for (Resident #1) because that's what's on the card (referring to the CNA Care Kardex) .I used the Hoyer lift on that Wednesday, but sometimes when her daughter was here, we would use the sit to stand for transfers. The daughter liked the sit to stand better; she (the daughter) would help and I'd use the sit to stand. Telephone interview with CNA #4 on [DATE] at 7:57 PM revealed she had cared for Resident #1 three times on the evening shift. Continue interview confirmed, I buddied up with CNA #3 to get the residents ready for bed .When they went to assist (Resident #1) the daughter had already put the resident in bed, and the sit to stand lift was in the room. I went and told .(RN #1) and then we finished getting our residents in bed. Interview with CNA #3 on [DATE] at 2:00 PM revealed CNA #3 routinely worked 7AM - 3 PM and sometimes worked over, up until 7 PM. Continued interviewed confirmed I used the Hoyer lift because that's what's on the card (referring to Kardex) to use .I worked 3 days over that week. I would ask the daughter when the resident wanted to go to bed and then I would go and get other residents ready. When I returned, the daughter had already put her to bed and the sit to stand was in the room. I asked the daughter, 'Who helped you put her in bed?' She said, 'I did .I can do it.' I notified the charge nurse (RN #1) that (Resident #1) daughter had used the sit to stand and put the resident to bed. CNA#3 stated she had not seen Resident #1 in any kind of pain while working. Interview with the resident's Power of Attorney (POA) in Resident #1's room on [DATE] at 3:39 PM, revealed she would transfer the resident with the sit to stand lift, but only with assistance of a CN[NAME] I never transferred mother without help stated PO[NAME] I had gone home for church on Wednesday (MONTH) 7th. I did not help put her back to bed that night. Telephone interview with CNA #6 on [DATE] at 6:21 PM, who provided care for Resident #1 on [DATE] evening shift, 7 PM-7 AM, revealed the resident went to church that night, and she put her to bed after church around 8 PM. (CNA) assisted me with the Hoyer lift and we put her in the bed. She didn't have any complaints of pain and we teamed up during the night and turned our residents. After we got her (Resident #1) in bed, around 10 PM, when we went back and checked to make sure she wasn't wet, and turned her. We checked on her every two hours throughout the night. There was nothing out of the ordinary with turning her. She didn't catch her foot in the covers or anything else. Again, she didn't have any complaints throughout the night. Telephone interview with CNA #10 on [DATE] at 6:38 PM, revealed she provided care to Resident #1 on (MONTH) 8, 7 AM-3 PM shift. Continued interview revealed, .that morning (Resident #1) said her leg was hurting when we were cleaning her up. I asked her which leg and one time she said her right, then she said her left. I told the charge nurse (LPN #2), and then I provided her AM care. After that, I had another aide come and we used the Hoyer lift, got her up and sat her in her wheelchair. She ate lunch while she was up in her wheelchair and later went to activities .every two hours we took her back to her room, used the Hoyer lift, placed her in bed, and provided incontinence care . then we used the Hoyer lift to put her back into her wheelchair .after the complaints of leg pain in the morning, there were no further complaints of pain . Telephone interview with CNA #9 on [DATE] at 6:40 PM, who provided care for Resident #1 on [DATE] evening shift, 3 PM-11 PM, revealed he had assisted the resident to bed sometime after 5:00 PM. I was told by staff, don't remember who it was .that you use the sit to stand lift with (Resident #1). Continued interview revealed another CNA helped him with the sit to stand and (POA) was in the room too, but did not help. I sat her (Resident #1) on the bed and swung her legs onto the bed. I asked her if her leg was hurting and she said it was. Continued interview confirmed the POA provided assistance with and removal of (Resident #1's) pants. That is when I noticed the swelling to her left hip. I went and told the nurse that her leg was swollen and looked like it needed an x-ray. The nurse came and looked at (Resident #1) and later the mobile x-ray came. We had to turn her quite a few times to try and get a good x-ray. (Resident #1) would grimace when we turned and repositioned her. There was no catching of her feet in covers or legs falling off the bed as we turned and repositioned her. Interview on [DATE] at 10:05 AM, with the Director of Nursing in the conference room confirmed the resident (#1) was to be transferred with the total lift (Hoyer lift) with 2 person assist only, and that is what's on her care plan. She was not aware of use of the sit to stand on the resident until after the resident was sent to the hospital. I was never informed of the use of a sit and stand for the resident or that the family member was transferring or assisting with transfers until after the injury, stated DON. Interview confirmed the sit and stand was not to be used for the transfer of Resident #1 because she could not stand and only the total lift (Hoyer lift) was to be used; use of improper lift equipment for Resident #1 placed her at harm.",2020-09-01
121,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2017-06-23,323,G,1,0,Q80711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, manufacturer's instructions review, observation, medical record review, and interview the facility failed to ensure safe transfer techniques were implemented for 1 resident (#1) of 1 resident reviewed for injury of unknown origin of 11 residents reviewed. The facility's failure resulted in harm to Resident #1. The findings included: Review of the facility's policy, Resident Lift, undated, revealed, .Residents who are unable to transfer themselves independently or with minimal assistance shall be transferred safely with a lift .Guideline .2. At least two (2) trained staff are needed to transfer a resident when using a lift .7. In order to lift safely, follow manufactures operational guidelines for lifting, positioning, and transfer .Note: Make sure to pull appropriate make and model manufacturer guidelines for the lift used and follow manufacturer's instructions. Review of the manufacturer's Safety Instructions for Intended use revealed, (Product name (sit to stand lift)) is a mobile raising aid .intended to be used on a horizontal surface for raising to a standing position and short transfer of residents .where the resident has been clinically assessed to correspond to the following categories .Sits in a wheelchair - Is able to partially bear weight on at least one leg - Has some trunk stability - Dependent on carer (care giver) in most situations - Physically demanding for carer . Review of facility's assessment, Mechanical Lifts - Function Flow Chart dated [DATE], revealed .Can the resident bear weight on at least one leg? No .Total lift required for transfer . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 3 out of 15 indicating the resident's cognition was severely impaired. Continued review revealed the resident required extensive assistance of 2 persons for bed mobility, transfers, and used a wheelchair for mobility. Medical record review of Resident #1's Care Plan dated [DATE] revealed problem of .Alzheimer's Disease with Cognitive Deficits and Impaired Mobility .Two person assist and hoyer (total lift transfer device) lift required during transfers . Medical record review of Progress Note dated [DATE] revealed .Musculoskeletal: No joint deformity .Nonambulatory . Medical record review of the CNA (certified nurse assistant) Care Kardex, undated, revealed .Transfers .Assist 2 .hoyer (total lift) . Medical record review of Physical Therapy (PT) PT Evaluation & Plan of Treatment dated [DATE] revealed .Standing Balance .Unable (total dependence) . Medical Record review of the Physician order [REDACTED].X-ray (L) hip 4 views STAT hip pain .May give Norco ,[DATE] mg (pain medication) by mouth every 8 hours as needed for hip pain . Medical Record review of Clinical page dated [DATE] 8:38 PM revealed .assisted to bed .had intense pain in left leg during the transfer .noted the inward rotation of her left leg and swelling in left upper thigh at hip area. NP (Nurse Practitioner) was notified and order received. Family is aware . Medical record of Physician order [REDACTED].please transfer to ED (emergency department) for eval (evaluation) + Hx (history) L (left) hip pain, (decrease) ROM (range of motion) and acute swelling . Medical Record review of the hospital Ortho-Trauma Consult Note dated [DATE] revealed Angulated spiral fracture of the proximal left femoral shaft . Medical Record review of the hospital discharge summary dated [DATE] revealed Resident #1 had an ORIF (open reduction internal fixation) to left femur on [DATE] and returned to the facility on [DATE]. Observation of Resident #1 on [DATE] at 1:40 PM revealed the head of the bed elevated 35 degrees, over-bed table in front of her, and currently eating lunch. Continued observation revealed the quarter upper rails were in the raised position on the bed with the resident's daughter was sitting in a chair beside Resident #1's bed. Interview with the Therapy Director in the physical therapy department on [DATE] at 2:40 PM revealed they (Therapy Department) provided recommendations on transfer methods. (Resident #1) would not be appropriate for a sit to stand lift because she was unable to stand; a total lift transfer would be appropriate because she cannot stand. Interview with CNA #2 (7 AM-3 PM shift) on [DATE] at 1:55 PM revealed CNA #2 had provided care for Resident #1 on Wednesday, (MONTH) 7th. Continued interview revealed .we're supposed to use the Hoyer lift for (Resident #1) because that's what's on the card (referring to the CNA Care Kardex) .I used the Hoyer lift on that Wednesday, but sometimes when her daughter was here, we would use the sit to stand for transfers. The daughter liked the sit to stand better; she (the daughter) would help and I'd use the sit to stand. Telephone interview with CNA #4 on [DATE] at 7:57 PM revealed she had cared for Resident #1 three times on the evening shift. Continue interview confirmed, I buddied up with CNA #3 to get the residents ready for bed .When they went to assist (Resident #1) the daughter had already put the resident in bed, and the sit to stand lift was in the room. I went and told .(RN #1) and then we finished getting our residents in bed. Interview with CNA #3 on [DATE] at 2:00 PM revealed CNA #3 routinely worked 7AM - 3 PM and sometimes worked over, up until 7 PM. Continued interviewed confirmed I used the Hoyer lift because that's what's on the card (referring to Kardex) to use .I worked 3 days over that week. I would ask the daughter when the resident wanted to go to bed and then I would go and get other residents ready. When I returned, the daughter had already put her to bed and the sit to stand was in the room. I asked the daughter, 'Who helped you put her in bed?' She said, 'I did .I can do it.' I notified the charge nurse (RN #1) that (Resident #1) daughter had used the sit to stand and put the resident to bed. CNA#3 stated she had not seen Resident #1 in any kind of pain while working. Interview with the resident's Power of Attorney (POA) in Resident #1's room on [DATE] at 3:39 PM, revealed she would transfer the resident with the sit to stand lift, but only with assistance of a CN[NAME] I never transferred mother without help stated PO[NAME] I had gone home for church on Wednesday (MONTH) 7th. I did not help put her back to bed that night. Telephone interview with CNA #6 on [DATE] at 6:21 PM, who provided care for Resident #1 on [DATE] evening shift, 7 PM-7 AM, revealed the resident went to church that night, and she put her to bed after church around 8 PM. (CNA) assisted me with the Hoyer lift and we put her in the bed. She didn't have any complaints of pain and we teamed up during the night and turned our residents. After we got her (Resident #1) in bed, around 10 PM, when we went back and checked to make sure she wasn't wet, and turned her. We checked on her every two hours throughout the night. There was nothing out of the ordinary with turning her. She didn't catch her foot in the covers or anything else. Again, she didn't have any complaints throughout the night. Telephone interview with CNA #10 on [DATE] at 6:38 PM, revealed she provided care to Resident #1 on (MONTH) 8, 7 AM-3 PM shift. Continued interview revealed, .that morning (Resident #1) said her leg was hurting when we were cleaning her up. I asked her which leg and one time she said her right, then she said her left. I told the charge nurse (LPN #2), and then I provided her AM care. After that, I had another aide come and we used the Hoyer lift, got her up and sat her in her wheelchair. She ate lunch while she was up in her wheelchair and later went to activities .every two hours we took her back to her room, used the Hoyer lift, placed her in bed, and provided incontinence care . then we used the Hoyer lift to put her back into her wheelchair .after the complaints of leg pain in the morning, there were no further complaints of pain . Telephone interview with CNA #9 on [DATE] at 6:40 PM, who provided care for Resident #1 on [DATE] evening shift, 3 PM-11 PM, revealed he had assisted the resident to bed sometime after 5:00 PM. I was told by staff, don't remember who it was .that you use the sit to stand lift with (Resident #1). Continued interview revealed another CNA helped him with the sit to stand and (POA) was in the room too, but did not help. I sat her (Resident #1) on the bed and swung her legs onto the bed. I asked her if her leg was hurting and she said it was. Continued interview confirmed the POA provided assistance with and removal of (Resident #1's) pants. That is when I noticed the swelling to her left hip. I went and told the nurse that her leg was swollen and looked like it needed an x-ray. The nurse came and looked at (Resident #1) and later the mobile x-ray came. We had to turn her quite a few times to try and get a good x-ray. (Resident #1) would grimace when we turned and repositioned her. There was no catching of her feet in covers or legs falling off the bed as we turned and repositioned her. Interview on [DATE] at 10:05 AM, with the Director of Nursing (DON) in the conference room confirmed the resident (#1) was to be transferred with the total lift (Hoyer lift) and 2 persons assist only. Continued interview confirmed she was not aware of anyone using the sit to stand lift with the resident until after the resident was sent to the hospital. I was never informed of the use of a sit to stand for the resident or that the family member was transferring or assisting with transfers until after the injury. Interview confirmed the sit to stand was not to be used for the transfer of Resident #1 because she could not stand and only the total lift (Hoyer lift) was to be used. Interview with Medical Director (MD) on [DATE] at 10:08 AM in the conference room revealed the fracture may have occurred up to a week prior to the complaint of pain on (MONTH) 8th. Continued interview revealed . the mobile x-rays obtained on (MONTH) 8th revealed no fracture or dislocation; don't know if the x-ray was misinterpreted or if it wasn't displaced. Continued interview confirmed she probably fractured upon the transfer but did not displace .whoever was there when the fracture occurred may not have been aware because it was not dislocated .the initial x-ray did not show the fracture .and she would not have been able to communicate that. Continued interview confirmed the give away was the thigh swelling. When the bones separate with a fracture is when you have pain that can become unbearable. Continued interview revealed the MD was unaware of Resident #1's family member transferring the resident until after the injury occurred. Continued interview revealed Resident #1 was unable to stand; she would require two people beside her to hold her weight; she is a large lady (280 pounds per MDS), and her frame is only capable of carrying maybe 100 pounds. Continued interview revealed if Resident #1 stood up (with a sit to stand lift) and her foot was planted when they tried to rotate her it could have created a torque (a rotating force) on the bone and fractured the femur resulting in a spiral fracture (a bone fracture occurring when torque is applied along the axis of a bone).",2020-09-01
122,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2019-08-21,558,G,1,0,J49Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, facility record review and interview, the facility failed to ensure reasonable accommodation of needs to prevent decline for 1 (#22) of 38 residents reviewed resulting in psychosocial and physical Harm for Resident #22. The findings include: Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Continued review revealed Resident #22 required extensive assistance of 1 staff member for bed mobility and 2 staff members for transfers. Medical record review of the Progress Notes Report dated 4/8/19 revealed .Maintenance man reported to this nurse, f/u (follow up) with resident regarding having his bed replaced. (named medical equipment provider) delivered bed for resident in the interim, so maintenance can work/replace the parts to the existing bed . Resident #22 was transferred to the rental bed at this time. Medical record review of the service document from the rental company dated 4/9/19 revealed the order requisition sheet for a rental bariatric bed. Continued review revealed .5/8/19 fixed . Medical record review of the Former Nurse Practitioner (NP) notes dated 4/25/19 revealed .Patient appears hemodynamically stable, afebrile, nontoxic, but presents with left lower extremity [MEDICAL CONDITION] (bacterial infection of the skin) in the setting of chronic [MEDICAL CONDITION] .Elevate extremities . Medical record review of the Former NP notes dated 5/19/19 revealed .As such, it is medically necessary that the bed be changed to one that will allow extremity elevation, as this patient is rather immobile and morbidly obese and does suffer from marginally compensated heart failure and chronic [MEDICAL CONDITION] now presenting with [MEDICAL CONDITION]. (named resident) will require extremity elevation throughout the day. See (named resident) back as directed, follow-up and treat as clinically indicated . Medical record review of the physician's orders [REDACTED].Treatment/Procedure .Elevate Legs At All times . Medical record review of the Former NP notes dated 5/31/19 revealed .(named resident) current (rental) bariatric hospital bed has a non functioning motor so that legs are unable to be elevated, chronically dependent (leg constantly in a downward position) now. He does remain on [MEDICATION NAME] (diuretic) and [MEDICATION NAME] (diuretic) for diuretic management .It is medically imperative that the patient be provided a functioning bariatric bed to assist with extremity elevation for fluid management, as he does contend with profound chronic [MEDICAL CONDITION] and [MEDICAL CONDITION] now resulting in [MEDICAL CONDITION] . Medical record review of the Progress Notes Report dated 6/3/19 revealed .Resident called nurse to room, very upset regarding legs continuing to swell and not going down, resident requested the nurse to call the NP d/t (due to) his wanting to go to hospital for evaluation. NP contacted with new orders received and noted to transport resident to ER (emergency room ) of choice for eval (evaluation) and tx (treatment). Resident was tearful when moved to stretcher due to pain in heels when they touched the stretcher. Blankets placed under resident's heels. A blanket was placed across resident abdomen for straps from stretcher. Resident medicated with routine [MEDICATION NAME] 10/325 mg (milligram) for pain prior to transfer . Medical record review of the Hospital History of Present Illness dated 6/3/19 revealed .Patient .with a Hx (history) of chronic leg pain who presents to the ED (emergency department) via EMS (emergency medical services) with complaint of bilateral lower extremity pain and swelling that began 3 weeks ago. Patient reports that he has received 3 rounds of antibiotics at (named facility) .rehab facility for [MEDICAL CONDITION] but denies improvement .reports of chills, leg swelling, and wounds on hips .Differential Diagnosis: [REDACTED]. Medical record review of the Progress Notes Report dated 6/4/19 revealed .Patient (pt) arrived back at facility on 6/4/19. Pt was very upset because bed had not been changed out while he was gone to ER. Legs very swollen and this writer can only feel faint pedal pulses. Report from (named nurse) was given at 8 PM (8:00 PM) last night but return was delayed until early morning because of transportation issues . Medical record review of the Progress Notes Report dated 6/4/19 revealed .Patient remains in bed, bilateral lower extremities remain very [MEDICAL CONDITION], remains on abt (antibiotic) for [MEDICAL CONDITION], afebrile, resident continues to c/o (complain of) bed not being changed out, will continue to monitor and report any changes . Medical record review of the care plan dated 6/4/19, revised on 7/3/19 revealed the care plan failed to address the need for elevation of legs and feet. Medical record review of the service document revealed Resident #22 was in a rental bariatric bed for 58 days. Interview with Resident #22 on 8/12/19 at 11:11 AM in Resident #22's room revealed the resident has had [MEDICAL CONDITION] for [AGE] years. Further interview revealed Resident #22 stated .this (bed) needed to be fixed . It would not elevate the legs. Continued interview with Resident #22 revealed the facility rented a bariatric hospital bed to use while his bed was being repaired. The rented hospital bed raised the resident's knees. Further interview with Resident #22 revealed he was transferred to theER on [DATE] for pain and swelling in the legs and [MEDICAL CONDITION] in the ankle. Continued interview with Resident #22 revealed when he was transferred back to the facility from the hospital, the rented hospital bed which did not elevate his legs and feet was still in the room. He had asked the Administrator about changing to his original bed which was repaired on 5/8/19 and was in the hallway beside his room for almost 1 month. Telephone interview with the Former Nurse Practitioner (NP) on 8/12/19 at 9:47 AM revealed she had cared for the resident for many years and was familiar with the resident's comorbidities. Continued interview with the Former NP revealed Resident #22 was being treated with diuretics and elevation of the legs. Further interview with the Former NP revealed the resident had not had [MEDICAL CONDITION] until recently. Continued interview with the Former NP revealed Resident #22's bed was not working to elevate the legs. His original bed had been repaired and was sitting in the hallway but the resident had not been moved to it. This continued for some time but she could not remember how long. Continued interview with the Former NP revealed when she came to see Resident #22 on 5/15/19 his legs were severely swollen. Interview with the Administrator on 8/13/19 at 3:51 PM in the West dining room confirmed he wrote on the service document 5/8/19 fixed showing the bed was fixed. Interview with the Administrator on 8/20/19 at 2:10 PM in the West dining room revealed the Former Maintenance Director ordered the parts for the bed. Continued interview with the Administrator when asked and shown the Progress Notes Reports when the Former Maintenance Director was made aware of the broken bed and when Resident #22 was transferred back into the fixed bed confirmed give or take 60 days. Telephone interview with the Former NP on 8/23/19 at 12:26 PM confirmed she agreed with the statement made in the NP notes dated 5/31/19 which revealed she had observed several times when the resident's lower legs were in a dependent position (hanging down) due to the motor not functioning. Continued interview with the Former NP confirmed she had spoken to staff nurses and the Corporate Nurse regarding her concerns. Resident #22 remained in the rental bed, unable to have his lower extremities elevated per physician's orders [REDACTED].",2020-09-01
123,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2019-08-21,580,D,1,0,J49Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview the facility failed to notify the physician when there was a significant change in condition for 1 (#22) of 38 residents reviewed. The findings include: Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Resident #22 required extensive assistance with 2 staff members for bed mobility, dressing, and toilet usage. Continued record review revealed total dependence with 1 staff member for bathing. Medical record review of Resident #22's Progress Notes dated 6/18/19 written by Licensed Practical Nurse (LPN) #1 revealed, .called to Resident's room to evaluate [MEDICAL CONDITION] area to right thigh area .area cleansed and maggots removed . Medical record review of Resident Progress Notes dated 6/18/19 written by LPN #2 revealed, .called to Resident's (#22) room to evaluate [MEDICAL CONDITION] area to right thigh. Area noted with increased moisture and maggots within [MEDICAL CONDITION] area. Area cleansed and maggots removed. Resident stated, I want to go to the hospital. Resident transported to (named hospital) per request. Telephone interview with LPN #2 on 8/14/19 at 2:02 PM revealed she had not called the Nurse Practitioner (NP) or Medical Director (MD) #2. Interview with LPN #1 on 8/14/19 at 3:38 PM in the West Dining Room confirmed she did not notify the NP or MD #2 on 6/18/19 when the maggots were discovered and Resident #22 was transferred to the hospital. Telephone interview with the Former MD #2 on 8/14/19 at 10:29 AM confirmed he was not notified of the maggots, increased [MEDICAL CONDITION], or transfer to the hospital on [DATE]. Telephone interview with the NP on 8/12/19 at 9:47 AM confirmed she was not notified by staff when (named Resident #22) presented with maggots in the plaques and fissures on his right thigh until a week after the finding. Refer to F600.",2020-09-01
124,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2019-08-21,600,J,1,0,J49Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, service reports, observation, and interview, the facility failed to prevent neglect for 3 (#1, #16, and #22) of 38 residents reviewed. The facility failed to provide needed care and services to prevent the infestation of fly larvae (maggots) in subcutaneous tissue (underneath the skin) and under skin folds for 1 (#22) of 5 residents reviewed. The facility failed to monitor and document bowel movements and failed to administer appropriate bowel medications for 12 (#1, #5, #7, #10, #16, #19, #21, #24, #25, #29, #36, #37) of 15 residents reviewed for bowel movements. The facility failed to prevent actual abuse to 1 (#23) of 38 residents reviewed. Actual Harm occurred when Residents #1 and #16 complained of severe abdominal pain and constipation necessitating a visit to the hospital. The facility's non-compliance resulted in Residents #1 and #16 psychological and physical harm. This failure placed Resident #22 in Immediate Jeopardy (a situation in which the provider's non-compliance 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, Interim Director of Nursing, Corporate Nurse and Corporate Vice President of Operations were notified of the Immediate Jeopardy on [DATE] at 4:00 PM in the Social Worker's office. An acceptable Allegation of Compliance was received on [DATE] at 8:45 PM which removed the immediacy of the jeopardy. Corrective actions were validated through review of documents, observations, and staff interviews conducted onsite on [DATE]. The Immediate Jeopardy was effective from [DATE] - [DATE]. F689 is Substandard Quality of Care. Noncompliance continues at a scope and severity of D to monitor the effectiveness of the corrective actions. The findings include: Review of facility policy, Abuse, Neglect, and Misappropriation of Property, revised ,[DATE], revealed .It is the organization's intention to prevent the occurrence of abuse, neglect, and misappropriation of resident property .Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or emotional distress .Criminal background checks will be conducted prior to permanent employment as well as a search of the State Aide Registry .During orientation all new Stakeholders will be trained on abuse .Each Stakeholder will receive annual training on abuse and neglect policies .The Facility Administrator will investigate all allegations of abuse .Every Stakeholder shall immediately report any allegation of abuse, injury of unknown source, of suspicion of crime .If the suspected perpetrator is a Stakeholder the charge nurse shall immediately remove that Stakeholder from resident care areas and suspend him/her while the matter is investigated .The Administrator/Director Of Nursing (DON) will take measures to secure the safety and well-being of the affected resident . Review of facility policy, BM (Bowel Movement) Regimen, reviewed [DATE], revealed .The facility will monitor and track residents to determine the need for dietary and or chemical intervention to treat chronic and/or acute episodes of constipation .If a resident has had no bowel movement for 3 days the resident will receive additional high fiber drink and/or food supplements .If the resident has had no BM for 3 days the resident will receive on the evening shift a designated laxative and if no BM by the following morning the resident will receive a suppository after breakfast and if no BM by the evening of the fourth day the resident will be given a Fleets enema . Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Resident #22 required extensive assistance with 2 staff members for bed mobility, dressing, and toilet usage. Continued record review revealed total dependence with 1 staff member for bathing. Medical record review of Resident #22's Progress Notes dated [DATE] written by Licensed Practical Nurse (LPN) #1 revealed, .called to Residents room to evaluate [MEDICAL CONDITION] area to right thigh area .area cleansed and maggots removed . There is no documentation she notified the physician. Medical record review of Resident Progress Notes dated [DATE] written by LPN #2 revealed, .called to Residents (#22) room to evaluate [MEDICAL CONDITION] area to right thigh. Area noted with increased moisture and maggots within [MEDICAL CONDITION] area. Area cleansed and maggots removed. Resident stated, I want to go to the hospital. Resident transported to (named hospital) ER per request. Observation on [DATE] at 10:34 AM in Resident #22's room revealed Resident #22 was in the bed in a supine (lying on back) position. Continued observation of Resident #22 revealed the right hip area appeared discolored, leather like, and appeared to have raised rounded plaques (small distinct raised patch or region) and fissures (long narrow opening or line of breakage). Continued observation revealed the same rounded plaques and fissures were observed on the left hip. Telephone interview with CNA (Certified Nurse Aid) #3 on [DATE] at 12:14 PM revealed on [DATE] CNA #3 went to Resident #22's room to give the resident a bed bath. The CNA was asked by Resident #22 to perform a light wash (not too vigorous cleansing) due to increased pain in his hip. As CNA #3 began to wash the right hip with a wash cloth and soapy water, maggots were noted coming from the right thigh area crawling on the resident's abdominal folds. Continued interview with CNA #3 revealed he stopped cleaning the area and notified Licensed Practical Nurse (LPN) (Wound Care Nurse) #1 and the Administrator. He asked CNA #2 to help him. Both CNA #2 and CNA #3 returned to the room and he removed the covers to show CNA #2 the maggots. LPN #1 left the room and returned with a brown bottle of Dakin's (A dilute hypochlorite (bleach) antibiotic solution that kills the micro-organisms, but also harms healthy cells in all concentrations) and a toothbrush to cleanse the wound and skin folds and to remove the maggots. Further interview with CNA #3 revealed LPN #1 told both CNA #2 and CNA #3 to pour the Dakin's solution on the plaques and fissures to clean the area with the solution and the toothbrush. Further interview with CNA #3 revealed the maggots looked medium to large. Continued interview with CNA #3 revealed Resident #22 could feel the maggots crawling once they came out of the wound. CNA #3 stated Resident #22 said, .I feel them, I feel them . Interview with CNA #2 on [DATE] at 2:42 PM in the conference room revealed the maggots were observed between 10:30 AM and 11:00 AM on [DATE]. CNA #3 had been giving Resident #22 a bed bath. Continued interview with CNA #2 revealed when she went into the room to assist CNA #3, Resident #22 was in a supine position on the bed. Continued interview with CNA #2 revealed the Wound Care Nurse LPN #1 was already in the room. CNA #3 removed the sheet covering Resident #22's body and CNA #2 observed maggots crawling on the stomach and in the skin folds. LPN #1 started pouring the Dakin's solution on Resident #22's thigh area, then CNA #2 stated, .I poured some . Continued interview with CNA #2 revealed, .The maggots would come out and I would scoop them in a cup . Continued interview with CNA #2 revealed the maggots looked yellow and white. Interview with LPN #1 on [DATE] at 3:21 PM in the West dining room revealed LPN #1 was requested in the room because Resident #22 thought he had maggots .and the resident requested to go to the hospital . Continued interview with LPN #1 revealed Resident #22 had [MEDICAL CONDITION] in the area where the maggots were located. The area had been raised and bumpy. Continued interview with LPN #1, the wound care nurse, revealed when asked how often she checked the site of the [MEDICAL CONDITION] LPN #1 stated .I don't look at it every day. I just go and check on Resident #22 once a week . Telephone interview with CNA #3 on [DATE] at 2:01 PM revealed Resident #22 complained of pain for about 3 weeks prior to the maggots coming out of the plaques and fissures and there were times when staff had to alter how they cleaned the area because it was so painful for the resident. Telephone interview with the Former Nurse Practitioner (NP) on [DATE] at 9:47 AM revealed she was not notified by staff when Resident #22 presented with maggots in the plaques and fissures; did not give any orders for Dakin's solution to be used; and was not notified until a week after the findings. Interview with Resident #22 on [DATE] at 3:13 PM in his room revealed Resident #22 felt the maggots when they were crawling on his skin. Continued interview revealed when staff told the resident it was maggots the resident started crying and stated Why me? It's one thing to have this fluid but now maggots. Continued interview with Resident #22 confirmed the resident was scared and insisted on going to the hospital. Telephone interview with the Former Medical Director (MD) #2 on [DATE] at 10:29 AM confirmed he was not notified of the maggots, increased lower extremity [MEDICAL CONDITION] or transfer to the hospital on [DATE]. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #1 scored 15 on the Brief Interview for Mental Status (BIMS) indicating she was alert, oriented, and able to make her needs known. Continued review of the MDS revealed Resident #1 was dependent on 1 person for bathing; required extensive assistance of 1 person with grooming; required limited assistance with transfers, dressing, and toileting; and was frequently incontinent of bowel and bladder. Medical record review of the Elimination Record for ,[DATE] and ,[DATE] revealed: [DATE] had a small BM (bowel movement) [DATE] - [DATE] no documentation [DATE] no BM [DATE] - [DATE] no documentation [DATE] no BM [DATE] - [DATE] no documentation [DATE] no BM. Medical record review of the Medication Administration Record [REDACTED]. Further review revealed no documentation [DATE] or [DATE]. Medical record review of the MAR indicated [REDACTED]. There is no documentation this was administered in ,[DATE] or ,[DATE]. Medical record review of the MAR indicated [REDACTED]. Further review revealed no documentation these medications were ever administered. All the above medications were ordered on admission ([DATE]). Medical record review of a note by the Former Medical Director #1 dated [DATE] revealed .Pt reports she has significant abdominal pain and distention. She reports she has not had a bowel movement in 7 days. She has already tried Milk of Magnesia, [MEDICATION NAME], Senna, and [MEDICATION NAME]. She denies pain, dyspnea, dysuria, nausea, and depression. She requests a trip to (named hospital) for management of her constipation. She reports feeling awful from constipation. Patient encouraged to attempt a suppository before requesting to go to hospital again. Senekot (laxative) 2 tabs BID (twice daily) scheduled and 2 tabs BID PRN constipation. Encouraged patient to call after 3 days if no BM from now on to prevent her current discomfort in the future . Medical record review of the emergency room (ER) notes dated [DATE] revealed . Patient c/o (complained of) lower abdominal pain x 1 week. Said she was at a picnic [DATE] and since then has had intermittent daily abdominal and pelvic pain which has worsened over the past week. Last bowel movement 7 days ago. Family member had found patient in dirty diaper this morning . A further ER note revealed a statement .Noted the patient's diaper was full of dried stool that had adhered to the patient's skin . Continued review of the ER (Emergency Department) record dated [DATE] revealed the resident's abdomen was soft with mild tenderness to deep palpation in the suprapubic (central front wall of the abdomen immediately above pubic bone) and epigastric (upper central region of abdomen) regions. There was also a palpable pulsatile mass on examination of the abdomen. Continued review of ER records revealed a CT (Computerized [NAME]ography) scan was performed on [DATE], which demonstrated .Infrarenal (below the kidneys) abdominal aortic aneurysm, enlarged in size, with retroperitoneal (toward the back of the body) stranding (thinning) concerning for threatened rupture. The neck of the aneurysm is poorly suitable for repair. She is not a candidate for repair of aneurysm now or in the future . Continued review of the hospital record dated [DATE] revealed Resident #1 began to have worsening kidney failure; refused [MEDICAL TREATMENT]; was placed on palliative care; and expired on [DATE] due to [MEDICAL CONDITION]. Telephone interview with the Former Medical Director #1 on [DATE] at 2:15 PM revealed during her rounds of the facility she did not document her findings in the resident records. Information, especially bowel movements, was not documented in the medical record because the staff was having problems with the new computer program. When she asked the Administrator about paper records she was told if they went back to paper the staff would never use the computer. Telephone interview with the complainant on [DATE] at 2:30 PM revealed the resident's family member found her in distress and drove her to the hospital. Interview with the Interim Director of Nursing (DON) on [DATE] at 1:15 PM in the Social Worker's office revealed Resident #1 was at an ophthalmology appointment and the resident's family member called to say Resident #1 was admitted to the hospital for abdominal pain. The Interim DON confirmed bowel movements were not documented because the facility was switching to a new documentation system and the staff was unfamiliar with how and where to document bowel movements. There were no Nursing Notes available from Resident #1's admission on [DATE] through her discharge on [DATE] including the incident which precipitated her discharge from the facility. Medical record review revealed Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #16 scored 13 on the BIMS indicating she was slightly cognitively impaired. Continued review of the MDS revealed Resident #16 was dependent on 1 person for bathing; required extensive assistance of 2 people with transfers; required extensive assistance of 1 person with dressing, toileting, and grooming; was frequently incontinent of urine; and was always incontinent of bowel. Medical record review of Nursing Notes dated [DATE] revealed .Called to resident room. Sitting on the toilet vomiting chunks of her dinner. Stated she does not feel well. Is sick to her stomach. BS (blood sugar) 289 (normal 70 - 110). NP notified and new orders received to transfer resident to hospital. Will monitor . The resident was transferred to the ER for evaluation on [DATE]. Medical record review of a Nursing Note dated [DATE] revealed .Received back from the ER. No needs voiced. States she feels better. Abd (abdomen) soft, non tender. No reports of feeling constipated at this time . The above 2 entries are the only ones in the medical record. There was no documentation of the resident being transferred to the hospital or post hospitalization status. Medical record review of the Elimination Record for ,[DATE] and ,[DATE] revealed: [DATE] and [DATE] the resident had no BM [DATE] no documentation [DATE], [DATE], [DATE] resident had no BM [DATE] no documentation [DATE] and [DATE] resident had no BM [DATE] - [DATE] no documentation. Review of facility investigation dated [DATE] revealed .Medical staff alleges Resident #16 was not sent out for fecal emesis (vomiting stool-colored material) after being given an order to do so and was found the next day in distress and sent out . Review of facility investigation dated [DATE] of a written statement by Licensed Practical Nurse (LPN) #3 revealed .On [DATE] (named Resident #16) was c/o (complaining of) abd (abdominal) pain. Oral laxatives were administered per bowel regimen ,[DATE] ([DATE]) with no effect. Suppository was administered ,[DATE] ([DATE]) with no immediate effect. Resident vomited shortly after administration and NP was made aware. Order was given to send (named Resident #16) to ER. After phone call to NP resident had a LARGE BM. Resident then stated symptoms had improved. NP was contacted again and made aware of BM and statement of relief by (named Resident #16) NP told me then not to send resident to ER. NP made rounds in facility on ,[DATE] ([DATE]) and (named Resident #16) stated she had started having pains again and wanted to go to the ER. NP gave order to send (named Resident #16) to ER and she was sent to (named hospital) . Review of the ER notes dated [DATE] revealed .The patient had a small bowel movement prior to my examination. The patient had a moderate amount of soft stool in her rectal vault (area where stool collects before being eliminated) but she could not comply with disimpaction due to significant discomfort. There is a large amount of [MEDICAL CONDITION] along the rectum which is distended with stool. Dilated loops of colon with stool consistent with constipation. She had another bowel movement prior to receiving the enema I had ordered. The enema resulted in good stool production. CT showed markedly stool throughout the colon. On re-exam her abdomen is soft, nontender, and nondistended. We will discharge her with prescriptions for Peri-[MEDICATION NAME] and Mag [MEDICATION NAME] as ordered . Medical record review of the MAR for ,[DATE] revealed an order for [REDACTED]. Interview with the Interim DON on [DATE] at 1:30 PM in the Social Worker's office confirmed BMs were not documented consistently due to problems with staff having difficulty entering data in the new system. Medical record review revealed Resident #23 was admitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly MDS dated [DATE] revealed a BIMS score of 00 indicating severe cognitive impairment. Continued review revealed Resident #23 expressed little interest in doing things, feeling depressed and hopeless, trouble falling asleep and having little energy. Further review revealed the resident was able to make her needs known to the staff through gestures as well as nodding and shaking her head. Medical record review of a Comprehensive Care Plan revised [DATE] revealed assessment and intervention occurred for communication deficits, mobility, skin management and bowel elimination. Review of the facility investigation of an interview between the Administrator and LPN #5 dated [DATE] revealed LPN #5 stated to the Administrator that .she (LPN #5) filled a medicine cup (half) way and went in the room to shock (Resident #23) out of her yelling and screaming . Further review of the facility investigation dated [DATE] revealed it was documented LPN #5 stated she .poured it (water) on her (Resident #23) chest and belly area . Interview with Resident #5, (Resident #23's roommate) with a BIMS of 15, on [DATE] at 10:15 AM in the resident's room revealed on [DATE] early in the morning but still dark LPN #5 entered the room on Resident #23's side (door side). Continued interview revealed Resident #5 stated the privacy curtain was pulled so that she was unable to see LPN #5 but recognized her voice. Further interview revealed Resident #5 next heard Resident #23 state stop pouring water on me. The resident stated after LPN #5 left the room she heard CNA #7 enter the room and ask Resident #23 why her gown and bottom sheet were damp. Interview with CNA #7 on [DATE] at 7:05 AM in the West dining room revealed on [DATE] at approximately 3:00 AM she was in the hall outside Resident #23's room with CNA #8. Continued interview revealed CNA #7 heard LPN #5 tell Resident #23 to stop yelling and stated you're going to wake everyone up. Further interview revealed CNA #7 heard Resident #23 state stop pouring water on me. The CNA stated after LPN #5 left the room, she entered to checked on Resident #23 and Resident #5. Further interview revealed Resident #23's right side of her gown, right side of her pillowcase at the resident's jaw-line and the fitted sheet on the right side at the resident's shoulder area were damp. CNA #7 stated Resident #23 stated she poured water on me and was unable to identify the person. Continued interview revealed CNA #7 left Resident #23's room to find the weekend supervisor, Registered Nurse (RN) #4. Further interview revealed as CNA #7 passed the back nurse's station she heard LPN #5 talking about pouring a medicine cup of water on Resident #23 to cause her to stop yelling. CNA #7 informed RN #4 of LPN #5 pouring water on Resident #23 to get her to stop yelling. Validation of the Allegation of Compliance (A[NAME]) to remove the Immediate Jeopardy was completed [DATE] through review of facility documentation, observations, and interviews. Surveyor verified the A[NAME] by: 1. Observation of the skin audits completed [DATE] revealed no new skin issues with residents. 2. Observation revealed Housekeeping supervisor and certified Dietary Manager assessing all rooms for the presence of food and removing it. 3. Observation of Maintenance Director installing blue light pest filters in hallways which previously had none. 4. Interview with the Administrator on [DATE] at 4:00 PM revealed the environmental lab was scheduled to visit the facility during the evening of [DATE]. They were observed entering the facility at 7:20 PM. 5. Review of inservice records revealed the Administrator, Maintenance Director, Dietary Manager, and Regional Maintenance Director were educated on [DATE] on reviewing and following up on all environmental concerns. 6. Review of inservice records dated [DATE] revealed education on reporting pest presence; removal of resident food items; daily skin observations for changes; cleaning rooms and emptying trash. This inservice will be presented to new hires during orientation. 7. Daily Ambassador Rounds tool was revised [DATE] by the Interim DON to include observation of pests in kitchen, common areas, and residential rooms. Observations will be made daily. 8. Regional Vice President of Operations conducted a round of the facility kitchen to observe for pests. Administration will conduct kitchen rounds 5 days per week to assess for pest or sanitation issues. 9. On [DATE] ad hoc QAPI meeting to discuss survey results, citation, and allegation of compliance and all agreed with the plan. 10. All audit findings will be reviewed during monthly QAPI meeting for further suggestions.",2020-09-01
125,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2019-08-21,609,D,1,0,J49Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, State Survey Agency Facility Reported Incidents database review, and interview, the facility failed to report neglect to the State Survey Agency for 1 (#22) of 38 residents reviewed. The findings include: Review of facility policy, Abuse, Neglect, and Misappropriation of Property, revised 5/2019, revealed .It is the organization's intention to prevent the occurrence of abuse, neglect, and misappropriation of resident property .Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or emotional distress .During orientation all new Stakeholders will be trained on abuse .Each Stakeholder will receive annual training on abuse and neglect policies .The Facility Administrator, or designee, will investigate all such allegations .All alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but not later than 2 hours after the allegation is made . Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated no cognitive impairment. Resident #22 required extensive assistance with 2 staff members for bed mobility, dressing, and toilet usage. Continued record review revealed total dependence with 1 staff member for bathing. Medical record review of Resident Progress Notes dated 6/18/19 written by Licensed Practical Nurse (LPN) #2 revealed, .called to Residents (#22) room to evaluate [MEDICAL CONDITION] area to right thigh. Area noted with increased moisture and maggots within [MEDICAL CONDITION] area. Area cleansed and maggots removed. Resident stated, I want to go to the hospital. Resident transported to (named hospital) ER per request. Telephone interview with CNA (Certified Nurse Aid) #3 on 8/8/19 at 12:14 PM revealed on 6/18/19 CNA #3 went to Resident #22's room to give the resident a bed bath. The CNA was asked by Resident #22 to perform a light wash (not too vigorous cleansing) due to increased pain in his hip. As CNA #3 began to wash the right hip with a wash cloth and soapy water, maggots were noted coming from the right thigh area crawling on the resident's abdominal folds. Continued interview with CNA #3 revealed he stopped cleaning the area and notified Licensed Practical Nurse (LPN) (Wound Care Nurse) #1 and the Administrator. He asked CNA #2 to help him. Both CNA #2 and CNA #3 returned to the room and he removed the covers to show CNA #2 the maggots. LPN #1 left the room and returned with a brown bottle of Dakin's (A dilute hypochlorite (bleach) antibiotic solution that kills the micro-organisms, but also harms healthy cells in all concentrations) and a toothbrush to cleanse the wound and skin folds and to remove the maggots. Further interview with CNA #3 revealed LPN #1 told both CNA #2 and CNA #3 to pour the Dakin's solution on the plaques and fissures to clean the area with the solution and the toothbrush. Further interview with CNA #3 revealed the maggots looked medium to large. Continued interview with CNA #3 revealed Resident #22 could feel the maggots crawling once they came out of the wound. CNA #3 stated Resident #22 said, .I feel them, I feel them . Review of the facility self-reported incidents confirmed the facility did not report this incident of neglect to the State Survey Agency. Refer to F600.",2020-09-01
126,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2019-08-21,641,D,1,0,J49Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to complete an accurate assessment of the resident status for 3 (#5, #14, and #21) of 38 residents reviewed. The findings include: Medical record review revealed Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #5 scored 14 on the Brief Interview for Mental Status (BIMS) indicating she was alert, oriented, and able to make her needs known. Continued review of the MDS revealed Resident #5 was dependent on 2 people for transfers, toileting, and bathing; required extensive assistance of 2 people with dressing and grooming; frequently incontinent of bowel; and had a suprapubic urinary drainage catheter in place. Medical record review of the Annual MDS dated [DATE] for Resident #5 revealed in the section on Bowel and Bladder, under Appliances it was documented as none of the above but the space for suprapubic catheter should have been marked. Under urinary continence it was marked not rated, resident had a catheter. Medical record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission MDS dated [DATE] revealed Resident #14 had a BIMS score of 15 which indicated no cognitive impairment. Continued review revealed Resident #14 required total dependence with 2 staff members for bed mobility and transfers. Continued review revealed Resident #14 required extensive assistance with 1 staff member for toileting. Continued review revealed Resident #14 was frequently incontinent of bowel. Continued review revealed Resident #14's use of a condom catheter was not addressed in the Bowel and Bladder section. Interview with the Corporate Nurse on 8/21/19 at 2:33 PM in the Social Services office confirmed the facility failed to capture the condom catheter on the Admission MDS. Medical record review revealed Resident #21 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed the resident was placed on hospice on 6/17/19 and there was no Significant Change MDS completed for Resident #21. Interview with the Administrator on 8/6/19 at 3:25 PM in the West dining room revealed there was no Significant Change MDS when the resident was placed on hospice. Continued interview with the Administrator confirmed she (MDS Coordinator) failed to address it (significant change).",2020-09-01
127,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2019-08-21,656,D,1,0,J49Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview the facility failed to have an updated care plan for 1 (#22) of 38 residents reviewed. The findings include: Review of the facility policy Comprehensive Care Plans revised 7/19/18 revealed .The Comprehensive Care Plan will be person-centered to include the discharge plans to meet the resident's preference and goals to address the resident's medical, physical, mental and psychosocial needs . Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #22 required extensive assistance with 2 staff members for bed mobility, dressing, and toilet usage. Continued record review revealed total dependence with 1 staff member for bathing. Medical record review of the Physician's Order Sheet dated 5/19/19 revealed .TREATMENT/PR[NAME]EDURE .ELEVATE LEGS AT ALL TIMES . Medical record review of the care plan dated 6/18/19 and 7/4/19 revealed the care plan was not revised to reflect orders to elevate Resident #22's legs at all times. Interview with Resident #22 on 8/12/19 at 11:11 AM in his room revealed the he had [MEDICAL CONDITION] for [AGE] years. Further interview revealed Resident #22 stated .this (the bed) needed to be fixed . It would not elevate his legs. Interview with the Corporate Nurse on 8/21/19 at 12:53 PM in the Social Services office confirmed the facility failed to update Resident #22's care plan to include elevation of the legs.",2020-09-01
128,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2019-08-21,658,F,1,0,J49Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview, the facility failed to provide care according to professional standards of practice by failing to monitor bowel movements; failing to intervene according to facility policy and physician's orders [REDACTED].#1,#5, #7, #10, #16, #19, #21, #24, #25, #29, #36, #37) of 15 residents reviewed for bowel movements. The facility failed to document nursing information for 3 (#1, #4, and #16) of 38 residents reviewed. The findings include: Review of facility policy, BM Regimen, reviewed 6/1/18, revealed .The facility will monitor and track residents to determine the need for dietary and or chemical intervention to treat chronic and/or acute episodes of constipation If a resident has had no bowel movement for 3 days the resident will receive additional high fiber drink and/or food supplements .If the resident has had no BM for 3 days the resident will receive on the evening shift a designated laxative and if no BM by the following morning the resident will receive a suppository after breakfast and if no BM by the evening of the fourth day the resident will be given a Fleets enema . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 scored 15 on the Brief Interview for Mental Status (BIMS) indicating she was alert, oriented, and able to make her needs known. Continued review of the MDS revealed Resident #1 was dependent on 1 person for bathing; required extensive assistance of 1 person with grooming; required limited assistance with transfers, dressing, and toileting; and was frequently incontinent of bowel and bladder. Medical record review of the Elimination Record for 6/2019 and 7/2019 revealed: 6/12/19 had a small BM (bowel movement) 6/13/19 - 6/18/19 no documentation 6/19/19 no BM 6/20/19 - 6/24/19 no documentation 6/25/19 no BM 6/26/19 - 7/8/19 no documentation 7/9/19 no BM. Medical record review of the MAR indicated [REDACTED]. Medical record review of the MAR indicated [REDACTED]. There is no documentation this was administered. Medical record review of the MAR indicated [REDACTED]. Telephone interview with the previous Medical Director on 8/13/19 at 2:15 PM revealed during her rounds of the facility she did not document her findings in the resident records. Information, especially bowel movements, was not documented in the medical record because the staff was having problems with the new computer program. When she asked the Administrator about paper records she was told if they went back to paper the staff would never use the computer. Medical record review revealed Resident #1 had no nursing notes in the computer either in their new program or the old program. Medical record review revealed Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission MDS dated [DATE] revealed Resident #16 scored 13 on the BIMS indicating she was slightly cognitively impaired. Continued review of the MDS revealed Resident #16 was dependent on 1 person for bathing; required extensive assistance of 2 people with transfers; required extensive assistance of 1 person with dressing, toileting, and grooming; was frequently incontinent of urine; and was always incontinent of bowel. Medical record review of Nursing Notes dated 6/23/19 revealed .Called to resident room. Sitting on the toilet vomiting chunks of her dinner. Stated she does not feel well. Is sick to her stomach. BS (blood sugar) 289. NP notified and new orders received. Will monitor . Medical record review of the Elimination Record for 6/2019 and 7/2019 revealed: 6/18/19 and 6/19/19 the resident had no BM 6/20/19 no documentation 6/21/19, 6/22/19, 6/23/19 resident had no BM 6/24/19 no documentation 6/25/19 and 6/26/19 resident had no BM 6/27/19 - 7/15/19 no documentation. Medical record review of the MAR for 7/2019 revealed an order for [REDACTED]. Review of the ER notes dated 7/10/19 revealed .The patient had a small bowel movement prior to my examination. The patient had a moderate amount of soft stool in her rectal vault (area where stool collects before being eliminated) but she could not comply with disimpaction due to significant discomfort. There is a large amount of [MEDICAL CONDITION] along the rectum which is distended with stool. Dilated loops of colon with stool consistent with constipation. She had another bowel movement prior to receiving the enema I had ordered. The enema resulted in good stool production. CT showed markedly stool throughout the colon. On re-exam her abdomen is soft, nontender, and nondistended. We will discharge her with prescriptions for Peri-[MEDICATION NAME] and Mag [MEDICATION NAME] as ordered . Medical record review of a Nursing Notes dated 7/11/19 revealed .Received back from the ER. No needs voiced. States she feels better. Abd soft, non tender. No reports of feeling constipated at this time . The above 2 entries are the only ones in the medical record. There is no documentation of the resident being transferred to the hospital; post hospitalization status; or follow-up by Social Services after hospitalization . Interview with the Interim Director Of Nursing (DON) on 8/13/19 at 8:30 AM in the West dining room revealed the facility changed to a new documentation system at the end of (MONTH) 2019. Continued interview revealed she confirmed some data on residents was lost and could not be retrieved and the missing notes on Residents #1 and #16 were in that category. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 5 Day MDS dated [DATE] revealed Resident #4 scored 15 on the BIMS indicating he was alert, oriented, and able to make his needs known. Continued review of the MDS revealed Resident #4 required limited assistance with bathing, transfers, dressing, and grooming; extensive assistance of 1 person with toileting; and was always incontinent of bowel and bladder. Medical record review of physician's orders [REDACTED]. Review of physician's orders [REDACTED].#4 was ordered [MEDICATION NAME] 4.5 Grams 4 times daily and scheduled for 4:00 AM, 10:00 AM, 4:00 PM, and 10:00 PM. Medical record review of the Medication Administration Record [REDACTED]. There was also no documentation in the Nursing Notes if the medication was held for some reason. Medical record review of physician's orders [REDACTED].Cleanse wound to left heel with wound cleanser; pat dry; apply Dakins 0.125% wet to dry dressing; change daily and as needed . Medical record review of the MAR for 7/2019 revealed there was no documentation the dressing was changed on 7/6/19 and 7/7/19. Medical record review of the hospital discharge notes revealed an order for [REDACTED]. Medical record review of physician's orders [REDACTED].Follow-up with Infectious Diseases and make appointment. Follow-up with (named Wound Clinic) . Medical record review revealed no documentation the appointment was scheduled or the resident went to the appointment. Interview with the Interim Director of Nurses (DON) on 8/21/19 at 12:30 PM in the Social Services Office confirmed the physician's orders [REDACTED].#4 in a timely fashion according to the physician's orders [REDACTED]. Medical record review of the Bowel Elimination Records revealed: Resident #5 had no BM documented 7/11/19 - 7/22/19 and 7/22/19 - 7/31/19 with a laxative administered 7/23/19. Resident #7 had no BM 7/18/19 - 7/22/19 and 8/1/19 - 8/8/19 with no medication intervention documented. Resident #10 had no BM documented 7/5/19 - 7/9/19 and 7/8/19 - 7/15/19 with no medication intervention documented. Resident #19 had no BM documented 7/12/19 - 7/16/19, 7/20/10 - 7/24/19, and 7/24/19 - 7/29/19 with no medication intervention documented. Resident #21 had no BM documented 7/12/19 - 7/16/19 with no medication intervention documented. Resident #24 had no BM documented 7/18/19 - 7/22/19, 7/23/19 - 7/27/19, 8/2/19 - 8/8/19 with no medication intervention documented. Resident #25 had no BM documented 7/25/19 - 7/29/19 with no medication intervention documented. Resident #29 had no BM documented 7/10/19 - 7/18/19 and 7/25/19 - 7/31/19 with no medication intervention documented. Resident #36 had no BM documented 7/7/19 - 7/12/19 and 7/12/19 - 7/17/19 with no medication intervention documented. Resident #37 had no BM documented 7/12/19 - 7/15/19 and 7/17/19 - 7/22/19 with no medication intervention documented. Telephone interview with the Former Medical Director #1 on 8/13/19 at 2:15 PM confirmed during her rounds of the facility she did not document her findings in the resident records. Information, especially bowel movements, was not documented in the medical record because the staff was having problems with the new computer program. When she asked the Administrator about paper records she was told if they went back to paper the staff would never use the computer. Interview with the Interim Director of Nursing (DON) on 8/21/19 at 1:15 PM in the Social Worker's office confirmed . bowel movements were not documented because of the facility switching to a new documentation system and the staff's unfamiliarity with how and where to document bowel movements .",2020-09-01
129,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2019-08-21,695,D,1,0,J49Z11,"**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 date and change oxygen tubing and humidifier canisters for 1 (#21) of 5 residents reviewed with oxygen. The findings include: Review of the facility policy Oxygen Administration dated 9/6/18 revealed .Check the mask, tank, humidifier canister, etc. (when in use), to be sure they are good working order and are securely fastened. Be sure there is water in the humidifier canister and that the water level is high enough that the water bubbles as oxygen flows through . Medical record review revealed Resident #21 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #21 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Medical record review of the care plan revised on 3/29/19 revealed .increase oxygen to 4 liters per nasal cannula . Observation and interview with Resident #21 on 8/5/19 at 11:24 AM in his room revealed the resident was lying in bed with his head elevated at a 45 degree angle and wearing a hospital gown. Continued observation revealed the resident was receiving oxygen therapy by nasal cannula. Further observation revealed the humidifier canister was not dated. Observation and interview on 8/6/19 at 8:59 AM in Resident #21's room revealed he had nasal cannula in place but the prongs were not in his nostrils. Continued interview with Resident #21 revealed when asked if he was comfortable with the prongs not in his nostrils the resident stated his nose was hurting. Continued observation revealed the humidifier canister was empty and undated. Interview with Registered Nurse (RN) #1 on 8/6/19 at 9:11 AM in Resident #21's room revealed RN #1 confirmed the humidifier canister was out of water and not dated. Interview with the Interim Director of Nursing (DON) on 8/22/19 at 11:14 AM in the Administrator's office confirmed .we should have oxygen tubing and the humidifier canister dated. Continued interview with the Interim DON confirmed .they (humidifier canisters) should be changed out when no water is in them .",2020-09-01
130,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2019-08-21,755,D,1,0,J49Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview the facility failed to obtain Physicians' Orders for a medicated solution and failed to ensure that only licensed personnel administered medications for 1 (#22) of 38 residents reviewed. The findings include: Record review of the facility policy Medication Administration General Guidelines revised 9/6/18 revealed .Medications are prepared and administered only by licensed nursing, medical, pharmacy or other personnel authorized by state regulations to prepare and administer medications . Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #22 required extensive assistance with 2 staff members for bed mobility, dressing, and toilet usage. Continued record review revealed total dependence with 1 staff member for bathing. Medical record review of Resident Progress Notes dated 6/18/19 written by Licensed Practical Nurse (LPN) #2 revealed, .called to Residents (#22) room to evaluate [MEDICAL CONDITION] area to right thigh. Area noted with increased moisture and maggots within [MEDICAL CONDITION] area. Area cleansed and maggots removed. Resident stated, I want to go to the hospital. Resident transported to (named hospital) ER per request. Medical record review of the Physicians' Order Sheets and Physician's Telephone Orders dated (MONTH) 2019 revealed no orders for Dakin's (a dilute hypochlorite (bleach) antibiotic solution. It kills the microorganisms but also harms healthy skin in all concentrations) solution for Resident #22. Interview with Resident #22 on 8/7/19 at 1:26 PM in his room revealed Certified Nurse Aide (CNA) #2 and CNA #3 began to cleanse the plaques and fissures by pouring a solution (Dakin's) on the area. Continued interview with Resident #22 revealed the Wound Care Nurse (LPN #1) gave the CNAs the solution to pour on the plaques and fissures Continued interview with Resident #22 revealed .maggots would come out and then they would clean them off . Interview with CNA #2 on 8/7/19 at 2:42 PM in the West dining room revealed, .Licensed Practical Nurse (LPN) #1 stepped out to get Dakin's (A dilute hypochlorite (bleach) solution that shows effectiveness against Gram-Positive bacteria such as strep and staph, as well as a broad spectrum of anaerobic organisms and fungi) solution. Upon return to the room LPN #1 started pouring the Dakin's solution on Resident #22's plaques and fissures on his right thigh, then CNA #2 stated, .I poured some . Telephone interview with CNA (Certified Nurse Aid) #3 on 8/8/19 at 12:14 PM revealed LPN #1 left the room, returned with a brown bottle of Dakin's and a toothbrush to start cleaning the plaques and fissures on his thigh and abdominal skin folds and to clear the maggots off. Further interview with CNA #3 revealed LPN #1 (Wound Care Nurse) told both CNA #2 and CNA #3 to pour the Dakin's on the plaques and fissures and to clean the area with the solution and the toothbrush. Telephone interview with the Former Nurse Practitioner (NP) on 8/12/19 at 9:47 AM confirmed she was not notified by staff when (named Resident #22) presented with maggots in the plaques and fissures on his right thigh, and did not give any orders for Dakin's solution to be used. Telephone interview with the Pharmacy Consultant on 8/21/19 at 8:28 AM revealed Dakins solution was diluted bleach used to cleanse wounds. Continued interview with the Pharmacy Consultant confirmed nurses can use it (Dakins solution) as long there is an order .",2020-09-01
131,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2019-08-21,835,J,1,0,J49Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation and interviews Administration failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident. The inactions and decisions of Administration contributed to physical and psychosocial harm for 3 (#1, #16, #22) of 38 residents reviewed. This failure placed Resident #22 in Immediate Jeopardy (a situation in which the provider's non-compliance 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, Interim Director of Nursing, Corporate Nurse and Corporate Vice President of Operations were notified of the Immediate Jeopardy on 8/21/19 at 4:00 PM in the Social Worker's office. An acceptable Allegation of Compliance was received on 8/21/19 at 8:45 PM which removed the immediacy of the jeopardy. Corrective actions were validated through review of documents, observations, and staff interviews conducted onsite on 8/21/19. The Immediate Jeopardy was effective from 6/18/19 - 8/21/19. The findings include: Review of Pest control customer service reports (This report is provided to identify sanitation deficiencies, structural defects and improper storage practices contributing to pest infestation.) revealed: 2/20/19 Small flies noted during service in kitchen .Reviewed with management . 3/20/19 Small flies noted under dishwasher sink .Reviewed with management .excess water noted under dishwasher .Keep area dry . 4/17/19 .Excess water noted under dishwasher .Keep area dry .Reviewed with management . 5/9/19 .Small flies noted during service by dishwasher sink .Reviewed with management . 6/5/19 .Small flies noted during service under dishwasher .Reviewed with management . 7/24/19 revealed .Excess water under dishwasher .Keep area dry .Illuminated light trap found unplugged, interior kitchen .Large flies noted in hallways .Reviewed with management . During the survey from 8/6/19 - 8/21/19 the survey team noted multiple flies and gnats in the West dining room and discussed this with management during the exit conference. 1. Interview with the Maintenance Director on 8/5/19 at 3:18 PM in the West dining room revealed the facility had a note pad for work orders at the nursing station but the staff would often stop him in the hall to tell him about a problem. Otherwise there was no consistent process for notification of needed equipment repairs. 2. Observation on 8/13/19 at 12:30 PM and 8/15/19 at 1:34 PM in the Dietary Department revealed flies and gnats and a small yellow round dryer underneath the sink of the garbage disposal. Continued observation in the dietary department revealed a dehumidifier and vacuum cleaner under a table. 3. Interview with the Dietary Manager on 8/13/19 at 1:57 PM in the West dining room revealed a month ago the connection in the drain of the three compartment sink had separated and was fixed by maintenance through reattachment. Continued interview revealed the floor under the dishwasher and garbage disposal needed to be repaired. The floor was old and the water would pool and not go down the drain. 4. Interview with the Maintenance Director on 8/13/19 at 2:01 PM in the West dining room confirmed the water had cracked the floor in the kitchen where water was pooling on the floor. Continued interview revealed the Administrator had not approved repair of the floor. 5. Telephone interview with the Pest Service Specialist on 8/26/19 at 9:49 AM revealed the Service Specialist had been servicing the facility for a year and was the primary Specialist. Continued interview with the Service Specialist confirmed when he would see things he would report it to management and they were supposed to fix it and their relationship was supposed to be a partnership. Continued interview with the Service Specialist confirmed the issues with the flies and gnats were a sanitation and structural problem. Continued interview confirmed .when you see pests activities like this it is a sign that it (named facility) was not cleaned regularly . 6. Interview with Resident #22 on 8/12/19 at 11:11 AM in Resident #22's room revealed the resident has had [MEDICAL CONDITION] for [AGE] years. Further interview revealed Resident #22 stated .this (bed) needed to be fixed . It would not elevate the legs. Continued interview with Resident #22 revealed the facility rented a bariatric hospital bed to use while his bed was being repaired. The rented hospital bed raised the resident's knees but left the lower leg and feet hanging down in a dependent position. Further interview with Resident #22 revealed he was transferred to theER on [DATE] for pain and swelling in the legs and [MEDICAL CONDITION] in the ankle. Continued interview with Resident #22 revealed when he was transferred back to the facility from the hospital, the rented hospital bed which did not elevate his legs and feet was still in the room. He had asked the Administrator about changing to his original bed which was repaired on 5/8/19 and was in the hallway beside his room for almost 1 month. 7. Medical record review of Resident Progress Notes dated 6/18/19 written by LPN #2 revealed, .called to Residents (#22) room to evaluate [MEDICAL CONDITION] area to right thigh. Area noted with increased moisture and maggots within [MEDICAL CONDITION] area. Area cleansed and maggots removed. Resident stated, I want to go to the hospital. Resident transported to (named hospital) ER per request. 8. Telephone interview with CNA #3 on 8/8/19 at 12:14 PM revealed he noted the maggots coming out of the plaques and fissures on the right hip of Resident #22 and notified both the Wound Care Nurse and the Administrator. CNA #3 continued the Administrator did not come to the room to see the resident. He also stated Resident #22 could feel the maggots crawling as they came out of the plaques and fissures and said I feel them, I feel them. 9. Interview with Resident #22 on 8/12/19 at 3:13 PM in his room revealed Resident #22 felt the maggots when they were crawling on his skin. Continued interview revealed when staff told the resident it was maggots the resident started crying and stated Why me? It's one thing to have this fluid but now maggots. Continued interview with Resident #22 revealed the resident was scared and insisted on going to the hospital. 10. Resident #22 had a [DIAGNOSES REDACTED].#22 was placed on a rental bed which flexed his knees but left his lower legs and feet in a downward position. On 6/4/19 the resident returned to the facility having been hospitalized for [REDACTED]. The bed had been repaired for 54 days and was in the hallway. 11. Interview with Resident #22 on 8/12/19 at 11:11 AM in his room revealed when he transferred back to the facility the rented hospital bed was still in the room. Continued interview with Resident #22 revealed he spoke with the Administrator about getting the original bed back but he kept telling Resident #22 he did not know when it would be ready. Resident #22 asked the Corporate Nurse what was the hold up? and the Corporate Nurse got nurses and the Administrator to transfer him back to the original bed. 12. Interview with the Administrator on 8/20/19 at 2:10 PM in the West dining room confirmed Resident #22 was not provided a functioning bed to elevate his legs as ordered for give or take 60 days. 13. Interview with the Interim DON on 8/12/19 at 9:30 AM in the West dining room revealed on 6/30/19, the facility began to use a new documentation program. Continued interview revealed the first week (6/30/19 - 7/7/19), the staff did not know how to use the part of the program needed to enter resident bowel movements so they were not documented. 14. Telephone interview with the Former Medical Director (MD) #1 on 8/13/19 at 2:15 PM revealed she was concerned about residents having bowel movements. When she asked the Administrator about going back to paper records until the staff was more familiar with the program the Administrator told her they would not go back to paper records or the staff would never learn how to navigate the program. As a result bowel movement records were not documented for at least a week. Continued interview with the former MD #1 revealed she was aware there were serious problems in the facility. She had addressed these concerns with the Administrator, but he rebutted all her allegations. The Medical Director stated .When these issues are brought to the Administrator's attention he talks a good game and promises change but seldom follows through. Whenever I bring a complaint to (named Administrator) he blames the residents rather than taking their complaints seriously and addressing their complaints . 15. Telephone interview with former MD #2 on 8/21/19 at 3:15 PM revealed the Administrator refused to accept there were any problems in the facility and if there were, they were the fault of the residents. Continued interview revealed if the Physician complained the wound dressings were not changed the Administrator stated it was because the resident refused to allow a dressing change. Further interview revealed if the Physician complained medications were not administered when scheduled the Administrator stated the resident refused the medication at the scheduled time. Continued interview revealed the Administrator told the Physician he would act on an issue then did nothing. Further interview confirmed the Medical Director felt the concerns in the facility were caused by and contributed to by the Administrator. Validation of the Allegation of Compliance (A[NAME]) to remove the Immediate Jeopardy was completed 8/21/19 through review of facility documentation, observations, and interviews. Surveyor verified the A[NAME] by: 1. Observation of the skin audits completed 8/21/19 revealed no new skin issues with residents. 2. Observation revealed Housekeeping supervisor and certified Dietary Manager assessing all rooms for the presence of food and removing it. 3. Observation of Maintenance Director installing blue light pest filters in hallways which previously had none. 4. Interview with the Administrator on 8/21/19 at 4:00 PM revealed the environmental lab was scheduled to visit the facility during the evening of 8/21/19. They were observed entering the facility at 7:20 PM. 5. Review of inservice records revealed the Administrator, Maintenance Director, Dietary Manager, and Regional Maintenance Director were educated on 8/21/19 on reviewing and following up on all environmental concerns. 6. Review of inservice records dated 8/21/19 revealed education on reporting pest presence; removal of resident food items; daily skin observations for changes; cleaning rooms and emptying trash. This inservice will be presented to new hires during orientation. 7. Daily Ambassador Rounds tool was revised 8/21/19 by the Interim DON to include observation of pests in kitchen, common areas, and residential rooms. Observations will be made daily. 8. Regional Vice President of Operations conducted a round of the facility kitchen to observe for pests. Administration will conduct kitchen rounds 5 days per week to assess for pest or sanitation issues. 9. On 8/21/19 ad hoc QAPI meeting to discuss survey results, citation, and allegation of compliance and all agreed with the plan. 10. All audit findings will be reviewed during monthly QAPI meeting for further suggestions.",2020-09-01
132,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2019-08-21,842,F,1,0,J49Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on Medical record review and interview the facility failed to maintain complete medical records for 12 (#1, #5, #7, #10, #16, #19, #21, #24, #25, #29, #36, #37) of 15 residents reviewed for bowel movements and /or treatments. The findings include: Review of facility policy, BM (Bowel Movement) Regimen, reviewed 6/1/18, revealed .The facility will monitor and track residents to determine the need for dietary and or chemical intervention to treat chronic and/or acute episodes of constipation .If a resident has had no bowel movement for 3 days the resident will receive additional high fiber drink and/or food supplements .If the resident has had no BM for 3 days the resident will receive on the evening shift a designated laxative and if no BM by the following morning the resident will receive a suppository after breakfast and if no BM by the evening of the fourth day the resident will be given a Fleets enema . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 scored 15 on the Brief Interview for Mental Status (BIMS) indicating she was alert, oriented, and able to make her needs known. Continued review of the MDS revealed Resident #1 was dependent on 1 person for bathing; required extensive assistance of 1 person with grooming; required limited assistance with transfers, dressing, and toileting; and was frequently incontinent of bowel and bladder. Medical record review of the Elimination Record for 6/2019 and 7/2019 revealed: 6/12/19 had a small BM (bowel movement) 6/13/19 - 6/18/19 no documentation 6/19/19 no BM 6/20/19 - 6/24/19 no documentation 6/25/19 no BM 6/26/19 - 7/8/19 no documentation 7/9/19 no BM. Medical record review of the Nurse's Notes confirmed there were no Nursing Notes available from admission on 2/23/18 to discharge on 7/9/19 including the incident which precipitated her discharge from the facility. Medical record review revealed Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #16 scored 13 on the BIMS indicating she was slightly cognitively impaired. Continued review of the MDS revealed Resident #16 was dependent on 1 person for bathing; required extensive assistance of 2 people with transfers; required extensive assistance of 1 person with dressing, toileting, and grooming; was frequently incontinent of urine; and was always incontinent of bowel. Medical record review of the Elimination Record for 6/2019 and 7/2019 revealed: 6/18/19 and 6/19/19 the resident had no BM 6/20/19 no documentation 6/21/19, 6/22/19, 6/23/19 resident had no BM 6/24/19 no documentation 6/25/19 and 6/26/19 resident had no BM 6/27/19 - 7/15/19 no documentation. Medical record review of the Medication Administration Record [REDACTED]. Continued review revealed there was no documentation that the medications were administered and no documentation in the Nursing Notes of the need for the medications. Medical record review of Nursing Notes dated 6/23/19 revealed .Called to resident room. Sitting on the toilet vomiting chunks of her dinner. Stated she does not feel well. Is sick to her stomach. BS (blood sugar) 289 (normal 70 - 110). NP notified and new orders received. Will monitor . The resident was transferred to the ER for evaluation. Medical record review of a Nursing Note dated 7/11/19 revealed .Received back from the ER. No needs voiced. States she feels better. Abd (abdomen) soft, non tender. No reports of feeling constipated at this time . The above 2 entries are the only ones in the medical record. There was no documentation of the resident being transferred to the hospital or post hospitalization status. Medical record review of the Bowel Elimination Records revealed: Resident #5 had no BM documented 7/11/19 - 7/22/19 and 7/22/19 - 7/31/19 with a laxative administered 7/23/19. Resident #7 had no BM 7/18/19 - 7/22/19 and 8/1/19 - 8/8/19 with no medication intervention documented. Resident #10 had no BM documented 7/5/19 - 7/9/19 and 7/8/19 - 7/15/19 with no medication intervention documented. Resident #19 had no BM documented 7/12/19 - 7/16/19, 7/20/10 - 7/24/19, and 7/24/19 - 7/29/19 with no medication intervention documented. Resident #21 had no BM documented 7/12/19 - 7/16/19 with no medication intervention documented. Resident #24 had no BM documented 7/18/19 - 7/22/19, 7/23/19 - 7/27/19, 8/2/19 - 8/8/19 with no medication intervention documented. Resident #25 had no BM documented 7/25/19 - 7/29/19 with no medication intervention documented. Resident #29 had no BM documented 7/10/19 - 7/18/19 and 7/25/19 - 7/31/19 with no medication intervention documented. Resident #36 had no BM documented 7/7/19 - 7/12/19 and 7/12/19 - 7/17/19 with no medication intervention documented. Resident #37 had no BM documented 7/12/19 - 7/15/19 and 7/17/19 - 7/22/19 with no medication intervention documented. Telephone interview with the Former Medical Director #1 on 8/13/19 at 2:15 PM confirmed during her rounds of the facility she did not document her findings in the resident records. Information, especially bowel movements, was not documented in the medical record because the staff was having problems with the new computer program. When she asked the Administrator about paper records she was told if they went back to paper the staff would never use the computer. Interview with the Interim Director of Nursing (DON) on 8/21/19 at 1:15 PM in the Social Worker's office confirmed . bowel movements were not documented because of the facility switching to a new documentation system and the staff's unfamiliarity with how and where to document bowel movements . Refer to F600.",2020-09-01
133,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2019-08-21,880,D,1,0,J49Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy, medical record review, observation and interview the facility failed to change the dressing and have a legible date on a PICC (Peripherally Inserted Central Catheter) (a catheter inserted in a peripheral vein and threaded to a vein close to the heart used for prolonged IV (intravenous) medications) for 2 (#31 and #32) of 2 residents reviewed with PICC lines. The findings include: Review of the facility policy Dressing Change For Vascular Access Devices dated 8/1/16 revealed .Central venous access device and midline dressing changes will be done at the established intervals and immediately if the integrity of the dressing is compromised, if moisture, drainage or blood is present or for further assessment if infection is suspected .Transparent semi-permeable membrane (TSM) dressing are changed every 7 days and PRN (as needed) .All catheters - Apply label on dressing with date and nurse's initials. Do not write on TSM dressing with pen or magic marker . Medical record review revealed Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #31 required IV medications. Medical record for Resident #31 review of the Physician Order Report dated 8/1/19-8/7/19 revealed Resident #31 received .dressing change PRN (as needed) soiling or dislodgement Special Instruction: Date and time dressing for change and readjust standing Midline schedule change . Observations on 8/5/19 at 2:37 PM and on 8/7/19 at 9:50 AM in Resident #31's room revealed the PICC line to the right upper arm had gauze over the insertion site and a transparent dressing over the site with illegible writing on the dressing. Observation and interview on 8/7/19 at 2:06 PM in Resident #31's room with the Nurse Practitioner (NP) revealed the same dressing on the PICC line with illegible writing on it. Continued interview with the NP confirmed during every shift the nurse should check the location; make sure it (PICC dressing) is timed and dated; assess for signs and symptoms of infection; and document. Continued interview with the NP when asked to look at the dressing confirmed she had .no idea when it was placed or when the dressing was changed . Interview with the ADON (Assistant Director of Nursing) on 8/7/19 at 2:30 PM in the West dining room confirmed .I should have marked it with a marker. I just marked it (PICC line transparent dressing) with a pen . Medical record review revealed Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission MDS dated [DATE] revealed Resident #32 had a BIMS score of 15 which indicated no cognitive impairment. Continued review revealed Resident #32 required IV medications while a resident in the facility. Medical record review of the Physician Order Report dated 8/1/19 to 8/7/19 revealed an order to .Change PICC Line dressing PRN soiling or dislodgement. Special Instructions: Date and Time dressing for change and readjust standing PICC dressing schedule change . Observation on 8/5/19 at 10:51 AM in Resident #32's room revealed the PICC line dressing was dated 7/25/19. The dressing had been reinforced with tape. Observation and interview on 8/5/19 at 11:20 AM in Resident #32's room with the ADON confirmed the PICC dressing was noted with a date of 7/25/19. Continued interview with the ADON when asked what the facility policy was regarding PICC line dressing changes she confirmed .they are changed once a week .",2020-09-01
134,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2019-08-21,921,E,1,0,J49Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, the facility failed to ensure a sanitary environment for the residents in 10 (#9, #16, #20, #23, #25, #34, #36, #42, and #44) of 30 rooms observed. The findings include: The initial facility tour revealed the following findings: Observation on 8/5/19 at 10:30 AM in room [ROOM NUMBER] revealed brown debris in the toilet. Observation on 8/5/19 at 10:40 AM in room [ROOM NUMBER] revealed an unlabeled basin and bedpan sitting on the bathroom floor. Observation on 8/5/19 at 10:46 AM in room [ROOM NUMBER] revealed an odor resembling old urine in the room. Observation on 8/5/19 at 10:51 AM in room [ROOM NUMBER] revealed the toilet seat had brown debris on it and there was yellow liquid in the toilet. Observation on 8/5/19 at 10:55 AM in room [ROOM NUMBER] revealed an unlabeled basin and bedpan sitting on the bathroom floor. These findings were confirmed on 8/5/19 at 11:30 AM with the nurse on the unit, LPN #2. Observation on 8/5/19 at 10:51 AM in the bathroom of room [ROOM NUMBER] revealed the soap dispenser cover was missing and there was no soap in the bathroom for the residents to use. Observation on 8/5/19 at 11:20 AM in the bathroom of room [ROOM NUMBER] revealed the ADON attempted to wash her hands but there was no soap in the bathroom. Continued observation confirmed the ADON left the bathroom; came back with body wash soap to wash her hands; and placed the body wash soap on the bathroom sink. Observation on 8/5/19 at 11:24 AM, 2:02 PM and 3:45 PM in the bathroom of room [ROOM NUMBER] revealed 2 unlabeled bed pans and 2 unlabeled wash basins on the floor 1 on each side of the toilet. Interview with Resident #32 on 8/5/19 at 1:32 PM in his room revealed he asked for a bar of soap and a staff member told him a soap dispenser was needed. Continued interview with the resident revealed .they just put in a dispenser today . Interview with Maintenance Director on 8/5/19 at 3:18 PM in the West dining room revealed the facility had a note pad for work orders at the nursing station or staff would stop him in the hall way. Continued interview with the Maintenance Director revealed he was not sure who was responsible to replace hand sanitizer or soap dispensers. Further interview with the Maintenance Director revealed he had replaced the soap dispenser today for room [ROOM NUMBER], and the soap dispenser was on the shelf behind the toilet. Continued interview with the Maintenance Director revealed he did not know the dispenser was not working. Further interview with the Maintenance Director confirmed he .expected them (staff) to report it to make my job more efficient . Interview with Certified Nurse Aide (CNA) #1 on 8/6/19 at 9:07 AM in room [ROOM NUMBER] revealed when asked if the staff could tell which bed pans and wash basins belonged to the resident she stated neither one of these. Continued interview with CNA #1 confirmed I don't know why they are on the ground. Interview with the Housekeeping Supervisor on 8/6/19 at 1:37 PM in the West dining room revealed the housekeeping staff only ensures the dispensers are filled while the maintenance department ensures the dispensers are on the wall and functioning. Interview with Resident #33 on 8/7/19 at 9:33 AM revealed the resident did not have soap for 2 weeks. Continued interview with Resident #33 on 8/7/19 at 9:40 AM in his room revealed the soap dispenser was broken because someone knocked it off. Continued interview revealed the resident was aware and notified one of the CNAs. Continued interview with the resident when asked what he used to wash his hands he stated .using hand sanitizer to wash hands . Continued interview with Resident #33 revealed .I heard housekeeping in there at times. I felt they could have done a better job . Interview with Resident #31 on 8/7/19 at 9:42 AM in his room revealed .it was a little rough. Wasn't any soap at the time, the dispenser was hanging on the wall at the time over to left. I had to pump but there was nothing in there . Continued interview with Resident #31 revealed he was using his own soap in the bottle when using the bathroom and would take it out when he finished. Observation on 8/5/19 at 10:55 AM in room [ROOM NUMBER] revealed an unlabeled basin and bedpan sitting on the bathroom floor. Observation on 8/5/19 at 11:05 AM in room [ROOM NUMBER] revealed yellow liquid in the toilet as well as an unlabeled basin and bedpan on the bathroom floor. Observation on 8/5/19 at 11:29 AM in room [ROOM NUMBER] revealed there was dried brown debris on the toilet seat and dried brown debris on a pillow in the chair. Observation on 8/5/19 at 11:51 AM in room [ROOM NUMBER] revealed a strong odor in the room. The Maintenance Director came into the bathroom and flushed the toilet, then came back with a bottle of air freshner and sprayed the bathroom.",2020-09-01
135,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2019-08-21,925,F,1,0,J49Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, pest control customer service report review, facility observation, and interview, the facility failed to maintain an effective pest control program to prevent infestation of insects (flies and gnats) in the kitchen, hallways, and resident rooms. The findings include: Review of the facility policy titled Pest Control dated (MONTH) 2005 revealed .This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents .Pest control services are provided by (named pest control service) .Maintenance services assist, when appropriate and necessary, in providing pest control services. Record Review of Pest control customer service reports revealed: 2/20/19 .Small flies noted during service in kitchen .Reviewed with management . 3/20/19 .Small flies noted under dishwasher sink .Reviewed with management .excess water noted under dishwasher .Keep area dry . 4/17/19 .Excess water noted under dishwasher .Keep area dry .Reviewed with management . 5/9/19 .Small flies noted during service by dishwasher sink .Reviewed with management . 6/5/19 .Small flies noted during service under dishwasher .Reviewed with management . 7/24/19 revealed .Excess water under dishwasher .Keep area dry .Illuminated light trap found unplugged, interior kitchen .Large flies in hallways .Reviewed with Management . Record Review of the Life Safety/Plant Ops Communication Report dated 7/8/19 revealed .drain lines, cleaning . Observation on 8/5/19 though 8/21/19 revealed the Illuminated Light Trap (to attract flies and gnats) was not working on the back hall on the right. Observation on 8/8/19 at 9:30 AM in rooms [ROOM NUMBERS] revealed gnats and flies. Continued observation on 8/8/19 at 9:45 AM revealed gnats and flies in the women's public restroom. Continued observation on 8/8/19 at 10:00 AM revealed flies and gnats in the West dining room. Observation on 8/8/19 at 2:00 PM in room [ROOM NUMBER] revealed 1 fly and gnats. Observation on 8/8/19 at 2:10 PM in room [ROOM NUMBER] revealed flies and gnats. Observation on 8/12/19 at 8:15 AM in room [ROOM NUMBER] revealed a fly and gnats. Observation on 8/12/19 at 8:30 AM in the back nurses station revealed flies and gnats. Observation on 8/12/19 at 11:11 AM in Resident #22's room revealed flies and gnats flying around the urinal with yellow liquid in it which was on top of the bedside table in front of the resident. Observation on 8/12/19 at 2:30 PM in the front nurses station revealed flies and gnats around 2 residents Observation on 8/13/19 at 7:30 AM in rooms 28, 29, 30, and 31 of the back hall revealed flies and gnats. Observation on 8/13/19 at 9:30 AM and 8/15/19 at 1:34 PM in the Dietary Department revealed flies and gnats and a small yellow round dryer underneath the sink of the garbage disposal. Continued observation in the dietary department revealed a dehumidifier and vacuum cleaner under a table. Observation on 8/14/19 at 11:00 AM in rooms [ROOM NUMBER] revealed flies and gnats. Observation on 8/14/19 at 11:15 AM at the back nursing station revealed flies and gnats. Observation on 8/15/19 at 7:25 AM at the front nursing station revealed flies. Observation on 8/15/19 at 7:35 AM in room [ROOM NUMBER] revealed flies and gnats. Observation on 8/15/19 at 1:12 PM at in the West dining room revealed a fly. Observation on 8/19/19 at 2:30 PM in the front nurses station revealed a fly crawling on the arm of Resident #9. Observation on 8/20/19 at 10:30 AM in rooms [ROOM NUMBERS] revealed flies and gnats. Observation on 8/20/19 at 1:44 PM revealed a fly flying around a resident and the resident swatting at the insect. Interview with Resident #33 on 8/7/19 at 9:33 AM in his room revealed he was concerned about flies and gnats in the room. During the entire survey from 8/7/19 - 8/21/19 the survey team experienced flies and gnats in the West dining room. Interview with Resident #22 on 8/7/19 at 1:26 PM in Resident #22's room revealed the resident had seen flies in the room prior to the maggots coming out of his thigh and crawling in his skin folds. Interview with LPN #2 on 8/7/19 at 4:26 PM at the nurses station confirmed she was assigned to care for Resident #22 on 6/18/19. Continued interview with LPN #2 confirmed .I did see maggots . Telephone interview with CNA #3 on 8/12/19 at 2:01 PM revealed, .the facility was full of flies and gnats and (named Resident #22) had made complaints about them . Interview with the Dietary Manager on 8/13/19 at 1:57 PM in the West dining room revealed a month ago the connection in the drain of the three compartment sink had come down and was fixed by maintenance through reattachment. Continued interview revealed the floor under the dishwasher and garbage disposal needed to be repaired. The floor was old and the water would pool and not go down the drain. Interview with the Maintenance Director on 8/13/19 at 2:01 PM in the West dining room confirmed the water had cracked the floor in the kitchen where water was pooling on the floor. Interview with the Dietary Manager on 8/15/19 at 12:30 PM in the Dietary Department confirmed .the garbage disposal was probably holding water. Continued interview with the Dietary Manager confirmed the dryer underneath the garbage disposal and sink had been used to dry the floors and the vacuum cleaner had been used to pick up excess water. Interview with a Family Member on 8/15/19 at 1:27 PM in room [ROOM NUMBER] on the front hall revealed she observed flies every time she came to visit her family member. Interview with the Administrator on 8/21/19 in the Social Services office confirmed he knew the Illuminated Trap in the right part of the back hall was not working. Telephone interview with the Pest Service Specialist on 8/26/19 at 9:49 AM revealed the Service Specialist had been servicing the facility for a year and was the primary Specialist. Continued interview with the Service Specialist confirmed when he would see things he would report it to management and they were supposed to fix it and it was a partnership between the facility and the Pest Service. Continued interview with the Service Specialist confirmed the issues with the flies and gnats were a sanitation and structural problem. Continued interview confirmed .when you see pests activities like this it is a sign that it (named facility) was not cleaned regularly .",2020-09-01
136,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2018-09-25,600,J,1,0,IY3T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, and interview, the facility neglected to provide necessary services to a reisdent by failing to supervise a resident with known exit-seeking behavior resulting in the resident's elopement from the facility for 1 (Resident #10) of 3 residents reviewed for elopement risk. This failure placed Resident #10 in Immediate Jeopardy (a situation in which the provider's non-compliance 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 was notified of the Immediate Jeopardy on 9/25/18 at 12:30 PM in the conference room. The Immediate Jeopardy was effective from 5/15/18 and is ongoing. The findings include: Review of undated facility policy, Elopement/Wandering revealed .The intent of the facility is to maintain resident safety by identifying residents who are at risk of wandering/elopement behavior .An elopement/wandering assessment will be completed upon admission and quarterly thereafter .Any resident displaying significant wandering behavior will be assessed for elopement/wandering risk and care planned appropriately .Care Plans and individual behavior plans will address wandering as a specific problem. Approaches will be formulated; patterns identified; and the causes determined .A wandering/elopement notebook containing pictures and pertinent demographic information will be maintained in social services; kept at nurses' station and receptionist desk . Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #10 scored 3 on the Brief Interview for Mental Status indicating he was severely cognitively impaired. Continued review of the MDS revealed Resident #10 required supervision with transfers, dressing, toileting; limited assistance with grooming; and extensive assistance with bathing. Medical record review of Baseline Admission Care Plan dated 7/19/18 revealed Resident #10 was at risk for possible wandering related to Dementia. Medical record review of the Comprehensive Care Plan dated 7/27/18 revealed Resident #10 was at risk for elopement as evidenced by exit-seeking behavior, wandering about the facility; asking staff to open the front door. Continued review revealed approaches included: 1. Observe resident for tailgating (following visitors out door) when visitors are in the building. 2. Use verbal and, if necessary, physical cues for redirection to persuade exit-seeking behaviors. 3. Seek a referral for a mental health evaluation from primary care physician as needed. 4. Refer to Social Services as needed. 5. Reevaluate elopement risk at least quarterly. 6. Provide staff supervision for resident when attending out-of-facility activity. 7. Chaplain services PRN (as needed) for emotional and psychosocial needs of the resident. Medical record review of Nursing Notes dated 7/20/18 revealed .exit seeking . asking multiple staff members which door to leave from .packing personal items throughout facility . Continued review of Nursing Notes dated 7/22/18 revealed .continues to be exit-seeking .has not actually opened any outer doors .wanders oblivious to where room is .carrying bag of clothes and linen around stating he is taking them to his momma's right around the corner .has opened outer door beside his room twice this shift . Medical record review of Event Note dated 7/30/18 revealed .Resident was noted missing as dinner trays were being passed. All available staff searched the perimeter of the building as well and two staff members drove their cars around the neighborhood and surrounding streets. Resident was located wandering a street over and was brought back to the building by staff . Surveyor traced a route to the location where the resident was found on 7/30/18 after he eloped. The route included going down a hill; across a 3 lane busy road (hospital access road) with a speed limit of 40 miles per hour and no sidewalk; then turned onto a busier street for a total of 0.45 miles from the facility. Review of a written statement by Certified Nurse Aide (CNA) #9 dated 8/6/18 revealed .Last time I seen (Resident #10) was around 3:45 PM when I clocked out for lunch. He was walking around the building. I came back from lunch about 4:15 PM. I started to check my patients and laying patients down. Dinner trays came out I passed them then started to feed patients. I went into Resident #10's room to feed a patient and noticed (Resident #10) tray was not opened so I started to look for him, I walk the building 3x (3 times) , I couldn't find him, then I told the nurse and supervisor. Then the supervisor called an elopement and everyone started to look, No one seen him, so (Named supervisor, RN #2) said she was going to ride around. She was going Old Hickory Boulevard and I went up Larkin Springs Road to Neely's Bend. I noticed him walking. I stopped beside him and told him to get in the car. He got inside and I called the nursing home to let them know I found him. We returned and he came in and started back walking around . Review of a statement from an unsampled resident dated 8/6/18 revealed .(named resident) saw (Resident #10) in the courtyard which was enclosed, with some family members of another resident. She then saw him by the door stating he was going outside to his truck to find some cigarettes. She states she then saw him leave with the family members (of another resident) . Review of facility investigation dated 7/30/18 revealed when Resident #10 was returned to the facility and asked why he left the facility he stated he was heading to my momma's house around the corner. Interview with the Social Worker on 9/11/18 at 8:57 AM in the conference room revealed Resident #10 was ambulatory. Continued interview revealed he likely exited behind visitors out the front door at an unknown time and was missed at meal time when a search was started. Further interview revealed he was found within 15 minutes and returned to the facility unharmed. Continued interview revealed he was placed on 1:1 monitoring; his daughter was called and she agreed with his transfer to a secure unit; and remained on 1:1 monitoring until his transfer on 8/3/18. Further interview revealed he was a known wandering risk and was in the elopement book (a notebook of resident pictures to identify residents at risk of elopement) kept at the front desk. Interview with CNA #9 on 9/11/18 at 9:50 AM in the conference room revealed Resident #10 was walking around the facility when she went on break at 3:40 PM. Continued interview revealed meal time was between 5:00 PM and 5:30 PM; she was handing out trays; and she noticed Resident #10 was missing. Further interview revealed she walked around the building 3 times but did not find him. Continued interview revealed she went to the Charge Nurse who announced the facility was missing a resident. Further interview revealed the Charge Nurse went one direction in her car and CNA #9 went the other way in her car. Continued interview revealed CNA #9 found Resident #10 at the intersection of Larkin Springs Road and Neely's Bend Road; picked him up; and returned to the facility. Further interview revealed Resident #10 stated he was going to visit some friends and he walked out with some people. Interview with CNA #9 on 9/24/18 at 4:00 PM in the conference room to re-establish the time line, revealed she last saw Resident #10 at 3:45 PM. Continued interview revealed between 5:00 PM and 5:30 PM trays were passed to residents and when she went to assist Resident #10's roommate at 5:15 PM she noticed Resident #10's tray untouched. Further interview revealed she walked around the building 3 times which took about 5 minutes then reported to the Charge Nurse. Continued interview revealed staff searched the outside of the building but did not find the resident. Further interview revealed she started driving and found him walking along a busy road close to 6:00 PM. Continued interview revealed Resident #10 was placed on 1:1 monitoring until he was discharged from the facility. Telephone interview with CNA #12 on 9/24/18 at 5:07 PM revealed Resident #10 was constantly trying to get out and he was destined to leave the facility. Continued interview revealed he hung by the door, asking how to get out, but she never saw him leave the facility. Interview with the Administrator on 9/11/18 at 1:45 PM in the conference room stated Resident #10 had exited the building with visitors and walked down the street. Continued interview with the Administrator confirmed the facility failed to supervise Resident #10 adequately to prevent him from eloping from the facility. Interview with CNA #9 on 9/24/18 at 4:00 PM in the conference room to re-establish the time line, revealed she last saw Resident #10 at 3:45 PM. Continued interview revealed between 5:00 PM and 5:30 PM trays were passed to residents and when she went to assist Resident #10's roommate at 5:15 PM she noticed Resident #10's tray untouched. Further interview revealed she walked around the building 3 times which took about 5 minutes then reported to the Charge Nurse. Continued interview revealed staff searched the outside of the building but did not find the resident. Further interview revealed she started driving and found him walking along a busy road close to 6:00 PM. Continued interview revealed Resident #10 was placed on 1:1 monitoring until he was discharged from the facility. In summary the last time Resident #10 was seen was at 4:00 PM when he was in the courtyard during smoke break. At 5:20 PM he had not eaten his dinner and was determined to be absent from the facility. At 6:00 PM he was found 0.45 miles from the facility, a distance which cannot be reached in 15 minutes.",2020-09-01
137,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2018-09-25,656,J,1,0,IY3T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, facility investigation review, and interview, the facility failed to implement the Care Plan for a resident who was found unresponsive with no pulse or respirations who was a full code (life saving measures to include chest compressions, intubation, advanced medications, and transfer to hospital) for 1 (Resident #11) of 3 residents reviewed for death; and failed to supervise a resident adequately to prevent his elopement from the facility for 1(Resident #10) of 9 records review for elopement. This failure placed Resident #10 and #11 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 Administrator was notified of the Immediate Jeopardy on [DATE] at 12:30 PM in the conference room. The Immediate Jeopardy was effective from [DATE] and is ongoing. An extended survey was conducted on [DATE] and [DATE] - [DATE]. The findings include: Medical record review revealed Resident #11 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed Resident #11 had been in the hospital [DATE] - [DATE] for Acute [MEDICAL CONDITION]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #11 was considered to be severely cognitively impaired. Continued review of the MDS revealed Resident #11 required extensive assistance with transfers and personal hygiene; was dependent on 1 person for dressing and bathing; and was always incontinent of bowel and bladder. Medical record review of the Physician order [REDACTED]. transfer to hospital. Further review revealed the form was signed by the resident's sister who was the resident's Power of Attorney. Medical record review of a facility Physician's Note dated [DATE] revealed Resident #11 was .profoundly cachectic and debilitated gentleman requiring multitudinous rehospitalization for management of an [DIAGNOSES REDACTED] due to continued aspiration. At this time he does remain with full course of treatment indicated on his POST form . Medical record review of the Comprehensive Care Plan dated [DATE] revealed .Resident has Advanced Directives on record. Full Code .Resident's Advanced Directives are in effect and their wishes and directions will be carried out in accordance with their Advanced Directives on an ongoing basis through next review date .Staff to follow Advanced Directives for Full Code . Medical record review of Nursing Notes dated [DATE] at 8:00 PM by Registered Nurse #1 revealed the .Resident at the beginning of the shift resting without distress. The outgoing nurse reported the patient came back from the hospital but not doing well, c/o (complained of) no pain checked his blood which was 305 (blood glucose level) and cover with s/s (sliding scale insulin) as ordered on ABT (antibiotics) which was given at 2100 (9:00 PM) r/t (related to) PNA (pneumonia) temp (temperature) 98.4 also changed his tube feeding, and flushed, sat (oxygen saturation) 100% (percent) with O2 at 2L (oxygen at 2 liters per minute) treatment at coccyx and was done, respiration even and nonlabored skin warm and dry upon entering the room again checking on him and the roommate about the 3rd time noticed that his face had changed and unresponsive. Checked on him and he was not breathing anymore, informed the family members who came to the facility and was here until the body was removed . Medical record review of the Event Note dated [DATE] revealed the event was .death - CPR not performed . Continued review revealed .Resident found absent of vitals by nurse. CPR not performed as she believed he was a DNR (Do Not Resuscitate) . Further review revealed the resident's sister was notified at 3:00 AM; the Nurse Practitioner (NP) was notified at 4:00 AM; and the Medical Director was notified at 8:00 AM. Continued review revealed no first aid/treatment given. Review of facility investigation of an undated written statement from RN #1 revealed .On [DATE] this nurse came to work to take over from the day nurse who said this patient (Resident #11) was in critical condition. This night nurse then started monitoring this patient by taking the vital signs, sat 100% on O2 2L, pulse 63 at the same time around 2200 (10:00 PM) tech called this nurse to the room to look at the patient bottom area with skin breakdown. This nurse helped to apply dressing at the coccyx. When the patient was coughing there was so much mucus coming and this nurse decided to suction the patient after given (giving) the patient medication and suctioning him he relaxed and this nurse continue(d) with medication pass. This nurse later went to the patient again around 2330 (11:30 PM) to check on him he was still breathing but the last time this nurse checked on the patient around 0130 - 0200 (1:30 AM - 2:00 AM) the patient was limp and his mouth blue (was) not breathing this nurse checked pulse none and he was gone (resident had expired). Called the family to inform them. The NP was informed and the DON (Director of Nursing) also was informed with a message left on voice mail and an order to release the body to the funeral home given by v.o. (verbal order) (from the NP). Patient body picked up by (Named funeral home) at 0600 (6:00 AM). Patient family was present . Interview with the Administrator and Director of Nursing (DON) on [DATE] at 1:45 PM in the conference room revealed the Administrator confirmed RN #1 failed to perform CPR on a resident who was a full code thus failing to follow the Care Plan. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #10 scored 3 on the Brief Interview for Mental Status indicating he was severely cognitively impaired. Continued review of the MDS revealed Resident #10 required supervision with transfers, dressing, toileting; limited assistance with grooming; and extensive assistance with bathing. Medical record review of Baseline Admission Care Plan dated [DATE] revealed Resident #10 was at risk for possible wandering related to Dementia. Medical record review of the Comprehensive Care Plan dated [DATE] revealed Resident #10 was at risk for elopement as evidenced by exit-seeking behavior, wandering about the facility; asking staff to open the front door. Continued review revealed approaches included: 1. Observe resident for tailgating (following visitors out door) when visitors are in the building. 2. Use verbal and, if necessary, physical cues for redirection to persuade exit-seeking behaviors. 3. Seek a referral for a mental health evaluation from primary care physician as needed. 4. Refer to Social Services as needed. 5. Reevaluate elopement risk at least quarterly. 6. Provide staff supervision for resident when attending out-of-facility activity. 7. Chaplain services PRN (as needed) for emotional and psychosocial needs of the resident. Medical record review of Nursing Notes dated [DATE] revealed .exit seeking . asking multiple staff members which door to leave from .packing personal items throughout facility . Continued review of Nursing Notes dated [DATE] revealed .continues to be exit-seeking .has not actually opened any outer doors .wanders oblivious to where room is .carrying bag of clothes and linen around stating he is taking them to his momma's right around the corner .has opened outer door beside his room twice this shift . Medical record review of Event Note dated [DATE] revealed .Resident was noted missing as dinner trays were being passed. All available staff searched the perimeter of the building as well and two staff members drove their cars around the neighborhood and surrounding streets. Resident was located wandering a street over and was brought back to the building by staff . Surveyor traced a route to the location where the resident was found on [DATE] after he eloped. The route included going down a hill; across a 3 lane busy road (hospital access road) with a speed limit of 40 miles per hour and no sidewalk; then turned onto a busier street for a total of 0.45 miles from the facility. Review of a written statement by Certified Nurse Aide (CNA) #9 dated [DATE] revealed .Last time I seen (Resident #10) was around 3:45 PM when I clocked out for lunch. He was walking around the building. I came back from lunch about 4:15 PM. I started to check my patients and laying patients down. Dinner trays came out I passed them then started to feed patients. I went into Resident #10's room to feed a patient and noticed (Resident #10) tray was not opened so I started to look for him, I walk the building 3x (3 times) , I couldn't find him, then I told the nurse and supervisor. Then the supervisor called an elopement and everyone started to look, No one seen him, so (Named supervisor, RN #2) said she was going to ride around. She was going Old Hickory Boulevard and I went up Larkin Springs Road to Neely's Bend. I noticed him walking. I stopped beside him and told him to get in the car. He got inside and I called the nursing home to let them know I found him. We returned and he came in and started back walking around . Review of a statement from an unsampled resident dated [DATE] revealed .(named resident) saw (Resident #10) in the courtyard which was enclosed, with some family members of another resident. She then saw him by the door stating he was going outside to his truck to find some cigarettes. She states she then saw him leave with the family members (of another resident) . Review of facility investigation dated [DATE] revealed when Resident #10 was returned to the facility and asked why he left the facility he stated he was heading to my momma's house around the corner. Interview with the Social Worker on [DATE] at 8:57 AM in the conference room revealed Resident #10 was ambulatory. Continued interview revealed he likely exited behind visitors out the front door at an unknown time and was missed at meal time when a search was started. Further interview revealed he was found within 15 minutes and returned to the facility unharmed. Continued interview revealed he was placed on 1:1 monitoring; his daughter was called and she agreed with his transfer to a secure unit; and remained on 1:1 monitoring until his transfer on [DATE]. Further interview revealed he was a known wandering risk and was in the elopement book (a notebook of resident pictures to identify residents at risk of elopement) kept at the front desk. Interview with CNA #9 on [DATE] at 9:50 AM in the conference room revealed Resident #10 was walking around the facility when she went on break at 3:40 PM. Continued interview revealed meal time was between 5:00 PM and 5:30 PM; she was handing out trays; and she noticed Resident #10 was missing. Further interview revealed she walked around the building 3 times but did not find him. Continued interview revealed she went to the Charge Nurse who announced the facility was missing a resident. Further interview revealed the Charge Nurse went one direction in her car and CNA #9 went the other way in her car. Continued interview revealed CNA #9 found Resident #10 at the intersection of Larkin Springs Road and Neely's Bend Road; picked him up; and returned to the facility. Further interview revealed Resident #10 stated he was going to visit some friends and he walked out with some people. Interview with CNA #9 on [DATE] at 4:00 PM in the conference room to re-establish the time line, revealed she last saw Resident #10 at 3:45 PM. Continued interview revealed between 5:00 PM and 5:30 PM trays were passed to residents and when she went to assist Resident #10's roommate at 5:15 PM she noticed Resident #10's tray untouched. Further interview revealed she walked around the building 3 times which took about 5 minutes then reported to the Charge Nurse. Continued interview revealed staff searched the outside of the building but did not find the resident. Further interview revealed she started driving and found him walking along a busy road close to 6:00 PM. Continued interview revealed Resident #10 was placed on 1:1 monitoring until he was discharged from the facility. Telephone interview with CNA #12 on [DATE] at 5:07 PM revealed Resident #10 was constantly trying to get out and he was destined to leave the facility. Continued interview revealed he hung by the door, asking how to get out, but she never saw him leave the facility. Interview with the Administrator on [DATE] at 1:45 PM in the conference room stated Resident #10 had exited the building with visitors and walked down the street. Continued interview with the Administrator confirmed the facility failed to supervise Resident #10 adequately to prevent him from eloping from the facility and failed to follow the Care Plan to prevent elopement. Interview with CNA #9 on [DATE] at 4:00 PM in the conference room to re-establish the time line, revealed she last saw Resident #10 at 3:45 PM. Continued interview revealed between 5:00 PM and 5:30 PM trays were passed to residents and when she went to assist Resident #10's roommate at 5:15 PM she noticed Resident #10's tray untouched. Further interview revealed she walked around the building 3 times which took about 5 minutes then reported to the Charge Nurse. Continued interview revealed staff searched the outside of the building but did not find the resident. Further interview revealed she started driving and found him walking along a busy road close to 6:00 PM. Continued interview revealed Resident #10 was placed on 1:1 monitoring until he was discharged from the facility. In summary the last time Resident #10 was seen was at 4:00 PM when he was in the courtyard during smoke break. At 5:20 PM he had not eaten his dinner and was determined to be absent from the facility. At 6:00 PM he was found 0.45 miles from the facility, a distance which cannot be reached in 15 minutes.",2020-09-01
138,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2018-09-25,658,J,1,0,IY3T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to follow acceptable standards of clinical practice by failing to perform Cardiopulmonary Resuscitation (CPR) on a resident who was a found unresponsive with no pulse or respirations who was a full code (chest compressions, intubation, advanced medications, and transfer to hospital) for 1 (Resident #11) of 3 residents reviewed for death. This failure placed Resident #11 in Immediate Jeopardy (a situation in which the provider's non-compliance 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 was notified of the Immediate Jeopardy on [DATE] at 3:50 PM in the conference room. The Immediate Jeopardy was effective from [DATE] and is ongoing. An extended survey was conducted on [DATE], and [DATE] - [DATE]. The findings include: Review of an undated facility policy, Cardiopulmonary Resuscitation, revealed .CPR will be attempted for any resident who is found to have no palpable pulse and/or discernable respirations unless there is a written physician order [REDACTED].If a resident is found unresponsive and without respirations a licensed staff member who is certified in CPR/BLS (Basic Life Support) shall promptly initiate CPR for residents .CPR will be continued by facility staff until EMS (Emergency Medical Services) arrives to assume responsibility for providing CPR .Upon identifying a resident with a change of condition which presents as an unresponsive condition: 1. Activate the facility emergency response process: Announce CODE BLUE (a means to notify staff a resident has no pulse and/or respirations) and includes retrieving resident medical record. 2. Assess resident for status of breathing and check for pulse. 3. Check the medical record for advance directive status. 4. Retrieve emergency cart and Automated External Defibrillator if available. 5. If resident record indicates CPR is to be instituted then initiate BLS if a pulse and/or respirations are undetectable .The Staff Development Coordinator will maintain an updated list of personnel for recertification (CPR/BLS) purposes and notify staff of recertification . Medical record review revealed Resident #11 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed Resident #11 had been in the hospital [DATE] - [DATE] for Acute [MEDICAL CONDITION]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #11 was considered to be severely cognitively impaired. Continued review of the MDS revealed Resident #11 required extensive assistance with transfers and personal hygiene; was dependent on 1 person for dressing and bathing; and was always incontinent of bowel and bladder. Medical record review of the Physician order [REDACTED]. transfer to hospital. Further review revealed the form was signed by the resident's sister who was the resident's Power of Attorney. Medical record review of a facility Physician's Note dated [DATE] revealed Resident #11 was .profoundly cachectic and debilitated gentleman requiring multitudinous rehospitalization for management of an [DIAGNOSES REDACTED] due to continued aspiration. At this time he does remain with full course of treatment indicated on his POST form . Medical record review of Nursing Notes dated [DATE] at 8:00 PM by Registered Nurse #1 revealed the .Resident at the beginning of the shift resting without distress. The outgoing nurse reported the patient came back from the hospital but not doing well, c/o (complained of) no pain checked his blood which was 305 (blood glucose level) and cover with s/s (sliding scale insulin) as ordered on ABT (antibiotics) which was given at 2100 (9:00 PM) r/t (related to) PNA (pneumonia) temp (temperature) 98.4 also changed his tube feeding, and flushed, sat (oxygen saturation) 100% (percent) with O2 at 2L (oxygen at 2 liters per minute) treatment at coccyx and was done, respiration even and nonlabored skin warm and dry upon entering the room again checking on him and the roommate about the 3rd time noticed that his face had changed and unresponsive. Checked on him and he was not breathing anymore, informed the family members who came to the facility and was here until the body was removed . Medical record review of the Event Note dated [DATE] revealed the event was .death - CPR not performed . Continued review revealed .Resident found absent of vitals by nurse. CPR not performed as she believed he was a DNR (Do Not Resuscitate) . Further review revealed the resident's sister was notified at 3:00 AM; the Nurse Practitioner (NP) was notified at 4:00 AM; and the Medical Director was notified at 8:00 AM. Continued review revealed no first aid/treatment given. Review of facility investigation of an undated written statement from RN #1 revealed .On [DATE] this nurse came to work to take over from the day nurse who said this patient (Resident #11) was in critical condition. This night nurse then started monitoring this patient by taking the vital signs, sat 100% on O2 2L, pulse 63 at the same time around 2200 (10:00 PM) tech called this nurse to the room to look at the patient bottom area with skin breakdown. This nurse helped to apply dressing at the coccyx. When the patient was coughing there was so much mucus coming and this nurse decided to suction the patient after given (giving) the patient medication and suctioning him he relaxed and this nurse continue(d) with medication pass. This nurse later went to the patient again around 2330 (11:30 PM) to check on him he was still breathing but the last time this nurse checked on the patient around 0130 - 0200 (1:30 AM - 2:00 AM) the patient was limp and his mouth blue (was) not breathing this nurse checked pulse none and he was gone (resident had expired). Called the family to inform them. The NP (Nurse Practitioner) was informed and the DON (Director of Nursing) also was informed with a message left on voice mail and an order to release the body to the funeral home given by v.o. (verbal order) (from the NP). Patient body picked up by (Named funeral home) at 0600 (6:00 AM). Patient family was present . Review of facility investigation revealed RN #1 was suspended on [DATE] pending the investigation. Continued review revealed a note from RN #1 dated [DATE] stating she resigned. Further review of her employee file revealed she was hired on [DATE]; she renewed her CPR certification on [DATE] with an expiration date of [DATE]. Interview with CNA #4 on [DATE] at 10:30 AM in the conference room revealed she came in at 11:00 PM on [DATE] for her shift. Continued interview revealed RN #1 stated Resident #11 was in bad shape. Further interview with CNA #4 revealed the resident was lying in bed with his eyes closed, pale, with shallow respirations. Continued interview revealed RN #1 told her the resident was actively dying to keep an eye on him. Further interview with CNA #4 revealed Resident #11 never opened his eyes all night and did not respond when the CNA turned him and performed hygiene care. Continued interview revealed the morning of [DATE] RN #1 came to tell her the resident had expired so she went in to perform post mortem care. Interview with the Administrator and Director of Nursing (DON) on [DATE] at 1:45 PM in the conference room revealed the DON was aware of Resident #11's death when she came into work on [DATE] and notified the Administrator shortly after, then the investigation was initiated. Continued interview revealed when a nurse discovers a resident who is unresponsive he/she will ask someone to bring the resident's record to the room where they will determine the resident's code status. Further interview revealed if the resident is a full code, CPR will be initiated while one staff member obtains the emergency cart; one staff member calls 911; and one staff member is available to open the doors for the Emergency Medical Services. Further interview revealed the Administrator did not feel it was a system failure but one nurse who failed to use her brain. and the Administrator confirmed RN #1 failed to perform CPR on a resident who was a full code.",2020-09-01
139,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2018-09-25,678,J,1,0,IY3T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to adequately monitor and intervene for a serious medical condition when a Registered Nurse (RN) failed to perform cardiopulmonary resuscitation (CPR) on a resident who was found unresponsive with no pulse or respiration who was a full code (life-saving measures to include chest compressions, airway management, medications, and transfer to hospital) for 1 (Resident #11) per investigation of 9 records, 6 of which did not have advanced directives; 1 did not have a POST; and 1 POST was signed 2 weeks after it was initially written. This failure placed Resident #11 in Immediate Jeopardy (a situation in which the provider's non-compliance 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 was notified of the Immediate Jeopardy on [DATE] at 3:50 PM in the conference room. The Immediate Jeopardy was effective from [DATE] and is ongoing. An extended survey was conducted on [DATE], and [DATE] - [DATE]. The findings include: Review of an undated facility policy, Cardiopulmonary Resuscitation, revealed .CPR will be attempted for any resident who is found to have no palpable pulse and/or discernable respirations unless there is a written physician order [REDACTED].If a resident is found unresponsive and without respirations a licensed staff member who is certified in CPR/BLS (Basic Life Support) shall promptly initiate CPR for residents .CPR will be continued by facility staff until EMS (Emergency Medical Services) arrives to assume responsibility for providing CPR .Upon identifying a resident with a change of condition which presents as an unresponsive condition: 1. Activate the facility emergency response process: Announce CODE BLUE (a means to notify staff a resident has no pulse and/or respirations) and includes retrieving resident medical record. 2. Assess resident for status of breathing and check for pulse. 3. Check the medical record for advance directive status. 4. Retrieve emergency cart and Automated External Defibrillator if available. 5. If resident record indicates CPR is to be instituted then initiate BLS if a pulse and/or respirations are undetectable .The Staff Development Coordinator will maintain an updated list of personnel for recertification (CPR/BLS) purposes and notify staff of recertification . Medical record review revealed Resident #11 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed Resident #11 had been in the hospital [DATE] - [DATE] for Acute [MEDICAL CONDITION]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #11 was considered to be severely cognitively impaired. Continued review of the MDS revealed Resident #11 required extensive assistance with transfers and personal hygiene; was dependent on 1 person for dressing and bathing; and was always incontinent of bowel and bladder. Medical record review of the Physician order [REDACTED]. transfer to hospital. Further review revealed the form was signed by the resident's sister who was the resident's Power of Attorney. Medical record review of a facility Physician's Note dated [DATE] revealed Resident #11 was .profoundly cachectic and debilitated gentleman requiring multitudinous rehospitalization for management of an [DIAGNOSES REDACTED] due to continued aspiration. At this time he does remain with full course of treatment indicated on his POST form . Medical record review of Nursing Notes dated [DATE] at 8:00 PM by Registered Nurse #1 revealed the .Resident at the beginning of the shift resting without distress. The outgoing nurse reported the patient came back from the hospital but not doing well, c/o (complained of) no pain checked his blood which was 305 (blood glucose level) and cover with s/s (sliding scale insulin) as ordered on ABT (antibiotics) which was given at 2100 (9:00 PM) r/t (related to) PNA (pneumonia) temp (temperature) 98.4 also changed his tube feeding, and flushed, sat (oxygen saturation) 100% (percent) with O2 at 2L (oxygen at 2 liters per minute) treatment at coccyx and was done, respiration even and nonlabored skin warm and dry upon entering the room again checking on him and the roommate about the 3rd time noticed that his face had changed and unresponsive. Checked on him and he was not breathing anymore, informed the family members who came to the facility and was here until the body was removed . Medical record review of the Event Note dated [DATE] revealed the event was .death - CPR not performed . Continued review revealed .Resident found absent of vitals by nurse. CPR not performed as she believed he was a DNR (Do Not Resuscitate) . Further review revealed the resident's sister was notified at 3:00 AM; the Nurse Practitioner (NP) was notified at 4:00 AM; and the Medical Director was notified at 8:00 AM. Continued review revealed no first aid/treatment given. Review of facility investigation of an undated written statement from RN #1 revealed .On [DATE] this nurse came to work to take over from the day nurse who said this patient (Resident #11) was in critical condition. This night nurse then started monitoring this patient by taking the vital signs, sat 100% on O2 2L, pulse 63 at the same time around 2200 (10:00 PM) tech called this nurse to the room to look at the patient bottom area with skin breakdown. This nurse helped to apply dressing at the coccyx. When the patient was coughing there was so much mucus coming and this nurse decided to suction the patient after given (giving) the patient medication and suctioning him he relaxed and this nurse continue(d) with medication pass. This nurse later went to the patient again around 2330 (11:30 PM) to check on him he was still breathing but the last time this nurse checked on the patient around 0130 - 0200 (1:30 AM - 2:00 AM) the patient was limp and his mouth blue (was) not breathing this nurse checked pulse none and he was gone (resident had expired). Called the family to inform them. The NP (Nurse Practitioner) was informed and the DON (Director of Nursing) also was informed with a message left on voice mail and an order to release the body to the funeral home given by v.o. (verbal order) (from the NP). Patient body picked up by (Named funeral home) at 0600 (6:00 AM). Patient family was present . Review of facility investigation of a written statement by Licensed Practical Nurse (LPN) #1 dated [DATE] revealed .During our shift (RN #1) asked me to help her find and set up a suction machine for (Resident #11). I left her in his room after we set the machine up. A while later I was at the NS (nurses' station) desk charting when (RN #1) came passing by with her med cart stating He died . When I asked who? She said (Resident #11) and proceeded toward the end of North Hall where her rooms are . Review of facility investigation of an interview between the DON and Certified Nurse Aide (CNA) #4 dated [DATE] revealed .When I came on he (Resident #11) had his eyes closed and lying in the bed. The nurse said he was in bad shape and just got back from the hospital. I saw him 30 minutes before (RN #1) found him. I heard the tube feeding of his roommate beeping and asked (RN #1) to check on him. She never said anything to me about being a full code or DNR . Review of facility investigation of an interview between the DON and CNA #5 dated [DATE] revealed .I walked past (RN #1) shortly after he passed away. All she said was she just had a patient die. That's the only thing I knew or heard . Review of facility investigation revealed RN #1 was suspended on [DATE] pending the investigation. Continued review revealed a note from RN #1 dated [DATE] stating she resigned. Further review of her employee file revealed she was hired on [DATE]; she renewed her CPR certification on [DATE] with an expiration date of [DATE]. Review of facility investigation revealed CNAs were not included in continued education on CPR yet are expected to participate in a Code Blue if a resident is found unresponsive. Telephone interview with LPN #1 on [DATE] at 10:05 AM revealed RN #1 had told her Resident #11 had passed away. Continued interview revealed the paperwork was on the chart to indicate if a resident was a DNR or full code. Further interview revealed if someone else is available that person can check the chart for the resident status but if not you may have to do it yourself. Continued interview revealed after you determine the code status then you decide if you are going to call a code (if you notify staff a resident has stopped breathing and has no pulse). Review of facility policy on CPR revealed if a resident is found unresponsive and without respirations a licensed staff member who is certified in CPR/BLS shall promptly initiate CPR for residents. Interview with CNA #4 on [DATE] at 10:30 AM in the conference room revealed she came in at 11:00 PM on [DATE] for her shift. Continued interview revealed RN #1 stated Resident #11 was in bad shape. Further interview with CNA #4 revealed the resident was lying in bed with his eyes closed, pale, with shallow respirations. Continued interview revealed RN #1 told her the resident was actively dying to keep an eye on him. Further interview with CNA #4 revealed Resident #11 never opened his eyes all night and did not respond when the CNA turned him and performed hygiene care. Continued interview revealed the morning of [DATE] RN #1 came to tell her the resident had expired so she went in to perform post mortem care. Further interview revealed the brother and sister arrived at the facility. Interview with the Administrator and Director of Nursing (DON) on [DATE] at 1:45 PM in the conference room revealed the DON was aware of Resident #11's death when she came into work on [DATE] and notified the Administrator shortly after, then the investigation was initiated. Continued interview revealed when a nurse discovers a resident who is unresponsive he/she will ask someone to bring the resident's record to the room where they will determine the resident's code status. Further interview revealed if the resident is a full code, CPR will be initiated while one staff member obtains the emergency cart; one staff member calls 911; and one staff member is available to open the doors for the Emergency Medical Services. Continued interview revealed some CNAs are CPR certified and can participate in a code while others can bring the cart; call 911; and open doors. Further interview revealed the Administrator did not feel it was a system failure but one nurse who failed to use her brain. and the Administrator confirmed RN #1 failed to perform CPR on a resident who was a full code.",2020-09-01
140,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2018-09-25,689,J,1,0,IY3T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to supervise a resident with known exit-seeking behavior resulting in the resident's elopement from the facility for 1 (Resident #10) of 3 residents reviewed for elopement risk. This failure placed Resident #10 in Immediate Jeopardy (a situation in which the provider's non-compliance 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 was notified of the Immediate Jeopardy on 9/25/18 at 12:30 PM in the conference room. The Immediate Jeopardy was effective from 5/15/18 and is ongoing. The findings include: Review of undated facility policy, Elopement/Wandering revealed .The intent of the facility is to maintain resident safety by identifying residents who are at risk of wandering/elopement behavior .An elopement/wandering assessment will be completed upon admission and quarterly thereafter .Any resident displaying significant wandering behavior will be assessed for elopement/wandering risk and care planned appropriately .Care Plans and individual behavior plans will address wandering as a specific problem. Approaches will be formulated; patterns identified; and the causes determined .A wandering/elopement notebook containing pictures and pertinent demographic information will be maintained in social services; kept at nurses' station and receptionist desk . Review of undated facility policy, Missing Resident, revealed .Notify the Charge Nurse .Room to room check will be conducted to identify all residents .Check all areas of the facility including bathrooms, closets, shower and tub rooms .Check areas outside the facility .If the resident has not been found within 15 minutes, or after a search of the facility and immediately outside the building the Charge Nurse will notify the police or local law enforcement agency; notify family or responsible party; notify attending physician; notify other regulatory agencies .When the resident returns to the facility the Charge Nurse will examine the resident for injuries; contact attending physician and report findings and condition of resident .A complete and thorough root cause analysis of the elopement should be done to prevent recurrence, ensure policies and procedures and systems are effective, and to protect other residents . Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #10 scored 3 on the Brief Interview for Mental Status indicating he was severely cognitively impaired. Continued review of the MDS revealed Resident #10 required supervision with transfers, dressing, toileting; limited assistance with grooming; and extensive assistance with bathing. Medical record review of Baseline Admission Care Plan dated 7/19/18 revealed Resident #10 was at risk for possible wandering related to Dementia. Medical record review of the Comprehensive Care Plan dated 7/27/18 revealed Resident #10 was at risk for elopement as evidenced by exit-seeking behavior, wandering about the facility; asking staff to open the front door. Continued review revealed approaches included: 1. Observe resident for tailgating (following visitors out door) when visitors are in the building. 2. Use verbal and, if necessary, physical cues for redirection to persuade exit-seeking behaviors. 3. Seek a referral for a mental health evaluation from primary care physician as needed. 4. Refer to Social Services as needed. 5. Reevaluate elopement risk at least quarterly. 6. Provide staff supervision for resident when attending out-of-facility activity. 7. Chaplain services PRN (as needed) for emotional and psychosocial needs of the resident. Medical record review of Nursing Notes dated 7/20/18 revealed .exit seeking . asking multiple staff members which door to leave from .packing personal items throughout facility . Continued review of Nursing Notes dated 7/22/18 revealed .continues to be exit-seeking .has not actually opened any outer doors .wanders oblivious to where room is .carrying bag of clothes and linen around stating he is taking them to his momma's right around the corner .has opened outer door beside his room twice this shift . Medical record review of Event Note dated 7/30/18 revealed .Resident was noted missing as dinner trays were being passed. All available staff searched the perimeter of the building as well and two staff members drove their cars around the neighborhood and surrounding streets. Resident was located wandering a street over and was brought back to the building by staff . Surveyor traced a route to the location where the resident was found on 7/30/18 after he eloped. The route included going down a hill; across a 3 lane busy road (hospital access road) with a speed limit of 40 miles per hour and no sidewalk; then turned onto a busier street for a total of 0.45 miles from the facility. Review of a written statement by Certified Nurse Aide (CNA) #9 dated 8/6/18 revealed .Last time I seen (Resident #10) was around 3:45 PM when I clocked out for lunch. He was walking around the building. I came back from lunch about 4:15 PM. I started to check my patients and laying patients down. Dinner trays came out I passed them then started to feed patients. I went into Resident #10's room to feed a patient and noticed (Resident #10) tray was not opened so I started to look for him, I walk the building 3x (3 times) , I couldn't find him, then I told the nurse and supervisor. Then the supervisor called an elopement and everyone started to look, No one seen him, so (Named supervisor, RN #2) said she was going to ride around. She was going Old Hickory Boulevard and I went up Larkin Springs Road to Neely's Bend. I noticed him walking. I stopped beside him and told him to get in the car. He got inside and I called the nursing home to let them know I found him. We returned and he came in and started back walking around . Review of a statement from an unsampled resident dated 8/6/18 revealed .(named resident) saw (Resident #10) in the courtyard which was enclosed, with some family members of another resident. She then saw him by the door stating he was going outside to his truck to find some cigarettes. She states she then saw him leave with the family members (of another resident) . Review of facility investigation dated 7/30/18 revealed when Resident #10 was returned to the facility and asked why he left the facility he stated he was heading to my momma's house around the corner. Interview with the Social Worker on 9/11/18 at 8:57 AM in the conference room revealed Resident #10 was ambulatory. Continued interview revealed he likely exited behind visitors out the front door at an unknown time and was missed at meal time when a search was started. Further interview revealed he was found within 15 minutes and returned to the facility unharmed. Continued interview revealed he was placed on 1:1 monitoring; his daughter was called and she agreed with his transfer to a secure unit; and remained on 1:1 monitoring until his transfer on 8/3/18. Further interview revealed he was a known wandering risk and was in the elopement book (a notebook of resident pictures to identify residents at risk of elopement) kept at the front desk. Interview with CNA #9 on 9/11/18 at 9:50 AM in the conference room revealed Resident #10 was walking around the facility when she went on break at 3:40 PM. Continued interview revealed meal time was between 5:00 PM and 5:30 PM; she was handing out trays; and she noticed Resident #10 was missing. Further interview revealed she walked around the building 3 times but did not find him. Continued interview revealed she went to the Charge Nurse who announced the facility was missing a resident. Further interview revealed the Charge Nurse went one direction in her car and CNA #9 went the other way in her car. Continued interview revealed CNA #9 found Resident #10 at the intersection of Larkin Springs Road and Neely's Bend Road; picked him up; and returned to the facility. Further interview revealed Resident #10 stated he was going to visit some friends and he walked out with some people. Interview with CNA #9 on 9/24/18 at 4:00 PM in the conference room to re-establish the time line, revealed she last saw Resident #10 at 3:45 PM. Continued interview revealed between 5:00 PM and 5:30 PM trays were passed to residents and when she went to assist Resident #10's roommate at 5:15 PM she noticed Resident #10's tray untouched. Further interview revealed she walked around the building 3 times which took about 5 minutes then reported to the Charge Nurse. Continued interview revealed staff searched the outside of the building but did not find the resident. Further interview revealed she started driving and found him walking along a busy road close to 6:00 PM. Continued interview revealed Resident #10 was placed on 1:1 monitoring until he was discharged from the facility. Telephone interview with CNA #12 on 9/24/18 at 5:07 PM revealed Resident #10 was constantly trying to get out and he was destined to leave the facility. Continued interview revealed he hung by the door, asking how to get out, but she never saw him leave the facility. Interview with the Administrator on 9/11/18 at 1:45 PM in the conference room stated Resident #10 had exited the building with visitors and walked down the street. Continued interview with the Administrator confirmed the facility failed to supervise Resident #10 adequately to prevent him from eloping from the facility. Interview with CNA #9 on 9/24/18 at 4:00 PM in the conference room to re-establish the time line, revealed she last saw Resident #10 at 3:45 PM. Continued interview revealed between 5:00 PM and 5:30 PM trays were passed to residents and when she went to assist Resident #10's roommate at 5:15 PM she noticed Resident #10's tray untouched. Further interview revealed she walked around the building 3 times which took about 5 minutes then reported to the Charge Nurse. Continued interview revealed staff searched the outside of the building but did not find the resident. Further interview revealed she started driving and found him walking along a busy road close to 6:00 PM. Continued interview revealed Resident #10 was placed on 1:1 monitoring until he was discharged from the facility. In summary the last time Resident #10 was seen was at 4:00 PM when he was in the courtyard during smoke break. At 5:20 PM he had not eaten his dinner and was determined to be absent from the facility. At 6:00 PM he was found 0.45 miles from the facility, a distance which cannot be reached in 15 minutes.",2020-09-01
141,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2016-10-18,278,D,0,1,K1NZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to complete an accurate Minimum Data Set (MDS) for 2 residents (#89, #56) of 34 residents reviewed. The findings included: Medical record review revealed Resident #89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the annual Minimum Data Set ((MDS) dated [DATE] revealed the resident had no dental problems. Observation with the MDS Coordinator on [DATE] at 2:50 PM revealed the resident lying on the bed. Continued observation revealed the resident had a broken front tooth and stated it happened at the hospital when I was intubated. Interview with the MDS Coordinator on [DATE] at 2:53 PM, in the hallway confirmed the MDS dated [DATE] was not accurate and did not reflect the resident's broken tooth. Medical record review revealed Resident #56 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a nursing note dated [DATE] at 1:13 PM revealed Resident unresponsive, VS (vital signs) ,[DATE], resp (respirations) 10, O2 sat (oxygen saturation) room air 57%, 2LM (oxygen at 2 liters per minute) 84%, HR (heart rate) 62. 911 notified and transported to .Hospital ER (emergency room ) for eval (evaluation) and tx (treatment). Medical record review of a Minimum Data Set Death in Facility Tracking record revealed the resident had expired in the facility on [DATE]. Interview on [DATE] at 7:40 AM with the Director of Nursing (DON), in the DON's office revealed the DON had been present on [DATE] when the resident was transferred to the emergency room and had accompanied the resident on the stretcher to the ambulance at the time of transfer. Continued interview confirmed the resident did not expire in the facility and confirmed the Death in Facility Tracking record was not accurate.",2020-09-01
142,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2016-10-18,315,D,0,1,K1NZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to assess 2 residents (#18, #101) for a bladder retraining program of 4 residents reviewed for urinary incontinence of 34 residents reviewed. The findings included: Review of the facility's policy, Bowel and Bladder Management, undated, revealed The facility will evaluate, monitor and track resident's bowel and bladder patterns and will identify the need for early intervention. Guideline: 1. Facility will evaluate Bowel and Bladder status upon admission, readmission, significant change and quarterly. 2. If a resident is incontinent, a baseline elimination status to assess bowel and bladder patterns will be completed upon admission, readmission, quarterly and with significant change. 3. The interdisciplinary team (IDT) will review bowel and bladder data to determine if retraining is an option or a pattern has been identified . Medical record review revealed Resident #18 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 scored a 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was independent with daily decision making and was always incontinent of bladder. Medical record review of a Urinary Continence Evaluation dated 6/16/15 revealed the resident was frequently incontinent. Medical record review revealed no documentation a Urinary Continence Evaluation had been completed since 6/16/15. Interview with Resident #18 on 10/16/16 at 9:00 PM, in the resident's room revealed the resident was aware of the urge to urinate. Interview with the Director of Nursing (DON) on 10/17/16 at 3:50 PM, in the DON's office confirmed the resident had not been assessed for a bladder retraining program since 6/16/15. Medical record review revealed Resident #101 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed the resident was discharged from the facility on 8/6/16. Medical record review of the admission MDS dated [DATE] revealed the resident scored a 14 on the BIMS indicating the resident was independent with daily decision making and the resident was always continent of bladder. Medical record review of the quarterly MDS dated [DATE] revealed the resident scored a 15 on the BIMS indicating the resident was independent with daily decision making and the resident was frequently incontinent of bladder. Medical record review of an admission Urinary Continence Evaluation dated 4/27/16 revealed the resident was continent of urine at the time of admission. Medical record review revealed no documentation a Urinary Continence Evaluation had been completed after 4/27/16. Interview with the DON on 10/18/16 at 8:10 AM, in the DON's office confirmed the resident had not been reassessed for a bladder retraining program after the decline in urinary continence was noted.",2020-09-01
143,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2016-10-18,371,F,0,1,K1NZ11,"Based on facility policy review, observation, and interview, the facility failed to properly store frozen food items in 1 of 1 walk-in freezer, failed to properly store dry stock items, failed to discard outdated food in 1 of 2 nourishment refrigerators, failed to properly air dry pans in 8 of 13 pans observed, and failed to ensure kitchen equipment and non-food contact surfaces were clean and maintained in a sanitary manner, affecting 67 of 73 residents. The findings included: Review of the facility policy, Food Storage, dated 1/12/16 revealed .All products should be dated . use by dates on all food stored in refrigerators and use dates according to the timetable in the Dry, Refrigerated and Freezer storage .Any expired or outdated food products should be discarded .Frozen foods should be stored in airtight containers or wrapped in heavy duty aluminum foil or special laminated papers. Label and date all food items .Dry Storage .Any opened products should be placed in seamless plastic or glass containers with tight fitting lids and labeled and dated .Continued review of policy revealed .Label and date all storage containers or bins. Keep free of scoops . Review of the facility policy, Pots and Pans, Sanitizing Solution, dated 7/12/16 revealed .Invert items on counter Allow all items to air dry . Review of the facility policy, Mixer, dated 2/1/16 revealed .After each use .Scrub machine (beater shaft, bowl saddle, shell, and base) . Review of the facility policy, Can Opener, dated 9/1/16 revealed .After each meal more frequently if needed .Scrub shank, paying close attention to blade . Review of the facility policy, Dish Machine, dated 2/1/12 revealed .After each meal remove debris and rinse interior of machine. Wipe exterior of machine . Review of the facility policy, Walls and Ceilings, dated 3/14/16 revealed .Vents must be .clean and free of debris . Observation with the Cook on 10/16/16 at 9:50 AM, in the dish room revealed 8 of 13 four inch steam table pans observed had been stored wet. Observation with the Cook on 10/16/16 at 9:58 AM, in the kitchen revealed a food storage bin approximately 1/4 full of sugar with a measuring cup stored in the bin. Observation with the Cook on 10/16/16 at 10:10 AM, in the kitchen revealed a commercial coffee pot with dried coffee on the sides and around the spigot and a build-up of coffee grounds stuck to the bottom and sides of the coffee pot. Continued observation revealed a food mixer with dried food debris on the sides, guard, and mixer table. Further observation revealed a commercial can opener with dried food debris on the blade. Observation with the Cook on 10/16/16 at 10:25 AM, in the kitchen revealed 3 of 4 ceiling vents with thick dust on the grates. Observation with the Cook on 10/16/16 at 10:30 AM, in the kitchen, of the Dry Stock room revealed the following items opened, not in sealed containers and contained no label or use by date, and were available for resident consumption: a). 3 five pound bags of pasta, one approximately 1/4 full, one approximately 1/3 full, and one approximately 1/2 full b). 4 two pound bags of dry cereal all approximately 1/2 full. Observation with the Cook on 10/16/16 at 10:40 AM, in the kitchen, of a walk-in freezer revealed a plastic bag with 9 hamburger patties, unlabeled, not stored in a sealed container, and available for resident consumption. Observation on 10/18/16 at 10:03 AM, of the nourishment refrigerator on the south wing revealed the following 3 four ounce bowls with cut fresh fruit with the use by date of 10/16/16 and available for resident consumption. Interview with the Cook on 10/16/16 at 10:45 AM, in the kitchen, confirmed the facility failed to properly store opened packages of frozen foods and dry stock items to maintain food quality and prevent cross contamination. Further interview confirmed the facility failed to ensure kitchen equipment, and ceiling vents were clean and maintained in a sanitary manner, and failed to properly air dry and store pans. Interview with the Registered Dietitian on 10/18/16 at 10:05 AM, in the south wing nourishment room confirmed the facility failed to dispose of food by the use by date.",2020-09-01
144,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2016-10-18,441,D,0,1,K1NZ11,"Based on facility policy review, observation, and interview the facility failed to ensure infection control during meal distribution on 1 of 3 halls observed. The findings included: Review of the facility policy, Handwashing/Hand Hygiene, dated 8/12 revealed .If hands are not visibly soiled, use an alcohol-based hand rub .for all the following situations .Before and after direct contact with residents .After contact with objects .in the immediate vicinity of the resident . Observation on 10/16/16 at 12:10 PM, on the South hall revealed Certified Nurse Aide (CNA) #4 delivered a meal tray to a room and exited the room without performing hand hygiene. Continued observation revealed CNA #4 retrieved a tray from the tray cart, delivered the tray to another resident, placed the tray on the bedside table, touched her glasses, opened the door to exit the room, and returned the refused tray to the cart. Continued observation revealed CNA #4 went to the kitchen to request peanut butter and jelly sandwiches for the resident, touched the door handle to the kitchen, and delivered the sandwiches to the resident without performing hand hygiene. Interview with CNA #4 on 10/16/16 at 12:19 PM, on the South hall confirmed CNA #4 had washed the hands prior to delivering lunch trays but had failed to perform hand hygiene between each resident and after touching objects while delivering meal trays. Interview with the Director of Nursing (DON) on 10/16/16 at 3:04 PM, in the DON's office confirmed the facility failed to ensure infection control during meal distribution per facility policy.",2020-09-01
145,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2016-10-18,502,D,0,1,K1NZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to ensure a laboratory test was completed as ordered for 1 resident (#39) of 5 reviewed for unnecessary medications of 34 residents sampled. The findings included: Medical record review revealed Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physician Telephone order dated 9/24/16 revealed .CMP (Comprehensive Metabolic Panel-blood test to evaluate organ function) next lab day .Dietary Recommendation . Continued review of the medical record revealed there was no documentation of CMP lab values. Interview with Registered Nurse (RN) #1 on 10/18/16 at 10:03 AM, in the conference room confirmed the CMP for Resident #39 had not been completed as ordered.",2020-09-01
146,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2016-10-18,514,D,0,1,K1NZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to maintain an accurate medical record for 1 (#56) of 34 residents reviewed. The findings included: Medical record review revealed Resident #56 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an electronic nursing note dated 7/19/16 at 1:13 PM revealed Resident unresponsive, VS (vital signs) 108/70, resp (respirations)10, O2 sat (oxygen saturation) room air 57%, 2LM (oxygen at 2 liters per minute) 84%, HR (heart rate) 62. 911 notified and transported to .Hospital ER (emergency room ) for eval (evaluation) and tx (treatment). Medical record review of an emergency room report dated 7/19/16 revealed .Initial Greet Date/Time 7/19/16 1115 (11:15 AM) .EMS (emergency medical services) was called after pt (patient) was noted to be unresponsive at SNF (skilled nursing facility) . Interview with the Director of Nursing (DON) on 10/18/16 at 7:40 AM, in the DON's office revealed on 10/19/16 in the morning, exact time unknown, the resident had been transferred to the emergency room and confirmed the medical record was not accurate and did not reflect the correct time the resident was found to be unresponsive.",2020-09-01
147,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2017-12-13,657,D,0,1,84HS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview the facility failed to revise the comprehensive care plan to prevent weight loss for 1 resident (#47) of 21 residents reviewed. The findings included: Review of facility policy titled Care Plans-Comprehensive with an effective date of 10/31/17 revealed, .The care plan will include how the facility will assist the resident to meet their needs, goals and preferences .Care plan interventions are implemented after consideration of the resident's problem areas and their causes .interventions will reflect action, treatment, or procedure to meet the objectives toward achieving the resident goals .Care plans are ongoing and revised as information about the resident and the resident's condition change . Medical record review revealed Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #47 had a 13.67% weight loss in 6 months and a 30 day weight loss of 2.44%. Continued review revealed the resident was on isolation for ,[MEDICAL CONDITION].-Difficle the last 2 months with multiple liquid stools contributing to the weight loss. Medical record review of Nutritional Note dated 11/15/17 revealed, .(resident) does not like the texture of pureed foods and does not eat them .likes the sweet items (ice cream and chocolate milk, health shakes; also likes grits) but not much else. Has not been eating mashed potatoes, which she used to like. Recommend additional fluids between meals .recommend sending additional fortified grits during the day . Medical record review of physician's orders [REDACTED].Push oral fluids while awake . Medical record review of the Comprehensive Care Plan dated 5/10/15 and revised 9/22/17 revealed the resident was at risk for nutritional deficits and weight loss due to actual weight loss, and refusal to be weighed at times. Approaches included the following: 5/11/15 Assess need for dietary modification and consult Registered Dietician if indicated. 9/22/17 Continue to encourage resident to be weighed. Continued review of the care plan revealed no further interventions were added after 9/22/17. Continued review revealed the care plan was not revised to include the resident's preferences of ice cream, chocolate milk, health shakes or the recommendations by the Dietician to offer fortified grits and provided additional fluids between meals. Interview with the Registered Dietician with the Corporate Dietician present on 12/13/17 at 9:15 AM in the conference room confirmed the comprehensive care plan was not revised to reflect the residents preferences and current interventions to prevent weight loss to Resident #47.",2020-09-01
148,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2017-12-13,757,E,0,1,84HS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, medical record review and interview the facility failed to keep 3 residents (#39, #61, #65) free from unnecessary medications for 8 residents reviewed for medications. The findings included: Review of facility policy Medication Administration, dated 5/16, revealed .Prior to administration, review and confirm MEDICATION ORDERS FOR [REDACTED]. Medical record review revealed Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 13, indicating he was cognitively intact. Medical record review of Transfer Orders dated 7/19/17 revealed .[MEDICATION NAME] (antibiotic) 500mg (milligrams) three times a day; for R (right) hip bone infection, from 06/15 to 07/27/2017 . Medical record review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Interview with the Director of Nursing (DON) on 12/12/17 at 3:25 PM in the conference room, after review of the MAR, confirmed the facility failed to stop administration of [MEDICATION NAME] to Resident #39 as ordered, resulting in unnecessary medication administration for the resident. Medical record review revealed Resident #61 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].[MEDICATION NAME] ([MEDICATION NAME]) 250 mg capsule. Give one capsule by mouth twice daily for 14 days . Medical record review of the MAR for (MONTH) and (MONTH) (YEAR) revealed [MEDICATION NAME] was started on 11/22/17 at 9:00 PM and given twice daily at 9:00 AM and 9:00 PM through 12/12/17 for a total of 20 days. Interview with Licensed Practical Nurse (LPN) #6 on 12/13/17 at 9:30 AM in the hall at the medication cart near Resident #61's room revealed the 9:00 AM medications had already been given for Resident #61 and [MEDICATION NAME] was one of the medications given. Further interview, after reviewing the order, the LPN confirmed the medication was only ordered for 14 days beginning on 11/22/17. Interview with the Director of Nursing (DON) on 12/13/17 at 9:55 AM in her office, after reviewing the [MEDICATION NAME] order for Resident #61, confirmed the order was for 14 days and the medication should have been discontinued on 12/6/17 and was not, resulting in unnecessary medication administration for the resident. Medical record review revealed Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission MDS dated [DATE] revealed Resident #65 had a BIMS of 13, indicating she was cognitively intact. Medical record review of a Physician order [REDACTED].[MEDICATION NAME] (antibiotic) 300 mg PO (by mouth) QID (four times per day) x (times) 7 days . Medical record review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Interview with the DON on 12/12/17 at 3:25 PM in the conference room, after review of the MAR, confirmed the facility failed to stop administration of [MEDICATION NAME] to Resident #65 as ordered, resulting in unnecessary medication administration for the resident.",2020-09-01
149,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2017-12-13,758,D,0,1,84HS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, medical record review and interview, the facility failed to monitor behaviors for 2 residents (#39, #65) of 8 residents reviewed for [MEDICAL CONDITION] medications. The findings included: Review of facility policy [MEDICAL CONDITION] Medication Policy & Procedure, dated 5/9/17, revealed .The facility will make every effort to comply with state and federal regulations related to the use of [MEDICAL CONDITION] medications in the long term care facility to include regular review for .side effects, risk and/or benefits .Will monitor for the presence of target behaviors on a daily basis . Medical record review revealed Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #39 received antianxiety medication during the assessment look-back period. Medical record review of a Physician order [REDACTED]. Medical record review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Further review revealed Behavior Monitoring was not documented for the 7 PM - 7 AM shift on 9/6/17 or 9/11/17. Medical record review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Further review revealed Behavior Monitoring was not documented for the 7 AM - 7 PM shift on 10/5/17, 10/14/17 or 10/28/17 and the 7 PM - 7 AM shift on 10/8/17, 10/17/17, 10/21/17, 10/22/17 or 10/26/17. Medical record review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Further review revealed Behavior Monitoring was not documented for the 7 AM - 7 PM shift on 11/1/17, 11/15/17, 11/16/17, 11/21/17 or 11/25/17 and for the 7 PM - 7 AM shift on 11/4/17, 11/9/17, 11/18/17, 11/19/17, 11/22/17, 11/23/17 or 11/30/17. Medical record review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Further review revealed Behavior Monitoring was not documented for the 7 AM - 7 PM shift on 12/1/17, 12/2/17, 12/6/17 or 12/7/17. Medical record review revealed Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission MDS dated [DATE] revealed Resident #65 had received antipsychotic medication during the assessment look-back period. Medical record review of a Physician order [REDACTED]. Further review of a Physician order [REDACTED]. Medical record review of the MAR for (MONTH) (YEAR) and (MONTH) (YEAR) revealed Resident #65 received the medication as prescribed. Further review revealed no behavior monitoring for [MEDICATION NAME] or [MEDICATION NAME]. Interview with the Director of Nursing on 12/13/17 at 10:00 AM in the conference room confirmed the facility failed to complete behavior monitoring for Resident #39 who was administered antianxiety medication and Resident #65 who was administered an antipsychotic medication.",2020-09-01
150,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2017-12-13,812,F,0,1,84HS11,"Based on facility policy, cleaning schedule, observation and interview the facility failed to keep 2 of 2 ice machines clean and sanitized. The findings included: Review of the facility policy Ice Machine dated 7/26/17 revealed .Unplug the ice machine. Remove ice. Wash inside of machine with approved detergent and hot water. Then use sanitizing solution and clean cloth to sanitize. Make sure the door liner, door gasket and door frame are free of scale and or mold. Remove rust spots .Frequency: weekly . Review of the cleaning schedule for the ice machine revealed no documentation of cleaning and sanitizing for the weeks of 11/19/17 and 11/26/17. Observation with the Dietary Manager on 12/11/17 at 12:15 PM revealed ice machine #1, located in the dietary department, had a pink line of debris along the hood of the inner ice bin. Observation with the Dietary Manager on 12/11/17 at 12:28 PM of ice machine #2, located on the East Hall Exit, revealed an accumulation of brown debris on the inside of the ice bin and on the inside perimeter. Continued observation revealed dust on the outside perimeter of the bin. Observation with the Dietary Manager on 12/12/17 at 1:44 PM on the East Hall Exit revealed the ice machine #2 had orange, and brownish colored debris on the inner side of the ice bin. Interview with the Dietary Manager on 12/12/17 at 2:03 PM in the conference room confirmed the facility failed to keep the ice machines in a sanitary manner.",2020-09-01
151,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2017-12-13,880,D,0,1,84HS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview the facility failed to store oxygen tubing in a sanitary manner and failed to date the humidification reservoir for 1 resident (#25) of 4 residents receiving oxygen. The findings included: Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed a Physician order [REDACTED]. Observation on 12/11/17 at 11:20 AM in Resident #25's room revealed an oxygen concentrator near the head of the bed with the nasal cannula/tubing lying on top of the concentrator and not in a bag. Observation with Licensed Practical Nurse (LPN) #1 on 12/11/17 at 11:27 AM in Resident #25's room revealed an oxygen concentrator near the head of the bed with the oxygen tubing lying on top of the concentrator and not in a bag. Continued observation revealed the humidification reservoir was not dated. Interview with LPN #1 on 12/11/17 at 11:30 AM in the hall near Resident #25's room confirmed the nasal cannula/tubing should be in a dated bag and the humidification reservoir should be dated. Continued interview with the LPN confirmed the facility failed to date and store the nasal canula/tubing in a sanitary manner and failed to date the humidification reservoir.",2020-09-01
152,"NHC HEALTHCARE, MCMINNVILLE",445076,928 OLD SMITHVILLE RD,MC MINNVILLE,TN,37110,2020-02-05,812,F,0,1,XDXR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, observation, and interview, the facility failed to label, date, correctly store resident foods, and discard expired food items, potentially affecting 105 of 105 residents residing in the facility. The findings include: Review of the facility policy titled, Safety & Sanitation Best Practice Guidelines revised ,[DATE] showed .Foods will be stored in their original container or .wrapped tightly in moisture-proof film, film, foil .Clearly labeled with the contents and the use by date . Observation and interview on [DATE] at 10:38 AM, with the Dietary Manager (DM), in the walk-in refrigerator, revealed 65 half pint whole milk cartons with an expiration date of [DATE], and 9 chicken tenders in a plastic container with no open date or expiration date. The DM confirmed the milk was expired, the chicken tenders were unlabeled, and available for resident use. Observation and interview on [DATE] at 10:45 AM, with the DM, in the walk-in freezer revealed a box of 160 sausage links and a 12 pound box of whole hog sausage patties open to air. The DM confirmed the sausage links and sausage patties were stored incorrectly, open to air, and available for resident use. During an interview on [DATE] at 1:15 PM, the Registered Dietician stated all open foods were to be labeled, dated, and expired foods were to be discarded.",2020-09-01
153,"NHC HEALTHCARE, MCMINNVILLE",445076,928 OLD SMITHVILLE RD,MC MINNVILLE,TN,37110,2019-02-27,638,D,0,1,WOQP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the Resident Assessment Instrument (RAI) Version 3.0 Manual, review of the Minimum Data Set (MDS) and interview the facility failed to complete a timely quarterly assessment for 1 resident (#4) of 3 residents reviewed for MDS assessments of 32 sampled residents. The findings include: Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the RAI Version 3.0 Manual Chapter 2: Assessments for the RAI revealed .The next non-comprehensive assessment is due within 92 days after the ARD (Assessment Reference Date) of the most recent .assessment . Medical record review for Resident #4 revealed an annual MDS had been completed with an ARD date of 10/9/18. Further review revealed a quarterly MDS assessment had not been completed 1/2019. Interview with the MDS Coordinator, Licensed Practical Nurse on 2/27/19 at 8:45 AM, in the MDS office, confirmed the quarterly assessment had not been completed timely for Resident #4.",2020-09-01
154,"NHC HEALTHCARE, MCMINNVILLE",445076,928 OLD SMITHVILLE RD,MC MINNVILLE,TN,37110,2018-05-09,641,D,0,1,KRDE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility documentation and interview, the facility failed to accurately assess 1 resident (#105) out of 3 residents reviewed for falls of 36 sampled residents. The findings included: Medical record review revealed Resident #105 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's Post Falls Investigation dated 3/30/18 revealed Resident #105 experienced a fall on 3/29/18 in the resident's room. Medical record review of the Minimum Data Set ((MDS) dated [DATE] revealed, .resident had any falls since admission . 0 (indicating none) . Interview with the MDS Coordinator on 5/9/18 at 8:30 AM, at the 400 unit nurse's station, confirmed the 4/14/18 MDS for Resident #105 was inaccurate for falls.",2020-09-01
155,"NHC HEALTHCARE, MCMINNVILLE",445076,928 OLD SMITHVILLE RD,MC MINNVILLE,TN,37110,2018-05-09,656,G,0,1,KRDE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to implement a comprehensive care plan, for pain management, for 1 Resident (#103) of 12 residents reviewed for pain of 36 residents sampled. The facility's failure to implement the pain management care plan on 2 occasions between 5/4/18 and 5/7/18 resulted in an increase in pain and harm to the resident. The findings included: Medical record review revealed Resident #103 was admitted to the facility on [DATE], on Palliative care, (specialized medical care for people with serious illness. This type of care is focused on providing relief from the symptoms and stress of a serious illness. The goal is to improve quality of life for both the patient and the family.) with [DIAGNOSES REDACTED]. Medical record review of the 30 day Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Further review revealed the resident had moderate pain and received routine and PRN (as needed) pain medication. Medical record review of the resident's care plan dated 4/24/18 revealed .risk for alteration in comfort/pain .administer medications as ordered .via PCA pump (Patient Controlled [MEDICATION NAME], method of allowing a person in pain to administer their own pain medication) . Review of the (MONTH) (YEAR) Medication and Treatment Administration Record Report revealed .[MEDICATION NAME] (a pain medication) PCA 1MG (milligram) HOUR PRN 0.5 MG BOLUS (as needed single dose of a drug given all at once) Q (every) 20 MIN (minutes)DO NOT EXCEED 4MG .Continued review revealed on 5/7/18 the order changed to .[MEDICATION NAME] 2MG HOUR WITH PRN 1MG BOLUS Q 20 MIN DO NOT EXCEED 4MG . and on 5/8/17 the order changed to .[MEDICATION NAME] 2MG HOUR WITH PRN 1MG BOLUS Q 20 MIN DO NOT EXCEED 5MG . Continued review revealed on 5/7/18 . [MEDICATION NAME] (a pain medication) 100 MG/5ML (milliliter) SOLUTION 0.5ML-1 ML (10MG-20MG) BY MOUTH EVERY HOUR AS NEEDED FOR PAIN . Review of a Nurse's Note dated 5/7/18 at 10:50 AM revealed .Pt (patient) stated this AM that current resting pain level @ (at) 7/10 (7 on a 0-10 scale with 10 being the worst pain) MD (Medical Doctor)notified. N/O (nursing order) to (increase) continuous infusion to 2 mg per hour and 1 mg boluses q (every) 20 min . Review of the PCA Pump Flow Sheet revealed on 5/4/18 Resident #103's level of pain was 4/10, on 5/5/18 4/10 and 6/10, on 5/6/18 5/10 and 7/10 and on 5/7/18 7/10 and 6/10. Interview with Resident #103 and a family member on 5/7/18 at 2:30 PM, in the resident's room, revealed the resident and the family member stated the PCA pump ran out on 5/4/18 and the facility had no replacement available. Interview with Resident #103's family member on 5/8/18 at 8:49 AM, in the resident's room, confirmed the PCA pump ran out again on 5/7/18 at 3:30 PM and was not restarted until 7:30 PM. Further interview revealed .he was having a lot of pain in his bottom . Interview with Licensed Practical Nurse (LPN) #1 on 5/9/18 at 10:14 AM, in the 100 hallway, confirmed on 5/7/18 .his pain pump ran out between 3 - 4 (PM) . Further interview confirmed no extra pump was available. Interview with Resident #103 on 5/9/18 at 10:43 AM, in the resident's room, confirmed when the PCA pump ran out of medication the first time, Resident #103 was asked ifthe pain was worse and stated .Yeah it probably was . Further interview confirmed the pain was worse the second time the PCA medication ran out stating .it got bad . Continued interview confirmed the resident stated .it (PCA pump replacement) needs to be on hand at all times . The resident further stated he was very upset, and if it had happened once, it should not have happened again. Interview with Assistant Director of Nursing (ADON) #1 on 5/9/18 at 1:23 PM, in the station 3 activity/dining room, confirmed the PCA pump medication ran out on 5/7/18 at approximately 3:00 PM, and the facility did not receive the pain medication from the pharmacy until approximately 6:30 PM or 7:00 PM. Further interview confirmed the resident received 4 doses of [MEDICATION NAME] between 3:30 PM to 10:00 PM and confirmed the 4th dose was given after the PCA pump had been restarted to get his pain .back under control . Continued interview confirmed the [MEDICATION NAME] was .not what his body is used to . Further interview confirmed ADON #2 was notified of the first occurrence on 5/4/18 and ADON #1 was notified of the second occurrence on 5/7/18. Interview with ADON #2 on 5/9/18 at 2:30 PM, in the class room, confirmed she was notified on 5/4/18 at 7:15 PM the PCA pump was empty and no extra pump was available in the medication room. Further interview confirmed the medication arrived at the facility approximately 9:30 PM to 10:00 PM on 5/4/18. Continued interview confirmed ADON #2 did not assess the Resident #103's pain level while the PCA pump was empty. Interview with the Director of Nursing (DON) on 5/9/18 at 2:42 PM, in the conference room, confirmed she was aware on 5/4/18 the PCA pump had run out. Further interview confirmed she spoke with the pharmacy on the morning of 5/7/18 regarding the pump running out of medication with no replacement immedicately available on 5/4/18, and the dosage increase ordered the morning of 5/7/18. Continued interview revealed .I don't know (the reason the pump ran out of medication again later that evening) . Further interview revealed the DON had not discussed either occurrence with the resident or the family member. Interview with Resident #103's family member on 5/9/18 at 4:41 PM, in the resident's room, revealed prior to admission to the facility the resident had experienced uncontrolled pain. Further interview confirmed the PCA pump was .his crutch . Continued interview confirmed the resident became anxious when the pain medication was unavailable and continues to worry it will happen in the future and his pain will not be controlled. The facility's failure to implement the pain management care plan resulted in an increase in pain and harm to the resident.",2020-09-01
156,"NHC HEALTHCARE, MCMINNVILLE",445076,928 OLD SMITHVILLE RD,MC MINNVILLE,TN,37110,2018-05-09,697,G,0,1,KRDE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure physician ordered pain medication was available for 1 Resident (#103) of 1 resident on Patient Controlled [MEDICATION NAME] (PCA) pump (method of allowing a person in pain to administer their own pain medication) of 12 residents reviewed for pain. The facility's failure to ensure the pain medication was available on 2 occasions between 5/4/18 and 5/7/18 resulted in an increase in pain and harm to Resident #103. The findings included: Medical record review revealed Resident #103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 30 day Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Further review revealed the resident had moderate pain and received routine and PRN (as needed) pain medication. Medical record review of the resident's care plan dated 4/24/18 revealed .risk for alteration in comfort/pain .administer medications as ordered .via PCA pump . Review of the (MONTH) (YEAR) Medication and Treatment Administration Record Report revealed .[MEDICATION NAME] (a pain medication) PCA 1MG (milligram) HOUR PRN 0.5 MG BOLUS (as needed single dose of a drug given all at once) Q (every) 20 MIN (minutes)DO NOT EXCEED 4MG .Continued review revealed on 5/7/18 the order changed to .[MEDICATION NAME] 2MG HOUR WITH PRN 1MG BOLUS Q 20 MIN DO NOT EXCEED 4MG . and on 5/8/17 the order changed to .[MEDICATION NAME] 2MG HOUR WITH PRN 1MG BOLUS Q 20 MIN DO NOT EXCEED 5MG . Continued review revealed on 5/7/18 . [MEDICATION NAME] (a pain medication) 100 MG/5ML (milliliter) SOLUTION 0.5ML-1 ML (10MG-20MG) BY MOUTH EVERY HOUR AS NEEDED FOR PAIN . Review of a Nurse's Note dated 5/7/18 at 10:50 AM revealed .Pt (patient) stated this AM that current resting pain level @ (at) 7/10 (7 on a 0-10 scale with 10 being the worst pain) MD (Medical Doctor)notified. N/O (nursing order) to (increase) continuous infusion to 2 mg per hour and 1 mg boluses q (every) 20 min . Review of the PCA Pump Flow Sheet revealed on 5/4/18 Resident #103's level of pain on a 0-10 scale with 10 being the worst pain was 4/10, on 5/5/18 4/10 and 6/10, on 5/6/18 5/10 and 7/10 and on 5/7/18 7/10 and 6/10. Medical record review of the Medication and Treatment Administration Record Report dated (MONTH) (YEAR) revealed the resident received 4 doses of [MEDICATION NAME] on 5/7/18 at the following times: 3:30 PM, 4:39 PM, 6:41 PM, and 8:27 PM. Observation and Interview with Resident #103, and a family member, on 5/7/18 at 2:30 PM, in the resident's room, revealed the resident lying in the bed with a PCA pump at the bedside. Further interview revealed the resident and his family stated the PCA pump ran out on 5/4/18 and the facility had no refill available. Interview with Resident #103's family member on 5/8/18 at 8:49 AM, in the resident's room, confirmed the PCA pump ran out again on 5/7/18 at 3:30 PM and was not restarted until 7:30 PM. Continued interview revealed the resident received sublingual (under the tongue) [MEDICATION NAME] while the pump was not infusing and was also given a dose of [MEDICATION NAME] once after the pump was restarted because he was in so much pain. Further Interview revealed .he was having a lot of pain in his bottom . Interview with Certified Nursing Assistant (CNA) #1 on 5/9/18 at 9:04 AM, in the 100 hallway, confirmed Resident #103's PCA pump ran out on 5/7/18. Continued interview revealed .Someone was supposed to deliver it at 4:30 PM and it was not here yet when I left at 7:00 PM .He was in pain . Interview with Licensed Practical Nurse (LPN) #1 on 5/9/18 at 10:14 AM, in the 100 hallway, confirmed on 5/7/18 .his pain pump ran out between 3 - 4 (PM) . Further interview confirmed no extra pump was available at the facility. Continued interview revealed the pharmacy was notified for a STAT (rush) delivery because normal delivery time was 00:00 to 2:00 AM. Continued interview confirmed this was the second time the PCA pump ran out of pain medication and none was available to replace. Interview with Resident #103 on 5/9/18 at 10:43 AM, in the resident's room, confirmed when the PCA pump ran out the first time the pain was worse and stated .Yeah it probably was . Further interview confirmed the pain was worse the second time the PCA ran out stating .it got bad . Continued interview confirmed the resident stated .it needs to be on hand at all times . The resident further stated he was very upset, and if it had happened once, it should not have happened again. Interview with LPN #2 on 5/9/18 at 12:39 PM, in the Nursing Secretary's Office at Station 2, confirmed the PCA pump was empty when she came on shift on 5/4/18 at 7:00 PM. Continued interview revealed the medication was received approximately 9:30 PM or 10:00 PM on 5/4/18. Interview with Registered Nurse (RN) #1 on 5/9/18 at 1:03 PM, in the station 3 activity/dining room, confirmed there was no extra pump kept in the medication room. Further interview revealed Resident #103's normal pain level with use of the PCA pump was .when he is using it 0 . Interview with Assistant Director of Nursing (ADON) #1 on 5/9/18 at 1:23 PM, in the station 3 activity/dining room, confirmed the PCA pump medication ran out on 5/7/18 at approximately 3:00 PM, and the facility did not receive the pain medication from the pharmacy until approximately 6:30 PM or 7:00 PM. Further interview confirmed the resident received 4 doses of [MEDICATION NAME] between 3:30 PM to 10:00 PM and confirmed the 4th dose was given after the PCA pump had been restarted to get his pain .back under control . Continued interview confirmed the [MEDICATION NAME] was .not what his body is used to . Further interview confirmed ADON #2 was notified of the first occurrence on 5/4/18 and ADON #1 was notified of the second occurrence on 5/7/18. Interview with ADON #2 on 5/9/18 at 2:30 PM, in the class room, confirmed she was notified on 5/4/18 at 7:15 PM the PCA pump was empty and no extra pump was available in the medication room. Further interview confirmed the medication arrived at the facility at approximately 9:30 PM to 10:00 PM on 5/4/18. Continued interview confirmed ADON #2 did not assess the resident's pain level while the pump was empty. Interview with the Director of Nursing (DON) on 5/9/18 at 2:42 PM, in the conference room, confirmed she was aware on 5/4/18 the PCA pump was empty. Further interview confirmed she spoke with the pharmacy on the morning of 5/7/18 regarding the pump running out of medication on 5/4/18 and the dosage increase ordered the morning of 5/7/18. Continued interview revealed .I don't know (the reason the pump ran out again later that evening) . Further interview revealed the DON had not discussed either occurrence with the resident or the family member. Interview with Resident #103's family member on 5/9/18 at 4:41 PM, in the resident's room, revealed prior to admission to the facility the resident had experienced uncontrolled pain. Further interview confirmed the PCA pump was .his crutch . Continued interview confirmed the resident became anxious when the pain medication was unavailable and continues to worry it will happen in the future and his pain will not be controlled.",2020-09-01
157,"NHC HEALTHCARE, MCMINNVILLE",445076,928 OLD SMITHVILLE RD,MC MINNVILLE,TN,37110,2018-05-09,880,D,0,1,KRDE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to post an isolation precaution sign on the door of 1 Resident (#82) of 1 resident on isolation precautions of 36 sampled residents. The findings included: Medical record review revealed Resident #82 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician order [REDACTED].ISOLATION (separation of those known to be infected with a contagious disease to prevent further infections) PT (patient) IN PRIVATE ROOM WITH ALL CARE AND TREATMENT PROVIDED IN ROOM . Medical record review of the resident's care plan dated 4/20/18 revealed .Need for isolation precautions .Maintain isolation per protocol . Observation during the initial tour of Resident #82's room on 5/7/18 at 11:05 AM, in the 100 hallway, revealed no precaution sign on the door and a bedside table, not labeled, in the hallway beside the resident's door. Observation of CNA #3 on 05/07/18 at 12:19 PM, in the100 hallway, obtain a gown and gloves from the bedside table, beside the resident's door, and put on the gown and the gloves to deliver the resident's lunch. Interview with Certified Nursing Assistant (CNA) #2 on 5/8/18 at 10:12 AM, in the rehab dining room, confirmed there should be a sign on the door to see the nurse before entering. Further interview confirmed a precaution sign was not on the door on 5/7/18. Interview with the Director of Nursing (DON) on 5/9/18 at 2:42 PM, in the conference room, confirmed the facility failed to post an isolation precaution sign on the resident's door to notify staff and visitors of the isolation precautions.",2020-09-01
158,CHRISTIAN CARE CENTER OF UNICOI COUNTY,445077,100 GREENWAY CIRCLE,ERWIN,TN,37650,2020-01-28,609,D,1,0,GTVW11,"**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 report an allegation of Misappropriation of Property to the State Survey Agency timely for 1 resident (Resident #1) of 5 residents reviewed. The findings included: Review of the facility policy titled Abuse Protocol, last revised 11/2019, showed .The facility must .Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made .in accordance with State Law . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a physician's order dated 8/15/19 showed .[MEDICATION NAME] ([MEDICATION NAME]) 325 mg (milligrams) 5 mg tablet .every 4 hours .pain . Review of a facility investigation dated 1/1/2020 showed Licensed Practical Nurse (LPN) #6 contacted the facility pharmacy for a refill of Resident #1's [MEDICATION NAME] (pain medication). The pharmacy informed the LPN that the pharmacy had dispensed 1 card containing 30 tablets of the medication to the facility on [DATE] (5 days earlier) for Resident #1. The facility completed an investigation but was unable to locate the missing medication. The resident was refunded the cost of the medication. During an interview on 1/28/2020 at 12:00 PM, the Regional Director of Administration stated .(the facility) was unable to determine what happened to the missing narcotics and that was why (the facility) had not reported the missing narcotics to the local or state agencies . In summary, the facility was unable to locate 30 tablets of [MEDICATION NAME] dispensed by the pharmacy for Resident #1 on 1/1/2020. As of 1/28/2020 the facility had not reported the missing medication to the State Survey Agency (28 days later).",2020-09-01
159,CHRISTIAN CARE CENTER OF UNICOI COUNTY,445077,100 GREENWAY CIRCLE,ERWIN,TN,37650,2018-04-04,657,D,1,0,RMJQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview, the facility failed to update a care plan for 1 of 4 sampled residents (Resident #4) following a fall. The findings included: Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident was severely cognitively impaired and needed extensive assistance of 2 people with transfers. Review of Falls Log indicated Resident #4 had falls on 1/25/18 and 1/27/18. Observation on 4/2/18 at 9:30 AM revealed Resident #4's bed was in a low position with a fall mat on the floor next to her bed. Review of the Care Plan dated 8/10/16 revealed the plan had not been updated to include a fall mat or placing the bed in a low position. Interview with the Director of Nursing (DON) on 4/4/18 at 12:23 PM, in the DON's office, revealed the care plan should have been updated after the interventions were initiated.",2020-09-01
160,CHRISTIAN CARE CENTER OF UNICOI COUNTY,445077,100 GREENWAY CIRCLE,ERWIN,TN,37650,2018-04-04,659,G,1,0,RMJQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview, the facility failed to follow the plan of care for 1 of 4 sampled residents (Resident #1). The facility's failure to follow the plan of care for transfers resulted in actual harm to Resident #1. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] for palliative care. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] indicated the resident was completely dependent upon staff to conduct all Activities of Daily Living (ADL's) and required maximum assist of 2 staff for transfers. Medical record review of the resident's Plan of Care dated 2/12/17 revealed .Alteration in ADL's related to dementia, immobility .total dependent care .transfer (with) max assist x (of) 2 (staff) . Medical record review of the Departmental Notes for Nursing dated 6/6/17 at 12:30 PM revealed the Hospice Certified Nursing Assistant (CNA) was getting the resident out of bed and transferring to a shower chair when the resident slid down the CNA's leg to the floor. The transfer was conducted solely by the Hospice CN[NAME] Interview with the Administrator on 4/11/18 at 1:15 PM, by phone, confirmed the Hospice CNA did not follow the plan of care for a 2-person transfer.",2020-09-01
161,CHRISTIAN CARE CENTER OF UNICOI COUNTY,445077,100 GREENWAY CIRCLE,ERWIN,TN,37650,2018-04-04,689,G,1,0,RMJQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, observations, and interview, the facility failed to ensure 1 of 4 residents (Resident #1) was kept safe from falls by contracted staff caring for residents. The facility's failure to ensure a safe transfer resulted in actual harm to Resident #1. The findings included: Review of the facility's policy titled Fall Risk Evaluation, Prevention, and Intervention reviewed 1/17/17 revealed .VII Procedure .D. When a fall occurs: 1. Assess for injuries, and provide treatment as necessary . The policy did not address not moving the resident. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the resident's Plan of Care dated 2/12/17 revealed .Alteration in ADL's related to dementia, immobility .total dependent care .transfer (with) max assist x (of) 2 (staff) . Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was severely cognitively impaired and was totally dependent on staff for all Activities of Daily Living (ADL's) and required the extensive assistance of 2 people for transfers. Medical record review of a Fall Risk Evaluation dated 3/21/17 revealed the resident was assessed as a high risk for falls. Review of the Departmental Notes for Nursing dated 6/6/17 and timed 12:30 PM revealed the contracted Hospice Certified Nursing Assistant (CNA) was getting the resident out of bed to transfer to a shower chair when the resident slid down the CNA's leg to the floor. The Hospice CNA called for assistance. The resident was examined in the shower room with no apparent injury .no redness or bruising noted . The family and physician were notified. Medical record review of Departmental Notes for Nursing dated 6/6/17 and timed 1:53 PM revealed .Noted right lateral ankle bruising/blueness with [MEDICAL CONDITION] and scratch. Resident frowns when ankle is touched . Continued review revealed the family was at bedside. Further review revealed the physician was notified and x-rays were ordered. Review of the Resident #1's x-rays completed on 6/6/17 indicated non-displaced fractures of the left distal femur, right trimalleollar, left distal tibia and distal fibula, and the right distal femoral. The x-ray reports further indicated the bones were diffusely severely osteopenic. Medical record review of Departmental Notes for Nursing dated 6/12/17 revealed the Nurse Practitioner had discussed the patient's status with the resident's family including .no need for inpatient evaluation if patient cannot undergo surgery, cancel transfer to hospital . Continued review revealed the Administrator had also discussed obtaining additional x-rays which must be performed at the hospital and the family declined .due to pain in moving her . Review of the investigation by the facility, dated 6/6/17 indicated the Hospice CNA attempted to transfer the resident to a shower chair. The resident was heavier than the CNA expected and the resident slid down the CNA's leg to the floor as an assisted fall. The Registered Nurse (RN) assessed the resident in the shower room and did not identify any injuries. The facility identified the Hospice CNA was not familiar with the resident or the care plan to determine how many people needed to assist the resident for transfer. A Post Fall Assessment Huddle was completed on 6/16/17 and identified that the Hospice CNA is to call for assistance. The huddle concluded that the resident initially did not have any injuries but was later found to have multiple injuries after x-rays were completed for the resident. Review of the (name) Hospice Education for the Hospice CNA revealed the last documented training for Resident Lifting and Transfers was completed on 1/31/12 and the last competency checks provided were dated (MONTH) and (MONTH) of 2011. Review of the contract between the hospice and the facility dated 5/2/07 indicated that all staff possessed the education, skills, and training necessary to provide facility services. Review of the Nursing Facility Services Agreement between hospice and the facility dated 5/2/07, revealed .Qualifications of Personnel (b) (i) are duly licensed, credentialed, certified and/or registered as required under applicable state laws (ii) possess the education, skills, training, and other qualifications necessary to provide Facility Services . Observations on 4/2/18 at 8:45 AM and 4/4/18 at 8:05 AM revealed Resident #1 was in her room. The resident was lying in bed with her arms contracted to her chest and her right leg was bent at the knee. Interview with the Administrator on 4/2/18 at 10:30 AM, in the MDS office, indicated all falls were investigated by Risk Management. Interview with Registered Nurse (RN) #19 on 4/3/18 at 8:00 AM, by phone, revealed when she was notified of the fall, the resident had already been transferred to the shower chair and was in the shower room. The RN assessed the resident at that time and did not see any obvious deformities or swelling. The resident was nonverbal and did not appear to be in any distress at the time. Further interview revealed the RN was approached by the resident's family member approximately 1 to 2 hours later and the resident appeared to be in pain when her lower extremities were touched. Continued interview revealed the RN then reassessed the resident and noticed swelling and discoloration to lower extremities. Interview with the Director of Nursing (DON) on 4/3/18 at 1:10 PM, in the MDS office confirmed if a fall occurs in the facility the resident should be assessed by a nurse before moving. Interview with Family Member #2 on 4/4/18 at 8:05 AM, in the resident's room, indicated the family comes to the facility at meals times to assist the resident with eating. Family Member #2 indicated the resident had been bed ridden at home for approximately [AGE] years prior to becoming a resident at the facility and had been mostly cared for by family at home. The family stated the resident was lying in bed on the day of the fall, and when they came to feed her the family member sat on the bed next to the resident and the resident made a face and groaned. The family member pulled the cover back and noticed the leg was swollen and discolored. The nurse was notified and x-rays were ordered. The family member stated the resident had increased pain but this has been controlled with a change in medications. Interview with Certified Nursing Assistant (CNA) #20 on 4/4/18 at 8:10 AM, by phone, revealed when she answered the call light the resident was on the floor in a sitting position with her legs bent beside her. Continued interview revealed she helped the Hospice CNA transfer the resident into the shower chair, and then immediately notified the charge nurse of the incident. Further interview revealed the resident had not appeared to be in distress due to the resident had not exhibited any crying or moaning at the time of the fall. Interview with the Hospice CNA on 4/4/18 at 10:30 AM, by phone revealed she was attempting to give the resident a shower. She sat the resident up on the side of the bed and locked the shower chair next to the bed for transfer. When she realized the resident was too heavy to lift by herself she slid the resident down her leg to the floor and put the call light on for assistance. When assistance from a facility CNA came, they transferred the resident to the shower chair and she took the resident to the shower prior to the resident being assessed by the nurse. She stated this was the first time she had worked with the resident and was not aware of the need for a 2 persons assist, and was not aware of where to look to find the information. Interview with the Administrator on 4/4/18 at 11:30 AM, in the MDS office, indicated the training for the Hospice CNA's were required prior to them assisting residents at the facility, along with a background check and proof of certification. Continued interview with the Administrator revealed the facility does not require the hospice agency to provide updated training documentation. Interview with the Administrator on 4/11/18 at 1:15 PM, by phone revealed the Hospice CNA was not using a gait belt to transfer the resident. The Administrator stated that they have numbers above each resident's bed who need help with transferring; 1 would need assistance of 1 person, 2 would need assistance of 2 people.",2020-09-01
162,CHRISTIAN CARE CENTER OF UNICOI COUNTY,445077,100 GREENWAY CIRCLE,ERWIN,TN,37650,2017-05-03,329,D,0,1,5FIN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure 1 resident (#16) received a medication in a decreased doseage as ordered by the physician, of 5 residents reviewed for unnecessary medications of 24 residents sampled. The findings included: Medical record review revealed Resident #16 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Medical record review of the Pharmacist Medication Review dated 3/8/17 revealed .Change Quetiapine (medication used to treat mental/mood disorders) to 75 mg (milligrams) q AM (every morning) and 75 mg q HS (every night) . Continued medical record review revealed a check mark and the physician's initials that indicated the dosage should be reduced as recommended by the pharmacist. Medical record review of the Physicians Orders dated 3/1/17 through 3/31/17, 4/1/17 through 4/30/17, and 5/1/17 through 5/31/17 revealed .Quetiapine 100 mg 1 tablet PO (by mouth) every evening . Medical record review of the Medication Administration Record [REDACTED].Quetiapine 100 mg 1 tablet PO every evening . was documented as administered through 5/2/17. Interview with the Director of Nursing (DON) on 5/3/17 at 10:42 AM, in the 100 nurse's station, revealed that it would be up to the shift leader to write the order, on a telephone order sheet, after the Medical Doctor (MD) had checked the pharmacy review to make the change.I've got the (MONTH) MAR, and it's not been changed .We missed it . Further interview confirmed the facility failed to follow the facilities process of implementing pharmacy recommendations and failed to ensure Resident #16 received a medication in a decreased doseage.",2020-09-01
163,CHRISTIAN CARE CENTER OF UNICOI COUNTY,445077,100 GREENWAY CIRCLE,ERWIN,TN,37650,2019-06-05,640,C,0,1,2MLG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, and interview the facility failed to submit a discharge Minimum Data Set (MDS) discharge assessment timely for one resident (#2) of 1 resident reviewed for discharge MDS assessments of 21 sampled residents. The findings include: Review of the RAI Version 3.0 Manual Chapter 2: Assessments for the RAI revealed .Discharge assessment .Must be submitted .within 14 days after the MDS completion date . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed Resident #2 was discharged home on[DATE]. Medical record review of the MDS assessments revealed a discharge assessment was completed on 1/1/19. Interview with Registered Nurse (RN) Information Nurse Consultant on 06/05/19 at 1:50 PM, in the Executive Director's office revealed .discharge assessment was completed but was never transmitted . Continued interview confirmed the facility failed to submit a discharge assessment for the 1/1/19 discharge for Resident #2.",2020-09-01
164,CHRISTIAN CARE CENTER OF UNICOI COUNTY,445077,100 GREENWAY CIRCLE,ERWIN,TN,37650,2019-06-05,656,D,0,1,2MLG11,"**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 implement a fall intervention for 1 resident (#18) and failed to develop a care plan to include the use of a lap belt for 1 resident (#33) of 21 sampled residents. The findings include: Review of the facility policy Care Plans, revised 11/2018, revealed .Identify needs .Include Physicians .orders Care Plans will be updated as changes occur . Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition. Further review revealed the resident required extensive assist of 2 staff members for bed mobility and transfers. Medical record review of a fall investigation dated 5/19/19 revealed the resident had a fall from the bed on 5/18/19. Further review revealed .New Intervention Description .Bed bolsters (long pillow used for support) in place . Medical record review of the care plan dated 3/8/2019 and revised 5/18/19 revealed .I may fall because of .my cognitive impairment .floor mat added to left side of bed and bed bolster . Observation of Resident #18 on 6/3/19 at 11:40 AM, in the resident's room, revealed the resident lying on the bed with an alarm on the bed and mats at the bedside. Further observation revealed no use of bed bolsters. Observation of Resident #18 on 6/4/19 at 1:47 PM, in the resident's room, revealed Resident #18 lying on the bed with an alarm on the bed and mats at the bedside. Further observation revealed no use of bed bolsters. Observation and interview of Resident #18 with Licensed Practical Nurse (LPN) #2 on 6/5/19 at 8:21 AM, in the resident's room, revealed the bed bolsters were not in use. Further interview confirmed .(Resident #18) .is supposed to have them . Interview with the MDS Coordinator on 6/5/19 at 8:39 AM, in the MDS office, confirmed the resident was care planned for the use of bed bolsters. Continued interview and observation, in the resident's room, confirmed the bed bolsters were not in use. Interview with the Executive Director (ED) on 6/5/19 at 10:38 AM, in the ED's office, confirmed the facility failed to follow the care plan for the use of bed bolsters for Resident #18. Medical record review revealed Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Continued review revealed the resident needed extensive assist of 2 staff members for bed mobility, transfer, toileting and had limited range of motion to all extremities. Medical record review of the Physician's Orders revealed .Self release lap belt in electric w/c (wheel chair) per resident request .4/10/19 . Medical record review of the care plan revealed no documentation of the use of a self release lap belt. Observation of Resident #33 on 6/3/19 at 3:19 PM, in the resident's room, revealed the resident sitting in an electric w/c with a self release lap belt in use. Observation of Resident #33 on 6/4/19 at 1:41 PM, in the resident's room, revealed the resident sitting in an electric w/c with a self release lap belt in use. Interview with the MDS Coordinator on 6/4/19 at 3:44 PM, in the MDS office, confirmed the lap belt had been in use since 4/10/19. Further interview confirmed the use of the self release belt had not been addressed on the resident's care plan. Interview with the ED on 6/5/19 at 7:35 AM, in the conference room, confirmed the facility failed to develop a care plan for Resident #33's use of a self release lap belt.",2020-09-01
165,CHRISTIAN CARE CENTER OF UNICOI COUNTY,445077,100 GREENWAY CIRCLE,ERWIN,TN,37650,2019-06-05,689,D,0,1,2MLG11,"**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 implement a fall intervention to prevent accidents for 1 resident (#18) of 3 residents reviewed for falls of 21 sampled residents. The findings include: Review of the facility policy Fall Prevention Program, last revised 3/2017, revealed .Document the fall risk measures in the resident care plan .Assess for safety devices a minimum of once per shift for placement and functioning . Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition. Further review revealed the resident required extensive assist of 2 staff members for bed mobility and transfers. Medical record review of a fall investigation dated 5/19/19 revealed the resident had a fall from the bed on 5/18/19. Further review revealed .New Intervention Description .Bed bolsters (long pillow used for support) in place . Medical record review of the care plan dated 3/8/2019 and revised 5/18/19 revealed .I may fall because of .my cognitive impairment .floor mat added to left side of bed and bed bolster . Observation of Resident #18 on 6/3/19 at 11:40 AM, in the resident's room, revealed the resident lying on the bed with an alarm on the bed and mats at the bedside. Further observation revealed no use of bed bolsters. Observation of Resident #18 on 6/4/19 at 1:47 PM, in the resident's room, revealed Resident #18 lying on the bed with an alarm on the bed and mats at the bedside. Further observation revealed no use of bed bolsters. Observation and interview of Resident #18 with Licensed Practical Nurse (LPN) #2 on 6/5/19 at 8:21 AM, in the resident's room, revealed the bed bolsters were not in use. Further interview confirmed .(Resident #18) .is supposed to have them . Interview with the MDS Coordinator on 6/5/19 at 8:39 AM, in the MDS office, confirmed the resident was care planned for the use of bed bolsters. Continued interview and observation, in the resident's room, confirmed the bed bolsters were not in use. Interview with the Executive Director (ED) on 6/5/19 at 10:38 AM, in the ED's office, confirmed the facility failed to implement care planned intervention to prevent accidents for Resident #18.",2020-09-01
166,CHRISTIAN CARE CENTER OF UNICOI COUNTY,445077,100 GREENWAY CIRCLE,ERWIN,TN,37650,2019-06-05,761,D,0,1,2MLG11,"Based on observation and interview the facility failed to properly label and store medications for 1 of 2 medication carts observed. The findings include: Observation and interview of the station 2 medication cart with Licensed Practical Nurse (LPN) #1 on 6/5/19 at 11:15 AM, on the station 2 hallway, revealed 2 medication cups in the medication cart with opened and unlabeled medications in the cups. Continued observation and interview confirmed LPN #1 had prepared the medications and placed the medications in the cups for administration to residents, and had then left the cart to do another task. Interview with the Executive Director (ED) on 6/5/19 at 12:34 PM, in the ED's office, confirmed the facility failed to properly label and store the medications in the medication cart.",2020-09-01
167,CHRISTIAN CARE CENTER OF UNICOI COUNTY,445077,100 GREENWAY CIRCLE,ERWIN,TN,37650,2018-06-13,641,D,0,1,KXBN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to ensure the Minimum Data Set (MDS) was accurate for 1 (#6) of 26 residents reviewed. The findings included: Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Hospice Certification of Terminal Illness signed by the physician on 1/16/18 revealed .This is to certify that the beneficiary, named below, is terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course . Medical record review of the quarterly MDS dated [DATE], revealed .section J1400 Prognosis. Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? (Requires physician documentation) . Continued review of the quarterly MDS dated [DATE] revealed the response to section J1400 was no. Interview with the MDS Coordinator on 6/12/18 at 11:00 AM, at the nursing station, confirmed the MDS dated [DATE] was not accurate and did not reflect the resident had a condition or chronic disease that might result in a life expectancy of less than 6 months.",2020-09-01
168,CHRISTIAN CARE CENTER OF UNICOI COUNTY,445077,100 GREENWAY CIRCLE,ERWIN,TN,37650,2018-06-13,655,D,0,1,KXBN11,"**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 use of antipsychotic and antianxiety medications for 1 resident (#16) of 5 residents reviewed who were admitted in the past 30 days. The findings included: Resident #16 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the readmission physician's orders [REDACTED]. Medical record review of the baseline Care Plan dated 5/31/18 revealed no documentation to address the resident's use of antipsychotic and antianxiety medications. Interview with the Director of Nursing (DON), on 6/13/18 at 9:10 AM, in the DON's office, confirmed a baseline Care Plan had not been developed to address the use of the antipsychotic and antianxiety medications.",2020-09-01
169,CHRISTIAN CARE CENTER OF UNICOI COUNTY,445077,100 GREENWAY CIRCLE,ERWIN,TN,37650,2018-06-13,656,D,0,1,KXBN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to develop a care plan to address Diabetes for 1 resident (#37) of 26 residents reviewed. The findings included: Medical record review revealed Resident #37 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the readmission physician's orders [REDACTED]. Medical record review of the current Care Plan dated 5/31/18 revealed no documentation to address the resident's Diabetes with the need for insulin. Interview with the Director of Nursing on 6/12/18 at 2:35 PM, in the Minimum Data Set office, confirmed a Care Plan was not developed to address the resident's Diabetes or insulin.",2020-09-01
170,CHRISTIAN CARE CENTER OF UNICOI COUNTY,445077,100 GREENWAY CIRCLE,ERWIN,TN,37650,2018-06-13,657,D,0,1,KXBN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to revise the Care Plan for 1 resident (#31) of 26 resident's reviewed. The findings included: Medical record review revealed Resident #31 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a nursing note dated 6/8/18 revealed the resident's family was concerned the resident was sick and had expiratory wheezing. Continued review of the nursing note revealed the physician was notified and orders were received. Medical record review of a chest x-ray dated 6/8/18 revealed Impression: 1. Density in the right infrahilar region which may be due to atelectasis versus developing infiltrate .2. Persistent small left pleural effusion with persistent left basilar atelectasis . Medical record review of a physician's orders [REDACTED]. Medical record review of the Care Plan dated on 5/9/18 revealed no documentation to address the resident's current Pneumonia and treatment. Interview with the Director of Nursing (DON) on 6/12/18 at 5:40 PM, in the Minimum Data Set office confirmed the Care Plan dated 5/9/18 was not revised to address the resident's treatment for [REDACTED].",2020-09-01
171,CHRISTIAN CARE CENTER OF UNICOI COUNTY,445077,100 GREENWAY CIRCLE,ERWIN,TN,37650,2018-06-13,686,D,0,1,KXBN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review,review of the facility skin assessment schedule, interview and observation the facility failed to complete a skin assessment in a timely manner prior to the development of a pressure ulcer for 1 resident (#29) of 2 residents reviewed for pressure ulcers. The findings included: Medical record review revealed Resident #29 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Skin assessment dated [DATE] revealed a picture with bilateral heels circled with a note .red blanchable . Medical record review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident was at risk for developing a pressure ulcer. Continued review of the MDS revealed the resident did not have a pressure ulcer. Medical record review of a Braden scale dated 5/25/18 revealed a score of 14, indicating the resident is at moderate risk for developing a pressure ulcer. Medical record review of a skin assessment dated [DATE] (Friday) revealed a picture of the right heel circled and a note Red heel/blanchable. Medical record review of the facility skin assessment schedule revealed the resident was scheduled to have a weekly skin assessment every Friday. Medical record review of a note on a skin assessment dated [DATE] (Friday), revealed refused skin assessment Medical record review of a nurse's note dated 6/11/18 revealed .Noted during treatment .resident had area of dark/non blanchable skin to Right heel measuring approximately 3.4 x 2 cm (centimeter), middle area more red/purple, surrounding skin more brown in appearance . Area dry and intact . Medical record review of a physician's orders [REDACTED].Float heels while in bed . Interview with the Director of Nursing on 6/12/18 at 1:35 PM, in the MDS office, confirmed if a resident refused a skin assessment the nurse should have returned later to attempt to complete the skin assessment or pass it on for the next shift to complete. Continued interview confirmed the facility failed to complete a skin assessment in a timely manner for Resident #29. Interview with the Wound Nurse on 6/12/18 at 1:40 PM, in the MDS office revealed the resident had a scheduled skin assessment to be completed every Friday. Continued interview confirmed the residents skin assessment was refused by the resident on 6/8/18 and not completed until 6/11/18 and a deep tissue injury was noted at that time. Further interview confirmed the facility failed to complete a skin assessment in a timely manner resulting in the development of a deep tissue injury. Observation of the resident's pressure ulcer with the Wound Nurse on 6/13/18 at 9:10 AM, in the resident's room revealed a dry deep tissue injury, approximately quarter size, purple in color to the right heel.",2020-09-01
172,CHRISTIAN CARE CENTER OF UNICOI COUNTY,445077,100 GREENWAY CIRCLE,ERWIN,TN,37650,2018-06-13,880,D,0,1,KXBN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the manufacturer's recommendations, medical record review, observation and interview the facility failed to appropriately disinfect a glucose meter (a meter to check blood sugar) after use for 1 resident (#3) of 1 resident observed after use of a glucose meter. The findings included: Review of the manufacturer's instructions for Sani-Cloth, Germicidal Disposable Wipe undated revealed .Areas of Use .Hospital, Healthcare, and Critical Care use .May be used on hard non-porous surfaces of; Bed railings; blood glucose meters .To disinfect nonfood contact surfaces only: Unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for a full two (2) minutes. Let air dry . Review of the facility Adult Sliding Scale Insulin Protocal dated 1/31/18 revealed .Fingerstick Blood Sugar .QID (4 times per day) . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of Certified Nursing Assistant (CNA) #1 on 6/12/18 at 11:08 AM, in Resident #3's room revealed the CNA completed a blood glucose check on the resident in his room; brought the glucose meter to a rolling table outside of the resident's room; disinfected the glucose meter for approximately 5 seconds and returned the meter to the case. Interview with CNA #1 on 6/12/16 at 11:15 AM, at the nurse's station confirmed the facility used sani-wipes to disinfect the glucose meter after each use. Continued interview confirmed the CNA was not aware of the manufacturer's instructions for the sani-cloth and failed to appropriately disinfect the glucose meter. Interview with the Director of Nursing on 6/12/18 at 12:50 PM, in the Minimum Data Set (MDS) office confirmed the facility failed to appropriately disinfect the glucose meter and failed to follow the manufacturer's recommendations.",2020-09-01
173,"NHC HEALTHCARE, SPRINGFIELD",445088,608 8TH AVE EAST,SPRINGFIELD,TN,37172,2017-08-11,241,E,0,1,BNHK11,"**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 dignity when a foley catheter was not contained in a dignity bag for 1 of 2 (Resident #41) sampled residents with a urinary catheter and 4 of 13 (Certified Nursing Assistant (CNA) # 7, 8, 9 and 13) staff did not request permission to enter resident rooms or referred to residents as boo. The findings included: 1. The facility's Quality of life-Dignity policy documented, .Residents shall be treated with dignity and respect at all times .Residents' private space and property shall be respected at all times .request permission before entering resident's rooms .speak respectfully to resident's .addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number .11. Demeaning practices .that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed . helping the resident to keep urinary catheter bags covered . 2. Medical record review revealed Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].catheter indwelling .provide catheter care . Observation in Resident #41's room on 8/7/17 at 4:02 PM and 8/8/17 at 8:05 AM revealed the urinary catheter bag hanging on the side of the bed without a dignity bag covering it. 3. Observation during a confidential resident interview on 8/8/17 at 8:05 AM in Resident #41's room revealed CNA #8 entered the room without asking permission and stated .ready for your breakfast . CNA #7 then entered Resident #41's room without knocking or requesting permission to enter to deliver a breakfast tray. Observation during a confidential resident interview on 8/8/17 at 11:07 am in Resident #73's room, revealed CNA #8 entered the room without knocking or requesting permission to enter the room and went to the B side of the room to assist the resident with the television. Observation on 8/10/17 at 8:33 AM revealed CNA #13 knocked on Resident #73's door and stated, .breakfast . without requesting permission to enter the resident's room. Observation on 8/10/17 at 8:35 AM revealed CNA #8 knocked on Resident #41's door and stated, .hey boo . and then entered the room without requesting permission to enter. Interview with the Director of Nursing (DON) on 8/11/17 at 4:30 PM outside the Conference Room, the DON confirmed the staff should ask permission before entering a resident's room, that Foley catheter bags should be in a dignity bag and that referring to a resident as Boo was not acceptable.",2020-09-01
174,"NHC HEALTHCARE, SPRINGFIELD",445088,608 8TH AVE EAST,SPRINGFIELD,TN,37172,2017-08-11,280,E,0,1,BNHK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of Interdisciplinary Care Plan Meeting sign in sheets, medical record review, observation and interview, the facility failed to include Certified Nursing Assistants (CNAs) in Interdisciplinary Care Planning Meetings for 4 of 5 (Resident # 17, 41, 73, and 140) sampled residents, failed to revise the care plan related to dental status for 2 of 5 (Resident #17 and 73) sampled residents with dental concerns, and failed to implement appropriate interventions for falls for 1 of 1(Resident #36) sampled residents reviewed for falls of the 37 residents reviewed during the stage 2 review. The findings included: 1. Review of the facility's Care Plan Development policy documented, .Standard The center will ensure an interdisciplinary and comprehensive approach to the development of the patient's plan of care .the meeting schedule will also be developed to assure a full interdisciplinary teams' presence and involvement in the care plan meeting .Who is responsible for care plan development: .Nursing staff as close to the patient care as possible .Care plans are updated as needed .New problems are handled as they arise, and are (to) be added to the current care plan even if the change in condition is not considered significant enough for a complete revision . 2. Medical record review revealed Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set ((MDS) dated [DATE] revealed Resident #17 was cognitively intact and had obvious or likely cavity or broken natural teeth. Review of the significant change MDS dated [DATE] revealed that Resident #17 was cognitively intact and had obvious or likely cavity or broken natural teeth. Observation in Resident #17's room on 8/7/17 at 4:00 PM, revealed Resident #17 had missing teeth on the middle upper gums. Interview with Resident #17 on 8/7/17 at 4:05 PM, in his room, Resident #17 was asked about his teeth. Resident #17 stated, I have some teeth that hurt, I want to be seen by a dentist . Interview with Certified Nursing Assistant (CNA) #2 on 8/9/17 at 8:56 AM, outside Resident #17's room, CNA #2 was asked if she had attended an interdisciplinary team meeting for her residents. CNA #2 stated, No. Interview with CNA #3 on 8/10/17 at 9:00 AM, near the East Hall nurses station, CNA #3 was asked if she ever attended Interdisciplinary Team Meetings for her residents. CNA #3 stated, .maybe a year ago . Interview with the MDS Coordinator 8/11/17 at 8:31 AM, in the MDS office, the MDS Coordinator was asked if she attended the interdisciplinary team meeting. The MDS Coordinator stated, No . The MDS coordinator was asked if there were ever CNAs in the interdisciplinary team meetings. The MDS Coordinator stated, Sometimes . The MDS Coordinator was asked if Resident #17's care plan should have been revised to reflect the changes in his dental status. The MDS Coordinator stated, Yes, had I known that information . The care plan was not revised to include Resident #17's missing teeth and dental concerns. The facility was unable to provide a copy of the Interdisciplinary Team Meeting sign in sheet for Resident #17. 3. Medical record review revealed Resident #41 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the facility's Interdisciplinary Care Plan Meeting sign in sheet dated 3/29/17 and 6/5/17 revealed only the Registered Dietician and the Social Worker signed in for the care plan meeting. Interview with CNA #11 on 8/10/17 at 3:50 PM, in the East Hall, CNA #11 was asked if she attends the care plan meetings. CNA #11 stated, .have not attended one . Interview with Licensed Practical Nurse (LPN) #4 on 8/10/17 at 3:55 PM, in the East Hall, LPN #4 was asked if CNAs attend the care plan meetings. LPN #4 stated, .No . 4. Medical record review revealed Resident #73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a significant change MDS assessment dated [DATE] revealed Resident #73 was coded for obvious or likely cavity or broken natural teeth. Review of the facility's Interdisciplinary Care Plan Meeting sign in sheet dated 2/2/17 revealed only Social Services, the Registered Dietician and the Occupational Therapy Assistant were in attendance at the meeting. On 3/31/17, the only staff that attended the meeting was Social Services and the Registered Dietician. On 7/31/17 the staff in attendance was the MDS staff, a Licensed Practical Nurse and the Assistant Social Worker. There was not a CNA in attendance at the interdisciplinary team meeting for this resident. Review of a care plan dated 5/8/17 revealed Resident #73 had no care plan for dental issues. Interview with the MDS Coordinator on 8/11/17 at 3:07 PM, in the Conference Room, the MDS Coordinator was asked if she would expect to see a care plan addressing Resident # 73's dental problems. The MDS Coordinator stated, Yes. 5. Medical record review revealed Resident #140 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's Interdisciplinary Care Planning Minutes dated 7/25/17 revealed the only staff members present for the meeting were the Director of Social Services and a Registered Nurse. Interview with the MDS Coordinator on 8/11/17 at 8:31 AM, in the MDS Coordinator office, the MDS Coordinator was asked if there were ever CNAs in the interdisciplinary team meetings. The MDS Coordinator stated, Sometimes . 6. Medical record review revealed Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly MDS dated [DATE] and a Significant Change MDS dated [DATE] revealed Resident #36 had severe cognitive impairment, had behaviors of pacing and rummaging, suffered with delusions and required extensive assistance with activities of daily living (ADL)s. Review of a care plan dated 8/8/17 documented, .I am at risk for falls . cognitive deficits, impaired balance . a history of falls .Orient Resident to surroundings, call light and location of personal items .Encourage me to ask for assistance .Verbally remind me not to get up alone .Remind patient as needed . Interview with the MDS Coordinator on 8/11/17 at 9:53 AM, in Conference Room, the MDS Coordinator was asked if the interventions on the care plan for Resident #36 were appropriate interventions. The MDS Coordinator stated, .Probably not . The care plan interventions for falls were inappropriate for a cognitively impaired resident.",2020-09-01
175,"NHC HEALTHCARE, SPRINGFIELD",445088,608 8TH AVE EAST,SPRINGFIELD,TN,37172,2017-08-11,309,D,0,1,BNHK11,"**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 timely pain assessments and timely administration of pain medication for 2 of 5 (Resident #41 and 190) residents reviewed for pain and failed to ensure a [MEDICAL TREATMENT] agreement contained the proper components for development and implementation of the resident's [MEDICAL TREATMENT] care plan or the interchange of information that is useful/necessary for the care of the [MEDICAL TREATMENT] resident. The findings included: 1.The facility's PAIN MANAGEMENT policy documented, .Pain management is extremely important to improve the quality of life for the suffering patients .Pain is so important that it can even change an individual's life .the goal of pain management is patient control of interventions for pain relief. Our goal is to promote comfort, independence . 2. Medical record review revealed Resident #41 was admitted to the facility on [DATE] with a readmission on 5/23/16 with [DIAGNOSES REDACTED]. A current physician's orders [REDACTED].BIOFREEZE 4% GEL (MENTHOL) TOPICALLY TO BILATERAL KNEES TWO TIMES A DAY AS NEEDED FOR JOINT PAIN . Review of the (MONTH) (YEAR) Medication, Treatment and Task Administration Record Report (MAR) revealed RN #4 administered [MEDICATION NAME] 20 mg tablet on 8/8/17 at 10:18 AM for pain reported as a 9 with an outcome of 3 documented at 10:57 AM. Interview with Registered Nurse (RN) #4 on 8/8/17 9:58 AM, in the East Hall, RN #4 was asked if there had been any reports of Resident #41 having pain. RN #4 stated, .no not to me . The medication was administered 20 minutes after the surveyor asked RN #4 if Resident #41 had requested any medication for pain. Interview with Resident #41 on 8/8/17 at 5:21 PM, in Resident #41's room, Resident #41 was asked about her complaint of pain that morning and Resident #41 stated, I had a pain pill and then later they rubbed some medicine on them. They're not hurting now or since earlier today. There was no documented pain assessment conducted prior to or after the administration of the Biofreeze. Interview with RN #4 on 8/10/17 at 11:35 AM in the East Hall nurses station, RN #4 was asked about pain assessments and topical medications for pain. RN #4 stated, .a pain level is done at anytime there is a complaint of pain .prn (as needed) topical there is a pain assessment before .reassessed after the medication . 3. Medical record review revealed Resident #190 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 5 day Minimum Data Set ((MDS) dated [DATE] revealed Resident #190 had a Brief Iinterview for Mental Status (BIMS) score of 13, indicating normal cognition, and received pain medication as needed. Review of the 14 day MDS dated [DATE] revealed Resident #190 had a BIMS of 13 and received non-pharmacological interventions for pain. A physician's orders [REDACTED].[MEDICATION NAME] .50 MG (milligram) TABLET .ONE .BY MOUTH EVERY 6 HOUR AS NEEDED FOR INCREASED PAIN . Observations on the East Hall on 8/10/17 at 7:20 AM, revealed Certified Nursing Assistant (CNA) #1 came to the East Hall nurse's station and reported to Licensed Practical Nurse (LPN) #4 that (Resident #190) is hurting and wants a pain pill. LPN #4 completed the controlled medication count with RN #2 and administered medications to another resident without addressing Resident #190's pain. While LPN #4 was administering medications to another resident, the surveyor went to Resident #190's room and the resident was lying in bed grimacing. Resident #190 was asked if he was hurting and he grabbed his right side and moaned, My right side hurts bad Resident #190 was asked how long he had been hurting and he stated, About an hour, I told them I needed something. Resident #190 was asked if he could rate his pain on a scale between 1 and 10, with 10 being the worst and he stated, 7. At 7:56 AM, LPN #4 entered Resident #190's room to obtain his vital signs. As she placed the blood pressure cuff on Resident #190's left arm, Resident #190 stated, I'm hurting. LPN #4 returned to her cart and did not perform a pain assessment at that time. Upon return to Resident #190's room LPN #4 asked him to rate his pain on the pain scale. Still grimacing, Resident #190 stated, 7. At 8:06 AM, LPN #4 administered Resident #190's pain medication with his morning medications. Resident #190's pain was reported to LPN #4 at 7:20 AM and he received his pain medication at 8:06 AM, 46 minutes after LPN #4 was made aware the resident was in pain. Interview with LPN #2 on 8/10/17 at 1:46 PM, on the East Hall near room [ROOM NUMBER], LPN #2 was asked how long a resident should wait to get pain medication after the resident reported the need for medication and LPN #2 stated, They should get it right away . Interview with the Director of Nursing (DON) on 8/11/17 at 5:08 PM, in the Conference Room, the DON was asked when a resident should receive pain medication after reporting pain and the DON stated, as soon as possible. 4. Review of the facility's [MEDICAL TREATMENT] ASS[NAME]IATES .NURSING HOME AGREEMENT dated (MONTH) 5, 1998, revealed that the agreement did not address the development and implementation of the resident's [MEDICAL TREATMENT] care plan or the interchange of information that is useful/necessary for the care of the [MEDICAL TREATMENT] resident. Interview with the DON on 8/10/17 at 9:25 AM, in the Assistant Director of Nursing/Dietary Office, the DON was asked if the [MEDICAL TREATMENT] Agreement addressed the development and implementation of the resident's [MEDICAL TREATMENT] care plan. The DON read over the agreement and stated, I don't see it specifically in here. The DON was asked if the [MEDICAL TREATMENT] Agreement addressed the interchange of information necessary for the care of the [MEDICAL TREATMENT] resident. The DON stated, Not specific, no.",2020-09-01
176,"NHC HEALTHCARE, SPRINGFIELD",445088,608 8TH AVE EAST,SPRINGFIELD,TN,37172,2017-08-11,314,D,0,1,BNHK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the European Pressure Ulcer Advisory Panel (EPUAP) and Pan Pacific Pressure Injury Alliance. Prevention and treatment of [REDACTED].Prevention and treatment of [REDACTED].#37) sampled residents reviewed of the 3 residents with pressure ulcers. The findings included: 1. The EPUAP European Pressure Ulcer Advisory Panel, National Pressure Ulcer Advisory Panel (NPUAP), and Pan Pacific Pressure Injury Alliance Prevention and treatment of [REDACTED].INTERNATIONAL NPUAP/EPUAP PRESSURE ULCER CLASSIFICATION SYSTEM .Category/Stage II .Partial Thickness Skin Loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough .intact or open serum filled blister .Category/Stage III .Full thickness tissue loss .Subcutaneous fat may be visible .slough may be present .May include undermining and tunneling .(page) 13 .Category/Stage IV: Full Thickness Tissue Loss .Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling .Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage, cannot be determined .(page) 16 .Conducting Skin and Tissue Assessment 1. In individuals at risk of pressure ulcers, conduct a comprehensive skin assessment .as part of every risk assessment .ongoing based on the clinical setting and the individual's degree of risk .Accurate documentation is essential for monitoring the progress of the individual and to aiding communication between professionals . 3. The facility's Skin Integrity Manual .ASSESSMENT/GUIDELINES/STAGING CRITERIA/PAIN policy documented, .ASSESSMENT . Admission, Readmission, and Return from Transfer Assessments .Time Frames .Initiated promptly on admission/readmission/or return .2. Tools .Braden .Assessment .Admission Nursing Assessment .Medication list, Skin Assessment Record .d. Wound Assessment Record .Wound assessment includes type, stage, locations and measurement of site .(length, width and depth) .Exudate .type, odor, amount, color .wound bed to include .necrotic tissue .slough .fribin ([MEDICATION NAME]), granulation, epithelization, tunneling/undermining .Periwound & (and) wound edge appearance to include description and measurement .signs/symptoms of infection . 4. Medical record review revealed Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] documented that Resident #37 had severely impaired cognition, was at risk for developing pressure ulcers, and had a stage 4 pressure ulcer with measurements 13.0 centimeters (cm) long, 15.0 cm wide and 6.0 cm deep. Review of an Admission Nursing Assessment Report dated 7/14/17 revealed a body diagram for Resident #37 that had the coccyx/sacral area marked stage IV (4) sacrum and the upper thigh/buttock area marked unstageable, and a nursing note that documented, .Decubitus ulcers noted to sacrum and R (right) thigh w/ (with) wound care as ordered. There were no other wound assessments performed for the stage IV coccyx/sacral wound or for the unstageable upper thigh/buttock wound on the Admission Nursing Assessment Report. Review of the Admission Nursing Assessment signed by an Registered Nurse (RN) on 7/15/17 documented .decubitis ulcer noted to sacrum and R (right) thigh w(with)/wound care as ordered There was no documentation that wound care orders were received on admission. A Braden Scale Report for Resident #37 was not performed until 7/16/17, with a score of 11 obtained which indicated a high risk for developing a pressure ulcer. There was no initial wound assessment completed on 7/14/17 and no assessments of the sacral/coccyx or ischial wounds on 7/15/17 or 7/16/17. The WEEKLY WOUND ASSESSMENT PROGRESS NOTES dated 7/18/17 documented, .readmitted to facility from (named hospital) (with) extensive wounds .Stg. (stage) 4 p/u (pressure ulcer) to sacral/coccyx .fascia, muscle, and sub q (subcutaneous) tissue (with) some bone exposure . Review of the physician's orders [REDACTED]. Review of the Medication, Treatment and Task Administration Record Report for (MONTH) revealed that wound treatments were not provided for the sacral/coccyx or right ischial wounds until 7/17/17. Observations in Resident #37's room on 8/9/17 at 2:13 PM, with Registered Nurse (RN) #1, revealed Resident #37 had a large, deep wound of the sacrum. RN #1 assessed the wounds with measurements of the sacral wound of 9.0 by (x)15.0 x 5.0 cm (length by width by depth in centimeters) and a large wound on the upper thigh/buttock region (ischium) with measurements obtained by RN #1 of 5.5 x 5.5 x 2.4 cm. Interview with Licensed Practical Nurse (LPN) #2 on 8/10/17 at 1:16 PM, at the East Hall nurse's station, LPN #2 was asked what was the procedure when a resident with pressure wounds was admitted to the facility after 5 PM on a Friday. LPN #2 stated, We have a check off list and we have so much we can do prior to them getting here if we have the transfer orders .we get them verified, we fax the orders from the transferring facility to Medical Doctor (MD) #1. She looks over the orders, adds to them, okays them, signs them and sends them back .they normally send wound orders with them from the hospital or we contact Registered Nurse (RN) #1 or Medical Doctor (MD) #1 or MD #2 .take their vitals (vital signs), do a head to toe assessment .look at their skin within an hour of them getting here .if there are dressings remove and see what's underneath .cover it with a clean dressing until we get orders (for wound care). We call RN #1, the wound care nurse, and she contacts MD #2 .calls us back with them, those treatment orders. I would do the treatment at that time. LPN #2 was asked if she obtained measurements or described the wound bed when she assessed a wound on admission. LPN #2 stated, No .the Braden scale is done with those admission forms. Interview with LPN #3 on 8/10/17 at 2:13 PM, at the East Hall nurses station, LPN #3 was asked if a wound assessment was performed on admission for Resident #37 and if the resident received wound care for the sacral and ischial wounds on 7/14, 7/15, or 7/16/17. LPN #3 confirmed that a wound assessment was not performed on the sacral and ischial wound and that an order had not been obtained for wound care. LPN #3 confirmed wound care treatments had not been provided for the sacral and ischial wounds from 7/14 to 7/17/17. LPN #3 was asked if wound assessments were done when residents with wounds were admitted on the weekends. LPN #3 stated The resident is assessed when the wound care nurse returns on Monday. LPN #3 confirmed that a wound assessment was not performed by the nursing staff on the admission of Resident #37. Telephone interview with MD #2 on 8/10/17 at 4:30 PM, MD #2 was asked if he expected the nurses to call him for orders when a resident is admitted with pressure wounds after 5 PM on Friday or on the weekend. MD #2 stated, Yes. MD #2 further stated .there is a delay in what I want started . Interview with RN #1 on 8/10/17 at 5:34 PM, in the Conference Room, RN #1 was asked to explain the procedure when admitting a resident after 5PM on Fridays or on weekends. RN #1 was asked, if it was important to get orders for the weekend. RN #1 stated, .Definitely Saturday or Sunday, she should have gotten treatment . Interview with the Director of Nursing (DON) on 8/11/17 at 5:08 PM, in the Conference Room, the DON was asked if it was appropriate for a resident with stage 4 pressure ulcer to not receive wound care on the weekend. The ADON stated, .they would need wound care, yes, Ma'am.",2020-09-01
177,"NHC HEALTHCARE, SPRINGFIELD",445088,608 8TH AVE EAST,SPRINGFIELD,TN,37172,2017-08-11,323,D,0,1,BNHK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation and interview the facility failed to ensure the environment was free from accident hazards for 1 of 54 (Resident #178) resident rooms when razors were found in the resident room. The findings included: 1. The facility's Hazardous Item Policy documented, .some potential hazardous items include .any item labeled KEEP OUT OF REACH OF CHILDREN. This would include disposable razors . 2. Medical record review revealed Resident #178 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #178 had a Brief Interview of Mental Status (BIMS) score of 4 indicating severe impairment for decision making. The care plan dated 6/8/17 addressed potential for elopement, wandering and rejection of care. 3. Observations on 8/7/17 at 11:15 AM in Resident #178's room revealed one disposable razor in the bathroom and one disposable razor in the nightstand. Observations on 8/07/17 10:45 AM in the 40 hall revealed Resident #178 wandering down the hall. At 12:44 PM Resident #178 was observed on the 40 hall wandering around inside the nurses station. On 8/07/17 at 12:46 PM Resident #178 was observed at the 40 hall medication cart. The resident picked up the water pitcher, placed it back on the medication cart and spilled water on the floor in the process, and then walked into another resident's room. 4. Interview with Registered Nurse (RN) #3 on 8/07/17 at 12:00 PM, in the 40 hall, RN #3 was asked about Resident # 178 and RN #3 stated, Yes, I am familiar .he wanders around frequently . RN #3 was asked if Resident #178 should have razors in his room and RN #3 stated, .I'm not sure . Interview with Licensed Practical Nurse (LPN) #6 on 8/07/17 at 12:31 PM in the dining room, LPN #6 was asked if Resident #178 was confused or was a wanderer. LPN # 6 stated, .he does wander frequently and yes, he is confused. LPN #6 was asked if Resident #178 should have razors stored in his room. LPN # 6 stated, I'll have to take a look at his chart . Interview with the Director of Nursing (DON) on 8/11/17 at 5:21 PM in the conference room, the DON was asked if it is acceptable for residents with dementia to have razors in their bathroom. The DON stated, .No it is not .",2020-09-01
178,"NHC HEALTHCARE, SPRINGFIELD",445088,608 8TH AVE EAST,SPRINGFIELD,TN,37172,2017-08-11,371,F,0,1,BNHK11,"Based on policy review, observation and interview, the facility failed to ensure food was stored, prepared and served under sanitary conditions as evidenced by 3 of 9 (Dietary Manager (DM), Dietary Technician (DT) #1, and Regional Administrator (RA) staff in the kitchen not wearing hair covers or beard protectors, carbon build up on the cookware and appliances, 36 wet nested trays, a sugar bin without a lid, and soiled gloves lying on the food preparation table and on a food cart, 1 of 2 (West Hall) nutrition refrigerators had an orange substance covering the bottom of the refrigerator and an unlabeled, undated white Styrofoam cup that contained an unknown brown liquid. The facility had a census of 89 with 84 of those receiving a meal tray from the kitchen on 8/7/17 and 87 of those receiving a meal tray from the kitchen on 8/8/17 and 8/9/17. The findings included: 1. The facility's PERSONAL HYGIENE policy documented, .Dietary partners shall wear hair restraints such as hats, hair coverings or nets, beard restraints .that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens . Observations in the Kitchen on 8/7/17 at 10:40 AM, revealed the DM and the RA with no hair cover. Observations in the Kitchen on 8/7/17 at 11:40 AM, and on 8/8/17 at 1:21 PM, revealed DT #1 without a beard cover. Interview with the Director of Dietary on 8/8/17 at 1:21 PM, in the Kitchen, the Director of Dietary was asked what she expected when Kitchen staff or other facility staff enters the kitchen. The Director of Dietary stated, Anybody that comes in the door to the Kitchen has to have a hair net. The Director of Dietary confirmed that beards should be covered. 2. The facility's MANUAL WAREWASHING policy documented, .Air-dry all items. Make sure all items are completely dry before stacking to prevent wet-nesting . Observations in the Kitchen, on 8/7/17 at 10:55 AM, revealed 36 trays wet-nested in the dishwasher area. Interview with the DM on 8/7/17 at 10:58 AM, near the dishwasher area, the DM confirmed that the trays were wet nested. The DM was asked if wet nesting is appropriate. The Dietary Manager stated, No . 3. The facility's OVENS policy documented, .Daily .Wipe up spill as they occur .Remove shelves .Scrape burned particles from hearth .Brush out interior, shelf ledges .Weekly .Remove shelves .take to pot and pan sink .scrub .Rinse and wipe dry .Scrape burned-on particles .Scrub interior .shelf ledges inside and outside of door, and frame .Rinse inside and outside of oven .Replace clean shelves . The facility's EQUIPMENT CLEANING SCHEDULE documented, .Food Processors, Blenders, Chopper .Disassemble, clean, and sanitize equipment parts, surfaces .after each use or between each product change .Ovens .Clean spills, Clean interior surfaces and racks .Range .Clean spills .Clean work surfaces .Slicers .Disassemble, clean, and sanitize equipment pats, surfaces .Toaster .Clean outside . The facility's SLICER policy documented, .After each use .Wash all removable parts in detergent solution .Rinse in clean water and sanitize in sanitizing solution .Use brush or thick cloth pad to clean stationary parts of slicer with mild detergent solution .Rinse with clean cloth and clear warm water . Observations in the Kitchen on 8/7/17 at 10:50 AM, revealed carbon build up on (4) 20-count cupcake tins and carbon build up on the outside of a sauce pan on the shelf of the 3 compartment sink. Observations in the Kitchen on 8/7/17 at 11:10 AM and on 8/8/17 at 1:25 PM, revealed a toaster oven with a dried substance and carbon build up inside the oven and covering all 4 burners of the range, and Observations in the Kitchen on 8/8/17 at 1:27 PM, revealed a bin containing sugar with no lid, a dried pink substance on the plastic blade of the [NAME]o Coupe and a dried pink substance on the blade of the meat slicer. Interview with the DM on 8/7/17 at 11:09 AM, in the Kitchen, the DM was asked about the cupcake tins and the sauce pan with carbon build up. The DM stated, .Those are not supposed to be in here because of that build up .I thought they had been thrown away . Interview with the Dietary Director on 8/8/17 at 1:35 PM, in the Kitchen, the Dietary Director was asked if there should be carbon build up on kitchen appliances. The Dietary Director stated, No, Ma'am. The Dietary Director was asked if the outside of the toaster oven was clean. The Dietary Director stated, No, Ma'am. Interview with the Dietary Director on 8/8/17 at 1:37 PM, in the Kitchen, the Dietary Director was asked if the sugar bin should be kept covered. The Dietary Director stated, Yes. The Dietary Director was asked if she expected the appliances to be free from food residue. The Dietary Director stated, Yes, absolutely. 4. Observations in the Kitchen on 8/8/17 at 5:09 PM revealed 2 pair of used dirty rolled up disposable gloves lying on the food preparation table and 1 pair of used rolled up disposable gloves lying on a food cart. Interview with the Dietary Director on 8/8/17 at 5:13 PM, in the Kitchen, the Dietary Director was asked if it was appropriate to leave used gloves on the food preparation table or a food cart. The Dietary Director stated, No. 5. The facility's NOURISHMENT PANTRIES policy documented, .Foods placed in the refrigerator will be covered, labeled and dated .Cleaning of the refrigerators and storage areas in the nourishment pantries will be the responsibility of Nursing, Dietary or Housekeeping Department . Observations in the West Nursing Station nutrition refrigerator on 8/9/17 at 3:10 PM, revealed a brown liquid in an uncovered, unlabeled and undated white Styrofoam cup and an orange substance covering the bottom of the refrigerator. Interview with Licensed Practical Nurse (LPN) #6 on 8/9/17 at 3:10 PM, beside the West nursing station nutrition refrigerator, LPN #6 was asked if it was acceptable to have a cup with a brown substance uncovered in the nutrition refrigerator and an orange substance covering the bottom of the nutrition refrigerator. LPN #6 stated, No.",2020-09-01
179,"NHC HEALTHCARE, SPRINGFIELD",445088,608 8TH AVE EAST,SPRINGFIELD,TN,37172,2017-08-11,411,D,0,1,BNHK11,"**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 dental services were provided for 1 of 3 (Resident #17) sampled residents reviewed of the 37 residents reviewed in the stage 2 sample for dental. The findings included: 1. The facility's DENTAL SERVICES policy documented, .All patients should have provisions for routine and emergency care by a dentist .The center will assist (if necessary) the patient in making an appointment and arranging transportation . 2. Medical record review revealed Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The significant change Minimum Data Set ((MDS) dated [DATE] documented that Resident #17 was cognitively intact and had obvious or likely cavity or broken natural teeth. The significant change MDS dated [DATE] documented that Resident #17 was cognitively intact and had obvious or likely cavity or broken natural teeth. Observations in Resident #17's room on 8/7/17 at 4:00 PM, revealed Resident #17 had missing teeth on the middle upper gums. Interview with Resident #17 on 8/7/17 at 4:05 PM, in his room, Resident #17 was asked about his teeth. Resident stated, I have some teeth that hurt, I want to be seen by a dentist . Interview with Licensed Practical Nurse (LPN #5) on 8/11/17 at 10:24 AM, at the East Hall nurses station, LPN #5 was asked if she had assessed Resident #17's dental status. LPN #5 stated, Yes. LPN #5 was asked if she had referred him for dental services. LPN #5 stated, I did refer him to the Social Services Director because he sets up the dental appointments. Interview with the Social Services Director on 8/11/17 at 10:11 AM, in the Social Services office, the Social Services Director was asked if Resident #17 should have received dental services. The Social Services Director stated, Yes, Ma'am.",2020-09-01
180,"NHC HEALTHCARE, SPRINGFIELD",445088,608 8TH AVE EAST,SPRINGFIELD,TN,37172,2017-08-11,431,D,0,1,BNHK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation and interview the facility failed to ensure medications were properly labeled and stored for 1 of 54 (room [ROOM NUMBER]) rooms. The findings included: 1. The facility's Hazardous Item Policy documented, .some potential hazardous items include .any item labeled KEEP OUT OF REACH OF CHILDREN . 2. Observations on 8/7/17 at 11:15 AM, in room [ROOM NUMBER], revealed one tube of zinc oxide and one tube of hemorrhoid medication not labeled with a resident's name and unsecured in the bathroom. Observations on 8/07/17 10:45 AM in the 40 hall revealed Resident #178 wandering down the hall. At 12:44 PM Resident #178 was observed on the 40 hall wandering around inside the nurses station. On 8/07/17 at 12:46 PM Resident #178 was observed at the 40 hall medication cart. The resident picked up the water pitcher, placed it back on the medication cart and spilled water on the floor in the process, and then walked into another resident's room. 3. Interview with the Director of Nursing (DON) on 8/11/17 at 5:21 PM, in the Conference Room, the DON was asked if it was acceptable for residents to have medications stored in their bathroom. The DON stated, .No it is not .",2020-09-01
181,"NHC HEALTHCARE, SPRINGFIELD",445088,608 8TH AVE EAST,SPRINGFIELD,TN,37172,2017-08-11,441,D,0,1,BNHK11,"Based on policy review, observation and interview the facility failed to ensure staff practiced proper infection control practices during a bed bath for 1 of 1 (Resident #3) sampled residents observed during a bed bath. The findings included: The facility's Bath, Bed policy documented, .to clean, refresh and soothe patient .Wash your hands .Put on gloves .Wash face and ears, rinse and dry .Wash neck, arms, chest and abdomen, rinse and dry .Wash thighs, legs, and feet, rinse and dry .Wash back, buttocks and genitalia, rinse and dry (wash female genitalia from front to back to avoid cross-contamination with feces) .Remove gloves .Wash hands . Observations in Resident #3's room on 8/10/17 at 8:55 AM, revealed Certified Nursing Assistant (CNA) #12 performing a bed bath for Resident #3. Washcloth #1 was used for Resident #3's face, both arms and 1 swipe across her abdomen. Washcloth #2 was used to swipe the top of the right leg and the top of the left leg; while Resident #3 held her legs up CNA #12 swiped the abdomen again then used the same cloth for the right side of Resident #3's back and her bottom which had stool present. CNA #12 left the dirty wash cloth under the resident's bottom and turned the resident to her opposite side. CNA #12 used washcloth #3 for the other half of the resident's back and bottom. CNA #12 removed her gloves and failed to perform hand hygiene. CNA #12 used 3 washcloths for the entire bath and did not perform hand hygiene during the bed bath. Interview with the Director of Nursing (DON) on 8/11/17 at 11:33 AM, in the Conference Room, the DON was asked about the procedure and use of only 3 wash cloths for a bed bath. The DON read this surveyor's notes and stated, I would expect a different washcloth to be used .going from clean to dirty .",2020-09-01
182,"NHC HEALTHCARE, SPRINGFIELD",445088,608 8TH AVE EAST,SPRINGFIELD,TN,37172,2017-08-11,497,E,0,1,BNHK11,"Based on review of Certified Nursing Assistant (CNA) inservice hours and interview the facility failed to ensure the minimum 12 hours of inservice was completed for 5 of 23 (CNA #3, 6, 7, 8, and 10) CNA's employed for the (YEAR) calendar year. The findings included: 1. The CNA list of inservices provided by the facility revealed the following CNA's did not have the required 12 hours of inservice: a. CNA #6 Hire date 8/10/11 completed 9 hours of inservice. b. CNA #10 hire date 11/4/13 completed 9.75 hours of inservice. c. CNA #3 hire date 9/3/2007 completed 11.75 hours of inservice. d. CNA #8 hire date 5/2/2007 completed 10.75 hours of inservice. e CNA #7 hire date 11/2/1987 completed 6.5 hours of inservice. Interview with the Administrator on 8/11/17 at 2:20 PM, in the Conference Room, the Administrator confirmed the list of CNA inservice hours provided was for the CNA's employed the entire year of (YEAR).",2020-09-01
183,"NHC HEALTHCARE, SPRINGFIELD",445088,608 8TH AVE EAST,SPRINGFIELD,TN,37172,2017-08-11,520,D,0,1,BNHK11,"Based on policy review, medical record review, observation and interview, the facility's Quality Assessment and Assurance Committee (QAA) failed to implement an effective ongoing quality program that identified developed, implemented and monitored appropriate plans of action for care plans and kitchen sanitation. The findings included: 1. The QAA Committee failed to ensure that services were provided in accordance with each resident's written plan of care related to revising care plans and implementing appropriate interventions for fall prevention and implementing a plan to ensure interdisciplinary team meetings included members of the direct care staff. The deficient practice of F-280 is a repeat deficiency and was cited on the recertification survey on 10/30/13 and 5/13/15. Refer to F280 2. The QAA Committee failed to ensure food was served under sanitary conditions related to lack of hair restraints, wet nesting dishes, cleaning ovens and equipment, pans with carbon buildup, used gloves lying on food preparation area and cleanliness of nourishment refrigerators. The deficient practice of F371 is a repeat deficient practice for failure to store, prepare and distribute food under sanitary conditions. The facility was cited F371 on the recertification survey on 10/30/13, 5/13/15 and on 5/19/16. Refer to F371 3. Interview with the QAA Coordinator on 8/11/17 at 6:17 PM in the Health Information Manager office, the QAA Coordinator did not identify care planning and kitchen sanitation as an ongoing concern that the QAA Committee had identified.",2020-09-01
184,"NHC HEALTHCARE, SPRINGFIELD",445088,608 8TH AVE EAST,SPRINGFIELD,TN,37172,2018-08-22,695,D,0,1,ITOM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to provide oxygen therapy and bilevel positive airway pressure/continuous positive airway pressure ([MEDICAL CONDITION]/[MEDICAL CONDITION]) as ordered for 1 of 5 (Resident #27) sampled residents reviewed for respiratory services. The findings included: 1. The facility's undated MEDICATIONS, ADMINISTERING policy documented, .will give medications only per physician's orders [REDACTED]. Medical record review revealed Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented Resident #27 was cognitively intact and received oxygen therapy. The physician's orders [REDACTED].OXYGEN .3 LITERS/MINUTE VIA NASAL CANNULA . The Treatment Administration Record Report for (MONTH) (YEAR) documented, .OXYGEN 3 LITERS/MINUTE VIA NASAL CANNULA .7am-7pm .7pm-7am .3L (liters) . Observations in Resident #27's room on 8/20/18 at 10:45 AM and 2:30 PM, 8/21/18 at 9:50 AM, 10:30 AM, and 4:20 PM, and 8/22/18 at 7:30 AM, revealed Resident #27 was receiving oxygen via nasal cannula at a flow rate of 1.5 liters/minute. Interview with the Director of Nursing (DON) on 8/22/18 at 11:45 AM, in Resident #27's room, the DON was asked what the oxygen flow rate should be set on the concentrator. The DON stated, Whatever is on the physician's orders [REDACTED].>2. The facility's .Non-invasive Positive Pressure Ventilation Continuous Positive Airway Pressure Bilevel Costive Airway Pressure policy with a revision date of 1/05 documented, .Non-invasive Positive Pressure Ventilation (NIPPV) is used to manage spontaneously breathing patients with severe hypoxemia caused by .sleep apnea .NIPPV included Continuous Positive Airway Pressure ([MEDICAL CONDITION]) and Bilevel Positive Airway Pressure ([MEDICAL CONDITION]) . The physician's orders [REDACTED].AT BEDTIME . The Treatment Administration Record (TAR) Report documented, .[MEDICAL CONDITION]/[MEDICAL CONDITION] .AT BEDTIME PER PRESCRIBED .August 20 .A (Administered) .August 21 .A . Observations in Resident #27's room on 8/20/18 at 10:45 AM and 2:30 PM, 8/21/18 at 9:50 AM, 10:30 AM, and 4:20 PM, and 8/22/18 at 7:30 AM, revealed a [MEDICAL CONDITION]/[MEDICAL CONDITION] machine in the middle of the room on a table against the wall, with the tubing and mask unattached, and a gray plastic pipe and house shoes placed of top of the mask and tubing. Interview with Resident #27 on 8/23/18 at 10:20 AM, in Resident #27's room, Resident #27 was asked if he used his [MEDICAL CONDITION]/[MEDICAL CONDITION]. Resident #27 stated, No. I haven't used it in about 2 months. It is broken, see it is laying on that table over there and has been for a long time. Interview with the DON on 8/22/18 at 11:45 AM, in the conference room, the DON confirmed the TAR documented the [MEDICAL CONDITION]/[MEDICAL CONDITION] treatment was administered at bedtime 8/20/18 and 8/21/18. Interview with the DON on 8/22/18 at 12:20 PM, in Resident #27's room, the DON confirmed the [MEDICAL CONDITION]/CIPAP was broken. The DON stated, I don't know why this tray won't go in here .",2020-09-01
185,"NHC HEALTHCARE, LEWISBURG",445094,1653 MOORESVILLE HIGHWAY,LEWISBURG,TN,37091,2020-02-01,584,D,0,1,SLUH11,"Based on observation and interview, the facility failed to provide a comfortable and homelike environment when staff and family members were knocking loudly on the kitchen door on 2 of 6 days (1/28/2020 and 1/29/2020) of the survey. The findings include: Observation in the 100 Hall on 1/28/2020 at 8:30 AM, 9:00 AM, 9:17 AM, 9:25 AM, 9:50 AM, 1:30 PM, 3:13 PM, 4:15 PM, 4:25 PM and 6:40 PM, showed several staff members knocking loudly on the kitchen doors. Observation in the 100 Hall on 1/28/2020 at 1:27 PM, showed a family member knocking loudly on the kitchen doors. Dietary Aide #1 opened the kitchen door and the family member asked why was the kitchen door locked. Dietary Aide #1 stated, Because state is here . Observation in the 100 Hall on 1/29/2020 at 8:17 AM, showed several staff members knocking loudly on the kitchen doors. During an interview on 1/28/2020 at 9:56 AM, Resident #82 stated, They just started banging on the door while state is here .they lock it when state's (state is) in the building . During an interview on 1/30/2020 at 11:33 AM, Resident #15 stated, They lock the door when state is here . During an interview on 1/29/20 at 12:15 PM, the Regional Registered Dietitian confirmed that the staff and family members should not be knocking loudly on the kitchen doors. During an interview on 2/1/2020 at 11:26 AM, the Director of Nursing (DON) confirmed that she would not expect the staff members to be knocking loudly on the kitchen doors.",2020-09-01
186,"NHC HEALTHCARE, LEWISBURG",445094,1653 MOORESVILLE HIGHWAY,LEWISBURG,TN,37091,2020-02-01,637,D,0,1,SLUH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to initiate a significant change Minimum Data Set (MDS) assessment within 14 days after hospice services were ordered for 1 of 29 sampled residents (Resident #28) reviewed. The findings include: Review of the medical record, showed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the (Named Hospice) PHYSICIAN ORDERS [REDACTED].Admit to hospice services (sign for with) primary DX (diagnosis): Bladder CA (Cancer) . Medical record review, showed there was not a Significant Change MDS completed after Resident #28's admission to hospice services. The facility failed to complete a significant change MDS within 14 days of Resident #28's admission to hospice services. During an Interview on 1/30/2020 at 3:35 PM, the MDS Coordinator confirmed that a significant change MDS related to hospice was not completed for Resident #28.",2020-09-01
187,"NHC HEALTHCARE, LEWISBURG",445094,1653 MOORESVILLE HIGHWAY,LEWISBURG,TN,37091,2020-02-01,641,D,0,1,SLUH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure an assessment was accurate related to [MEDICAL TREATMENT] and hospice for 2 of 29 sampled residents (Resident #28 and #55) reviewed. The findings include: 1. Review of the medical record, showed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the (Named Hospice) PHYSICIAN ORDERS [REDACTED].Admit to hospice services (sign for with) primary DX (diagnosis): Bladder CA (Cancer) . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #28 was not coded for receiving hospice services. Review of the Physician order [REDACTED].Hospice to evaluate and treat as indicated per (Named Hospice) . During an interview on 1/30/2020 at 3:35 PM, the MDS Coordinator confirmed that the quarterly MDS dated [DATE] should have been coded for hospice services. 2. Review of the medical record, showed Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED].[MEDICAL TREATMENT] evey Tuesday, Thursday, and Saturday . Review of the quarterly MDS assessment dated [DATE], showed Resident #55 was not coded as receiving [MEDICAL TREATMENT]. During an interview on 1/30/2020 at 1:48 PM, the MDS Coordinator confirmed that the quarterly MDS dated [DATE] should have been coded for [MEDICAL TREATMENT].",2020-09-01
188,"NHC HEALTHCARE, LEWISBURG",445094,1653 MOORESVILLE HIGHWAY,LEWISBURG,TN,37091,2020-02-01,656,D,0,1,SLUH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure a comprehensive plan of care was developed for a [DIAGNOSES REDACTED].#65) reviewed. The findings include: Review of the medical record, showed Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan revised 1/28/2020, showed there was not a comprehensive Care Plan to reflect a [DIAGNOSES REDACTED]. During an interview on 2/1/2020 at 10:15 AM, Patient Coordinator #1 confirmed that Resident #65 did not have a Care Plan for the [DIAGNOSES REDACTED].",2020-09-01
189,"NHC HEALTHCARE, LEWISBURG",445094,1653 MOORESVILLE HIGHWAY,LEWISBURG,TN,37091,2020-02-01,689,D,0,1,SLUH11,"**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 residents' rooms were free from accident hazards when equipment was stored unsafely and a cord was hanging freely from the ceiling in 2 of 59 rooms (Resident #18's room and Resident #31's room). The findings include: Review of the facility's policy titled, DEPARTMENTAL FIRE PR[NAME]EDURES NURSING, revised 8/2018, showed that you should not place equipment into occupied patient rooms. 1. During an interview on 1/28/2020 at 4:52 PM, Life Enrichment Coordinator #1 confirmed that Life Enrichment Coordinator #2 pushed the meal cart into Resident #18's room during the fire drill. During an interview on 1/28/2020 at 7:09 PM, the Administrator confirmed that equipment should not be stored in occupied resident rooms. During an interview on 2/1/2020 at 11:33 AM, the Director of Nursing (DON) confirmed that equipment or meal carts should not have been stored in the resident's room. 2. Review of the medical record, showed Resident #31 had a [DIAGNOSES REDACTED]. Observation in the resident's room on 1/27/2020 at 10:30 AM, 1:20 PM, 4:55 PM, and 1/28/2020 at 7:30 AM, 12:15 PM, and 12:48 PM, showed a long black cord hanging freely from the ceiling of Resident #31's room. During an interview on 1/28/2020 at 5:45 PM, Licensed Practical Nurse (LPN) #1 stated, .I have been off 4 days .it wasn't there the last day I worked . During an interview on 1/28/2020 at 5:55 PM, the Maintenance Director confirmed that the black cord hanging from the ceiling could be an accident hazard. During an interview on 1/28/2020 at 6:00 PM, the Administrator stated, .I did not know this (cord) was hanging here .",2020-09-01
190,"NHC HEALTHCARE, LEWISBURG",445094,1653 MOORESVILLE HIGHWAY,LEWISBURG,TN,37091,2020-02-01,690,D,0,1,SLUH11,"**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 that an indwelling urinary catheter was secured for 1 of 2 sampled residents (Resident #77) reviewed. The findings include: The facility's policy titled, CATHETER CARE, INDWELLING (MALE AND FEMALE), dated 2005, showed to secure the catheter tubing at the insertion site. Review of the medical record showed, Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed that Resident #77 had an indwelling catheter. Review of the Care Plan dated 4/25/2019, showed no indication that Resident #77 refused to have his indwelling urinary catheter secured. Review of the physician's orders [REDACTED].#77 had an indwelling urinary catheter. Observation in the resident's room on 1/29/2020 at 9:52 AM, showed Resident #77's indwelling catheter tubing was unsecure and hanging freely. During an interview on 1/29/2020 at 10:50 AM, Patient Care Coordinator #1 stated that the resident would refuse to have his catheter secured. During an interview on 1/29/2020 at 2:29 PM, the Certified Nursing Assistant (CNA) Instructor stated, .anchor the tubing . During an interview on 1/29/2020 at 3:34 PM, the Director of Nursing (DON) stated that the resident would refuse to have his indwelling catheter secured. Medical record review showed, there was no documentation that Resident #77 would refuse to have his indwelling urinary catheter secured.",2020-09-01
191,"NHC HEALTHCARE, LEWISBURG",445094,1653 MOORESVILLE HIGHWAY,LEWISBURG,TN,37091,2020-02-01,842,D,0,1,SLUH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to maintain complete and accurate weights for 1 of 12 sampled residents (Resident #18) reviewed. The findings include: Review of the facility's undated policy titled, Weights, showed that if a discrepancy is noted with the weights the patient should be re-weighed using the same type of scale. Review of the medical record, showed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Weight Variance Report showed the following weights: 7/3/2019 - 121 lbs (pounds) 7/4/2019 - 173 lbs (52 lbs difference in 1 day) 9/12/2019 - 156 lbs 9/13/2019 - 145 lbs (11 lbs difference in 1 day) 9/19/2019 - 156 lbs 9/20/2019 - 145 lbs (11 lbs difference in 1 day) 11/20/2019 - 151 lbs 11/30/2019 - 127 lbs (24 lbs difference in 10 days) 12/1/2019 - 136 lbs 12/30/2019 - 127 lbs 1/1/2020 - 140 lbs (13 lbs difference in 2 days) 1/3/2020 - 127 lbs (13 lbs difference in 2 days) 1/3/2020 -140 lbs (13 lbs difference the same day) During an interview on 1/30/2020 at 12:50 PM, the Regional Registered Dietician (RD) confirmed that Resident #18's weights were incorrect. During an interview on 2/1/2020 at 11:35 AM, the Director of Nursing (DON) confirmed that Residents 18's weights were inaccurate.",2020-09-01
192,"NHC HEALTHCARE, LEWISBURG",445094,1653 MOORESVILLE HIGHWAY,LEWISBURG,TN,37091,2020-02-01,880,E,0,1,SLUH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were followed in 2 of 3 isolation rooms (Resident #55 and #73's rooms), failed to maintain infection control practices for respiratory therapy masks and oxygen tubing for 6 of 10 sampled residents (Resident #74, #31, #39, #28, #61, and #33) receiving respiratory services, failed to ensure linens were removed properly from a resident's room (Resident #77), failed to ensure an indwelling catheter bag and tubing were kept off of the floor for 1 of 2 sampled residents (Resident #77) reviewed with an indwelling urinary catheter, and 2 of 4 Certified Nursing Assistants (CNA #1 and #3) failed to perform hand hygiene and proper catheter care for 1 of 2 sampled residents (Resident #55) reviewed during indwelling catheter care. The findings include: Review of the facility's policy titled, STANDARD PRECAUTIONS, revised 1/10/2020, showed that appropriate Contact Precautions sign should be placed on the residents' room doors. 1. Observation outside of the resident's room on 1/27/2020 at 10:45 AM, showed no signage posted on Resident #55's door to alert the staff and visitors of isolation precautions. Observation outside of the resident's room on 1/27/2020 at 11:20 AM and 12:28 PM, showed no signage posted on Resident #73's door to alert the staff and visitors of isolation precautions. During an interview on 1/30/2020 at 7:34 AM, the Director of Nursing (DON) confirmed that the isolation rooms should have signage on the door to alert the staff and visitors of isolation precautions. Review of the facility's policy titled, DEPARTMENTAL PR[NAME]EDURES, revised 10/1/2008, showed that respiratory equipment at the beside should be covered with a plastic bag when not in use. 2. Observation in the resident's room on 1/27/2020 at 9:30 AM, 1/28/2020 at 10:09 AM, and 1/29 2020 at 8:30 AM, showed Resident #74's Bilevel Positive Airway Pressure ([MEDICAL CONDITION]) mask was uncovered. Observation in the resident's room on 1/27/2020 at 10:30 AM, 1:20 PM, and 4:55 PM, and on 1/28/2020 at 7:30 AM and 12:15 PM, showed Resident #31's [MEDICAL CONDITION] mask and nebulizer mask were uncovered. Observation in the resident's room on 1/27/2020 at 11:00 AM and 3:29 PM, and on 1/28/2020 at 7:57 AM, showed Resident #39's [MEDICAL CONDITION] mask was uncovered. Observation in the resident's room on 1/27/2020 at 12:45 PM and 4:55 PM, 1/28/2020 at 7:15 AM and 1:06 PM, and on 1/29/2020 at 8:30 AM, showed Resident #28's Continuous Positive Pressure Airway Pressure ([MEDICAL CONDITION]) mask and nebulizer mask were uncovered. Observation in the resident's room on 1/28/2020 at 8:07 AM, 9:15 AM, and 12:38 PM, showed Resident #61's nebulizer mouth piece was uncovered. Observation in the resident's room on 1/29/2020 at 9:31 AM, showed Resident #33's bi-nasal cannula oxygen tubing was lying on the floor at the foot of the bed. Resident #33 activated her call light and CNA #2 entered the room and assisted Resident #33 with her oxygen tubing, placing the tubing in Resident #33's nose. During an interview on 1/30/2020 at 7:34 AM, the DON confirmed that the respiratory masks should be covered and that the oxygen tubing should be changed when found on the floor. Review of the facility's undated policy titled, Handling Linen, showed that the staff should remove soiled linen from the residents rooms in a pillowcase or a trash bag. 3. Observation in the resident's room on 1/29/2020 at 10:05 AM, showed CNA #1 exited Resident's #77 room carrying dirty linen down the hall with her gloved hand. During an interview on 1/30/2020 at 7:34 AM, the DON confirmed that the linen should be in a plastic bag or pillow case when transporting the linen through the halls. 4. Observation in the resident's room on 1/28/2020 at 7:36 AM and 3:40 PM, and on 1/29/2020 at 9:52 AM, showed that Resident #77's indwelling urinary catheter bag and tubing were lying on the floor. During an interview on 1/30/2020 at 7:34 AM, the DON confirmed that the catheter bag and tubing should not be on the floor. Review of the facility's undated policy titled, Hand Washing and Hand Sanitizer, showed that the staff should wash their hands for at least fifteen (15) seconds. 5. Observation during indwelling urinary catheter care in Resident #55's room on 1/29/2020 at 9:52 AM, showed that CNA #1 washed her hands for 10 seconds. Observation during indwelling urinary catheter care in Resident #55's room on 1/29/2020 at 1:54 PM, showed that CNA #3 washed her hands multiple times for 5-10 seconds. During an interview on 1/30/2020 at 7:34 AM, the DON confirmed that the staff should wash their hands for at least 20 seconds. Observation in the resident's room on 1/29/2020 at 2:04 PM, showed that CNA #3 cleaned, rinsed, and dried only the top half of Resident #55's penis during indwelling catheter care. During an interview on 1/30/2020 at 7:34 AM, the DON confirmed that during catheter care, the staff should cleanse the entire penis in a circular motion starting at the tip of the penis.",2020-09-01
193,"NHC HEALTHCARE, KNOXVILLE",445098,809 EAST EMERALD AVE,KNOXVILLE,TN,37917,2019-06-03,609,D,1,0,10P111,"**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 report an allegation of abuse to the state survey agency timely for 1 resident (#1) of 3 residents reviewed for abuse. The findings included: Review of facility policy Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation dated 12/11/17 revealed 6. Reporting Policy .It is the policy of this facility that 'abuse' allegations .are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source .are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 14 day Minimum Data Set ((MDS) dated [DATE] revealed the resident had moderate cognitive impairment. Review of a facility investigation dated 5/27/19 at 8:45 AM revealed Resident #1 reported an allegation of inappropriate contact to a Certified Occupational Therapy Assistant (COTA). Continued review revealed the COTA immediately reported the incident to the Administrator, Director of Nursing (DON) and the physician. Further review revealed Resident #1 alleged the incident occurred the morning of 5/25/19, but did not report it to the facility until 5/27/19. Continued review revealed Resident #1 was examined by the physician on 5/27/19 at 12:30 PM and no obvious physical injuries or conclusive findings were discovered. Further review revealed the resident was sent to a local hospital on [DATE] at 2:23 PM for further examination by a Sexual Assault Nurse Examiner (SANE) nurse and no clinical findings of an assault were discovered. Continued review revealed the facility reported the incident to the state survey agency on 5/27/19 at 3:23 PM (6 hours and 38 minutes after the facility was aware of the allegation). Telephone interview with the Administrator on 6/4/19 at 8:25 AM confirmed the facility failed to report the allegation until 5/27/19 at 3:23 PM (6 hours and 38 minutes after the facility was aware) and the facility failed to follow facility policy.",2020-09-01
194,"NHC HEALTHCARE, KNOXVILLE",445098,809 EAST EMERALD AVE,KNOXVILLE,TN,37917,2017-10-18,431,E,0,1,DDHK11,"Based on review of facility policy, observation, and interview, the facility failed to discard expired medications in 1 of 4 medication refrigerators, and to secure controlled medications under a double lock system for 2 of 3 medication refrigerators of 4 medication refrigerators reviewed. The findings included: Review of the facility policy Medication Storage in the Facility dated 6/2016 revealed .medications .are stored safely .following manufacture's recommendations .outdated .are immediately removed from inventory, disposed of according to procedures for medication disposal . Review of the facility policy Medication Ordering and Receiving from Pharmacy dated 6/2016 revealed .medications included in the Drug Enforcement Administration (DEA) classification as controlled substances and medications classified as controlled substances .subject to special .requirements .kept under double lock . Observation and interview with Registered Nurse (RN) #1 on 10/18/17 at 10:40 AM, in the 3rd floor Medication Storage Room, revealed inside the medication refrigerator, 1 premixed intravenous (IV) solution of Vancomycin (antibiotic) 750 milligrams (mg) in 250 milliliters (ml) 0.9 percent Normal Saline solution dated 10/11/17. Continued observation and interview confirmed the expired IV antibiotic solution was available for use. Observation and interview with the RN/Resident Care Coordinator (RN/RCC) on 10/18/17 at 10:55 AM, in the Front Nursing Station, with no door to separate the nursing station from the hallway, revealed a locked medication refrigerator. Further observation and interview with the RN/RCC of the medication refrigerator, confirmed 2 vials of Lorazepam (antianxiety medication) 2 mg/ml with no double lock system to secure the controlled medication. Observation and interview with the RN/RCC on 10/18/17 at 11:10 AM, in the West Nursing Station, with no door to separate the nursing station from the hallway, revealed a locked medication refrigerator. Further observation and interview of the medication refrigerator with the RN/RCC, confirmed 1 vial of Lorazepam 2 mg/ml with no double lock system to secure the controlled medication. Interview with the Administrator on 10/18/17 at 11:10 AM, in the West Nursing Station, confirmed the facility failed to discard expired medication and failed to secure controlled medications under a double lock system.",2020-09-01
195,"NHC HEALTHCARE, KNOXVILLE",445098,809 EAST EMERALD AVE,KNOXVILLE,TN,37917,2018-12-05,641,D,0,1,5IOI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure the Minimum Data Set (MDS) was accurate for 1 resident (#9) of 36 sampled residents. The findings include: Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Medication Order dated 12/20/17 revealed a physician's orders [REDACTED]. Medical record review of the Nurse's Notes dated 9/1/18 documented, .placed wanderguard to (R) (right) ankle . Medical record review of the Quarterly ((MDS) dated [DATE] revealed Resident #9 had a Brief Interview for Mental Status score of 3, indicating the resident was severely cognitively impaired. Further review revealed Resident #9 required limited assist of one staff member for locomotion on the unit and was not assessed as having as wandering behavior. Medical record review of the Recreation Quarterly Progress Note dated 9/4/18 revealed, .(Resident #9) continues his same daily routine .with much confusion and ambulates around his rooma nd (and) the facility as he likes through the day Pt (patient) .walks around the facility and has to be redirected many times as he will wonder (wander) in and out of other rooms in the facility . Medical record review of Resident #9's Comprehensive Care Plan dated 4/4/18 and updated 9/12/18 revealed .Resident has wandering tendencies . Observation and interview with Certified Nursing Assistant #1 on 12/03/18 at 12:29 PM, in the 2nd floor dining room, revealed Resident #9 confused and wandering. Interview confirmed .He does this all day, he wanders talking . Interview with Licensed Practical Nurse #1 on 12/04/18 at 3:51 PM, on the east hall, revealed Resident #9 wanders daily about the facility. Further interview revealed .He has wandered since admission; it's something he's always done . Interview with MDS Coordinator #1 on 12/05/18 at 10:28 AM, in the MDS office, revealed Resident #9 wanders and was not coded on the MDS as wandering. Further interview confirmed the MDS was not accurate to reflect the resident's wandering behavior.",2020-09-01
196,"NHC HEALTHCARE, KNOXVILLE",445098,809 EAST EMERALD AVE,KNOXVILLE,TN,37917,2018-12-05,644,E,0,1,5IOI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to resubmit a PASARR Level 1 (Pre Admission Screening and Resident Review that determines whether or not an individual who has an active [DIAGNOSES REDACTED].#56 and #59) of 4 residents reviewed for PASARR level 2 (The results of this evaluation result in a determination of need, determination of appropriate setting and a set of recommendations for service to inform the individual's plan of care) of 36 residents reviewed. The finding include: Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Pre-Admission Screening and Resident Review (PASARR) dated 6/11/14 revealed Resident #56 did not have a [DIAGNOSES REDACTED]. Medical record review of a Psychiatric Progress Note dated 10/19/18 revealed .Pt (patient) seen for the management of dementia, anxiety, and depression . Medical record review of Resident #56's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #56 had current [DIAGNOSES REDACTED]. Medical record review of Resident #56's Comprehensive Care Plan updated 11/6/18 revealed, .Side effects, potential for: [MEDICATION NAME] (an antidepressant medication), [MEDICATION NAME] (a mood stabilization medication) .Dx (diagnosis) depression, anxiety, behaviors .becomes agitated .Mental Health Consult & Tx (treatment) . Medical record review of the current physician's orders [REDACTED].[MEDICATION NAME] HCL (a medication for depression) 30 mg (milligrams) . with order dated 1/19/18 and .[MEDICATION NAME] Acid (a medication for mood stabilization) 250 mg/5ml (milliliters) . with order dated 3/8/18. Further review revealed, .Psychiatric services to evaluate and treat as needed . with order dated 5/18/17. Medical record review of the Diagnostic Problem List dated 12/4/18 revealed, .Anxiety Disorder .Start date 6/12/14 .End date 9/22/17 .[MEDICAL CONDITION] .Start date 12/22/14 .End date 2/20/18 .Generalized Anxiety Disorder .Start date 9/22/17 .Major [MEDICAL CONDITION] .Start Date .9/22/17 .End date .5/14/18 .Adjustment Disorder with Depressed Mood .Start dated .5/14/18 . Interview with MDS Coordinator #2 on 12/04/18 at 2:20 PM, in the MDS office, confirmed the facility failed to submit a PASARR change of status when the resident was diagnosed with [REDACTED]. Medical record review revealed Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #59's PASARR Level 1 dated 11/5/16 revealed a PASARR Level 1 was submitted on Resident #59 prior to admission to the facility. Continued review revealed the Primary 1 Axis [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #59 had a BIMS of 15 indicating the resident was cognitively intact. Continued review revealed no documentation of a Psychiatric/Mood Disorder of Anxiety. Medical record review of the Psychiatric Consult dated 8/17/18 revealed, .Pt seen for management of mood and anxiety . Continued review revealed .Based on [DIAGNOSES REDACTED]. Medical record review of Resident #59's Annual MDS dated [DATE] revealed the resident had documentation of a new Psychiatric/Mood Disorder of Anxiety. Medical record review of Resident #59's Comprehesive Care plan dated 11/7/18 revealed the resident was care planned for mood as evidence by [DIAGNOSES REDACTED]. Medical record review of the Psychiatric Consult dated 11/7/18 revealed, .Symptom(s) .Challenge(s) Addressed in Today's Session .Anxiety .New/Ongoing Target Sx (symptoms) .Anxiety .[DIAGNOSES REDACTED].Anxiety disorder due to known physiological condition . Medical record review of the Psychiatric Consult dated 11/14/18 revealed .Summary of Session: SW (Social Worker) referred patient d/t (due to) anxiety/depression d/t difficulty adjusting to LTC (long term care) . Interview with MDS Coordinator #2 on 12/5/18 at 10:40 AM, in conference room, confirmed Resident #59 received a new [DIAGNOSES REDACTED]. Continued interview confirmed the facility failed to resubmit a PASARR Level 1 to determine if Resident #59 would be approved for PASARR Level 2 services. Interview with the Director of Nursing (DON) on 12/5/18 at 11:36 AM, in the conference room, confirmed the facility failed to resubmit a PASARR Level 1 for Resident #59 after the resident received a new [DIAGNOSES REDACTED].",2020-09-01
197,"NHC HEALTHCARE, KNOXVILLE",445098,809 EAST EMERALD AVE,KNOXVILLE,TN,37917,2018-12-05,656,D,0,1,5IOI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to develop and implement a comprehensive care plan to include care of a concussion after a fall for 1 resident (#100) of 2 residents reviewed for falls of 36 residents reviewed. The findings include: Medical record review revealed Resident #100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Daily Skilled Nurse's Note revealed Resident #100, on 11/23/18 at 10:45 PM, was found on her bedroom floor with a laceration to her head. Further review revealed the resident was sent to the emergency room (ER) at 11:40 PM, and returned to the facility on [DATE] at 7:26 AM. Continued review revealed Resident #100 returned to theER on [DATE] at 12:10 PM, after complaints of increased drowsiness s/p (status [REDACTED]. Medical record review of the Comprehensive Care Plan revealed no care plan on the care and management of concussions for Resident #100. Interview with Minimum Data Set (MDS) Coordinator #2 on 12/5/18 at 2:20 PM, in the MDS office confirmed she failed to develop a care plan for the care of Resident #100's concussion. Interview with the Director of Nursing on 12/4/18 at 4:15 PM, in the Conference Room, confirmed the facility failed to develop and implement a care plan for the care of a concussion following a fall for Resident #100.",2020-09-01
198,"NHC HEALTHCARE, KNOXVILLE",445098,809 EAST EMERALD AVE,KNOXVILLE,TN,37917,2018-12-05,657,D,0,1,5IOI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to revise a care plan for fall risk and skin integrity following a fall with a laceration for 1 resident (#100) of 36 residents reviewed. The findings include: Medical record review revealed Resident #100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Daily Skilled Nurse's Note revealed Resident #100 on 11/23/18 at 10:45 PM, was found on her bedroom floor with a laceration to her head. Further review revealed the resident was sent to the emergency room (ER) at 11:40 PM, and returned to the facility on [DATE] at 7:26 AM. Review of the hospital's Discharge Instructions dated 11/24/18 at 6:44 AM, revealed Laceration Care, Adult .if sutures or staples were used: Keep the wound clean and dry .keep the wound completely dry for the first 24 hours or as told by your health care provider, after that time, you may shower or bathe. However, make sure that the wound is not soaked in water until after the sutures or staples have been removed. Clean the wound one time each day .wash the wound with soap and water. Rinse the wound with water to remove all soap. Pat the wound dry with a clean towel. Do not rub the wound . Medical record review of the Baseline Care Plan, undated, for Resident #100 revealed care areas for Fall Risk and Skin/Wound. Further review revealed the Fall Risk Care Plan was updated on 11/24/18 with CNA (Certified Nursing Assistant) instructed to stay with pt (patient) while toileting. Continued review revealed no revision to the Skin/Wound Care Plan and no documentation of the scalp laceration. Medical record review of the Complete Patient Care Plan, dated 11/28/18 revealed care plans for Falls and At Risk for Alteration in Skin Integrity with no revision or documentation of care or treatment of [REDACTED]. Interview with Minimum Data Set (MDS) Coordinator #2 on 12/5/18 at 2:20 PM, in the MDS office confirmed it was her responsibility to develop, revise, and review the care plans and the facility failed to revise the care plans for Resident #100 falls and skin integrity to include the scalp laceration. Interview with the Director of Nursing on 12/4/18 at 4:15 PM, in the Conference Room, confirmed the facility failed to update and revise the care plans on Falls and Skin Integrity for Resident #100 for the care and treatment of [REDACTED].",2020-09-01
199,"NHC HEALTHCARE, KNOXVILLE",445098,809 EAST EMERALD AVE,KNOXVILLE,TN,37917,2018-12-05,684,D,0,1,5IOI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of medical records, observation, and interview, the facility failed to follow hospital discharge instructions following a fall for 1 (#100) resident of 2 residents reviewed for falls of 36 residents sampled. The findings include: Review of the facility policy Transfer Documentation, revised 1/2017, revealed .Responsibilities upon patient's return to the center .physician's orders should accompany the patient from the hospital. admission orders [REDACTED].Begin a new Medication Record using the new physician orders received upon return . Review of the facility policy Return From Transfer/Medical Appointment with Specialist, undated, revealed .Any patient that is transferred to the ER (emergency room ) .the facility will resume previous in-house orders and include any changes from the ER evaluation . Medical record review revealed Resident #100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Daily Skilled Nurse's Notes revealed Resident #100, on 11/23/18 at 10:45 PM, was found on her bedroom floor with a laceration to her head. Further review revealed the resident was sent to the ER at 11:40 PM, and returned to the facility on [DATE] at 7:26 AM. Review of the hospital's Discharge Instructions dated 11/24/18 at 6:44 AM, revealed Laceration Care, Adult .if sutures or staples were used: Keep the wound clean and dry .keep the wound completely dry for the first 24 hours or as told by your health care provider, after that time, you may shower or bathe. However, make sure that the wound is not soaked in water until after the sutures or staples have been removed. Clean the wound one time each day .wash the wound with soap and water. Rinse the wound with water to remove all soap. Pat the wound dry with a clean towel. Do not rub the wound . Medical record review of the Daily Skilled Nurse's Note for Resident #100, dated 11/24/18 at 7:26 AM, revealed .returned from hospital .Laceration c (with) 2 sutures to (r) (right) posterior scalp intact .only orders is to remove sutures in 10 days . Medical record review of the 11/2018 and 12/2018 Medication, Treatment and Task Administration Record Report (MAR/TAR) revealed no documentation or observations had been added for the treatment and care of the laceration and sutures to Resident #100's head. Observation of Resident #100 on 12/4/18 at 8:30 AM, in the resident's room, revealed 2 sutures intact to the right posterior side of the head. Interview with the Registered Nurse/Resident Care Coordinator (RN/RCC) #1 and RN #1 on 12/4/18 at 2:25 PM, in the Conference Room, confirmed RN #1 failed to add the laceration/suture care to the MAR/TAR for Resident #100. Interview with Certified Nursing Assistants (CNA) #2 and #3 on 12/4/18 at 2:45 PM, in the third floor lounge, confirmed they were assigned to care for Resident #100 and were not aware Resident #100 had sutures in her scalp. Interview with the Medical Director on 12/4/18 at 3:00 PM, in the 3rd floor chart room, confirmed the facility failed to follow the ER discharge orders for Resident #100. Interview with the Director of Nursing on 12/4/18 at 4:15 PM, in the Conference Room, confirmed the facility failed to place the discharge instructions for the care and treatment of [REDACTED].#100 on the MAR/TAR. Further interview confirmed the facility failed to follow the ER discharge instructions for Resident #100 following a fall with laceration/sutures.",2020-09-01
200,"NHC HEALTHCARE, KNOXVILLE",445098,809 EAST EMERALD AVE,KNOXVILLE,TN,37917,2018-12-05,695,D,0,1,5IOI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of nursing standards of care, medical record review, observation, and interview, the facility failed to provide respiratory care to address 1 resident's (#105) decline in respiratory status of 8 residents reviewed for respiratory care of 36 residents reviewed. The findings include: Review of Brunner and Suddarth's Textbook of Medical-Surgical Nursing, Twelfth Edition, Lippincott publisher 2010 revealed, Assessing for Heart Failure - Be alert for the following signs and symptoms: GENERAL - Fatigue .Dependent [MEDICAL CONDITION], Weight Gain .Respiratory - Dyspnea on exertion . Medical record review revealed Resident #105 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Nursing assessment dated [DATE] revealed, A&O x3 (alert and orient to person, place and time) .Respirations even/unlabored with diminished bases (less lungs sounds heard in lower lungs) .Expressed need for therapy before returning home. Medical record review of a Nurse Practitioner's progress note dated 11/26/18 revealed, Pt (patient) seen today following admission .pt reports doing okay, just with little energy .called back to her room later this afternoon because her O2 (oxygen) saturation dropped to 86% on room air (normal O2 saturation value 94-99%) 1) [MEDICAL CONDITIONS] with exertional dyspnea (shortness of breath) will give additional 40 mg (milligrams) [MEDICATION NAME] (diuretic) .now .3) [MEDICAL CONDITION] with exacerbation .Schedule [MEDICATION NAME] QID (respiratory nebulizer treatments 4 times a day) .Aggressive [MEDICAL CONDITION] toilet (medical and nursing measures to address lung function). Encourage pt to splint and cough. Check CXR (chest X-ray) 2 views now . Medical record review of the Nurse Practitioner's progress noted dated 11/27/18 revealed, .9) Volume overload (too much retained fluid) - SP (status [REDACTED]. Medical record review of the Daily Skilled Nurses Notes revealed from 11/28/18-12/1/18 the resident's oxygen saturation averaged 94% with no record of the amount of liters oxygen being delivered per minute when the oxygen level was measured. Medical record review of the Daily Skilled Nurses Note on 12/3/18 at 12:00 PM, revealed no recorded vital signs. Continued review of the one entry for 12/3/18 revealed, Resting in bed at this time. NC (nasal cannula) in place delivering O2. Pt had SOB (shortness of breath) this am (morning) and didn't have NC in. NC placed and O2 sat 91% shortly thereafter. Call light in reach. Will monitor . Medical record review of the Nurse Practitioner's progress noted dated 12/4/18 revealed, Pt seen today for reports of SOB. Pt treated for [REDACTED]. Despite diuretics, her SOB has not improved. O2 demand has increased (need for increased liters of supplemental oxygen) and pt feels as if she cannot get enough air in. Pt does report unilateral LLE (lower leg [MEDICAL CONDITION] in both legs) since admission O2 sat (saturation) 90% on 5 Lpm (5 liters per minute of oxygen by nasal cannula) .1) SOB - obtain .CXR. Give [MEDICATION NAME] 40 mg IM (intramuscular) 1 dose now .2) Acute hypoxemic (low oxygen level) resp (respiratory) failure - now on 5 Lpm (5 liters per minute). Pt's O2 sat during exam was 89-91%. Pt did not require O2 prior to hospitalization . With [MEDICAL CONDITION] will attempt to keep sat >90%. Avoid high O2 flow (amount of oxygen administered per minute) d/t (due to) unknown hypercapnia (excessive carbon [MEDICATION NAME] in the bloodstream) hx (history) . Medical record review of the Daily Skilled Nurses Notes from 11/26/18-12/4/18 revealed no record of the resident being assisted to splint and cough. Medical record review of the Baseline Care Plan, undated and unsigned, revealed Care Area .Respiratory .Oxygen 1.5 L (liters per minute) keep sats (oxygen saturation) 90%-92%. Continued review revealed no intervention listed related to the aggressive [MEDICAL CONDITION] toilet prescribed by the Nurse Practitioner (NP) to assist the resident to splint and cough. Observation and interview with the resident on 12/3/18 at 9:00 AM, in her room, revealed she was seated on her bed, appeared short of breath and this increased when she attempted to answer more than a few questions. Observation and interview with the resident on 12/5/18 at 2:00 PM, in her room, revealed she was seated on her bed with unlabored respirations. Interview continued and the resident stated she was .better .up all night off and on going to the bathroom (the same night after receiving the 40 mg of [MEDICATION NAME] IM). Interview with the resident's Licensed Practical Nurse (LPN) #2 on 12/3/18, at 3:00 PM, in the conference room, revealed the LPN restated the information provided on his nursing entry for 12/03/18. In addition, he added the resident had been in the low 80's (referring to oxygen saturation) when she returned from the bathroom without her oxygen). Continued interview confirmed he had not notified the Nurse Practitioner who was onsite of the low oxygen saturation and had not assessed the resident's lung sounds. Interview with the Resident Care Coordinator (RCC) #1 on 12/4/18 at 9:05 AM, at the third floor nursing station, revealed the resident was not weighed on Monday 12/3/18 and stated LPN #2 told the RCC, .She should have been. Interview continued and revealed the NP had not seen the resident on Monday 12/3/18. Further interview confirmed a NP had not seen the resident for the previous 6 days and the resident had not been weighed since 11/30/18. Interview with the NP on 12/4/18 at 8:45 AM, in the third floor nursing station, revealed I have never seen the resident (#105) .plan to assess her this morning . Interview with RCC #2 on 12/4/18 at 1:15 PM, in the conference room, revealed the resident's weight this day was 153 pounds and confirmed this was an increase of 5 pounds from the last weight of 148 pounds, 4 days earlier. Further interview confirmed the weight was to be done every Monday and had not been done as ordered. Continued interview revealed the chest x-ray had been reported and included in the findings The lungs again demonstrate patchy infiltrate in the right base, probably with effusion (fluid)). There is an active process in the left base . Interview with the Director of Nurses (DON) on 12/4/18 at 1:45 PM, in the conference room, revealed the nurses were to take SaO2 (oxygen saturation level in the bloodstream) on all residents as part of the routine vital signs. Continued interview revealed the DON could not provide a formal respiratory care policy. A document titled O2 Saturation Guidelines, undated, was provided for the interview. Further interview confirmed the 3 guidelines provided did not require the information of the amount of oxygen being delivered when oxygen saturation was obtained. Continued interview revealed .a lot of problems with residents' oxygen levels are found by the rehab staff . Further interview revealed Resident #105 had not been fully assessed daily by the nursing staff for her respiratory status and had not been care planned to receive the Aggressive [MEDICAL CONDITION] toilet prescribed by the NP on 11/26/18.",2020-09-01
201,"NHC HEALTHCARE, KNOXVILLE",445098,809 EAST EMERALD AVE,KNOXVILLE,TN,37917,2019-12-18,656,D,0,1,C5Z011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to follow the care plan for falls for 1 resident (#86) of 23 sampled residents. The findings include: Medical record review revealed Resident #86 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Baseline Care Plan, dated 11/19/19, revealed .fall risk .bed in lowest position . Medical record review of Resident #86's Admission Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Further review revealed the resident required extensive assistance of 2 persons for transfers, bed mobility, and toileting. Medical record review of the Comprehensive Care Plan, dated 12/3/19 revealed .Keep bed in lowest position . Medical record review of the Certified Nursing Assistant Care Plan, dated 12/3/19, revealed to keep Resident #86's bed in lowest position. Review of an Event Report dated 12/12/19 revealed Resident #86 had an unwitnessed fall from bed, without injury, on 12/12/19 at 6:20 PM. Continued review revealed .PT (patient) BACK UP AGAINST THE BED WITH BRIEF OBSERVED DOWN TO ANKLES BED IN HIGH POSITION . Observation on 12/17/19 at 3:57 PM, in the resident's room, revealed Resident #86 lying in a low positioned bed. Interview and review of the facility fall investigations with Licensed Practical Nurse (LPN) #1 on 12/18/19 at 9:12 AM, in the conference room, confirmed the resident was not in the low position bed on 12/12/19. Interview with the Director of Nursing on 12/18/19 at 9:54 AM, in the conference room, confirmed the care planned low bed intervention was not in place at the time of the fall.",2020-09-01
202,"NHC HEALTHCARE, KNOXVILLE",445098,809 EAST EMERALD AVE,KNOXVILLE,TN,37917,2019-12-18,689,D,0,1,C5Z011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility documentation review, observation and interview the facility failed to add a new intervention after a fall for 1 resident (#69) and failed to implement a care plan intervention to prevent accidents for 1 resident (#86) of 5 residents reviewed for accidents. The findings include: Review of the facility policy, Falls Policy, revised 7/14/17 revealed .Based on the preceding assessment, the staff and/or physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falls .If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falls, until falling reduces or stops or until a reason is identified for its continuation . Medical record review revealed Resident #69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #69's care plan revised 3/5/19 revealed .Bed Alarm, ensure functioning and placement qshift (every shift) . Continued review revealed no new interventions had been implemented after the 9/20/19 fall. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #69 had a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident had severe cognitive impairment and required extensive assistance of 1 for bed mobility, transfers, toileting, and personal hygiene. Medical record review of a Falls Risk assessment dated [DATE] revealed Resident #69 scored a 19. Continued review revealed a resident score greater that 13 indicated a high risk for falls. Review of an Event Report facility dated 9/20/19 revealed Resident #69 had an unwitnessed fall in the resident's room on 9/20/19 without injury. Continued review revealed the immediate measures implemented was a bed alarm (implemented on 3/5/19). Observation on 12/18/19 at 8:30 AM, in the resident's room, revealed Resident #69 sleep in bed with a bed alarm in place, a fall mat to the left side of the bed, and the call light within reach. Interview with the Director of Nursing (DON) on 12/18/19 at 2:00 PM, in the DON's office, confirmed the facility failed to implement a new falls intervention after the fall on 9/20/19 and failed to follow the facility policy for falls. Medical record review revealed Resident #86 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Baseline Care Plan, dated 11/19/19, revealed .fall risk .bed in lowest position . Medical record review of Resident #86's Admission MDS dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Further review revealed the resident required extensive assistance of 2 persons for transfers, bed mobility, and toileting. Medical record review of Resident #86's Fall Risk Assessment Tool dated 11/26/19 revealed the resident was a high fall risk. Medical record review of the Certified Nursing Assistant Care Plan dated 12/3/19, revealed .Keep bed in lowest position . Medical record review of the Comprehensive Care Plan dated 12/3/19 revealed Resident #86 had a history of [REDACTED]. Review of an Event Report dated 12/12/19 revealed Resident #86 had an unwitnessed fall from bed without injury on 12/12/19 at 6:20 PM. Further review revealed .PT (patient) BACK UP AGAINST THE BED WITH BRIEF OBSERVED DOWN TO ANKLES BED IN HIGH POSITION .Patient fell to floor from bed trying to roll herself off a bedpan . Observation on 12/17/19 at 3:57 PM, in the resident's room, revealed Resident #86 lying in a low positioned bed. Interview and review of the facility fall investigations with Licensed Practical Nurse (LPN) #1 on 12/18/19 at 9:12 AM , in the conference room, confirmed the resident's bed .was not in the low position as I would have expected for a resident here for falls and [MEDICAL CONDITION] . Interview with the DON on 12/18/19 at 9:54 AM, in the conference room, confirmed the low bed intervention was not in place. In summary, the facility failed to ensure the low bed intervention was in place to prevent a fall for Resident #86 on 12/12/19.",2020-09-01
203,"NHC HEALTHCARE, ATHENS",445099,1204 FRYE ST,ATHENS,TN,37303,2017-11-01,371,F,0,1,TV5F11,"Based on facility policy review, observation, and interview, the facility failed to store beverages in a sanitary manner, and failed to maintain dietary equipment, in a clean and sanitary manner in 1 of 2 dietary observations made affecting 63 of 68 residents. The findings included: Review of a facility policy, Safety & Sanitation Best Practice Guidelines Sanitation Manual[NAME]Washing revised 1/2011, revealed .Remove all traces of food .utensils .shall be cleaned and sanitized .throughout the day at a frequency necessary to prevent recontamination of equipment and utensils . Review of a facility policy, Safety & Sanitation Best Practice Guidelines Cleaning Procedures revised 1/2011, revealed . Cleaning procedures .Ovens .Scrape burned particles from hearth, brush out interior .Mixer .Clean mixer beater shaft . Review of a facility policy Safety & Sanitation Best Practice Guidelines Sanitation Machine Washing revised 1/2011, revealed .Check the machine for cleanliness and clean at least once each day or more often .Use an acid cleaner on the machine at least once a week . Review of a facility policy Safety & Sanitation Best Practice Guidelines Sanitation Refrigerator and Freezer Storage revised 1/2011, revealed .To prevent cross-contamination, partner (facility employee) and patient personal food items may not be stored in refrigerator/freezer in Dietary . Observation/Interview with the Assistant Dietary Manager on 10/30/17 at 9:40 AM, in the kitchen, revealed [NAME] A mixer with dried debris on the beater shaft B. A can opener with dried debris on the base, and under the blade C. Dried burnt debris on the interior bottom, sides, and doors in 1 of 2 ovens observed D. A microwave with dried flaky debris on the interior top Further observation in the kitchen revealed [NAME] 4 of 6 1/4 pans and 1 of 2 baking pans with flaky debris on the rims and inside B. 1 of 8 knives with dried orange colored debris on the blade Interview confirmed all items were available for use. Observation with the Assistant Dietary Manager on 10/30/17 at 9:55 AM, in the dish room, revealed the dish machine with thick dried debris on the door, sides, and top of the machine. Observation with the Assistant Dietary Manager on 10/30/17 at 10:00 AM, in the kitchen, of a reach in cooler revealed an employee's personal beverage stored with patient beverages. Interview with the Assistant Dietary Manager on 10/30/17 at 10:05 AM, in the kitchen, confirmed the facility failed to maintain a sanitary environment in the kitchen and failed to follow facility policy.",2020-09-01
204,"NHC HEALTHCARE, ATHENS",445099,1204 FRYE ST,ATHENS,TN,37303,2019-11-20,791,D,0,1,ZZRT11,"**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 1 resident (#11) received routine dental services of 18 residents sampled. The findings include: Review of the facility's policy Dental Services, undated, revealed .To ensure patients are receiving the care and services necessary for proper denture and dental health .Build accountability into each process to ensure effectiveness .Establish process for communication of dental needs .of patients .Ensure all partners are aware of process for communication of dental needs . Medical record review revealed Resident #11 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 score of 15, indicating the resident was cognitively intact. Medical record review of the care plan dated 9/3/19 revealed .risk of altered nutrition status .Dental consult as warranted . Medical record review of a Food and Nutrition Services progress note dated 9/10/19 revealed .Staff contacted RD (Registered Dietician) to notify of (Resident #11's name) reporting she is having trouble with her dentures and needs new ones. She reports that she is getting choked on her food because she can't chew it. Diet change to Low Sodium, Mechanical with ground meats for ease of chewing. Reassess diet texture change as needed/when new dentures are obtained . Medical record review of a physician's orders [REDACTED]. Interview with Resident #11 on 11/18/19 at 2:47 PM, in the resident's room, revealed her dentures no longer fit and she wanted new dentures. Further interview revealed she had reported the issue to the facility but had not been seen by the dentist. Interview with the Social Services Assistant on 11/19/19 at 12:34 PM, in the social services office, revealed the nursing staff maintained the list of residents to be seen by the dentist. Interview with the Resident Care Coordinator (RCC) on 11/19/19 at 12:46 PM, in the RCC's office, revealed the nursing staff did not maintain the list of residents to be seen by the dentist and the RCC was not aware of which residents were on the list. Interview with the Administrator on 11/19/19 at 12:49 PM, in the Administrator's office, revealed he maintained the list of residents to be seen by the dentist. Continued interview confirmed he had not been made aware of the resident's need to be seen by the dentist and Resident #11 had not been added to the dental list. Further interview confirmed it was his expectation to be notified immediately of dental concerns so the resident can be added to the dental list to be seen at the next visit or sooner if needed. Interview with the Director of Nursing (DON) on 11/19/19 at 12:53 PM, in the Administrator's office, confirmed she was unaware Resident #11 had a need to see the dentist. Continued interview confirmed it was her expectation for the RD or the staff member who informed the RD of Resident #11's need to be seen by the dentist to have notified the Administrator or DON.",2020-09-01
205,"NHC HEALTHCARE, PULASKI",445101,993 E COLLEGE ST,PULASKI,TN,38478,2017-06-28,225,D,1,0,2N5911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, facility investigation review, and interview, the facility failed to report an allegation of abuse to the state agency timely for 1 resident (#3) of 2 residents reviewed for abuse. The findings included: Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility investigation revealed an allegation of abuse was reported by Certified Nursing Assistant (CNA #1) on 5/31/17 at 2:30 PM. Continued review revealed the CNA reported the abuse to the Charge Nurse who reported to the Director of Nursing and Social services. Interview with the Administrator confirmed the facility failed to report the allegation of abuse to the State Agency until (MONTH) 1, (YEAR) at 10:30 AM. Continued interview confirmed the facility failed to report the abuse within two hours as required.",2020-09-01
206,"NHC HEALTHCARE, PULASKI",445101,993 E COLLEGE ST,PULASKI,TN,38478,2019-10-09,761,E,0,1,OEZ411,"Based on policy review, observation, and interview, the facility failed to ensure medications were stored securely and safely when 2 of 3 (Licensed Practical Nurse (LPN) #1 and #2) nurses left medications out of site and unattended. The findings include: 1. The facility's MEDICATION STORAGE IN THE FACILITY policy dated 6/2016, documented, .Medications and biologicals are stored safely, securely, and properly .The medication supply is accessible only to licensed nursing personnel .B .medication supplies are locked when not attended by persons with authorized access . 2. Observations during medication administration in Resident #35's room on 10/8/19 at 3:10 PM, revealed LPN #1 entered Resident #35's room to administer a medication and a bolus enteral feeding. LPN #1 placed a crushed medication on the overbed table, and entered the bathroom, leaving the medication out of site and unattended. LPN #1 returned to administer the enteral bolus feeding, but then entered the bathroom to obtain water for the enteral water flush, leaving the medication on the overbed table out of site and unattended. LPN #1 returned to administer the enteral bolus feeding, after LPN #1 administered the feeding, LPN #1 entered the bathroom to rinse out the enteral syringe, leaving the medication out of site and unattended. 3. Observations during medication administration in Resident's #20's room on 10/9/19 at 9:44 AM, revealed LPN #2 entered Resident #20's room to administer oral medications and insulin. LPN #2 placed the medication and the insulin syringe on the overbed table, and entered the bathroom, leaving the oral medications and insulin syringe out of site and unattended. LPN #2 returned to administer the insulin, gave Resident #20 a glass of water, and then returned to the bathroom, leaving the oral medications out of site and unattended. Interview with the Assistant Director of Nursing (ADON) on 10/9/19 at 2:05 PM, in the ADON Office, the ADON was asked if medications should have been left at the bedside out of site and unattended. The ADON stated, No.",2020-09-01
207,"NHC HEALTHCARE, PULASKI",445101,993 E COLLEGE ST,PULASKI,TN,38478,2017-12-13,609,D,0,1,D4AU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to thoroughly investigate and report timely an allegation of abuse for 1 of 1 (Resident #109) sampled residents. The findings include: Review of the facility's Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation policy documented, .Any partner having either direct or indirect knowledge of any event that might constitute abuse, neglect, misappropriation of patient property or exploitation must report the event immediately .It is the policy of this facility that abuse allegations .are reported per Federal and State Law . Medical record review revealed Resident #109 was admitted to the facility on [DATE] and last readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a nurses note dated 9/3/17 documented, .pt (patient) upset this afternoon stating that two men came into her room and was beating her and whipping her with many items. Stated that they hit her so hard they made her pee herself and they almost threw her off the bed. Pt stated they looked mexican . Interview with the Director of Nursing (DON) on 12/11/17 at 2:27 PM, in the conference room, the DON stated, .I wasn't aware that nursing note was in the record . The DON was asked if there had been an investigation. The DON stated, No. The DON was asked what was facility policy regarding allegations of abuse. The DON stated, .report it immediately .I spoke with the nurse and the nurse said she didn't think of it as abuse but screened her for hallucinations since she has had hallucinations in the past . Interview with Licensed Practical Nurse (LPN) #1 on 12/13/17 at 9:04 AM, in the conference room, LPN #1 was asked why she did not report Resident's 9/3/17 allegation of abuse. LPN #1 stated, .It's my bad .she has hallucinations at times .I was trying to document her behaviors .I should have reported it to the DON . Interview with the Administrator on 12/13/17 at 9:15 AM, in the DON's office, the Administrator was asked what he expected his staff to do when there are allegations of abuse. The Administrator stated, .report it to us (administration) immediately .",2020-09-01
208,"NHC HEALTHCARE, PULASKI",445101,993 E COLLEGE ST,PULASKI,TN,38478,2017-12-13,880,D,0,1,D4AU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were followed when 2 of 3 (Licensed Practical Nurse (LPN) #2 and 3) nurses failed to perform hand hygiene during medication administration. 1. The facility's INFECTION CONTROL MANUAL .HANDWASHING procedure documented, Wash hands before and after contact with each patient, after toileting, smoking or eating, and before and after removal of gloves . 2. Observations on the 300 hall on 12/12/17 at 11:00 AM, revealed LPN #2 removed a bottle of Aspirin from the cart, donned gloves, placed an Aspirin in a plastic medication cup, removed her gloves, finished preparing medications, entered room [ROOM NUMBER]A, donned gloves, administered nasal spray and medications, removed gloves, walked out to the medication cart, donned gloves, cleaned the nozzle on the nasal spray bottle, removed gloves, and signed out the medications. LPN #2 failed to perform hand hygiene between glove changes during medication administration. 3. Observations on the 200 hall on 12/12/17 at 12:01 PM, revealed LPN #3 donned gloves, mixed an intravenous (IV) medication, cleaned a glucometer with a bleach wipe, removed her gloves, set up oral medications, donned gloves, obtained supplies and set up the glucometer, removed her gloves, entered room [ROOM NUMBER]A, donned gloves, connected the IV to the pump, picked up the call light and bed control off the floor, removed her gloves, donned new gloves, administered oral medications, performed a finger stick, removed her gloves, donned new gloves, connected the IV to the resident and started the pump, exited the room, disposed of the lancet, cleaned the glucometer, removed her gloves, and signed out the medications. LPN #3 failed to perform hand hygiene between glove changes during medication administration. 4. Interview with the Director of Nursing (DON) on 12/13/17 at 11:25 AM, in the DON's office, the DON was asked what she expected her staff to do between glove changes. The DON stated, Wash their hands.",2020-09-01
209,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2020-01-29,636,D,0,1,RG4511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, and interview, the facility failed to complete a timely annual Minimum Data Set (MDS) assessment for 1 resident (Resident #3) of 9 residents reviewed for MDS assessments. The findings include: Review of the RAI Version 3.0 Manual Chapter 2: Assessments for the RAI revealed .The Annual assessment .must be completed on an annual basis .AND within 92 days since the .previous .Quarterly . Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During review of the medical record and interview on 1/29/2020 at 3:17 PM, the MDS Nurse confirmed Resident #3 had a Quarterly MDS completed on 8/14/2019. No MDS assessments had been completed since that date. During an interview on 1/29/2020 at 3:45 PM, the MDS Nurse confirmed Resident #3's next annual MDS should have been completed on 11/14/2019. The resident's Annual MDS had not been completely timely (76 days overdue).",2020-09-01
210,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2020-01-29,638,D,0,1,RG4511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, and interview, the facility failed to complete a timely quarterly Minimum Data Set (MDS) assessment for 1 resident (Resident #4) of 9 residents reviewed for MDS assessments. The findings include: Review of the RAI Version 3.0 Manual Chapter 2: Assessments for the RAI revealed .The Quarterly assessment .must be completed at least every 92 days following the previous .assessment of any type . Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During review of the medical record and interview on 1/29/2020 at 3:17 PM, the MDS Nurse confirmed Resident #4 had a quarterly MDS completed on 8/23/2019. No MDS assessments had been completed since that date. During an interview on 1/29/2020 at 3:45 PM, the MDS Nurse confirmed Resident #4's next quarterly MDS should have been completed on 11/23/2019. The resident's Quarterly MDS had not been completely timely (67 days overdue).",2020-09-01
211,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2020-01-29,658,D,0,1,RG4511,"**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 adequate supply of medications were available for 1 resident (Resident #131) of 8 residents reviewed for medication administration, resulting in staff borrowing pain medication from Resident #11 to administer to Resident #131. The findings include: Review of the facility policy titled, Acquisition of Medications for Residents, undated, showed .Pharmacy will provide medications for the residents .Reorder requests can be made by writing the drug needed on the provided refill request form, pulling the refill sticker from the pharmacy label and placing it on the provided refill request form, or calling the pharmacy . Resident #131 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #131's Physician Recapitulation Orders dated 1/1/2020-1/31/2020, revealed .[MEDICATION NAME] 5-325 (also called Hydro/APAP-used to treat pain) TABLET-Give one tablet by mouth twice a day . Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a controlled drug record for Resident #11 showed, .HYDRO/APAP .5-325MG (MILLIGRAM) .FOR PAIN . On 1/13/2020, Licensed Practical Nurse (LPN) #2 borrowed 1 pill from Resident #11's pain medications to administer to Resident #131. During an interview on 1/29/2020 at 10:50 AM, the facility Pharmacist stated a Pharmacist is on call 24 hours a day 7 days a week. The facility does not have an emergency box with pain medication. If a pain medication is needed the Pharmacist will come in and get the medication prepared. The staff will sometimes borrow from other residents if it is in the middle of the night. During an interview on 1/29/2020 at 1:10 PM, LPN #3 stated when a resident's pain medication is in the red zone (a colored area on the medication card indicating the medication needs to be re-filled) on the narcotic card, nursing staff are to pull the label sticker and re-order the medication. During a telephone interview on 1/29/2020 at 1:35 PM, LPN #2 stated if she borrowed a narcotic medication from a resident, it would be because there was none available for another resident; .that is the only reason I would borrow .If it is a weekend we can call the Pharmacist in an emergency, but if the medication is routine we usually borrow the medications from someone else . During an interview 1/29/2020 at 2:10 PM, the facility Pharmacist stated the pain medication had not been re-ordered for resident #131 until 1/14/2020. The process is for the nurse to pull the label from the medication card; there is an area in red that lets them know when it's time to re-order. During an interview on 1/29/2020 at 2:18 PM, the Director of Nursing stated it was her expectation for the nurses to order medications timely. The Director of Nursing confirmed the facility had not ordered medications timely for Resident #131.",2020-09-01
212,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2020-01-29,684,D,0,1,RG4511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide proper positioning while seated in a wheelchair for 1 resident (Resident #53) of 28 sampled residents. The findings include: Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan dated 5/6/2019 revealed .Assist with all mobility needs prn (as needed) .Rehab to eval (evaluate) and treat as needed . Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had severe cognitive impairment and used a wheelchair for mobility. Observation of Resident #53 on 1/27/2020 at 11:08 AM, revealed the resident was propelling herself down the hallway in a wheelchair. The resident's feet were not touching the floor and there were no foot rests on the wheelchair. During an interview and observation of Resident #53 on 1/28/2020 at 2:00 PM, Licensed Practical Nurse (LPN) #5 confirmed Resident #53's feet were not touching the floor and there were not footrests on the wheelchair. LPN #5 stated therapy could be consulted for positioning when a wheelchair was not the correct height for a resident, but there was no documentation of a therapy consult for Resident #53. During an interview on 1/28/2020 at 2:14 PM, Certified Nursing Assistant (CNA) #1 stated Resident #53 sometimes used the tips of her toes to propel herself in the wheelchair. CNA #1 stated the resident's feet did not touch the floor when she was seated in the wheelchair. Observation of Resident #53 on 1/28/2020 at 4:38 PM, revealed the resident seated in a wheelchair in the hallway propelling herself using her arms. The resident's feet were not touching the floor and there were no foot rests on the wheelchair. During an interview on 1/29/2020 at 8:35 AM, the Assistant Director of Nursing (ADON) confirmed it was her expectation for the nursing staff to evaluate a resident who was not properly positioned in a wheelchair. The ADON stated a different wheelchair should be obtained or consulted therapy. During an interview on 1/29/2020 at 8:49 AM, the Rehabilitation Director stated Resident #53 had not been evaluated by the therapy department for wheelchair positioning.",2020-09-01
213,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2020-01-29,689,D,0,1,RG4511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, review of manufacturer guidelines, record review, observation, and interview, the facility failed to use a mechanical lift safety for 1 (Resident #20) of 142 residents screened for accidents during the initial pool, which resulted in Resident #20 being left in a mechanical lift unattended. The findings include: Review of the facility policy titled, Lift Free Policy, dated 11/8/1994, showed .Effective 11/9/1994 it will be facility policy for all employees in the Nursing Department to use the mechanical lifts for lifting those residents identified .as requiring the use of a lift .the policy is instituted for the safety of our .residents . Review of the manufacturer guidelines for use of the mechanical lift dated 1/2014, showed .Before Approaching the patient .ensure that the battery pack supplied is fully charged before use . Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #20 was severely cognitively impaired and required extensive assistance of one staff member for bed mobility and transfers. During observation in the resident's room on 1/27/2020 at 11:18 AM, Resident #20 was sitting on a pad in a mechanical lift, suspended above the wheelchair. CNA #2 was attempting to lower the resident using the lift to the wheelchair. Certified Nursing Assistant (CNA) #2 stated .it will not go on down the battery must be dead. I'll have to get another battery to use . CNA #2 exited the resident's room, leaving the resident unattended, and proceeded to walk up the hallway to the nurse's station. CNA #2 returned to the room with a different battery for the lift. The battery did not work. CNA #2 exited the room a second time and left the resident unattended to obtain another battery for the lift. She returned to the resident's room with the new battery. The second battery applied to the lift did work, and at 11:30 AM, 12 minutes later, Resident #20 was lowered to her wheelchair using the mechanical lift. During an interview on 1/27/2020 at 11:32 AM, CNA #2 stated, .I should not have left resident unattended in the room .because lift battery not working . During an interview on 1/29/2020 at 10:01 AM, the Director of Nursing stated it was her expectation for the staff not to leave a resident unattended while in a lift device. The facility did not ensure the safety of Resident #20.",2020-09-01
214,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2020-01-29,726,D,0,1,RG4511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview, and staff skills and competency reviews, the facility failed to provide skills competencies for 1 (CNA #2) of 4 Certified Nursing Assistants (CNA) reviewed, which resulted in CNA #2 using a mechanical lift incorrectly for Resident #20. The findings include: Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #20 was severely cognitively impaired and required extensive assistance of one staff member for bed mobility and transfers. Observation in the resident's room on 1/27/2020 at 11:18 AM, showed Resident #20 sitting on a pad in a mechanical lift suspended above the wheelchair. CNA #2 was attempting to lower the resident using the lift to the wheelchair. CNA #2 stated .it will not go on down. The battery must be dead .I'll have to get another battery to use . CNA #2 exited the resident's room, leaving the resident unattended, and proceeded to walk up the hallway to the nurse's station. CNA #2 returned to the room with a different battery for the lift. The battery did not work. CNA #2 exited the room a second time and left the resident unattended to obtain another battery for the lift. She returned to the resident's room with the new battery. The second battery applied to the lift did work, and at 11:30 AM, 12 minutes later, Resident #20 was lowered to her wheelchair using the mechanical lift. During an interview on 1/27/2020 at 11:32 AM, CNA #2 stated .I should not have left resident unattended in the room .because lift battery not working . Review of staff training and competencies titled, .CNA Skills Day Checklist . dated 7/2/2019, showed CNA #2 did not receive the skills competency for the year 2019. During an interview on 1/29/2020 at 3:00 PM, theAssistant Director of Nursing stated, .(CNA #2) was on vacation on 7/2/2019 and did not attend the annual CNA skills day .she did not receive the skills checklist and she did not complete the competency .the facility usually has a make-up day, but we did not have one for last year (2019) .",2020-09-01
215,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2020-01-29,759,D,0,1,RG4511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to ensure the medication error rate was less than 5 percent. There were 32 opportunities with 3 errors resulting in a 9% medication error rate. The errors involved 2 of 8 residents (Residents #389 and #112) in the sample. The findings include: Resident #389 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Physician admission orders [REDACTED].TAKE 34 GRAMS DAILY .FOR CONSTIPATION .SERTRALIN ([MEDICATION NAME]) (also called [MEDICATION NAME] a medication used to treat depression) 100 MG (milligram), take 1 1/2 TAB PO (by mouth) DAILY FOR MOOD/DEPRESSION . During observation of the 200 hallway medication administration pass on 1/28/2020 at 8:05 AM, Licensed Practical Nurse (LPN) #1 prepared and administered the following medications to Resident #389: [MEDICATION NAME] 17 gm and [MEDICATION NAME] 50 mg. During an interview on 1/28/2020 at 9:08 AM, LPN #1 confirmed he administered [MEDICATION NAME] 17 gm, and the order was for 34 gm, and administered [MEDICATION NAME] 50 mg, and the order was for [MEDICATION NAME] 150 mg. During an interview on 1/29/2020 at 2:18 PM, the Director of Nursing (DON) confirmed the facility did not follow Physician orders [REDACTED].#389. Resident #112 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Physician Recapitulation Orders dated 1/1/2020-1/31/2020, showed .POTASSIUM CL (Chloride) ER (Extended Release) 20 MEQ (Milliequivalents) give one tablet by mouth daily .May Crush Medications .No . During observation of the 500 hallway medication administration pass on 1/28/2020 at 8:17 AM, LPN #4 crushed and administered Potassium Chloride ER 20 MEQ by mouth in apple sauce. During an interview on 1/28/2020 at 8:50 AM, LPN #4 confirmed she had crushed and administered Potassium Chloride ER 20 MEQ to Resident #112. During an interview on 1/28/2020 at 9:04 AM, the DON confirmed Potassium Chloride ER should not be crushed and the facility did not follow the physician's orders [REDACTED]. During an interview on 1/28/2020 at 2:55 PM, the Medical Director stated the Potassium CL should not have been crushed but would not cause the resident any adverse effects.",2020-09-01
216,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2020-01-29,812,D,0,1,RG4511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure expired liquid protein supplements were not available for resident use in 1 medication cart of 4 medication carts observed. The findings include: During observation of the 200 hallway East side medication cart on [DATE] at 8:50 AM, two 30 ounce bottles of sugar free liquid protein, both bottles 1/2 full, with an expiration date of [DATE], was on the cart. During an interview on [DATE] at 8:54 AM, Licensed Practical Nurse (LPN) #1 confirmed both bottles of liquid protein expired on [DATE] and were available for resident use. During an interview on [DATE] at 2:18 PM, the Director of Nursing confirmed the facility had not removed 2 expired protein supplements from the 200 hallway East side medication cart.",2020-09-01
217,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2020-01-29,849,D,0,1,RG4511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to obtain and maintain a hospice plan of care and hospice visit notes in the medical record for 1 of 3 residents (Resident #127) reviewed for hospice needs. The findings include: Resident #127 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].#127 was admitted to hospice care. Review of the admission Minimum Data Set ((MDS) dated [DATE], showed Resident #127 had severe cognitive impairment and received hospice services. Review of the medical record showed no documentation of a hospice care plan or hospice visit notes for Resident #127. During an interview on 1/29/2020 at 1:26 PM, Licensed Practical Nurse (LPN) #3 confirmed the hospice care plan and the visit notes for Resident #127 were not maintained on the resident's medical record. During an interview on 1/29/2020 at 2:23 PM, the Director of Nursing confirmed the hospice care plan and visit notes were not maintained on Resident #127's medical record.",2020-09-01
218,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2017-05-24,309,D,1,0,YFPH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review and interview, the facility failed to administer medications as ordered for 1 Resident (#2) of 3 residents reviewed. The findings included: Review of the facility policy, Medication Pass Times, not dated revealed medications ordered to be administered at bedtime will be given at 9:00 PM. Continued review revealed medications ordered to be administered BID (twice a day) will be given at 9:00 AM and 9:00 PM. Medical record review revealed Resident #2 was admitted to the facility for Orthopedic Aftercare on 5/9/17. [DIAGNOSES REDACTED]. The resident was discharged from the facility and transported by the resident's daughter (complainant) to another facility on 5/18/17. Medical record review of a Nurses Note dated 5/9/17 and timed 10:20 PM, revealed Resident #2 was alert and oriented to person, place, and situation. Continued review revealed the resident required 2 person assistance for Activities of Daily Living, toileting, and transfers. The resident was able to feed self with tray setup. Medical record review of Physician's Orders dated 5/2017 revealed .[MEDICATION NAME] (medicine for [MEDICAL CONDITION]) 100 MG (milligrams) CAPSULE Give one capsule .twice a day .AMPYRA (medicine for MS) ER (extended release) 10 M[NAME] Give one tablet .twice a day .[MEDICATION NAME] (antibiotic) 250 MG TABLET. Give one tablet .every evening at bedtime .Montelukast Sod (sodium)(medicine for allergies [REDACTED].every evening at bedtime . Medical record review of an electronic Medication Administration Record [REDACTED]. Interview with the Director Of Nursing (DON) on 5/23/17 at 4:15 PM, in the DON's office confirmed the 9:00 PM medications were not administered within the expected time frame of 1 hour prior to and 1 hour after the ordered administration time on 5/13/17 for Resident #2 and confirmed the facility failed to follow the physician's orders.",2020-09-01
219,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2017-11-15,314,D,0,1,ED6811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility protocol, medical record review, observation, and interview, the facility failed to implement interventions for the treatment of [REDACTED].#106) of 3 residents reviewed for pressures ulcer of 26 residents reviewed. The findings included: Review of the facility protocol Wound and Skin Care Protocols revealed .Purpose: .2. To prevent pressure ulcer formation by identifying those .who are high risk for pressure ulcers and to develop appropriate interventions. 3. To promote healing of pressure ulcers .Preventative Measures for guest (resident) scoring 17 or less on the Braden Scale. A .Guest will be repositioned every 2 hours if they are unable to position themselves .Suspected Deep Tissue Injury-depth unknown .Purple or maroon localized area of discolored intact skin .due to damage of underlying soft tissue from pressure .The wound may further evolve and become covered by thin eschar (dead tissue) . Medical record review revealed Resident #106 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #106 required extensive assistance of 1 person for bed mobility and transfer. Medical record review of the MDS dated [DATE], revealed the resident required extensive assistance of 2 persons for bed mobility. Medical record review of Nurses Notes revealed the following: 8/22/17 - .admitted for skilled services PT/OT (physical and occupational therapy) .Alert and Oriented x1 (to person) with confusion .Heels soft red but blanchable .Braden (score of the facility's skin risk assessment tool) 16 . 10/27/17 - Weekly skin assessment .No open areas No ulcers No pressure Heels are clear . 11/3/17 - Weekly skin assessment .L (left) and R (right) outer heel pink but blanchable. Heel guards and skin prep in place. 11/7/17 - .9:36 PM .Called to room per CNA (certified nursing assistant). Skin concern noted to right lateral heel. 6.0 cm (centimeter) L (length) x (by) 4.0 cm W (width) non open area of non blanchable [DIAGNOSES REDACTED] (periwound) with a 2.0 cm L x 2.0 cm W non open black/purple area in center . Medical record review of the Wound Care Nurse assessments revealed the following: 8/23/17 - .Bilateral heels red sluggish blanching skin .Heels to be floated off surface on pillows while in bed . 11/8/17 - .right lateral heel new area SDTI measuring 2.5 x 2.0 cm. Skin intact dark blue purple in color. Periwound (area surrounding the pressure ulcer) blanching [DIAGNOSES REDACTED] . 11/14/17 - Wound care follow up right heel SDTI. Area larger in size, measures 2.5 x 5.0 cm. Dark red purple in color, skin intact. Periwound sluggish blanching red skin .continue current treatment and offloading on pillows . Medical record review of the physician's orders [REDACTED]. 11/7/17 - Dietary Consult for new pressure area .Float heels when in bed or chair as pt (patient) allows. 11/8/17 - Wound care assessment SDTI Rt (right) heel. Treatment initiated. Medical record review of the Comprehensive Care Plan, dated 8/22/17 revealed .Potential for skin breakdown associated with decreased mobility .Approaches .Reposition q (every) 2 hrs (hours) .11//8/17 - Pressure area to Rt (right) heel .Approaches .Encourage resident to float heels while in bed . Further review revealed floating the heels when in chair was not included as ordered on [DATE]. Medical record review of the bedside Care Plan provided for the CNA staff revealed a Task List including float heels off surface on pillows while in bed . Further review revealed floating the heels when in chair was not included. Observations of Resident #106 revealed the following: 11/13/17 at 10:30 AM, revealed the resident seated in a reclined chair with both heels laying directly on the footrest of the recliner, heels were not floated. 11/14/17 at 12:35 AM, with the Wound Care Nurse, revealed the resident seated in the reclining chair with both heels laying directly on the footrest of the recliner, heels were not floated. 11/15/17 at 10:15 AM, revealed the resident lying in the bed with both heels resting on the mattress, heels were not floated. Observation and interview with the Licensed Practical Nurse (LPN) #1 on 11/15/17 at 10:30 AM, in Resident #106's room, confirmed the resident's heels were not floated off of the mattress of the bed. Observation continued and LPN #1 uncovered the resident's feet, placed feet on a pillow with the heels resting on the pillow, not floated. Interview continued and LPN #1 stated Once up .stays up in the recliner most of the day (referring to the dayshift hours). Interview with the NP on 11/15/17 at 9:30 AM, in the conference room, revealed Resident #106 had been .in and out of the facility in the past . and when admitted [DATE] wasn't doing well at first .stabilized now . Interview continued and the NP confirmed the resident's overall health status had shown some improvement. Further interview confirmed the resident had a right heel pressure ulcer identified on 11/7/17 and the pressure ulcer had increased in size from 11/7-11/14/17. Interview with the Wound Care Nurse on 11/15/17 at 1:20 PM, in the conference room, revealed Resident #106 had prolonged periods of lethargy and the nurse stated this contributed to the resident lying on her back with the right heel rotated out laterally. Interview continued and confirmed the following: the Wound Care Nurse had not been aware the resident was in the reclined chair each day; the heels were not floated on 11/14/17 when resident was in the chair; the observation of LPN #1 placing Resident 106's feet on a pillow at 11:00 AM was not floating the heel, .when her heel is touching something there isn't pressure relief .; and the pressure ulcer identified as a SDTI on 11/7/17 had increased in size of width by 3 cm over the previous 7 days. Interview with the Director of Nursing on 11/15/17 at 2:45 PM, in the conference room, confirmed Resident #106's Comprehensive Care Plan included an intervention to float heels off of the bed, but did not include when in the chair, as ordered on [DATE]. Interview continued and confirmed the bedside CNA care plan did not include floating the heels while in the chair. Further interview confirmed the facility failed to implement interventions for the treatment of [REDACTED].",2020-09-01
220,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2018-11-15,578,D,0,1,OF3B11,"**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 ensure accuracy of advanced directives for 1 resident (#138) of 43 sampled residents. The findings include: Review of the facility's POST Form (Physicians Orders for Scope of Treatment - an advanced directive form that describes the health care wishes for someone facing a life-threatening medical condition) Policy and Procedure, undated, revealed .Once the POST form has been adequately filled out, it will be signed by the DPOA (Durable Power of Attorney)/surrogate and/or resident .placed in the chart .If the POST form is present on admission from an outside facility .If a physician's signature is present, no further action is necessary. It will remain in the resident's chart . Medical record review revealed Resident #138 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #138's current care plan dated [DATE] revealed .Code Status DNR (Do Not Resuscitate) .Will have comfort measures ongoing as needed .educate staff on DNR status .Label Chart of DNR status . Medical record review of Resident #138's current POST form (from an outside facility) dated [DATE], revealed the CPR (Cardiopulmonary Resuscitation) box checked, indicating the resident would receive CPR if the resident had no pulse and was not breathing. Medical record review of the physician recapitulation orders dated (MONTH) (YEAR) revealed .DNR . Observation and interview with Licensed Practical Nurse (LPN) #5 on [DATE] at 9:56 AM, at the 4th floor nurse's station, revealed a DNR sticker on Resident #138's physical chart. Continued observation revealed the current POST form indicated the resident was to be resuscitated. Continued interview with LPN #5 confirmed the hospital may have changed the resident's code status but the resident remained a DNR status at the facility. Interview with the Director of Nursing on [DATE] at 4:09 PM, in the conference room, confirmed Resident #138's physician's recapitulation orders, code status sticker, and current care plan did not reflect the status indicated on the resident's current POST form .it (POST form) should be looked at and addressed . Continued interview confirmed the resident's advanced directives were inaccurate and the facility failed to follow facility policy.",2020-09-01
221,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2018-11-15,641,D,0,1,OF3B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 2 residents (#23, #142) of 34 residents reviewed for MDS assessment of 43 residents sampled. The findings include: Medical record review revealed Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #23's Care Plan (resident's current care plan) dated 7/6/16 revealed the resident was care planned for potential for sad and or declining mood related to nursing home admission and health issues. Continued review revealed .5/7/18 NP (Nurse Practitioner) eval (evaluation) of behaviors and review of meds (medications) Add dx (diagnosis): [MEDICAL CONDITION] . Medical record review of a Nurse Practitioner Progress note dated 5/7/18 revealed .Seen for f/u (follow-up) confusion, delusions . conts (continues) with behaviors . Continued review revealed .Problem NEW to examiner [MEDICAL CONDITION] .[MEDICATION NAME] (antipsychotic medication) 25mg (milligram) qhs (every night) .12.5mg q (every) am (morning) Psych (psychiatric) f/u . Medical record review of a Psychiatric Consult dated 5/17/18 revealed .long term resident seen today for follow up .Staff report patient is still hallucinating at times . Continued review revealed Resident #23 was ordered [MEDICATION NAME] for the [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #23 had a Brief Interview for Mental Status Score of 3 indicating the resident was severely cognitively impaired. Continued review revealed in the Behavior Section of the MDS no documentation Resident #23 had exhibited any delusions during the quarterly review time period and no documentation of the [MEDICAL CONDITION]. Interview with the MDS Coordinator on 11/15/18 at 10:45 AM, in the conference room, confirmed the facility failed to accurately complete a quarterly MDS for Resident #23 to include the [DIAGNOSES REDACTED]. Continued interview confirmed the facility failed to document Resident #23's delusions in the behavior section of the MDS. Medical record review revealed Resident #142 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission MDS dated [DATE], the 14 day MDS dated [DATE], and the MDS dated [DATE], did not indicate the resident was receiving [MEDICAL TREATMENT]. Interview with Licensed Practical Nurse, (LPN) #3 on 11/15/18 at 12:35 PM, in the conference room, confirmed the 3 MDS assessments dated 9/24/18, 9/30/18, and 10/22/18, did not reflect the resident was receiving [MEDICAL TREATMENT] and were not accurate.",2020-09-01
222,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2018-11-15,644,D,0,1,OF3B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to resubmit a pre-admission screening and resident review (PASARR) Level 1 for 1 resident (#23) of 8 residents reviewed for PASARR Level 2 evaluations of 43 residents sampled. The findings include: Medical record review revealed Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #23's PASARR Level 1 dated 7/15/11 revealed the facility submitted a PASARR Level 1 which was negative for PASARR Level 2 services. Medical record review of Resident #23's Care Plan (resident's current care plan) dated 7/6/16 revealed the resident was care planned for potential for sad and or declining mood related to nursing home admission and health issues. Continued review revealed .5/7/18 NP (Nurse Practitioner) eval (evaluation) of behaviors and review of meds (medications) Add dx (diagnosis): [MEDICAL CONDITION] . Medical record review of a Nurse Practitioner Progress note dated 5/7/18 revealed .Seen for f/u (follow-up) confusion, delusion . conts (continues) with behaviors . Continued review revealed .Problem NEW to examiner [MEDICAL CONDITION] . [MEDICATION NAME] (antipsychotic medication) 25mg (milligram) qhs (every night) .12.5mg q (every) am (morning) Psych (psychiatric) f/u . Medical record review of the Psychiatric Consult dated 5/17/18 revealed .long term resident seen today for follow up . Staff report patient is still hallucinating at times . Continued review revealed Resident #23 was ordered [MEDICATION NAME] for the [DIAGNOSES REDACTED]. Interview with the Director of Nursing (DON) on 11/15/18 at 10:22 AM, in the conference room, confirmed the facility failed to resubmit a PASARR Level 1 for Resident #23 after the resident received a new [DIAGNOSES REDACTED].",2020-09-01
223,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2018-11-15,689,D,0,1,OF3B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility documentation, observation, and interview, the facility failed to ensure a safety device was functional for 1 resident (#88) of 5 residents reviewed for falls. The findings include: Medical record review revealed Resident #88 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Fall Risk assessment dated [DATE] revealed the resident was at risk for falls. Medical record review of the admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had moderately impaired cognitive skills, did not walk, and had no falls since admission to the facility. Medical record review of the Care Plan reviewed on 9/11/18 revealed .At risk for Falls r/t (related to) generalized weakness .PSA (personal safety alarm) to bed . Medical record review of the physician's recapitulation orders for 11/2018, revealed the resident was to have a PSA when in bed. Medical record review of a nursing note dated 11/5/18 revealed At approx (approximately) 9pm resident was witnessed laying in floor beside bed on floor mat. When asked about what happened resident stated 'I am trying to get up and go downstairs.' No injuries apparent, resident has no c/o (complaints of) pain or discomfort. When assisted back into bed resident stated 'You're just wasting your time. I'm going to get back up again.' .Daughter is aware of fall. Review of facility's fall investgation, for the fall on 11/5/18, revealed the PSA did not alarm at the time of the fall on 11/5/18. Observation on 11/15/18 at 1:05 pm revealed the resident lying on a low bed, with a curved mattress, bilateral floor mats and a PSA in place. Interview with the Assistant Director of Nursing (ADON) on 11/14/18 at 1:20 PM, in the conference room, confirmed when the resident fell from the bed on 11/5/18, the PSA did not sound.",2020-09-01
224,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2018-11-15,758,D,0,1,OF3B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to attempt a Gradual Dose Reduction (GDR) of a [MEDICAL CONDITION] medication for 1 resident (#51) of 6 residents reviewed for unnecessary medications of 43 residents sampled. The findings include: Medical record review revealed Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical Record Review of the Quarterly Minimum Data set ((MDS) dated [DATE] revealed Resident #51 had Dementia, Depression, and a [MEDICAL CONDITION]. Further review revealed Resident #51 received antipsychotic and antianxiety medications all 7 days of the 7 day lookback period, and no GDR had been attempted. Continued review revealed a GDR had not been documented by a physician as clinically contraindicated. Medical record review of the (MONTH) (YEAR) physician's orders [REDACTED]. Medical record review of a handwritten document from the facility's Consultant Pharmacist dated 11/15/18 revealed .a medication regimen review has been completed monthly for (Resident #51). Further review confirmed .I have not made a GDR recommendation to the prescriber . Interview with Registered Nurse (RN) #1 on 11/15/18 at 9:16 AM, in the Conference Room confirmed a GDR was not completed. Telephone interview with the Mental Health Nurse Practitioner on 11/15/18 at 10:00 AM, in Conference Room confirmed an [MEDICATION NAME] GDR was not attempted. Interview with Director of Nursing (DON) on 11/15/18 at 1:475 PM, in the DON's office confirmed there wasn't a GDR completed and there was no documentation that a GDR was contraindicated.",2020-09-01
225,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2018-11-15,761,D,0,1,OF3B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, observation, and interview, the facility failed to discard expired medications/supplies in 1 of 3 medication carts and in 3 of 4 medication storage rooms. The findings include: Review of the facility policy, Medication Storage, dated 8/1/15, revealed .All out-dated, deteriorated, or unusable drugs shall be stored in a designated area away from other drugs . Observation of the medication cart and interview with Licensed Practical Nurse (LPN) #1 on 11/15/18 at 10:05 AM, in the 300 unit medication cart room revealed 1 opened bottle of glucose testing strips, 1/2 full, expired on 10/11/18. Interview with LPN #1 confirmed the glucose testing strips were expired and available for resident use. Observation and interview with LPN #2 on 11/15/18 at 10:15 AM, in the 300 unit medication storage room, revealed the following supplies expired and available for resident use: 11 blood specimen collection needles with an expiration date of 5/2017. Interview with LPN #2 confirmed the supplies were expired and available for resident use. Observation and interview with LPN #4 on 11/15/18 at 1:20 PM, of the 400 hall medication room, confirmed there were 5 [MEDICATION NAME] acetate suppositories, with an expiration date of 7/2018, available for resident use.",2020-09-01
226,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2018-11-15,880,D,0,1,OF3B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation, and interview the facility failed to follow infection control guidelines during meal service on 1 of 4 floors. The findings include: Review of facility Personal Hand Sanitization Policy (undated) revealed .All employees will use waterless hand rub or soap and water to clean their hands: .Before having direct contact with residents .After contact with a resident's intact skin .After contact with inanimate objects in the immediate vicinity of the resident . Observation of Certified Nursing Assistant (CNA) #1 on 11/13/18 at 12:40 PM, on the 400 unit, revealed CNA #1 entered room [ROOM NUMBER]. Further observation revealed inside the room, CNA #1 touched the wheelchair then exited room without performing hand hygiene. Continued observation revealed CNA #1 then entered room [ROOM NUMBER], pulled up the resident in bed, and touched the blanket. Further observation revealed CNA #1 exited room [ROOM NUMBER] without performing hand hygiene, removed a meal tray from the cart in the hall, then entered room [ROOM NUMBER] and placed the meal tray on the bedside table. Continued observation revealed, CNA #1 then exited room [ROOM NUMBER] without performing hand hygiene and knocked on the door to room [ROOM NUMBER]. Further observation revealed CNA #1 removed a meal tray from the cart in the hall and carried it into room [ROOM NUMBER]. Continued observation revealed CNA #1 set up the meal tray, then touched the table and exited the room without performing hand hygiene. Interview with CNA #1 on 11/13/18 at 12:46 PM, on the East 400 hall, confirmed she hadn't washed her hands before she handed out the meal trays. Interview with Director of Nursing (DON) on 11/14/18 at 2:58 PM, in DON's office confirmed she expected staff .to wash hands before you go in a room, before you go out of a room, anytime you are going in and out of somebody's room . Continued interview confirmed .I would expect them to wash their hands .",2020-09-01
227,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2018-02-07,655,D,0,1,UOI611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility's Drug Information Report, medical record review, observation, and interview, the facility failed to provide an interim plan of care for 1 resident (#91) of 45 residents reviewed. The findings included: Review of the Drug Information Report provided with the electronic Information Medication Administration Record [REDACTED].[MEDICATION NAME] (medication to treat heart arrhythmias).it can.cause a new serious abnormal heart rhythm (QT prolongation (indicator of a delay in repolarization of the heart).). This problem can lead to a new type of abnormal (possibly fatal) heartbeat (torsade de pointes). If this new serious heart rhythm occurs, it is usually when [MEDICATION NAME] treatment is first started.This medication is used to treat a serious (possibly life-threatening) type of fast heartbeat. Medical record review revealed Resident #91 was admitted to the facility on [DATE] following an acute care hospital stay 11/16/17 through 11/30/17 with a new onset of [MEDICAL CONDITION] Fibrillation (A-Fib). Medical record review of the hospital cardiology note dated 11/30/17 revealed, .[MEDICATION NAME] started yesterday (11/29/17) has put pt (patient) back in NSR (normal sinus rhythm).if pt stays in NSR on [MEDICATION NAME], cardioversion will be canceled. Medical record review of the facility's Baseline Care Plan dated 11/30/17, revealed .Clinical Reason for Admission.[MEDICAL CONDITION] Fibrillation. Continued review revealed the drug [MEDICATION NAME], prescribed for Resident #91 on 11/29/17, 1 day prior to admission, wasn't included as a Care Need. Medical record review of the physician's orders [REDACTED]. Record review of the following 12/4/17 physician's orders [REDACTED]. [MEDICAL CONDITION].[MEDICATION NAME] [AGE] mg (milligrams) BID (twice a day).High risk of brady (low heart rate) torsade (torsade de pointes) 2 (secondary to) acquired (increased) QT. Medical record review of a nursing entry dated 12/4/17 at 2:49 PM revealed the resident was transferred by ambulance to the local acute care hospital, .unstable.P (pulse) 53. Medical record review of the hospital cardiology consult dated 12/5/17, revealed .I reviewed the EKG that was performed on 1[DATE]17 demonstrating sinus [MEDICAL CONDITION] with ventricular rate of 51 beats per minute. Medical record review of the hospital's transfer to Nursing Home Orders dated 12/11/17, revealed the drugs [MEDICATION NAME] and [MEDICATION NAME] had been discontinued and instructions to .Remove foley (indwelling urinary catheter) 1/1/18 at HS (bedtime) for urology appointment the following day. Medical record review of the facility's Baseline Care Plan dated 11/30/17, revealed the resident's return to the hospital on [DATE] through 12/11/17 was not included, the new [DIAGNOSES REDACTED]. Observation of Resident #91 on 2/5/18 at 10:25 AM, revealed the resident was napping in bed. Interview with Licensed Practical Nurse (LPN) #1, self-identified as an Administrative Nurse, on 2/7/18 at 3:15 PM, in the conference room, confirmed the resident's Baseline Care Plan did not include the use of [MEDICATION NAME], the precautions (especially when [MEDICATION NAME] is newly prescribed), or any cardiac assessments required for safe administration. Continued interview confirmed the complication of [MEDICAL CONDITION] was recognized by the physician extender during an initial assessment of Resident #91 on 12/4/17. Continued interview confirmed the resident's hospital stay 12/4/17-12/11/17 wasn't reflected in the Baseline Care Plan dated 11/30/17, the Baseline Care Plan wasn't reviewed or revised when the resident returned after a 7 day hospital stay, and the plan of care did not include the indwelling urinary catheter upon return from the hospital.",2020-09-01
228,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2018-02-07,689,D,0,1,UOI611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, review of facility fall investigation, observation, and interview, the facility failed to implement new interventions to prevent future falls for one Resident (#101), of 5 residents reviewed for falls, of 45 residents reviewed. The findings included: Review of facility policy Falls Policy, not dated, revealed, .Treatment/Management.1. Based on the preceding assessment, the staff, and/or physician will identify.pertinent interventions to try to prevent subsequent falls and address the serious consequences of fall.Monitoring/Follow-up.2. The staff will monitor and document the individual's response to interventions intended to reduce falling or consequences of falling. Medical record review revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Interim Care Plan Addendum dated 4/21/17 revealed, .At risk for falls related to.h/o (history of) falls, unsteady gait. Continued review revealed, .Nursing Interventions.orient the resident to room, bed controls, light and call-light.Instruct and remind the resident to use call-light to ask for assist.Keep path around the bed and to the bathroom clear from clutter. Medical record review of the High Risk Patient Selection Form, not dated, revealed an admission assessment for risk for falls. Continued review revealed the resident was assessed as a fall risk due to falling in past the 30 days with interventions to include therapy screening, wheelchair assessment and walking assessment. Medical record review of the resident's current care plan dated 5/11/17 revealed, .Resident at risk for falls secondary to: difficulty in walking, dementia. Continued review revealed, .Approaches.monitor resident for poor safety awareness.keep pathways free from clutter.keep wheelchair locked during transfers.educate resident on up with assistance only.non-skid footwear (which was marked out with a line through it).keep call light within reach.monitor environment for safety.maintain bed at lowest level for safety.fall precautions. Medical record review of a Post Falls Nursing assessment dated [DATE] revealed the resident had a fall on 5/31/17 at 7:00 PM in the resident's bathroom.CNA (certified nursing assistant) yelled help. Went to see what was going on. CNA reported patient was on the floor in the bathroom.Exiting commode while unattended.Patient states he used grab bars to stabilize himself to the floor when he got his legs twisted up. He did have an abrasion to left rib area. Continued review revealed, .Patient's position after the fall?.Patient was found on the floor sitting on his bottom up against the wall between the toilet and wheelchair.Patient has an abrasion to the rib area going up his side. Medical record review of Nurse's Notes dated 6/1/17 revealed, .Follow-up for event on 5/31/17. Resident was attempting to transfer self from toilet to chair. His feet got tangled.he stabilized himself to floor. Medical record review of a Nurse's Note dated 6/6/17 revealed, .Follow-up note for previous fall on 5/31/17.Spoke with Rt (resident) concerning fall. Rt stated he attempted to transfer from toilet to wheelchair unattended and his legs got twisted up in catheter tubing. He states he was able to stabilize himself to the floor. Reinforcement of use of call light and asking for assistance when transferring. Will continue to monitor. Medical record review of a Nurse's Note dated 11/29/17 and timed 6:50 PM, revealed, .Called to pt's (patient's) room. Observed pt lying on his left side in the bathroom with blood pooled under his head. After raising pt up a large laceration was noted to his left ear.pressure dressing was applied.pt was transferred to w/c (wheelchair).order to send to ER for evaluation. Medical record review of Post Falls Nursing assessment dated [DATE] revealed, .called to pt's room, observed pt lying on his left side in the bathroom.fell from wheelchair.trying to go to the bathroom. Continued review revealed, .What immediate interventions were initiated to prevent future falls.Pressure alarm to chair and frequent observation started. Review of the resident's care plan revealed the intervention to add pressure alarm was not added to the resident's care plan. Medical record review of a Nurse's Note dated 12/1/17 at 2:00 PM, revealed .Follow up for event (fall) on 11/29/17.Patient is alert and oriented x 4 (to person, place, time, and situation) c (with) BI[CONDITION] (Brief Interview for Mental Status) score of 15 (no cognitive impairment) on 10/23/17. At time of event patient continued to be cognitively intact. Patient stated he was toileting himself when he fell .Patient is anticipated to return to facility once medically stable. Review of a Post Falls Investigation dated 12/1/17 revealed, .Will assess need for interventions upon return to facility. Observation of the resident on 2/6/18 at 2:00 PM, in the resident's room, revealed the resident laying in the bed and sleeping. Continued observation revealed no pressure pad alarms in place. Interview with LPN #1 and observation of the resident on 2/6/18 at 2:05 PM, in the resident's room, confirmed no pressure pad alarms were in place. Interview with the Falls Nurse and Director of Nursing (DON) on 2/7/18 at 1:06 PM, in the Falls Nurse's office, confirmed the Falls Nurse was unaware of the intervention to add a pressure pad alarm to the resident's chair after the resident's fall on 11/29/17. Continued interview with the Falls Nurse confirmed the Falls Nurse had not reassessed the resident or implemented any additional falls interventions to prevent future falls when the resident returned to the facility after hospitalization for the fall that occurred on 11/29/17.",2020-09-01
229,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2019-02-12,689,D,0,1,IS2411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Resident Assessment Instrument Manual (RAI), facility policy review, medical record review, observation, and interview the facility failed to identify falls and complete a fall investigation for 1 resident (#118) of 5 residents reviewed for falls of 33 sampled residents. The findings include: Review of the RAI manual (3.0 version) dated 10/2018, (J1700: Fall) revealed .Fall unintentional change in position coming to rest on the ground, floor or onto the next lower surface (e.g., onto a bed mat, chair, or bedside mat) .identified when a resident is found on the floor or ground . Review of the facility policy Falls revised 7/14/2017, .Cause Identification 1. For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall .3. The staff and /or physician will continue to collect and evaluate information until either the cause of the falling is identified . Medical record review revealed Resident #118 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed the resident was at high risk for falls. Review of the quarterly Minimum Data Set ((MDS) dated [DATE], revealed the Resident had a Brief Interview for Mental Status (BIMS) score of 4, which indicated severly impaired cognitive skills; required extensive assist of 2 persons for bed mobility and transfers; and extensive assist of 1 person for dressing, eating, toilet use, and personal hygiene. Medical record review of the nurses notes for the following dates revealed: 8/8/18-fell from bed, no apparent injuries. 11/11/18-found with bottom on fall mat and upper body/head on bed, no injuries. 11/24/18-found kneeling next to bed holding onto bed rail, no injuries. 2/10/19-fall on 2/9/19 found on mat, no injuries. Continued medical record review revealed there was no documentation of a facility fall assessment or fall investigation for the falls on 11/11/18 and 2/9/19; and no fall investigation for the 11/24/18 (there was a fall assessment completed). Interview with the Risk Manager on 2/11/19, 2:40 PM in the day room revealed when the resident was found to be on the fall mats, it was not considered to be a fall. Continued interview with the Risk Manager revealed the Resident had not sustained any injuries. Further interview with the Risk Manager in the day room, confirmed fall investigations had not been completed on 11/11/18, 11/24/18 and 2/9/19 on 3 of the 4 falls listed. Observation on 2/12/19, at 8:35 AM and 9:40 AM, revealed Resident #118 was lying in bed. Continued observation revealed the bed was in low position and floor mats in place. Interview with the Director of Nursing on 2/12/19 at 9:25 AM, in the 2nd floor day room confirmed all falls are to be assessed and investigated with new interventions put in place to prevent further occurrences.",2020-09-01
230,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2019-02-12,698,D,0,1,IS2411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to remove a pressure dressing per the Physician's Order for 1 (#68) of 2 residents reviewed of 3 residents receiving [MEDICAL TREATMENT] of 33 residents sampled. The findings include: Medical record review revealed Resident #68 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 had a Brief Interview for Mental status score of 13, indicating he was cognitively intact. Further review revealed the resident received [MEDICAL TREATMENT] treatments (process of removing excess water and toxins from the blood in people whose kidneys can no longer perform this function) on a routine basis. Medical record review of the Complete Patient Care Plan updated 1/8/19 revealed .I receive [MEDICAL TREATMENT] (form of [MEDICAL TREATMENT]) .remove pressure dressing (dressing applied over the [MEDICAL TREATMENT]) post (after) [MEDICAL TREATMENT] days per md (physician) orders . Medical record review of the Physician's Orders dated 2/1/19-4/30/19 revealed .[MEDICAL TREATMENT] .REMOVE PRESSURE DRESSING POST [MEDICAL TREATMENT] DAYS 4-6 (hours) AFTER RETURNING FROM [MEDICAL TREATMENT]. MONDAY WEDNESDAY AND FRIDAY . Observation and interview with Resident #68 on 2/12/19 at 8:03 AM, in the resident's room revealed the resident lying on the bed with the pressure dressing in place over the access site on the right upper arm. Further interview with the resident revealed the pressure dressing had not been removed after he returned from the [MEDICAL TREATMENT] clinic on the previous day (2/11/19). Observation and interview with the Licensed Practical Nurse (LPN) Supervisor on 2/12/19 at 8:07 AM, in the resident's room confirmed the pressure dressing was in place to the right upper arm [MEDICAL TREATMENT]. Further interview confirmed the dressing should have been removed on 2/11/19 after the resident returned from the [MEDICAL TREATMENT] clinic. Interview with the LPN Supervisor on 2/12/19 at 2:43 PM, at the 2nd floor nurse's station confirmed Resident #68 had returned to the facility from the [MEDICAL TREATMENT] clinic on 2/11/19 at 6:56 PM. Further interview confirmed the pressure dressing should have been removed by 11:00 PM on 2/11/19 per the Physician's Order. Interview with the Risk Manager on 2/12/19 at 2:59 PM, in the Risk Manager's office confirmed the facility failed to remove Resident #68's pressure dressing per Physician's Order.",2020-09-01
231,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2019-02-12,761,F,0,1,IS2411,"**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 and supplies available for resident use in 2 of 3 medication storage rooms. The findings include: Review of the facility policy MEDICATION STORAGE IN THE FACILITY effective date 6/2016 revealed .Outdated medications .are immediately removed from inventory, disposed of according to procedures for medication disposal . Observation of the 2nd floor medication storage room and interview with Licensed Practical Nurse (LPN) #1 on 2/12/19 at 12:18 PM revealed (1) 20 milliliter bottle of injectable [MEDICATION NAME] (medication used for numbing) with an expiration date of (MONTH) 1, (YEAR) and (1) 1000 milliliter bag of D5 IV fluid ([MEDICATION NAME] 5% in water intravenous fluid) with an expiration date of (MONTH) (YEAR). Further observation revealed (in the supply cabinet) (2) red topped lab tubes with an expiration date of 9/30/18, (1) red topped lab tube with an expiration date of 7/31/18, and (1) insulin syringe with an expiration date of 10/2018. Further interview with LPN #1 revealed all above items were expired and had remained available for resident use. Observation of the 3rd floor medication storage room and interview with Registered Nurse (RN) #1 revealed (in the supply cabinet) (2) red topped lab tubes with an expiration date of 12/31/18, (1) 22 gauge (size of the needle) Intravenous cannula (device used to obtain access to a vein to administer intravenous fluids or medications) with an expiration date of 6/2018, (2) 20 gauge intravenous cannulas with an expiration date of 10/2018, and (2) chlora prep one step applicators (used to clean the skin to prevent infection) with expiration date of 10/2014 and 3/2015. Further interview with RN #1 confirmed all above listed supplies were expired and available for resident use.",2020-09-01
232,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2019-02-12,812,F,0,1,IS2411,"Based on facility policy review, observation and interview the facility failed to maintain a sanitary kitchen as evidenced by undated, unlabeled and open to air food items in 1 of 1 freezers and 1 of 1 dry storage rooms observed. The findings include: Review of the facility policy, Safety & Sanitation Best Practice Guidelines-Dry Storage, revised 11/2017, revealed .Foods will be stored in their original packages, if possible. If opened, packages should be closed securely to protect product. Products that are not easily identified such as flour, sugar, salt, etc. should be clearly labeled with the common name of the food when removed from the original packages . Review of the facility policy, REFRIGERATOR AND FREEZER STORAGE revealed .Foods will be stored in their original container or a NSF (National Sanitation Foundation) approved container or wrapped tightly in moisture-proof film, foil, etc. Clearly labeled with contents and the use by date . Observation of the kitchen on 2/10/19 at 9:45 AM, with the Assistant Dietary Manager revealed the following in the dry storage area: (1) 2 pound (lb) package of brown sugar open to air and undated. (1) 24 ounce (oz) package of unsweetened shredded coconut, 1/4 package remaining, open to air and undated. (1) 5 lb package of bacon muffin mix,1/2 package remaining, open to air and undated. (2) 9.7 oz packages of sugar substitute open to air and undated. (1) 32 oz package of powdered sugar, 3/4 full, open to air and undated. (1) large square clear bin with a white powdered substance, not labeled and undated. Assistant Manager stated .It smells like flour . He did not know what the white powdered substance was. (1) 50 lb bag of rice with use by date 2/16/19, 1/4 of the bag remaining, open to air. (1) 24 oz package of crispy fried onions undated and open to air. (1) 5 lb package of egg noodles, 1/4 of the package remaining, undated and open to air. (1) 2 lb 3 oz bag of bran cereal with raisins, 1/8 of the bag remaining, undated and open to air. (1) 2 lb 3 oz bag of bran cereal with raisins,1/2 of the bag remaining, undated and open to air. (1) 2 lb 3 oz bag of toasted oats cereal,1/2 of the bag remaining, undated and open to air. (1) 2 lb 3 oz bag of sugar frosted flakes,1/2 of the bag remaining, undated and open to air. (1) 2 lb 3 oz bag of crisp rice cereal,1/2 of the bag remaining, undated. (1) 2 lb 3 oz bag of crisp rice cereal,1/2 of the bag remaining, undated and open to air. (2) 2 lb 3 oz bags of corn flakes cereal,1/8 of the bags remaining, undated and open to air. (1) 2 lb 3 oz bag fruit whirls cereal,1/4 of the bag remaining, undated and open to air. (1) 2 lb 3 oz bag fruit whirls cereal, full bag remaining, undated and open to air. Observation of the walk in freezer with the Assistant Dietary Manager on 2/10/19 at 10:00 AM, revealed the following: (1) 120 count box of croissant roll dough, 3/4 of the box remaining, undated and open to air. (1) 10 lb box of pork sausage patties with 36 sausage patties remaining, undated and open to air. (1) box of frozen biscuit dough with 216 biscuits per box, 22 biscuits remaining, undated and open to air. Interview with the Dietary Manager on 2/10/19 at 10:10 AM, in the kitchen confirmed all dry foods should be dated and sealed after opening .There is no excuse for it . Observation of the walk in freezer in the kitchen with the Dietary Manager, on 2/12/19 at 9:35 AM revealed the following: (1) 120 count box of croissant roll dough, 3/4 of the box remaining, undated and open to air. (1) 7.62 kilogram (kg) box of frozen hash brown patties, 1 of 4 bags undated and open to air. Interview with the Dietary Manager on 2/12/19 at 10:05 AM, in the kitchen confirmed the facility failed to discard undated and food items left open to air.",2020-09-01
233,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2019-05-21,609,D,1,0,JKQQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of a facility investigation, medical record review and interviews, the facility failed to ensure an allegation of abuse was reported timely to the facility Administrator and to other officials (State Survey Agency and Adult Protective Services) in accordance with Federal and State law for 1 resident (#1) of 3 residents reviewed for Abuse on 3 nursing units for 3 sampled residents. The findings included: Review of facility policy Patient Protection and Response Policy for Allegation/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation dated 12/11/17 revealed .6. Reporting Policy .Any partner having either direct or indirect knowledge of any event that might constitute abuse .must report the event immediately, but not later than 2 hours after forming the suspicion if the events that cause the suspicion involve abuse . Review of a facility investigation dated 4/30/19 revealed Certified Nursing Assistant (CNA) #2 reported to the charge nurse on 4/30/19 she witnessed possible abuse by CNA #1 toward Resident #1 on the evening of 4/29/19. Continued review revealed the charge nurse notified Administration of the allegation and the Director of Nursing (DON) and Assistant Director of Nursing (ADON) interviewed CNA #2. Further review revealed CNA #2 reported she witnessed CNA #1 grab the arm of Resident #1 and forcefully push her back into her wheelchair with an open hand. 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 was severely cognitive impaired. Continued review revealed the resident required extensive assistance of 2 persons for bed mobility and extensive assistance of 1 person for transfers. Telephone interview with CNA #1 on 5/21/19 at 10:20 AM revealed she put her hands on the shoulder of the resident to ease her back into her chair because she was afraid the resident would fall. Interview with the Administrator on 5/21/19 at 10:50 AM, in the Conference Room, confirmed the facility failed to report an allegation of abuse within 2 hours and failed to follow facility policy.",2020-09-01
234,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2018-08-16,609,D,1,0,Y10D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, and interviews, the facility failed to ensure an allegation of abuse was reported timely to the state agency for 1 resident (#3) of 3 residents reviewed for abuse of 3 sampled residents. The findings included: Review of facility policy titled Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation revised 12/11/17 revealed .6. Reporting Policy .It is the policy of this facility that 'abuse' allegations .are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment .are reported immediately, but not later than 2 hours after the allegation is made . Medical record review revealed Resident #3 was admitted to the facility 12/8/12 with [DIAGNOSES REDACTED]. Medical record review of the annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 was moderately cognitive impaired and required extensive assistance for bed mobility, transfers, and personal hygiene. Review of a facility investigation dated 7/25/18 revealed on 7/25/18 at approximately 3:30 PM Resident #3 reported to her granddaughter a Certified Nursing Assistant (CNA) had gotten irritated with her, choked her, and threw water on her about a week ago. Continued review revealed the granddaughter reported the allegation to the nurse. Further review revealed the nurse interviewed Resident #3 and then reported the allegation to the appropriate administrative personnel, who initiated an investigation. Continued review revealed on 7/26/18 the resident changed her report of the incident and stated the CNA actually hit her on the leg, but did not choke her. Further review revealed the alleged incident was not reported to the state survey agency. Interview with the Director of Nursing (DON) on 8/16/18 at 1:00 PM, in the Conference Room, confirmed the facility failed to report the alleged incident to the state survey agency and the facility failed to follow facility policy.",2020-09-01
235,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2017-12-05,329,D,1,0,TVBT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, facility documentation, medical record review, and interview, the facility administered unnecessary medications for 2 residents (#3 and #24) of 15 residents reviewed for medication errors. The findings included: Review of the facility policy Preparation and General Guidelines dated 6/2016, revealed .Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so .Right resident, right drug, right dose, right route, and right time, are applied for each medication being administered .The Medication Administration Record [REDACTED]. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of untitled facility documentation dated 8/10/17, revealed .Med (Medication) cart nurse .(Licensed Practical Nurse (LPN) #5) was on lunch break .(Resident #3) had a scheduled dose of [MEDICATION NAME] (narcotic pain medication) 10 mg (milligrams) due .patient's husband, requesting the medication be given .(Registered Nurse (RN) #2) .administered the medication .signed out of the narcotic count log and the IMAR (electronic medication administration record) .(LPN #5) returned from lunch, he (LPN #5) noted the medication would not scan in IMAR due to already being signed out but administered anyway (LPN #5 administered another dose) . Telephone interview with LPN #5 on 10/18/17 at 9:15 AM, revealed on 8/10/17, LPN #5 returned from lunch, obtained a dose of the scheduled [MEDICATION NAME] 10 mg for Resident #3, administered the medication, returned to the medication cart, began to sign out the narcotic on the resident's [MEDICATION NAME] record sheet, and noted the narcotic had already been signed out for the scheduled dose by RN #2. Continued interview confirmed LPN #5 had administered a second dose of [MEDICATION NAME] and reported the medication error to his Charge Nurse, RN #1. Further interview confirmed LPN #5 had not followed the facility's policy for safe medication administration. Interview with the Director of Nursing on 10/19/17 at 4:34 PM, in the conference room, confirmed Resident #3 received an unnecessary dose of [MEDICATION NAME]. Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum (MDS) data set [DATE] revealed Resident #24 had a Brief Interview of Mental Status (BIMS) score of 3, indicating severely impaired cognitive abilities. Medical record review of the Nurse's Notes dated 10/26/17 for Resident #24, written by RN #4, revealed .8:30 PM Pt (patient) is screaming @ (at) the top of her lungs, combative, trying to throw herself into the floor. PRN (as needed) and scheduled [MEDICATION NAME] given (anti-anxiety medication) outcome not effective. Pt is threatening staff. (On call physician service) paged (on-call medical service) .NP (Nurse Practitioner) gave (an order to RN #4) .1 mg [MEDICATION NAME] IM (intramuscular) x1 dose now for increased agitation and combative behavior. Interview with RN #4 on 12/4/17 at 3:28 PM, in the conference room, confirmed the order for [MEDICATION NAME] had been initially written incorrectly for an oral dose and re-written incorrectly [MEDICATION NAME] 2MG/ML VIAL Give 1mg (1ml) IM .Verbal order .(on call physician service) . Further interview revealed RN #4 was counseled not to include concentrations when writing future orders. Telephone interview with LPN #8 on 12/4/17 at 3:43 PM confirmed RN #4 received the order for a 1 time dose of [MEDICATION NAME] 1 mg IM on 10/26/17 for Resident #24. Further interview revealed he borrowed from another resident's supply of [MEDICATION NAME] at 8:30 PM and incorrectly administered a 1ml (2 mg) IM dose to Resident #24. Further interview revealed LPN #8 did not use the [MEDICATION NAME] supplied in the facility's emergency medication box because he wanted to administer the [MEDICATION NAME] quickly. Continued interview revealed LPN #8 discovered the medication error during counting (reconciling the number of controlled medications at shift change) with the oncoming night shift nurse, there was a shortage of a half milliliter (0.5 ml in the 4 ml multi-dose [MEDICATION NAME] vial supplied by the pharmacy). During the interview, LPN #8 stated the sign out sheet for the [MEDICATION NAME] was reviewed for the first time during the counting procedure and he realized a double dose had been administered. Interview confirmed the pharmacy information printed on the [MEDICATION NAME] sign-out sheet read [MEDICATION NAME] 2 mg/ml .Inject 0.5-1mg (0.25-0.5 ml) . Continued interview confirmed LPN #8 had not read the information on the vial of [MEDICATION NAME] and administered 2 mg instead of the ordered 1 mg dose. Interview revealed the error was reported to RN #3, the night shift supervisor. Further interview revealed LPN #8 had participated in the facility-wide in-service conducted on 10/19/17 What Are the Eight Rights of Medication Administration Safety. Continued interview confirmed he did not follow the third right Right Dose when he administered the double dose of [MEDICATION NAME] on 10/26/17. Telephone interview with the night shift nursing supervisor, RN #3, on 12/5/17 at 11:08 AM, confirmed LPN #8 initially reported the medication error of 10/26/17 to her. Continued interview revealed I wasn't sure if I was the one responsible to report it (the medication error) to (on call physician service) .it happened 2-3 hours before I came on duty . Interview continued and confirmed RN #3 did not report the medication error to her supervisor on the morning of 10/27/17. Further interview confirmed RN #3 had not initiated the facility's Medication Error Checklist and Report after LPN #8 reported the medication error. Interview with the Assistant Director of Nursing on 12/4/17 at 2:42 PM, in the conference room, confirmed Resident #24 received a double dose of [MEDICATION NAME] and RN #3 failed to report the medication error to the on call physician and to initiate an incident report. Continued interview revealed the [MEDICATION NAME] order was transcribed incorrectly by RN #4 and confirmed nursing principles for accurate recording and transcription of telephone orders had not been shared with the facility's nurses who receive and transcribe orders.",2020-09-01
236,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2017-12-05,333,J,1,0,TVBT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of facility contract, review of the Practical Nurse Program code of conduct, medical record review and interviews, the facility failed to prevent significant medication errors for 3 residents (#1, #4, #11) of 15 residents reviewed for medication errors. Resident #1 received 9 medications in error prescribed for Resident #2. The error resulted in Resident #1 becoming sedated, having decreased respirations, requiring multiple doses of [MEDICATION NAME] (medication used to treat an overdose of opioids in an emergency situation). Resident #4 did not receive his prescribed medications, including a diuretic, an oral diabetic medication to control elevated blood sugars, a beta blocker (a medication which carries a precaution of not discontinuing suddenly), and a blood thinner to prevent blood clots in a resident with a fractured femur through 7 shifts, from the evening of 8/25/17 through 8/27/17. Resident #11 had an non-prescribed [MEDICATION NAME] medication administered on 4/9/17. The facility's failure to ensure medications were administered to the correct resident and failure to ensure residents received all prescribed medications, resulted in significant medication errors and placed Resident #1, #4, and #11 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death). The Nursing Home Administrator (NHA) and Director of Nursing (DON), were informed of the Immediate Jeopardy on 12/4/17, at 9:00 AM in the Administrator's office. The IJ was effective 4/9/17 and is ongoing. Noncompliance continues at the severity of J level. An extended survey was conducted from 12/4/17 through 12/5/17. The facility was cited Substandard Quality of Care at F-333(J). The findings included: Review of the facility policy Preparation and General Guidelines dated 6/2016, revealed .Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so .Right resident, right drug, right dose, right route, and right time, are applied for each medication being administered .The Medication Administration Record [REDACTED]. Review of the contract between the facility and the technical college with the practical nursing program Clinical Affiliation Agreement . dated 5/10/16, revealed .While enrolled in clinical experience at the Facility .students .will be subject to applicable policies of the Institution (NHC Healthcare Fort Sanders) and the Affiliate (Practical Nurse Program) .Institution shall be responsible for supervising students at all times while present at the Facility for clinical experience .Affiliate shall retain complete responsibility for patient care providing adequate supervision of students at all times .Students will not be expected nor allowed to perform services in lieu of staff employees . Review of the (Practical Nurse Program) Code of Conduct undated, revealed .When giving meds (medications) YOU ARE RESPONSIBLE to use the correct patient identifiers-Never Ever Assume .Respect and ensure the safety and well-being of the patients .act to obtain appropriate supervision . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident was unable to complete the Brief Interview for Mental Status, indicating severe cognitive impairment. Further review of the MDS revealed he required extensive assist for most activities of daily living. Medical record review revealed Resident #1 began receiving hospice services 8/5/17, with a [DIAGNOSES REDACTED]. Medical record review of the Physician Orders and the Medication Administration Record [REDACTED]. Continued review revealed Resident #1 had PRN (as needed) medications of [MEDICATION NAME] for pain or fever, [MEDICATION NAME] for anxiety and [MEDICATION NAME] sulfate for pain or air hunger. Continued review of the MAR for August, September, and (MONTH) (YEAR), revealed the resident had received one dose each of the [MEDICATION NAME], and [MEDICATION NAME] sulfate in (MONTH) (YEAR), and did not receive any PRN medications in (MONTH) or (MONTH) (YEAR). Medical record review revealed Resident #2, who was the roommate of Resident #1, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician Orders and the Medication Administration Record [REDACTED]. Medical record review of Resident #1's Nurse's Note dated 10/6/17 revealed .At 10:15 AM pt (patient) given incorrect medication of Roommates (Resident #2) .Meds (medication) given [MEDICATION NAME] (narcotic pain medication) .insulin (medication to treat [MEDICAL CONDITION]) .NP (Nurse Practitioner) was in building .ORDERS immediately given and instituted .IV (intravenous fluids) D5W (5% [MEDICATION NAME] in water/to treat low blood glucose) .[MEDICATION NAME] (medication to treat narcotic overdose in an emergency situation) . Medical record review of Resident #1's Hospice General Inpatient Admission Note dated 10/6/17 revealed .Current uncontrolled symptoms .Respiratory Distress .Medication reaction response . Medical record review and review of facility documentation for 10/6/17 through 10/7/17 revealed Resident #1 received 25 doses of [MEDICATION NAME] after he received Resident #2's extended release [MEDICATION NAME]. Telephone interview with the Student Nurse (student nurse assigned to License Practical Nurse (LPN) #1 on the morning of 10/6/17) on 10/11/17 at 1:05 PM, confirmed .She (LPN #1 precepting the student nurse) hadn't come in room yet .I wasn't sure if coming to give meds with me .I usually don't give meds myself .I didn't know to check with resident .I thought she was in close distance behind me but she wasn't .I gave .insulin in left upper arm .Then gave the meds .made sure he (Resident #1) swallowed them .It was fast .I know I messed up horribly . Continued interview confirmed she gave Resident #2's medications to Resident #1 without LPN #1 present in the room. Telephone interview with LPN #1 (nurse assigned to Resident #1 on morning of 10/6/17) on 10/11/17 at 1:55 PM, confirmed .She (Student Nurse) walked up to cart while pulling (Resident #2) meds and (LPN #1) drew up insulin .Pulled his (Resident #2) picture up .showed her (Student Nurse) picture .I told her to hang on one second and I walked back to cart .when walk back in she (Student Nurse) was walking towards the sharps containers from (Resident #1's) bed .I said did you give that insulin She (Student Nurse) said yes .Then I said where are those pills? .She (Student Nurse) said I gave them to him too .The student said she didn't ask resident name . Continued interview with LPN #1 confirmed the student nurse gave Resident #2's medications to Resident #1 while she (LPN #1) was not present in the room. Interview with the Director of Nursing (DON) on 10/11/17 at 4:14 PM in the conference room, confirmed Resident #1 received Resident #2's medications on 10/6/17 at 10:15 AM which included aspirin (medication to treat pain) 325 mg tablet, [MEDICATION NAME] (medication to treat constipation) 5 mg tablet, [MEDICATION NAME] (medication to treat depression) 10 mg tablet, [MEDICATION NAME] (medication to treat Diabetes) 28 units, [MEDICATION NAME] sodium (medication to treat constipation) 100 mg tablet, [MEDICATION NAME] ER (extended release) ( medication to treat moderate to severe pain) 180 mg tablet, duloxetine DR (delayed release) (medication to treat depression, anxiety and nerve pain) 60 mg capsule, cranberry (supplement to prevent urinary tract infections) 450 mg tablet and a vitamin B complex (vitamin to prevent vitamin deficiency) capsule. Interview with the Nurse Practitioner on 10/12/17 at 9:11 AM, in the conference room, confirmed .If he (Resident #1) hadn't gotten [MEDICATION NAME] it would have killed him .I would consider it a significant med error, could cause their death . Interview with the Director of Nursing (DON) on 10/12/17 at 9:33 AM, in the conference room, confirmed .It was a significant med error . placing Resident #1 in Immediate Jeopardy. Telephone interview with the Medical Director on 10/16/17 at 4:41 PM, confirmed Resident #1 was at risk for respiratory collapse due to the medication error. Continued interview confirmed the medication error jeopardized the resident's safety. Telephone interview with the Pharmacy Consultant on 10/16/17 at 3:20 PM, confirmed .Gave a naive (no previous exposure) pt a large long acting medication ([MEDICATION NAME] ER) . Continued interview with the Pharmacy Consultant confirmed Resident #1 received significant medication error on 10/6/17. Telephone interview with the Clinical Instructor on 10/17/17 at 11:54 AM, confirmed .The students are not to give meds to residents without licensed personnel . Interview with the DON on 10/17/17 at 4:45 PM, in the conference room, confirmed .My nurse was responsible for the event on 10/6/17; she holds a license and was to supervise the student nurse . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of untitled facility documentation dated 8/28/17, revealed .On Friday 8/25/17 the house supervisor .(Registered Nurse #2) discharged (Resident #4) out of the .system .Patient did not receive medications on 8/26/17 or 8/27/17 . Medical record review of Medication and Treatment Administration Record Report, dated 8/2017, revealed Resident #4 was prescribed the following medications: [REDACTED]. Continue review revealed Resident #4 did not receive the prescribed evening medications on 8/25/17, and did not receive any of the 14 medications on 8/26/17 or 8/27/17. Interview with RN #1 (nurse supervisor) on 10/17/17 at 9:30 AM, in the 2nd floor nursing station, confirmed Resident #4 had not received his medications for a full weekend due to being discharged from the computer system. Interview continued and revealed the medication nurses .were not being vigilant. Interview with RN #2 on 10/18/17 at 1:25 PM, in the conference room, confirmed RN #2 had accidentally discharged Resident #4 during the afternoon of 8/25/17. Continued interview revealed .Once I contacted the pharmacy, I thought they would re-enter his medications and they (medications) would not have to be checked in at the facility . Continued interview revealed the routine process was for medications entered into the IMAR (electronic medication administration record) by the pharmacy to be waiting in a que for the facility's house supervisor to review and confirm for accuracy, and medications would then .populate on the IMAR for the nurses to give . Interview confirmed the evening and night nurse supervisors would have received a flashing notice of any resident's medications waiting to be checked in and Resident #4's medications waiting in the que were not checked in from 8/25/17 through 8/27/17. Continued interview revealed, over the weekend, as each oncoming shift supervisor logged in (to the IMAR software), Resident #4 would have continued in the que and needed to be checked in. Further interview confirmed the resident did not receive his medications, including a diuretic, an oral diabetic medication to control elevated blood sugars, a beta blocker (a medication which carries a precaution of not discontinuing suddenly), and a blood thinner to prevent blood clots in a resident with a fractured femur through 7 nursing shifts, from the evening of 8/25/17 through 8/27/17. Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of untitled facility documentation undated, revealed .Nurse gave wrong patch on 04/09/2017 .Placed a nitro patch ([MEDICATION NAME] to prevent chest pain) instead of a nicotine patch ([MEDICATION NAME] to aid smoking cessation) .Nurse stated got distracted was very busy on floor . Further review of the facility documentation revealed it was signed by LPN #4. Interview with LPN #4 on 10/18/17 at 2:30 PM, in the conference room, revealed, .I had been interrupted a few times already that morning and can't remember if it (the Nitro-Patch) scanned without a problem .or didn't get scanned by me .a lot of dynamics going on, he didn't feel well and his wife was wanting him to go to church . Further interview confirmed the Nitro-Patch was imprinted with the name and dosage of the medication and the error was discovered the following morning by another nurse. Interview continued and confirmed LPN #4 had not verified the right medication prior to administration. Interview with the DON on 10/19/17, at 4:34 PM, in the conference room, confirmed Resident #4's medication error and Resident #11's medication error were significant medication errors. Noncompliance continues at a J level for monitoring the effectiveness of corrective actions and evaluation of monitoring by the Quality Assessment/Performance Improvement Committee. The facility is required to submit an Acceptable Allegation of Compliance. Refer to F490, and F520",2020-09-01
237,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2017-12-05,441,D,1,0,TVBT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the facility Infection Control Manual, review of the Infection Control Policy, medical record review, and interview, the facility failed to follow contact isolation infection control guidelines for 1 resident (#16) of 7 residents reviewed for Extended Spectrum Beta Lactamases (ESBL) (an antibiotic resistant micro-organism) in their urine. The findings included: Review of the facility Infection Control Manual revised 10/1/08, revealed .use Contact Precautions for patients known or suspected to be infected or colonized with epidemiologically significant microorganisms that can be transmitted by direct contact with patient or indirect contact with environmental surfaces or patient care equipment .Place the patient who contaminates the environment or who does not or cannot assist in maintaining appropriate hygiene or environmental control in a private room .May allow resident to stay with roommate if total care for transfers/mobility . Review of the Infection Control Policy for ESBL, VRE ([MEDICATION NAME]-Resistant [MEDICATION NAME]), MRSA (Methicillin-Resistant Staphylococcus Aureus) in the urine dated 9/26/17, revealed .initiate contact precautions .Resident may stay with roommate, if urine is contained . Medical record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #15 scored 5 out of 15 for the Brief Interview for Mental Status indicating the resident had moderate cognitive impairment. Further review of the MDS revealed the resident required extensive assist for most activities of daily living and was incontinent of bladder. Medical record review of Resident #15's Urinalysis Report dated 9/18/17 revealed .LEUK[NAME]YTE ESTERASE (white blood cells associated with infection) .LARGE . Medical record review of Resident #15's Microbiology Report dated 9/18/17 revealed .Urine .Escherichia coli (E.coli) .ESBL . Medical record review of the Care Plan dated 9/22/17 revealed Resident #15 was placed on contact isolation on 9/22/17. Further review revealed Resident #15's family requested the resident not be treated with antibiotics on 9/26/17. Medical record review of Resident #15's Nurse's Note dated 9/26/17 revealed .(urinary) catheter placed .ESBL urine contained . Medical record review revealed Resident #15 and Resident #16 were roomates at that time. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].coli, and Chronic Atrial Fibrillation. Medical record review of the MDS dated [DATE] revealed Resident #16 was unable to complete the Brief Interview for Mental Status, indicating severe cognitive impairment. Further review of the MDS revealed she required extensive assist for most activities of daily living. Medical record review of Resident #16's Nurse's Note dated 9/26/17 revealed .Family upset about pt (patient) being in bedroom c (with) pt in contact isolation. Pt moved to different room per family request .UA (urinalysis) obtained .per family request . Medical record review of Resident #16's Microbiology Report dated 9/26/17 revealed .URINE .Escherichia coli . Medical record review of Resident #16's Nurse's Note dated 9/30/17 revealed .Contact isolation initiated for ESBL .proteus mirabilis urine culture . Medical record review of the Care Plan dated 10/2/17 revealed Resident #16 was placed on contact isolation and had a history of [REDACTED]. Interview with Licensed Practical Nurse (LPN) #7 on 10/9/17 at 1:11 PM, at the 2nd floor nurses station, confirmed Resident #15 was placed on contact isolation on 9/22/17. Telephone interview with Resident #16's granddaughter on 10/9/17 at 7:19 PM confirmed .Asked her to be tested on Tuesday (9/26/17) .All the infected resident's stuff was on Grandmother side of room .Her (Resident #15) food tray .cups had been thrown on her side of the room .My grandmother used that resident's toilet .The other resident catheter was emptied in there .she (Resident #16) touched things in the room . Interview with Registered Nurse (RN) #1 on 10/10/17 at 9:50 AM, in the Director of Nursing (DON's) office, confirmed .She (Resident #16) is prone to get infections .She is a carrier of [DIAGNOSES REDACTED] (Clostridium difficile, a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon) . Telephone interview with the Nurse Practitioner on 10/10/17 at 11:10 AM, confirmed .tested her (Resident #16) because in room with (Resident #15) .They both have E. coli and ESBL .The urine was contained in the brief . Interview with the Assistant Regional Nurse on 10/10/17 at 4:30 PM, in the conference room, revealed the facility felt the risk was minimal for Resident #16 and confirmed the Assistant Regional Nurse did not know why the facility had not planned to move Resident #16 on 9/26/17, when the other affected residents were moved. Interview with the Assistant Director of Nursing (Infection Control Nurse) on 10/16/17 at 9:50 AM, in the conference room, confirmed the facility failed to follow the facility policy by not moving Resident #15 to another room once she was diagnosed with [REDACTED].#16 to be exposed to ESBL during the dates of 9/18/17 through 9/26/17.",2020-09-01
238,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2017-12-05,490,J,1,0,TVBT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of facility contract, review of the Practical Nurse Program code of conduct, medical record review and interviews the Administrator failed to ensure there were not significant medication errors for 3 residents (#1, #4 and #11) of 15 residents reviewed for medication errors. Resident #1 received 9 medications in error prescribed for Resident #2. The error resulted in Resident #1 becoming sedated, having decreased respirations, requiring multiple doses of [MEDICATION NAME] (medication used to treat an overdose of opioids in an emergency situation). Resident #4 did not receive his prescribed medications, including a diuretic, an oral diabetic medication to control elevated blood sugars, a beta blocker (a medication which carries a precaution of not discontinuing suddenly), and a blood thinner to prevent blood clots in a resident with a fractured femur from the evening of 8/25/17 through 8/27/17. Resident #11 had an non-prescribed [MEDICATION NAME] (a medication patch with [MEDICATION NAME] which is used to treat chest pain, by relaxing and widening blood vessels) medication administered on 4/9/17. The Administrator's failure to ensure medications were administered to the right residents and failure to ensure Resident #4 received all prescribed medications, resulted in significant medication errors and placed Resident #1, #4, and #11 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death). The Nursing Home Administrator (NHA) and Director of Nursing (DON), were informed of the Immediate Jeopardy on 12/4/17, at 9:00 AM in the Administrator's office. The IJ was effective 4/9/17 and is ongoing. Noncompliance continues at the severity of J level. An extended survey was conducted from 12/4/17 through 12/5/17. The facility was cited Substandard Quality of Care at F-333(J). The findings included: Medical record review revealed the facility had medication errors for Residents #1, #3, #4, #6, #7, #8, #9, #10, #11 and #24 between 2/28/17 and 10/26/17. The medication errors for Residents #1, #4, and #11 were significant medication errors. Interview with the DON on 10/16/17 at 10:33 AM, in the conference room, with review of the medication errors revealed Resident #7, #8, and #9 on 2/28/17; 3/9/17; and 3/20/17 consecutively, the wrong narcotic was administered after borrowing medications. Further interview revealed the medication errors for Resident #10 on 3/31/17 and Resident #11 on 4/9/17 involved 2 residents who received other residents' medications. Continued interview revealed Resident #3's medication error on 8/10/17, occurred when the assigned nurse disregarded 2 medication safety checks. Further interview revealed Resident #6's medication error on 9/17/17 involved an incorrect order entry of an antibiotic medication by the nurse responsible for addressing quality issues with the nursing staff. Continued interview confirmed the medication errors were seen as isolated events with individual nurses counseled. Further interview with the DON regarding the medication errors and whether all contributing factors were addressed, revealed .I am not going to be able to show you a conclusion to each investigation . and confirmed a plan of correction for each medication error was not developed. Further interview confirmed the Administrator led the Quality Improvement Committee and failed to identify and implement corrective measures to address medication administration errors. Interview with the DON on 10/17/17 at 5:15 PM, in the conference room, confirmed .There isn't a written process for investigation of medication errors .we don't do a root cause analysis (for medication incidents) .only for untoward events. Interview with the Regional Consultant on 12/4/17 at 1:34 PM, in the conference room, confirmed the facility was responsible to perform root cause analysis of all medication errors in an effort to prevent future medication errors. Interview with the NHA, DON and Regional Consultant on 12/5/17 at 3:41 PM, in the conference room, confirmed each of the facility's medication errors had been considered to be isolated events and not included in the quality improvement committee work. Continued interview confirmed the Administrator, Director of Nurses, and Medical Director failed to monitor and observe for safe administration of medications. Noncompliance continues at a J level for monitoring the effectiveness of corrective actions and evaluation of monitoring by the Quality Assessment/Performance Improvement Committee. The facility is required to submit an Acceptable Allegation of Compliance. Refer to F-333 (J) and F-520 (J)",2020-09-01
239,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2017-12-05,502,D,1,0,TVBT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview the facility failed to obtain accurate laboratory results for 1 resident (#5) of 14 residents reviewed for medication errors. The findings included: Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Physician order [REDACTED]. Medical record review of Physician order [REDACTED]. D5NS (5% [MEDICATION NAME] in normal saline intravenous) 200 cc (cubic centimeters) bolus, 125 cc/hr (hour) x1 liter. 20 (milligram) [MEDICATION NAME] ([MEDICATION NAME]) after bolus (5% [MEDICATION NAME] in normal saline) . Medical record review of the Medication and Treatment Administration Record Report dated 8/2017 revealed Resident #5 received a D5W 200 ml bolus at 2:33 PM on 8/29/17 and [MEDICATION NAME] ([MEDICATION NAME]) 20 mg IV at 2:36 PM on 8/29/17 PM. Medical record review of the Medication and Treatment Administration Record Report dated 8/20/17 and the daily skilled Nurse's Notes did not reflect when the [NAME]exlate 30 mg PO now had been administered. Medical record review of physician progress notes [REDACTED].Repeat K (potassium) .waiting .will give IVF (intravenous fluids) .[MEDICATION NAME] . Medical record review of Physician order [REDACTED].DC (discontinue) PO (by mouth) K .[NAME]xelate (medication to lower Potassium levels) 30 mg . Medical record review of Resident #5's Chemistry Report dated 8/29/17 revealed a critical potassium level of 7.3 (normal range 3.5-5.1) collected at 5:00 AM, released at 9:17 AM, and called as a critical level to the facility. Medical record review of Resident #5's Chemistry Report dated 8/29/17 revealed a critical potassium level of 7.3 collected at 5:00 AM, released at 12:49 PM, and called as a critical level to the facility. Medical record review of Resident #5's Laboratory Report dated 8/29/17 revealed a potassium level of 4.4 collected at 9:57 AM, released at 12:14 PM, and not called to the facility. Interview with RN #2 on 10/18/17 at 1:25 PM, in the conference room, revealed, as the house supervisor on 8/29/17, her duties included calling critical lab values to the Physician following telephone notification by the lab. Further interview revealed an elevated potassium level of 7.3 was called to the Physician on 8/29/17 and a repeat blood draw to verify the potassium level was ordered. Continued interview revealed RN #2 received a second call from the lab for Resident #5 on 8/29/17, with a report of a critical potassium level of 7.3. Interview continued and confirmed Resident #5 received the now dose of [NAME]exlate. Further interview confirmed, when the printed copies of Resident #5's Chemistry Reports were received at the facility, RN #2 noted the repeated potassium value of 4.4 had not been called to the facility. Continued interview confirmed the repeat lab, drawn at 9:57 AM, requested by the Physician, indicated a potassium level of 4.4 and was not called to the facility. In summary, the facility did not receive telephone notification from the lab for the potassium level of 4.4, collected at 9:57 AM, by Physician order [REDACTED]. The facility did receive a second telephone notification of the critical potassium level of 7.3 (rerun as a lab quality control measure from the 5:00 AM blood sample). The nursing staff failed to identify whether the second critical potassium level called to the nursing home was obtained from the second blood specimen drawn. The second notification of the critical potassium level of 7.3 (exactly the same value as the first critical level) was acted on by the nursing staff and Resident #5 received [NAME]exlate to lower his potassium level.",2020-09-01
240,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2017-12-05,520,J,1,0,TVBT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility Quality Improvement Committee documents, medical record review, and interview, the Quality Improvement Committee failed to identify and implement corrective measures to address medication administration errors for 10 residents (#1, #3, #4, #6, #7, #8, #9, #10, #11 and #24) of 15 residents reviewed. The Quality Improvement Committee failed to ensure systems were in place for residents to receive medications as ordered by the physician and to be free of significant medication errors. The facility's failure to ensure medications were administered to the right resident resulted in a significant medication errors and placed Residents #1, #4, and #11 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death). The Nursing Home Administrator (NHA) and Director of Nursing (DON), were informed of the Immediate Jeopardy on 12/4/17, at 9:00 AM in the Administrator's office. The IJ was effective 4/9/17 through 12/5/17 and is ongoing. Noncompliance continues at the severity of J level. An extended survey was conducted on 12/4/17 through 12/5/17. The facility was cited Substandard Quality of Care at F-333(J). The findings included: Review of the facility's (MONTH) (YEAR) Quality Improvement Committee meeting revealed the minutes included initiation of a facility-wide QAPI (quality assessment/performance improvement) Plan. Review of the Goals in the QAPI Plan revealed, Priority will be set for those goals that are considered high-risk, high-volume or problem-prone areas . Continued review revealed the 6 current high priority identified areas did not include medication administration. Review of the facility's Quality Improvement Committee meeting minutes from 1/19/17 through 9/21/17 revealed medication administration errors were not identified by the committee. Medical record review revealed the facility had medication errors for Residents #1, #3, #4, #6, #7, #8, #9, #10, #11 and #24 between 2/28/17 and 10/26/17. The medication errors for Residents #1, #4, and #11 were significant medication errors. Interview with the Director of Nurses (DON) on 10/16/17 at 10:33 AM, in the conference room, confirmed a significant medication error occurred on 10/6/17, when Resident #1 received [MEDICATION NAME] ER (extended release) 180 mg (milligrams), a medication that was ordered for the resident's roommate, put him in an acute condition (sedation and respiratory depression requiring [MEDICATION NAME] administration, a medication used to treat an overdose of opioids in an emergency situation) . Interview with the DON on 10/16/17 at 10:33 AM, and on 10/17/17 at 4:55 PM, in the conference room, and review of the medication errors from 2/28/17 through 9/17/17, revealed: 2/28/17 - Residents #7 received one dose of a wrong narcotic, not the prescribed narcotic pain medication, due to a borrowing error. Interview confirmed the DON had counseled the Licensed Practical Nurse (LPN) responsible for the medication error. 3/9/17- Resident #8 received one dose of a wrong narcotic, not the prescribed narcotic pain medication, due to a borrowing error. Interview confirmed the DON had counseled the LPN responsible for the medication error. 3/20/17- Resident #9 received one dose of a wrong narcotic, not the prescribed narcotic pain medication, due to a borrowing error. Continued interview revealed there was an actual form and procedure to have 2 nurses verify the correct medication was borrowed. Further interview confirmed the DON had counseled the LPN responsible for the medication error. 3/31/17 - Resident #10 received 1 dose of Pramipexole VK 0.5 mg (Anti-[MEDICAL CONDITION] medication), prescribed for the resident's roommate. Continued interview with the DON confirmed he had counseled LPN #6 and had not investigated the circumstances beyond the human error made by a LPN .employed for at least [AGE] years . 4/9/17 - Resident #11 had a Nitro-Patch ([MEDICATION NAME] Patch) administered without an order, and was not discovered for 24 hours. Interview confirmed the DON had counseled Licensed Practical Nurse (LPN) #4 who had placed the wrong patch ([MEDICATION NAME] Patch) on Resident #11. Further interview confirmed no further facility investigation or interventions were done related to the significant medication error. 8/10/17 - Resident #3 received an extra dose of [MEDICATION NAME] when her assigned nurse disregarded 2 medication administration safe checks and gave a second dose in error. During interview the DON stated LPN #5 had been counseled by LPN #2 following the medication error on 8/10/17. 8/28/17 - Resident #4 did not receive any of his prescribed medications for 7 consecutive nursing shifts, from 8/25/17 through 8/27/17, and the error was not discovered until 8/28/17. Interview revealed the medication error began on the evening of 8/25/17, after Resident #4 was discharged from the facility computer system in error. During interview, the DON stated he counseled Registered Nurse (RN) #2 related to Resident #4's erroneous discharge and confirmed the additional 7 staff nurses responsible for Resident #4's care were not interviewed or included in the investigation. 9/17/17 - Resident #6 did not have an antibiotic administered as prescribed. Interview revealed an order entry for an antibiotic was not completed correctly, and resulted in Resident #6 receiving an antibiotic every day, instead of the physician ordered every other day interval, resulting in the resident receiving 1 extra dose of the antibiotic. Further interview revealed LPN #2, identified as the LPN who assisted the DON with IMAR (electronic medication record) and quality concerns, was responsible for the medication error and was counseled. Review of Medication Error Report filed on 10/27/17 to address the 10/26/17 medication error revealed Resident #24 received a double dose of [MEDICATION NAME] when Registered Nurse (RN) #4 failed to transcribe the medication order correctly and LPN #8 failed to follow the 8 rights of medication administration. Continued review revealed the nurse supervisor on duty (RN #3) failed to notify the on call physician service and initiate a Medication Error Report. Interviews with LPN #8, RN #3 and RN #4 revealed the 3 licensed nurses had not followed the directions received during the (MONTH) (YEAR) in-services related to safe medication administration. Interview with the DON on 10/16/17 at 10:33 AM, in the conference room, regarding the medication errors and whether all contributing factors were being addressed, revealed .I am not going to be able to show you a conclusion to each investigation . and confirmed a plan of correction for each medication error was not developed. Telephone interview with the facility's consulting Pharmacist on 10/16/17 at 3:20 PM, revealed, .Everything is automated now .All I know about what has been given is from what is on the IMAR (electronic medication administration record) .the only medication error I have been involved in happened last week (Resident #1's 10/6/17 medication error). Telephone interview with the facility's Medical Director on 10/16/17 at 4:20 PM, revealed, .They called right after the mistake occurred (the 10/6/17 medication error for Resident #1) .We understood this gentleman was not doing well .on Hospice .but didn't want to hasten his demise .nothing to be gained by moving him to a higher level of care, not sure he would have survived the transfer .If steps hadn't been taken immediately, he would have suffered respiratory collapse . Interview with the Medical Director and review of the medication errors from 4/9/17 to the present time revealed the medication errors were not all known to him. Continued interview confirmed the medication errors had not been brought to the QAPI committee. Sounds like we need to increase medication error awareness .all medication errors should be reviewed by the committee. Interview with the DON on 10/17/17 at 5:15 PM, in the conference room, confirmed .There isn't a written process for investigation of medication errors .we don't do a root cause analysis (for medication incidents) .only for untoward events. Interview by phone with the facility's consulting Pharmacist on 10/18/17 at 2:40 PM, revealed, .I didn't know about the incident with the Nitro-Patch ([MEDICATION NAME] Patch) before today .If you look at the facility's responsibilities, the DON (Director of Nurses) is supposed to let us know about these medication errors. Noncompliance continues at a J level for monitoring the effectiveness of corrective actions and evaluation of monitoring by the Quality Assessment/Performance Improvement Committee. The facility is required to submit an Acceptable Allegation of Compliance. Refer to F-333 (J) and F-490 (J)",2020-09-01
241,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2020-02-20,550,D,0,1,PNQL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to treat 1 of 20 residents (Resident #25) reviewed for indwelling urinary catheters with dignity related to not covering the resident's indwelling urinary catheter drainage bag with a privacy cover. The findings include: Review of the medical record, showed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED].#25, showed .Suprapubic Catheter change Q (every) month on the 8th and PRN (as needed) . Observation in the resident's room on 2/18/2020 at 3:49 PM and on 2/19/2020 at 8:32 AM, showed Resident #25's indwelling urinary catheter bag was placed on the right side of bed facing the door, without a privacy cover. During an interview conducted on 2/18/2020 at 4:28 PM, Licensed Practical Nurse #1 confirmed Resident #25's indwelling urinary catheter bag was not placed in a privacy cover. During an interview conducted on 2/18/2020 at 4:39 PM, the Director of Nursing stated that her expectations were for the indwelling urinary catheter bags to be placed in a privacy cover while residents were up and about and when the catheter bags were facing the door when the residents were in their rooms.",2020-09-01
242,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2020-02-20,600,D,1,1,PNQL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to prevent abuse for 2 of 2 residents (Resident #47 and Resident #[AGE]) involved in a resident to resident altercation. The findings include: Review of the facility policy titled, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, revised 12/11/2017, showed physical abuse included slapping, pinching, and kicking. Review of the medical record, showed Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record, Quarterly Mininmum Data Set ((MDS) dated [DATE] showed Resident #47 had a Brief Interview for Mental Status (BI[CONDITION]) score of 99 indicating severe cognitive impairment. Review of the medical record, showed Resident #[AGE] was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE], showed Resident #[AGE] had a BI[CONDITION] score of 3 indicating severe cognitive impairment. Review of the facility investigation dated 1[DATE]19, showed Resident #47 was found in Resident #[AGE]'s room rearranging the sheets on Resident #[AGE]'s bed. Continued review showed the actions of Resident #47 scared Resident #[AGE] and she grabbed Resident #47's hands which caused a skin tear to her right hand. Resident #[AGE] had an X-ray of the right 5th digit because of pain due to physical contact with Resident #47. During an interview conducted on [DATE]20 at 8:35 AM, Family Member #2 stated, (named Resident #47) was aggressive and wandered into other resident's rooms and fought with other residents. During an interview conducted on [DATE]20 at 3:48 PM, Certified Nurse Aid (CNA) #3 stated she was walking to the dining room around 8:00 PM or 9:00 PM and she heard (named Resident #[AGE]) yell help. When she entered (named Resident #[AGE]'s) room (named Resident #[AGE]) was lying in bed and (Named Resident #47) was standing over (named Resident #[AGE]) and her wheel chair was right behind her. (named Resident #47) had (named Resident #[AGE]'s) blankets in her hands. Resident #[AGE] was grabbing the blankets and also grabbed (named Resident #47's) hands. During an interview conducted on 2/20/2020 at 4:40 PM, Social Worker #2 stated (named Resident #47) got easily annoyed. During an interview conducted on 2/20/2020 at 5:22 PM, the Director Of Nursing confirmed there was a physical altercation between Resident #47 and Resident #[AGE] which resulted in a skin tear for Resident #47 and pain to the right hand resulting in a need for an Xray for Resident #[AGE].",2020-09-01
243,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2020-02-20,657,D,1,1,PNQL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview the facility failed to revise a care plan for 1 of 52 residents (Resident #47) reviewed for behaviors. The findings include: Review of the facility policy titled, Care Plan Development, revised 7/3/2008, showed care plans were updated as needed, and on quarterly basis within 7 days of completion of the Minimum Data Set (MDS) assessment. Review of the medical record, showed Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record, Quarterly Minimum Data Set ((MDS) dated [DATE] showed Resident #47 had a Brief Interview for Mental Status score 99 indicating severe cognitive impairment. Continued review showed Resident #47 had behaviors of wandering, hitting, kicking, pushing, scratching, and grabbing others. Review of the care plan dated 7/1/2019, 1[DATE]19, and 11/7/2019 showed no new behavior interventions for Resident #47. Review of the facility investigation dated 1[DATE]19 showed Resident #47 was found in Resident #[AGE]'s room rearranging the sheets on Resident #[AGE]'s bed. Continued review showed the actions of Resident #47 scared Resident #[AGE] and she grabbed Resident #47's hands which caused a skin tear the right hand. Resident #[AGE] had an X-ray of the right 5th digit because of pain due to physical contact with Resident #47. During an interview conducted on 2/20/2020 at 4:40 PM, Social Worker #2 confirmed the behavioral care plan for Resident #47 was not updated to reflect behaviors prior to the resident to resident incident on 11/3/2019.",2020-09-01
244,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2018-02-28,584,D,0,1,TOUP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation, and interview, the facility failed to maintain a safe and orderly environment in 1 resident room of 50 resident rooms on the first floor. Findings include: Review of facility policy,Housekeeping Cleaning Schedule, Daily undated revealed .Patient Rooms .Damp dust all horizontal and vertical surfaces of patient furniture .Remove clutter and arrange furniture neatly .Damp dust all light fixtures, window sills, blinds, etc. with disinfectant solution .Spot clean walls . Observation of room [ROOM NUMBER] on 2/27/18 at 12:09 PM revealed an unsampled resident in bed near the door with a BIMS( Brief Interview of Mental Status) of 99 and none interviewable. Continued observation revealed the resident's family member was sitting in a chair. Further observation revealed there was narrow access around the resident's bed. Continued observation revealed multiple items were present in the room in cardboard boxes and plastic totes lining all of the walls around the perimeter of the room extending into the normal walkway and the entire area was extremely cluttered. Observation revealed a bed was in the corner of the room with cardboard and plastic containers, creating only a narrow access around the bed to bathroom, sink and commode. Boxes were lining all the walls around the perimeter extending into the walkway; the shower also had boxes stacked from the floor to the ceiling. Observations of room [ROOM NUMBER] on 2/27/18 at 3:00 PM and 2/28/18 11:00 AM revealed the same continued cluttered and unsafe environment. Interview with Registered Nurse (RN) #3 at the West Nurse station on 2/28 12:00 PM revealed several staff members had asked the resident's family to remove the clutter, boxes, etc. and she would not comply with the request. Continued interview with RN #3 states it was s safety issue for the resident with all the clutter in the room and having to walk around the multiple objects presents a unsafe environment. Interview with Certified Nurse Assistant (CNA) #5 on 2/27/18 at 1:00 PM at the West Nurse's Station revealed it was difficult to care for the resident with all the clutter and get around the narrow pathways in the room. Interview with RN #4/Unit Manager on 2/27/18 at 1:07 PM at the West Nurse's station revealed the staff was unable to keep a safe physical environment due to the refusal by the resident's family member. Interview with Environmental Services Technician #1 on 2/27/18 at 1:21 PM in the hall near room [ROOM NUMBER] revealed the resident's family member refused to allow staff to organize or clean the resident's room with cleaning supplies. Interview with the Administrator on 2/28/18 at 2:38 PM in her office confirmed the resident's room was not kept in a sanitary, orderly, and safe manner.",2020-09-01
245,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2018-02-28,585,E,0,1,TOUP11,"Based on review of facility policy, review of the Grievance Log and interview, the facility failed to address reported greivances and failed to confirm or take corrective action regarding the facility findings and conclusions. Findings include: Review of facility policy, Grievance Procedure, dated 11/2016 revealed . the person with the grievance could contact various entities to report an allegation. Further review revealed no information addressing what the facility process was to address and document the grievance, including a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued. Review of the facility grievance log dated12/2017 through 1/2018 revealed the facility failed to include the specific concern/grievance, the investigation steps taken, a summary of the conclusion, a statement if the concern was confirmed or not or a dated written decision. Interview with the Social Services Director on 2/27/18 at 2:25 PM in the conference room confirmed the facility had no documentation to show the summary of the pertinent findings or conclusions regarding the resident's concerns; whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility or a date written decision was issued. Further interview revealed .After I'm done with the investigation and put information on the log, I dispose of all the paperwork . Interview with the Administrator and the Administrator-in-Training on 2/27/18 at 4:30 PM in the conference room, confirmed the facility failed to provide a summary of the pertinent findings or conclusions regarding the resident's concerns, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, or a written decision. Interview with the Regional Social Worker on 2/27/18 at 5:20 PM in the and conference room, when asked about the Resident's concerns on 12/8/17 and 12/17/17 from the grievance log, the Regional Social Worker stated .I don't know . Further interview when asked how the facility would track Resident concerns yielded no response from the Administrator or the Regional Social Worker.",2020-09-01
246,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2018-02-28,641,E,0,1,TOUP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure the (Mininmum Data Set) accurately reflected the residents state of the assessment reference date for 5 hospice resident (#24, #52, #60, #81, #106) of 11 hospice residents reviewed. Findings include: Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Hospice Certification of Terminal Illness form revealed Resident #24 was admitted to hospice services on 9/13/17. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] for Resident #24 revealed hospice services was not captured on the assessment. Medical record review revealed Resident #52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Hospice Certification of Terminal Illness form revealed Resident #52 was admitted to hospice services on 10/1/17. Medical record review of the Quarterly MDS dated [DATE] for Resident #52 revealed hospice services was not captured on the assessment. Medical record review revealed Resident #106 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Hospice Certification of Terminal Illness form revealed Resident #106 was admitted to hospice services on 5/24/17. Medical record review of the Quarterly MDS dated [DATE] for Resident #106 revealed hospice was not captured on the assessment. Interview with Registered Nurse (RN) #5/MDS Coordinator on 2/28/18 at 3:42 PM in her office confirmed Residents #24, #52, and #106 were receiving hospice services. Continued interview confirmed the facility failed to accurately assess each resident as having hospice services on their individual MDS. Medical record review revealed Resident #81 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #81 was assessed as receiving hospice services. Medical record review of a Quarterly MDS dated [DATE] revealed Resident #81 was not receiving hospice services. Medical record review of a Hospice Contact Information form revealed Resident #81 .has elected his or her Hospice benefit starting 4/7/17 . Interview with Licensed Practical Nurse (LPN) #3 on 2/27/18 at 8:30 AM in the East Nurse Station confirmed Resident #81 had been receiving hospice services for several months. Interview with RN #5/MDS Coordinator on 2/27/18 at 9:40 AM in the East Nurse's station confirmed the facility failed to capture hospice services for Resident #81 on the Quarterly MDS dated [DATE]. Medical record review revealed Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed hospice services were ordered for Resident #60 on 10/10/17. Further review revealed no order for the discontinuation of the hospice service. Medical record review of the Hospice Certification of Terminal Illness revealed Resident #60's was admitted to hospice services on 10/9/17. Medical record review of the Significant Change MDS dated [DATE] revealed hospice services were provided while the resident was in the facility. Medical record review of the Quarterly MDS dated [DATE] revealed hospice services was not captured on the assessment for Resident # 60. Interview with RN #5/MDS Coordinator on 2/28/18 at 11:58 AM in the conference room confirmed the facility failed to accurately assess the hospice status on the Quarterly MDS dated [DATE] for Resident #60.",2020-09-01
247,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2018-02-28,656,G,0,1,TOUP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to follow the interventions on the Comprehensive Care Plan for 1 (Resident #81) of 39 residents reviewed. This failure resulted in actual Harm to the resident. Findings include: Medical record review revealed Resident #81 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #81 had a Brief Interview for Mental Status of 9 indicating she was moderately cognitively impaired. Continued review revealed the resident required assistance of 2 or more people for transfers and toileting. Medical record review of a Comprehensive Care Plan updated 8/23/17 and 11/13/17 revealed a problem of required assistance with activities of daily living. Continued review revealed an intervention to Assist patient with transfers using two person assist. Medical record review and interview with Certified Nurse Aide (CNA) #6 on 2/28/18 at 3:50 PM by the East shower room door confirmed she was transferring Resident #81 alone when she fell into the bathtub on 12/15/17. Continued interview revealed the CNA was asked if the resident was ever a 2 person assist with transfers stated, She used to be, but she's gotten stronger and I try to let her do as much as she wants to. She gets anxious when you touch her and likes to do things herself. Interview with the Director of Nursing on 2/28/18 at 11:41 AM in the Administrator's office confirmed the resident was to be transferred with assistance of 2 or more people at the time of the fall on 12/15/17. Continued interview confirmed the facility failed to transfer Resident #81 with assistance of 2 people resulting in a sacral fracture (HARM)",2020-09-01
248,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2018-02-28,657,D,1,1,TOUP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to revise the Care Plan for 1 Resident # 285 of 39 Resident Care Plans reviewed. Findings include: Medical record review revealed Resident #285 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the care plan dated 12/4/17 revealed: Resident #285 was at risk for falls with interventions including: call light in reach and bed in lowest position while in bed, educate on call light use; resident able to return demonstration due to Dementia may need additional reminders, non-skid footwear on while up, and keep area free of clutter. Continued review of the careplan revealed an intervention dated 12/6/17: and on 12/7/17 fall mats to both sides of the bed. Medical record review of the Care Plan dated 12/4/17 revealed the resident to be at risk fo fall. Continued review revealed interventions were not revised after 12/17/17 fall. Interview with the Director of Nursing on 2/27/18 at 2:40 PM in the Director of Nursing office, confirmed the facility failed to update the care plan for Resident #285 after fall on 12/17/17.",2020-09-01
249,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2018-02-28,689,G,0,1,TOUP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, hospital records, facility post fall investigation and interview, the facility failed to prevent falls for 2 residents (#81 and #285) of 23 residents reviewed for falls. This failure resulted in actual Harm for Resident #81 and Resident #285. Findings include: Medical record review revealed Resident #81 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #81 had a Brief Interview for Mental Status (BIMS) score of 9 indicating she was moderately cognitively impaired. Continued review revealed the resident required assistance of 2 or more people for transfers and toileting. Medical record review of a Comprehensive Care Plan dated 8/23/17 and 11/13/17 revealed the resident required assistance with activities of daily living (ADL). Continued review revealed an intervention to Assist patient with transfers using two person assist. Medical record review of Post Falls Nursing assessment dated [DATE] revealed Resident #81 had a fall on 12/15/17 at 9:40 PM. Further review revealed, .PT (patient) was being transferred from toilet to wheelchair by CNA (Certified Nurse Assistant) CNA .CNA said while transferring the PT she pulled the wheelchair closer and PT got startled and let go of CNA and fell backwards into the bathtub on the left side and hit her shoulder . Continued review revealed the resident's position after the fall was .Sitting in bathtub, leaning to left, head against wall. Pain following the fall? Y (yes) .Pain Intensity: 07 .Immediate intervention was sending PT to hospital. Care plan intervention is transfer with gait belt . Medical record review of Nurse's Notes dated 12/16/17 at 1:55 AM revealed, .(At 9:40 PM) Pt. was being transferred by CNA .from toilet to wheelchair. During transfer Pt. fell into bathtub hit head and (left) shoulder .Family requested Pt. be sent to (hospital) .Pt left (at 11:00 PM). Pt had bump on back of head (and) bruise on (left) shoulder, arm (and) hand . Medical record review of the Emergency Department (ED) record dated 12/16/17 revealed, .The pt family reports that she was in using the restroom when she told her caregiver that she was about to fall and they did not catch her as she fell backwards into the bathtub. She hit the back of her head, her L (left) shoulder and buttock on the bathtub. She complains of lower back pain .shoulder/hand pain and tailbone pain .Physical Examination .Head: On exam: Moderate, occipital, swelling, occipital hematoma no bleeding .Back: lower back tenderness .Musculoskeletal: No swelling, L shoulder tenderness .Radiology results .probable sacral fx (fracture) .Reexamination/Reevaluation .remaining sacral pain .Impression and Plan head injury, shoulder strain, sacral fx . Medical record review of the hospital report of the sacrum (a triangular bone in the lower back formed from fused vertebrae and situated between the two hipbones of the pelvis) and the coccyx (a small triangular bone at the base of the spinal column) dated 12/16/17 revealed, .Focal lucency (absorbing less radioactive energy) in the inferior third of the sacrum which is nonspecific, but does raise possibility of underlying nondisplaced sacral fracture .Osteopenia and [MEDICAL CONDITION] spinal changes . Interview with CNA #6 on 2/28/18 at 3:50 PM by the East Shower Room door confirmed she was transferring Resident #81 without assistance when the resident fell into the bathtub on 12/15/17. Continued interview revealed the CNA#6 was asked if the resident was ever a 2 person assist with transfers and CNA #6 stated, She used to be, but she's gotten stronger and I try to let her do as much as she wants to. She gets anxious when you touch her and likes to do things herself. Further interview revealed the CNA #6 was asked if she used the gait belt to transfer the resident after the fall and CNA #6 stated, No. I guess I should because we have enough of them. Interview with the Director of Nursing (DON) on 2/28/18 at 11:41 AM in the Administrator's office confirmed the resident was to be transferred with assistance from 2 or more people at the time of the fall on 12/15/17. Continued interview confirmed the facility failed to transfer Resident #81 with assistance of 2 people resulting in and a sacral fracture (HARM). Medical record review revealed Resident #285 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical Record review of the 14 day MDS dated [DATE] revealed a BIMS score of 9 (indicating the resident was moderately impaired). Further review revealed the resident was extensive assist with 2 person for bed mobility, transfer, toilet use and personal hygiene. Continued review revealed Resident #285 was not steady, only able to stabilize with staff assistance for moving from seated to standing position, walking, turning around and facing opposite direction while walking, moving on and off toilet and surface to surface transfer (transfer between bed and chair or wheelchair). Medical record review of the Care Plan dated 12/4/17 revealed: Resident 285 at risk for falls with interventions including: call light in reach and bed in lowest position while in bed, educate on call light use; resident able to return demonstration due to Dementia may need additional reminders; and non-skid footwear on while up, keep area free of clutter. Intervention dated 12/6/17; low bed. Intervention dated 12/7/17: fall mat to both side of bed. Medical record Review of the POS [REDACTED]. Further review revealed PT (Patient) was found sitting in front of bathroom sink. Continued review revealed .Pt has a small laceration on the back of the head with small amount of bleeding .A bandage was put on it and then the head was wrapped .upon assessment Pt has a sluggish pupil response and her SBP (Systolic Blood Pressure) was 99 which was lower than normal. The doctor was called and gave the order to send to the ER (emergency room ) for eval (evaluation). Pt was sent to ER for eval. Further review revealed: Describe task: patient attempting at time of fall: Ambulating in room unattended. Location of incident: Patients room. Safety device in use: Patient was wearing footwear. Pain following the fall? Y (YES). Pain intensity: 06. Immediate intervention: Send to ER. Medical record review of Emergency Department (ER) records dated 12/17/17 revealed, The patient presents following a fall. Staff states the patient fell backwards and struck her head on the ground at the nursing home. There was no report of loss of consciousness. Location: Left scalp lower extremity. The character of symptoms is bleeding. The degree at present is minimal. The exacerbating factor is movement. Risk factor consist of age and frequent falls. Additional history: She was just released from the hospital recently, with a history of frequent falls and dementia. Continued review revealed. Impression and Plan: Diagnosis: [REDACTED].Plan: Condition: Stable. Disposition: discharged to nursing home. Medical record review of ER records dated 12/17/17 of the computerized tomography (CT) of the cervical spine revealed, No clear evidence of acute trauma to the cervical spine. CT of the head revealed, No acute intracranial abnormality is evident . right posterior parietal/occipital scalp hematoma with overlying skin staples present. Interview with CNA #7 on 2/28/18 at 5:10 PM confirmed the resident was found sitting up on her buttocks in front of the sink with a laceration to the back of her head and a small amount of bleeding. Review of the Facility Post Fall Investigation for revealed a telephone interview with Family Member #1 on 2/17/17 at 8:30 AM confirmed a family friend notified her. The facility failed to supervise Resident #285 which had a hisory of being a high risk for falls resulting in a fall with injury with staples to the back of her head. (HARM). Medical record review of ER records dated 12/17/17 of the computerized tomography (CT) of the cervical spine revealed, No clear evidence of acute trauma to the cervical spine. CT of head revealed, No acute intracranial abnormality is evident .right posterior parietal/occipital scalp hematoma with overlying skin staples present. Interview with CNA #7 on 2/28/18 at 5:10 PM confirmed the resident was found sitting up on her buttocks in front of the sink with a laceration to the back of her head and small amount of bleeding. Telephone interview with Family Member #1 on 2/17/17 at 8:30 AM confirmed a family friend notified her Resident #285 had staples to the back of her head after a fall. (HARM).",2020-09-01
250,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2018-02-28,800,E,0,1,TOUP11,"Based on review of the therapeutic diet spread sheet, observation and interview, the facility dietary department staff failed to serve food at the portion specified on the therapeutic diet spreadsheet for 16 residents of 141 residents receiving a meal tray. Findings include: Review of the therapeutic diet spreadsheet for Week 1 Day Monday dated 2/26/18 revealed Regular and Mechanical Soft textured diets were to receive 1 cup (8 ounces) pasta and 4 ounces (oz) of meat sauce. Further review revealed the pureed textured diets were to receive 6 oz of pureed pasta and 4 oz of pureed meat sauce. Observation on 2/26/18 beginning at 11:23 AM of the dietary department resident mid-day meal trayline service with Registered Dietitian (RD) #1 present revealed the dietary staff member serving 4 ounces (oz) of pasta and 4 oz of meat sauce. Further observation revealed the dietary staff member serving 6 oz of the combined pureed pasta and pureed meat sauce for the first meal cart served and 3 pureed textured diets served in the main dining room. Interview with RD #1 on 2/26/18 beginning at 11:23 AM at the dietary department resident mid-day meal trayline confirmed the facility failed to serve the food portion per the therapeutic spreadsheet for 16 residents of 141 residents reviewed.",2020-09-01
251,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2018-02-28,812,D,0,1,TOUP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation, and interview, the facility dietary department failed to dispose of expired food and failed to maintain dietary equipment in a sanitary manner in 2 of 6 observations. Findings include: Review of the facility policy Refrigerator and Freezer Storage, dated ,[DATE] revealed .Commercially prepared .Salad ( .pimento .) .Storage Time Manufacturer's expiration date or 7 days after opening (whichever comes first) .Special Instructions .date when opened and with use by date. Cheese .Storage Time Manufacturer's expiration date or best if used by date .Special Instructions .if removed from the original packaging, date with expiration date or best if used by date . Observation on [DATE] beginning at 8:59 AM in the dietary department with the Certified Dietary Manager (CDM) present revealed the walk-in refrigerator had a container of pimento cheese dated ,[DATE]. Interview with the CDM on [DATE] beginning at 8:59 AM in the dietary department walk-in refrigerator confirmed the pimento cheese was dated ,[DATE]. Further interview revealed when asked what the facility policy was regarding how long they keep opened food or leftovers, the CDM stated .throw out after 7 days . Observation on [DATE] beginning at 12:45 PM with Registered Dietitian (RD) #1 and the CDM present revealed 5 of 8 hood filters with greasy debris present, 5 of 6 protective glass hood light covers with an accumulation of debris on the interior and exterior of the cover. Further observation revealed the side splash guard of the grill had an accumulation of blackened debris. Interview with RD #1 and CDM on [DATE] beginning at 12:45 PM in the dietary department confirmed the dietary department failed to maintain the hood filters, hood light covers, and the side splash guard of the grill in a sanitary manner.",2020-09-01
252,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2018-02-28,908,D,0,1,TOUP11,"Based on observation and interview, the facility dietary department failed to maintain the hood lights in an operating condition in 2 of 6 observations. Findings include: Observation on 2/27/18 beginning at 12:45 PM and on 2/28/18 at 2:15 PM in the dietary department with Registered Dietitian (RD) #1 and the Certified Dietary Manager (CDM) present revealed 5 of 6 lights in the hood over the production equipment were not operating. Interview with RD #1 and the CDM on 2/27/18 beginning at 12:45 PM in the dietary department confirmed the facility failed to have the hood lights maintained in an operating condition.",2020-09-01
253,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2019-05-07,760,D,1,0,8UMM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview the facility failed to administered the correct medications for 1 (#1) of 3 residents reviewed on 4/27/19 related to Licensed Practical Nurse #2 during the evening medication pass. The findings include: Review of the facility policy, Medication Administration--General Guidelines , effective 6/2016 revealed .medications are administered as prescribed in accordance with good nursing principles and practices .the five rights are applied for each medication being administered . Medical record review revealed Resident #1 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Admission Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status score of 7 indicating severe cognitive impairment Medical record review of a comprehensive care plan revised 4/9/19 revealed Resident #1 was monitored and assessed for functional potential, mobility and generalized weakness. Medical record review of the Physician's orders revealed medications given in error to Resident #1 included: Keflex for infection; [MEDICATION NAME] to relax the muscles; Requip for [MEDICAL CONDITION] or Restless Leg Syndrome; [MEDICATION NAME] for Constipation, [MEDICATION NAME] for Benign [MEDICAL CONDITION] of the Prostate; and [MEDICATION NAME] for depression and [MEDICAL CONDITION]. Medical record review of the SBAR (Situation, Background, Appearance, Review/Notify) form dated 4/27/19 revealed a med error occurred. Medical record review of a transfer form from the facility to the hospital dated 4/27/19 revealed the key reason for transfer was a possible allergic reaction with the primary reason for transfer being diagnostic testing, not admission. Continued review revealed a medication error involving Resident #1 had occurred. Interview with the Director of Nursing on 5/6/19 at 9:00 AM in the conference room confirmed LPN #2 made a medication error by administering the wrong medications to Resident #1 on 4/27/19 during the evening medication pass. Interview with the Nurse Practioner on 5/6/19 at 11:40 AM in the conference room confirmed LPN #2 gave Resident #1 the wrong medication on 4/27/19 during the evening medication pass.",2020-09-01
254,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2020-01-08,761,D,0,1,OQRZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured in 1 of 7 (C Hall Medication Cart) medication storage areas. The findings include: 1. The facility policy titled, MEDICATION STORAGE IN THE FACILITY, dated 6/2016 documented, .Medication rooms, carts, and medications supplies are locked when not attended by persons with authorized access . 2. Observation in the C Hall outside of room [ROOM NUMBER] on 1/7/20 at 4:20 PM, showed an unlocked and unattended medication cart. During an interview conducted on 1/8/20 at 7:50 AM, the Director of Nursing (DON) was asked if a medication cart should be left unlocked and unattended. The DON stated, No.",2020-09-01
255,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2020-01-08,880,E,0,1,OQRZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were followed when 3 of 5 nurses (Registered Nurse (RN) #1, Licensed Practical Nurse (LPN) #1 and #2) failed to perform hand hygiene, failed to clean an oral inhaler, and failed to rinse a Percutaneous Endoscopic Gastrostomy (PEG) tube syringe after use for 3 of 5 sampled residents (Resident #142, #40, and #291) observed during medication administration. The findings include: 1. Review of the facility manual titled, INFECTION CONTROL MANUAL, dated 12/1998, showed that hand hygiene should be performed after removing gloves. 2. Observation in the resident's room on 1/7/20 at 8:37 AM, showed RN #1 administered medications to Resident #142. RN #1 moved the over bed table, pull the privacy curtain, adjusted pillows on the bed, and reached in her pocket and donned gloves. RN #1 did not perform hand hygiene between touching objects in the room and donning her gloves. 3. Observation of RN #1 in the C Hall outside of room [ROOM NUMBER] on 1/7/20 at 8:45 AM, showed RN #1 dropped Resident #142's oral inhaler on the floor. RN #1 picked up the oral inhaler, put it in a labeled bag and placed it in the medication cart. RN #1 did not clean the inhaler before returning it back to the medication cart. 4. Observation in the resident's room on 1/7/20 at 9:00 AM, showed LPN #1 administered medications through a PEG tube to Resident #40 and placed the syringe back into the plastic bag. LPN #1 did not rinse the syringe before placing it into the bag. 5. Observation in the resident's room on 1/7/20 at 10:12 AM, showed LPN #2 administered oral medications to Resident #291, removed an old [MEDICATION NAME] from his right shoulder, and applied a new patch to his left shoulder. LPN #2 removed her gloves, donned clean gloves, and administered an injection to his left lower abdomen. LPN #2 did not perform hand hygiene after the removal of her gloves and before donning clean gloves. 6. During an interview conducted on 1/8/20 at 10:30 AM, the Director of Nursing (DON) was asked if hand hygiene should be performed before and after donning gloves. The DON stated, Yes. The DON was asked if an oral inhaler was dropped on the floor, should it be cleaned before placing it in a storage bag and in the medication cart. The DON stated, Yes. The DON was asked if PEG syringes should be cleaned after use. The DON stated, Yes.",2020-09-01
256,"NHC HEALTHCARE, COOKEVILLE",445110,815 SOUTH WALNUT AVENUE,COOKEVILLE,TN,38501,2020-02-05,880,D,0,1,8DF811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record review, observation, and interview the facility failed to follow infection control practices for 2 residents (#34 and #125) of 3 residents in isolation precautions of 18 sampled residents. The findings include: Review of the facility policy Transmission-Based Procedures revised date 11-2019 showed .Enhanced Barrier Precautions .In addition to Standard Precautions, use Enhanced Barrier Precautions (EBP) during high-contact patient care activities .EBP expands the use of PPE (personal protective equipment) beyond situations in which exposure to blood and body fluids is anticipated .Equipment .Appropriate Contact Precautions sign on door . Record review revealed Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident plan of care dated 1/31/2020 showed .enhanced barrier percation (precaution) in place . Review of the physician's order dated 2/1/2020 showed .enhanced barrier precautions r/t (related to) ESBL (Extended Spectrum Beta-Lactamase) in the urine . Observation on 2/3/2020 at 11:40 AM, on the 400 hall, showed no isolation sign on Resident #34's door to indicate the resident was in isolation. Interview with Licensed Practical Nurse (LPN) #2 on 2/3/2020 at 11:40 AM, on the 400 hall, confirmed that Resident #34 was on enhanced barrier precautions for ESBL in the urine and an isolation sign had not been posted on the resident's door. Record review revealed Resident #125 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident plan of care revised date 2/3/2020 showed .pt (patient) on enhanced barrier precautions related to lice on scalp . Observation on 2/3/2020 at 9:30 AM, on the 100 hall, showed no isolation sign on Resident #125's door to indicate the resident was in isolation. This surveyor entered the resident's room and was thereafter verbally informed by a staff member that an isolation room had been entered. Interview with LPN #1 on 2/3/2020 at 11:35 AM, on the 100 hall, confirmed the resident was on isolation for head lice and an isolation sign had not been posted on Resident #125's door. Interview with the Director of Nursing on 2/4/2020 at 3:05 PM, in the conference room, confirmed the facility had not posted isolation signs for Residents #34 and #125.",2020-09-01
257,"NHC HEALTHCARE, COOKEVILLE",445110,815 SOUTH WALNUT AVENUE,COOKEVILLE,TN,38501,2019-02-06,756,D,0,1,JQRT11,"**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 rationale in response to pharmacy recommendations for 1 resident (#53) of 5 residents reviewed for unnecessary medications, of 36 sampled residents. The findings include: Review of the facility policy Consultant Pharmacist Reports, dated 6/2016, revealed .Recommendations are acted upon and documented by .the prescriber. 1) Prescriber accepts and acts upon suggestion or rejects and provides an explanation for disagreeing . Medical record review revealed Resident #53 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #53's quarterly Minimum (MDS) data set [DATE] revealed Resident #53 had a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. Medical record review of a Note to Attending Physician/Prescriber from the Consultant Pharmacist dated 7/23/18 revealed .Patient has continued on current dose of [MEDICATION NAME] (a medication used to treat anxiety) since 4/2018. Please evaluate risks vs (versus) benefits of current dose and consider reduction. If a reduction is not indicated, please document reasoning below .Recommend: Discontinue [MEDICATION NAME] 7.5 mg (milligrams) bid (twice daily). Start [MEDICATION NAME] 3.75 mg po (by mouth) qam (every morning) and 7.5 mg po qpm (every evening) . Continued review of the document revealed the Physician signed the recommendation with the box indicating disagree checked. The line for the Physician's rationale read .DO NOT D/C (discontinue) . Medical record review of a Note to Attending Physician/Prescriber from the Consultant Pharmacist dated 8/17/18 revealed .Consider drawling labs to evaluate benefits vs risks of [MEDICATION NAME] (a medication used to treat high cholestral) in this patient .Recommend: Order lipid panel and liver function tests . Continued review of the document revealed the Physician signed the recommendation with the box indicating disagree checked. The line for the Physician's rationale was left blank. Interview with Assistant Director of Nursing on 2/06/19 at 7:35 AM, in the conference room, confirmed .They don't always fill out the form . Continued interview confirmed the facility failed to obtain a Physician's rationale in response to the Pharmacist's recommendations dated 7/23/18 and 8/17/18.",2020-09-01
258,"NHC HEALTHCARE, COOKEVILLE",445110,815 SOUTH WALNUT AVENUE,COOKEVILLE,TN,38501,2019-02-06,812,F,0,1,JQRT11,"Based on review of facility policy, observation, and interview the facility failed to maintain a sanitary kitchen evidenced by improperly storing the flour scoop, undated food items in dry food storage, and open to air items in 1 of 1 walk in freezers, potentially affecting 85 residents. The findings include: Review of the facility policy Dry Storage, revised 11/2017, revealed .Scoops should be stored in a sanitary method with handles of scoops not contacting food . Review of the facility policy Refrigerator and Freezer Storage, revised 11/2017, revealed .Refrigerated and frozen foods will be stored properly for optimal product safety . Observation and interview with the Director of Dietary Services (DDS) on 2/4/19 at 10:05 AM, of the flour bin, in the kitchen, revealed the flour scoop improperly stored with the scoop placed inside the bin and resting on top of the flour. Continued interview confirmed .it was touching the flour . Further interview confirmed the facility failed to properly store the flour scoop. Observation and interview with the DDS on 2/4/19 at 11:20 AM, of the dry storage, in the kitchen, revealed an undated 21lb. (pound) bag of corn flakes, half used, an undated 21 lb. bag of bran flakes, half used, an undated 21 lb. bag of fruit wheels, a quarter used, an undated 21 lb. bag of frosted flakes, three-quarters used, and an undated 32 ounce bag of flake coconut, half used. Continued interview confirmed the facility failed to properly store dry food items available for resident consumption. Observation and interview with the DDS on 2/4/19 at 11:31 AM, of the walk in freezer, outside the kitchen, revealed an undated 30 lb. bag of winter vegetables, in a large plastic bag inside a cardboard box, open to air. Further observation revealed an undated 30 lb. bag of vegetable stew, in a large plastic bag inside a cardboard box, open to air. Continued interview confirmed the facility failed to properly store frozen food items available for resident use.",2020-09-01
259,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2019-05-01,609,D,1,0,22N711,"**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 report an allegation of abuse within 2 hours to the State Survey Agency for 1 resident (#4) of 3 residents sampled for abuse, of five sampled residents. The findings included: Review of facility policy, Abuse, (undated) revealed .if you have reasonable suspicion that a crime has occurred against a resident .Federal Law Requires that you report your suspicion directly to .the State Survey Agency . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 scored a 14 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Medical record review of a Nursing Note dated 3/26/19 at 10:00 PM revealed .Pt (patient) A&O (alert and oriented) .some confusions (at) times . Medical record review of a Nursing Note dated 4/11/19 at 4:00 AM revealed .went to check on pt .not responding in usual manner .very lethargy .speech sluggish . Continued review revealed the resident was transferred to a local hospital with altered mental status and a urinary tract infection [MEDICAL CONDITION]. Review of the facility investigation dated 4/24/19 revealed a caseworker with Adult Protective Services (APS) contacted the facility on 4/24/19 and advised them while Resident #4 was in the hospital the resident alleged she was sexually abused by an unidentified male staff member at the facility sometime prior to her hospitalization on [DATE]. Further review revealed the facility did not report the allegation to the State Survey Agency. Interview with the Director of Nursing and the Risk Manger on 4/30/19 at 6:00 PM, in the conference room, confirmed the facility failed to report an allegation of abuse to the State Agency within 2 hours of notification of the allegation. In summary, the facility was aware of an allegation of abuse on 4/24/19 and as of 4/30/19, the facility had not reported the allegation of abuse to the State Survey Agency (7 days).",2020-09-01
260,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2017-07-26,225,D,1,0,RMD011,"**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 ensure an allegation of abuse was reported to the State Survey Agency for 1 resident (#5) of 3 residents reviewed for abuse of 5 sampled residents. The findings include: Review of the facility policy Abuse dated 11/2016 revealed .The facility must ensure that all alleged violations involving mistreatment, neglect, exploitation, mistreatment, misappropriation of resident property or abuse .are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency) . Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Brief Interview for Mental Status (BIMS) dated 5/22/17 revealed Resident #5 was severely cognitively impaired. Medical record review of a psychiatric progress note dated 6/6/17 revealed Resident #5 was reported to have periods of extreme agitation and was noted to show a significant overall decline, altered mental status, and was unable to focus. Review of a facility investigation dated 6/12/17 revealed the granddaughter of Resident #5 reported to the Assistant Director of Nursing (ADON) during a visit her grandmother stated a partner at the facility had slapped her. Continued review revealed Resident #5 could not identify the partner nor could she state when the alleged incident occurred. Further review revealed the resident did not report the alleged incident until the granddaughter told the resident .tell .about the lady that slapped you from here . Continued review revealed Resident #5 stated a woman had slapped her in the face when she was at the beauty shop and the person had short and long hair. Further review revealed the resident stated the incident happened a few days ago .down on .old highway .at the building with bricks .beauty shop . Continued review revealed the Risk Manager informed the granddaughter a complete investigation would be conducted and she (Risk Manager) would notify the police, but the granddaughter stated .No I am going to take her so it will not alert anyone . Interview with the Risk Manager on 7/26/17 at 10:00 AM, in Conference room [ROOM NUMBER], confirmed an allegation of abuse involving Resident #5 was reported to the facility on [DATE] and the facility failed to report the allegation to the state survey agency timely.",2020-09-01
261,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2019-07-31,569,C,0,1,77NT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, medical record review, review of the facility's documentation of the Notification Summary Report (resident trust funds/Resident Statement), and interview, the facility failed to refund the balance of a Patient Trust Fund, within the required time frame, for 2 discharged residents (#402 and #403) of 313 Patient Trust Funds reviewed. The findings include: Review of the facility policy, Patient Trust, Subject: Refunds, revised date ,[DATE], revealed .Timing (Schedule) the funds should be refunded within 30 days of death or discharge . Medical record review revealed Resident #402 was admitted to the facility on [DATE]. Continued review revealed the Resident was discharged to the hospital on [DATE]. Review of the Resident Statement (trust fund) revealed the Resident expired on [DATE]. Continued review revealed Resident #402 had a balance of $1719.70. Medical record review revealed Resident #403 was admitted to the facility on [DATE]. Continued review revealed Resident #403 was discharged to the hospital on [DATE]. Review of the Resident Statement (trust fund) revealed the Resident expired on [DATE]. Continued review revealed Resident #403 had a balance of $1686.57. Interview with the Trust Bookkeeper on [DATE] at 8:40 AM, in the business office, confirmed the facility had not refunded the Resident's Trust Fund accounts for Residents #402 and #403. Continued interview confirmed the facility had not refunded the accounts within the required time frame.",2020-09-01
262,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2019-07-31,645,D,0,1,77NT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to refer 1 resident (#90) identified with a possible serious mental disorder to the state-designated authority for a Level II Preadmission Screening and Resident Review (PASARR) of 6 residents reviewed for PASARR of 37 sampled residents. The findings include: Medical record review revealed Resident #90 was admitted to the facility on [DATE] with diagnosed including: [DIAGNOSES REDACTED]. Medical record review of a PASARR Level I assessment dated [DATE] revealed the resident had no [DIAGNOSES REDACTED]. Medical record review of a Psychiatric Evaluation dated 3/11/19 revealed .Worsening depression .she reports the increase of [MEDICATION NAME] (medication to treat depression) did not help .she does admit to a history of mood swings and thinks she may have [MEDICAL CONDITION] (a psychiatric disorder) .Diagnosis .[MEDICAL CONDITION] 1 Disorder . Interview with the Minimum Data Set (MDS) Coordinator on 7/30/19 at 1:39 PM, in the conference room, confirmed the facility failed to refer Resident #90 to the state-designated authority for a Level II PASARR evaluation to determine if the resident required specialized services after her [DIAGNOSES REDACTED].",2020-09-01
263,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2019-07-31,656,D,0,1,77NT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to implement a comprehensive care plan for pain management for 1 resident (#266) of 3 residents reviewed for pain of 37 residents sampled. The findings include: Medical record review revealed Resident #266 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the comprehensive care plan dated 4/2/19 revealed . risk for alteration of her comfort d/t (due to) decreased mobility, and dx (diagnosis) of OA ([MEDICAL CONDITION], a type of arthritis that occurs when the flexible tissues at the ends of the bones wear down), Chronic pai[DIAGNOSES REDACTED] and [MEDICAL CONDITION] (widespread muscle pain and tenderness) . administer medications as ordered . Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Further review revealed the resident had frequent pain rated at 7 on 0-10 pain scale (pain scale with zero being no pain and 10 as the worst pain possible.) Medical record review of the Physicians Order Report dated 6/29/19- 7/29/19 revealed .[MEDICATION NAME] (a pain medication) .Chronic pai[DIAGNOSES REDACTED] .Four times a day; 09:00 AM, 01:00 PM, 05:00 PM, 09:00 PM . Medical record review of the Administration Log report dated 7/1/19- 7/25/19 revealed the 7/1/19 9:00 PM dose of [MEDICATION NAME] had been administered at 10:52 PM, the 7/4/19 9:00 PM dose of [MEDICATION NAME] had been administered at 10:48 PM, the 7/10/19 9:00 PM dose of [MEDICATION NAME] had been administered at 12:00 AM on 7/11/19, the 7/13/19 9:00 PM dose of [MEDICATION NAME] had been administered at 11:59 PM, the 7/15/19 9:00 PM dose of [MEDICATION NAME] had been administered at 11:56 PM, and the 7/18/19 9:00 PM dose of [MEDICATION NAME] had been administered at 11:42 PM. Interview with Resident #266 on 7/28/19 at 3:32 PM, in the resident's room, revealed her medications are sometimes administered late. Interview with the Director of Nursing (DON) on 7/29/19 at 4:05 PM, in the conference room, confirmed the medication administration time frame was for the medications to be administered during the period of one hour before to one hour after the scheduled administration time. Telephone interview with Licensed Practical Nurse (LPN) #1 on 7/29/19 at 7:56 PM, revealed medications on the 7:00 PM- 7:00 AM shift were often administered late .when there's only one nurse for 53 patients there is no way to do 53 patients .when there's 2 nurses you can get the meds done correctly . Interview with Resident #266 on 7/30/19 at 7:33 AM, in the resident's room, revealed 9:00 PM medications are sometimes administered late .I go from my 5 o'clock (PM) meds (medications) until 11:30 (PM) at night .that's 7 hours that I wouldn't get my medication if I take my 5 o'clock meds at 4 o'clock (PM) .that's a long time to go without medicine because my pain medicine is in that and if I have to wait that long it causes me to have pain . Telephone interview with LPN #2 on 7/30/19 at 8:18 AM, revealed the 9:00 PM medication administration is sometimes late .it does take me a while sometimes .I'm the only nurse on that unit .max (maximum census) is 54 but the census now is 53 sometimes it may be 10:30 (PM) or 11:30 (PM) . Interview with the Medical Director on 7/30/19 at 2:35 PM, in the conference room, revealed Resident #266 had chronic pain. Further interview revealed his expectation was for all medications to be given as ordered. Continued interview revealed the pain medications administered late would cause the resident to have increased pain.of course it would .I think I would be complaining too if I was the patient . Interview with the DON on 7/31/19 at 9:16 AM, in the conference room, confirmed the comprehensive care plan had not been implemented to provide pain medications as ordered for Resident #266.",2020-09-01
264,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2019-07-31,697,D,0,1,77NT11,"**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 pain medication was administered timely resulting in an increase in pain for 1 resident (#266) of 3 residents reviewed for pain of 37 sampled residents. The findings include: Review of the facility policy Medication Administration dated 6/2018 revealed, .Medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms, and help in the medical management of [DIAGNOSES REDACTED].at the right time . Medical record review revealed Resident #266 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the comprehensive care plan dated 4/2/19 revealed, . risk for alteration of her comfort d/t (due to) decreased mobility, and dx (diagnosis) of OA ([MEDICAL CONDITION], a type of arthritis that occurs when the flexible tissues at the ends of the bones wear down), Chronic pai[DIAGNOSES REDACTED] and [MEDICAL CONDITION] (widespread muscle pain and tenderness) . administer medications as ordered .monitor for break-through pain .monitor and document response to pain meds .administer prescribed pain medication as needed/ordered to maintain patient comfort level .perform ongoing pain assessments to determine if the pain management regimen is meeting the patient's pain relief goal . Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Further review revealed the resident had frequent pain rated at 7 on 0-10 pain scale (pain scale with zero being no pain and 10 as the worst pain possible). Medical record review of the Physicians Order Report dated 6/29/19- 7/29/19 revealed .[MEDICATION NAME] (a pain medication) .Chronic pai[DIAGNOSES REDACTED] .Four times a day; 09:00 AM, 01:00 PM, 05:00 PM, 09:00 PM . Medical record review of the Administration Log report dated 7/1/19- 7/25/19 revealed the 7/1/19 9:00 PM dose of [MEDICATION NAME] had been administered at 10:52 PM, the 7/4/19 9:00 PM dose of [MEDICATION NAME] had been administered at 10:48 PM, the 7/10/19 9:00 PM dose of [MEDICATION NAME] had been administered at 12:00 AM on 7/11/19, the 7/13/19 9:00 PM dose of [MEDICATION NAME] had been administered at 11:59 PM, the 7/15/19 9:00 PM dose of [MEDICATION NAME] had been administered at 11:56 PM, and the 7/18/19 9:00 PM dose of [MEDICATION NAME] had been administered at 11:42 PM. Interview with Resident #266 on 7/28/19 at 3:32 PM, in the resident's room, revealed her medications are sometimes administered late. Interview with the Director of Nursing (DON) on 7/29/19 at 4:05 PM, in the conference room, confirmed the medication administration time frame was for the medications to be administered during the period of one hour before to one hour after the scheduled administration time. Telephone interview with Licensed Practical Nurse (LPN) #1 on 7/29/19 at 7:56 PM, revealed medications on the 7:00 PM- 7:00 AM shift were often administered late .when there's only one nurse for 53 patients there is no way to do 53 patients .when there's 2 nurses you can get the meds done correctly . Interview with Resident #266 on 7/30/19 at 7:33 AM, in the resident's room, revealed 9:00 PM medications are sometimes administered late .I go from my 5 o'clock (PM) meds (medications) until 11:30 (PM) at night .that's 7 hours that I wouldn't get my medication if I take my 5 o'clock meds at 4 o'clock (PM) .that's a long time to go without medicine because my pain medicine is in that and if I have to wait that long it causes me to have pain . Telephone interview with LPN #2 on 7/30/19 at 8:18 AM, revealed the 9:00 PM medication administration is sometimes late .it does take me a while sometimes .I'm the only nurse on that unit .max (maximum census) is 54 but the census now is 53 sometimes it may be 10:30 (PM) or 11:30 (PM) . Interview with Resident #266 on 7/30/19 at 10:00 AM, in the resident's room, revealed, .my normal pain level is about 7 or 8 . Further interview revealed when the 9:00 PM meds are late .oh it may be a 10 by then .it gets worse . Interview with the Medical Director on 7/30/19 at 2:35 PM, in the conference room, confirmed Resident #266 had chronic pain. Further interview revealed his expectation was for all medications to be given as ordered. Continued interview revealed the pain medications administered late would cause the resident to have increased pain.of course it would .I think I would be complaining too if I was the patient . Interview with the DON on 7/31/19 at 9:16 AM, in the conference room, confirmed the facility failed to administer Resident #266's pain medications in a timely manner resulting in an increase in pain for Resident #266.",2020-09-01
265,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2019-07-31,725,D,0,1,77NT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility's Assignment Sheets, review of the facility's Midnight Census Reports, resident interviews, and staff interviews, the facility failed to maintain adequate staffing levels to ensure timely administration of medications for 1 resident (#266) residing on 1 unit (2 East) of 10 units observed. The findings include: Medical record review revealed Resident #266 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the comprehensive care plan dated 4/2/19 revealed . risk for alteration of her comfort d/t (due to) decreased mobility, and dx (diagnosis) of OA ([MEDICAL CONDITION], a type of arthritis that occurs when the flexible tissues at the ends of the bones wear down), Chronic pai[DIAGNOSES REDACTED] and [MEDICAL CONDITION] (widespread muscle pain and tenderness) . administer medications as ordered .Administer prescribed pain medications as needed/ordered to maintain patient comfort level .[DIAGNOSES REDACTED].[MEDICAL CONDITION] (stroke) .GOAL .will remain free of .episodes of her diasease (disease) process .Administer medications as ordered . Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Further review revealed the resident had frequent pain rated at 7 on 0-10 pain scale (pain scale with zero being no pain and 10 as the worst pain possible.) Medical record review of the Physicians Order Report dated 6/29/19- 7/29/19 revealed .[MEDICATION NAME] (a pain medication) .Chronic pai[DIAGNOSES REDACTED] .Four times a day; 09:00 AM, 01:00 PM, 05:00 PM, 09:00 PM .[MEDICATION NAME] (medication used for irregular heartbeats) . twice a day; 09:00 AM, 05:00 PM .Levetiracetam (medication used for [MEDICAL CONDITION]) .at bedtime; 09:00 PM .[MEDICATION NAME] (medication used for sleep) .at bedtime; 09:00 PM .[MEDICATION NAME] (medication used for high blood pressure) .at bedtime; 09:00 PM . Medical record review of the Administration Log report dated 7/1/19- 7/25/19 revealed the 7/1/19 9:00 PM medications had been administered at 10:52 PM, the 7/4/19 9:00 PM medications had been administered at 10:48 PM, the 7/10/19 9:00 PM medications had been administered at 12:00 AM on 7/11/19, the 7/13/19 9:00 PM medications had been administered at 11:59 PM, the 7/15/19 9:00 PM medications had been administered at 11:56 PM, the 7/16/19 5:00 PM medications had been administered at 7:41 PM, and the 7/18/19 9:00 PM medications had been administered at 11:42 PM. Review of the Facility's Midnight Census Reports dated 7/1/19, 7/4/19, 7/10/19, 7/13/19, 7/15/19, 7/16/19, 7/18/19 revealed a resident census of 53 for the 2 East Unit. Review of the Facility's assignment sheets dated 7/1/9, 7/4/19, 7/10/19, 7/13/19, 7/15/19, 7/18/19 revealed one LPN on duty on the 2 East Unit for the 7:00 PM to 7:00 AM shift. Further review of the Facility's assignment sheet dated 7/16/19 revealed one LPN on duty on the 2 East Unit for 7:00 AM to 7:00 PM shift until 9:00 AM when another nurse came on duty. Continued review of the facility assignment sheet dated 7/23/19 revealed one LPN on duty on the 2 East Unit from 3:00 PM to 5:30 PM. Further review of the facility assignment sheet dated 7/24/19 revealed on LPN on duty on the 2 East Unit for the 7:00 AM to 7:00 PM shift. Interview with Resident #266 on 7/28/19 at 3:32 PM, in the resident's room, revealed her medications are sometimes administered late. Continued interview revealed the nurses had told the resident the medications were administered late due to one nurse working on that unit. Interview with Licensed Practical Nurse (LPN) #7 on 7/28/19 at 3:50 PM, at the 2 East nurse's station, revealed she had been .pulled to another floor . on 7/23/19 and 7/24/19 leaving one nurse on the 2 East Unit. Interview with LPN #3 on 7/28/19 at 3:56 PM, at the 2 East nurse's station, revealed she works the 7:00 AM to 7:00 PM shift. Further interview revealed nurses are frequently .pulled to another floor .leaving one nurse to care for 53 residents . Continued interview revealed the last time this occurred was on 7/23/19 and 7/24/19. Interview and observation of the assignment sheets dated 7/23/19 and 7/24/19 with the Director of Nursing (DON) on 7/29/19 at 2:16 PM, in conference room A, revealed the facility's goal for staffing for the 2 East Unit was to have two LPNs on staff for the 7:00 AM to 7:00 PM shift. Further interview confirmed on 7/23/19 one LPN had been on duty from 3:00 PM until 7:00 PM due to the other LPN had been pulled to cover the 3 East Unit leaving one nurse to provide care for 53 residents. Continued interview confirmed one LPN had been on duty on the 2 East Unit on 7/24/19 for the entire shift of 7:00 AM to 7:00 PM to provide care for 53 residents. Interview with the 2 East Unit Manager on 7/29/19 at 3:39 PM, in the Unit Manager's office, revealed medications are frequently administered late when there is one nurse on duty. Further interview revealed the Unit Manager would do all of the charting, take phones calls, and take physician orders [REDACTED]. Continued interview revealed the Unit Manager works 5 days a week and the LPN on duty would have to administer medications, chart, take phone calls, and take physician orders [REDACTED]. Interview with the DON on 7/29/19 at 4:05 PM, in the conference room, confirmed the medication administration time frame was for the medications to be administered during the period of one hour before to one hour after the scheduled administration time. Telephone interview with LPN #1 on 7/29/19 at 7:56 PM, revealed medications on the 7:00 PM to 7:00 AM shift were often administered late .when there's only one nurse for 53 patients there is no way to do 53 patients .when there's 2 nurses you can get the meds done correctly . Interview with LPN #4 on 7/30/19 at 7:23 AM, on the 2 East hallway, revealed the medications are sometimes administered late .that happens .sometimes I'm just busy with other things Continued interview revealed it was difficult to get the medications administered on time when there is one nurse on duty. Interview with LPN #5 on 7/30/19 at 7:27 AM, on the 2 East hallway, revealed medications are to be administered .1 hour before or 1 hour after the scheduled time. Further interview revealed it was difficult to administer meds on time when there was one LPN on duty .we have 52 to 53 patients . Interview with Resident #266 on 7/30/19 at 7:33 AM, in the resident's room, revealed 9:00 PM medications are sometimes administered late .I go from my 5 o'clock (PM) meds (medications) until 11:30 (PM) at night .that's 7 hours that I wouldn't get my medication if I take my 5 o'clock meds at 4 o'clock (PM) .that's a long time to go without medicine because my pain medicine is in that and if I have to wait that long it causes me to have pain . Telephone interview with LPN #2 on 7/30/19 at 8:18 AM, revealed the 9:00 PM medication administration is sometimes late .it does take me a while sometimes .I'm the only nurse on that unit .max (maximum census) is 54 but the census now is 53 sometimes it may be 10:30 (PM) or 11:30 (PM) . Interview with LPN #5 on 7/30/19 at 9:21 AM, on the 2 East hallway, revealed Resident #266's 5:00 PM medications had been administered at 7:41 PM on 7/16/19 .that's the day my partner (LPN #4) called in . Interview with Resident #266 on 7/30/19 at 10:00 AM, in the resident's room, revealed .my normal pain level is about 7 or 8 Further interview revealed when the 9:00 PM meds are late . oh it may be a 10 by then . it gets worse . Interview with the Medical Director on 7/30/19 at 2:35 PM, in the conference room, revealed Resident #266 had chronic pain and history of a stroke. Further interview revealed his expectation was for all medications to be administered as ordered. Continued interview revealed the pain medications administered late would cause the resident to have increased pain.of course it would .I think I would be complaining too if I was the patient . Further interview revealed the [MEDICATION NAME] and [MEDICATION NAME] administered late would place the resident at .potential risk for arrhythmia (irregular heartbeat) .for anything related to blood pressure .she has already had a stroke . Interview and observation of the 2 East Unit with Certified Nursing Assistant (CNA) #2 on 7/30/19 at 10:05 PM, on the 2 East hallway, revealed no nurse was on the unit. Continued interview with CNA #2 revealed the night shift nurse had called in and the Shift Supervisor had been covering the unit but was not currently on the floor. Interview with LPN #6 on 7/30/19 at 10:10 PM, at the 2 East nurse's station, revealed she had just arrived to the unit. Further interview revealed she had been called to come in to work at 11:00 PM due to the nurse who had been scheduled for the 7:00 PM to 7:00 AM shift had called in. Interview with the Shift Supervisor on 7/30/19 at 10:12 PM, at the 2 East nurse's station, revealed she had been on another unit assisting with a pharmacy delivery but was the nurse responsible for the 2 East Unit until another nurse arrived. Continued interview revealed the night shift nurse had called in. Further interview revealed the day shift nurses had stayed over to administer the 9:00 PM medications. Continued interview revealed the Shift Supervisor had been covering the 2 East Unit with a census of 53 residents from 9:30 PM until another nurse arrived at 10:00 PM but had also been assisting with the other units in that building and had not been on the 2 East Unit the entire time. Interview and observation of the Assignment sheets, Midnight Census Reports, and Administration Log Reports with the DON on 7/31/19 at 9:16 AM, in the conference room, confirmed Resident #266's 9:00 PM medications had not been administered timely on 7/1/19, 7/4/19, 7/10/19, 7/13/19, 7/15/19, and 7/18/19. Continued interview confirmed there had been 1 LPN on duty for the 7:00 PM to 7:00 AM shift with a resident census of 53 for these dates. Further interview confirmed Resident #266's 5:00 PM medications had not been administered timely on 7/16/19. Continued interview confirmed 2 LPN's had been scheduled to work the 7:00 AM to 7:00 PM shift on 7/16/19 but one of the LPN's had called in with a resident census of 53. Further interview confirmed the facility failed to provide adequate staffing to provide timely administration of Resident #266's medications.",2020-09-01
266,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2019-07-31,760,D,0,1,77NT11,"**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 1 resident (#266) was free from significant medication errors of 7 residents reviewed for medication administration of 37 residents sampled. The findings include: Review of the facility policy Medication Administration dated 6/2018 revealed .Medications are administered safely and appropriately to aid resident to overcome illness, relieve and prevent symptoms, and help in the medical management of [DIAGNOSES REDACTED].at the right time . Medical record review revealed Resident #266 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the comprehensive care plan dated 4/2/19 revealed . risk for alteration of her comfort d/t (due to) decreased mobility, and dx (diagnosis) of OA ([MEDICAL CONDITION], a type of arthritis that occurs when the flexible tissues at the ends of the bones wear down), Chronic pai[DIAGNOSES REDACTED] and [MEDICAL CONDITION] (widespread muscle pain and tenderness) . administer medications as ordered .Administer prescribed pain medications as needed/ordered to maintain patient comfort level .[DIAGNOSES REDACTED].[MEDICAL CONDITION] (stroke) .GOAL .will remain free of .episodes of her diasease (disease) process .Administer medications as ordered . Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Further review revealed the resident had frequent pain rated at 7 on 0-10 pain scale (pain scale with zero being no pain and 10 as the worst pain possible.) Medical record review of the Physicians Order Report dated 6/29/19- 7/29/19 revealed .[MEDICATION NAME] (a pain medication) .Chronic pai[DIAGNOSES REDACTED] .Four times a day; 09:00 AM, 01:00 PM, 05:00 PM, 09:00 PM .[MEDICATION NAME] (medication used for irregular heartbeats) . twice a day; 09:00 AM, 05:00 PM .Levetiracetam (medication used for [MEDICAL CONDITION]) .at bedtime; 09:00 PM .[MEDICATION NAME] (medication used for sleep) .at bedtime; 09:00 PM .[MEDICATION NAME] (medication used for high blood pressure) .at bedtime; 09:00 PM . Medical record review of the Administration Log report dated 7/1/19- 7/25/19 revealed the 7/1/19 9:00 PM medications had been administered at 10:52 PM, the 7/4/19 9:00 PM medications had been administered at 10:48 PM, the 7/10/19 9:00 PM medications had been administered at 12:00 AM on 7/11/19, the 7/13/19 9:00 PM medications had been administered at 11:59 PM, the 7/15/19 9:00 PM medications had been administered at 11:56 PM, the 7/16/19 5:00 PM medications had been administered at 7:41 PM, and the 7/18/19 9:00 PM medications had been administered at 11:42 PM. Interview with Resident #266 on 7/28/19 at 3:32 PM, in the resident's room, revealed her medications are sometimes administered late. Continued interview revealed the nurses had told the resident the medications were administered late due to one nurse working on that unit. Interview with the Director of Nursing (DON) on 7/29/19 at 4:05 PM, in the conference room, confirmed the medication administration time frame was for the medications to be administered during the period of one hour before to one hour after the scheduled administration time. Telephone interview with Licensed Practical Nurse (LPN) #1 on 7/29/19 at 7:56 PM, revealed medications on the 7:00 PM- 7:00 AM shift were often given late .when there's only one nurse for 53 patients there is no way to do 53 patients .when there's 2 nurses you can get the meds done correctly . Interview with Resident #266 on 7/30/19 at 7:33 AM, in the resident's room, revealed 9:00 PM medications are sometimes administered late .I go from my 5 o'clock meds (medications) until 11:30 at night .that's 7 hours that I wouldn't get my medication if I take my 5 o'clock meds at 4 o'clock .that's a long time to go without medicine because my pain medicine is in that and if I have to wait that long it causes me to have pain .if I don't ask for them at 8:30 (PM) or 9:00 (PM) then I may have to wait and then I'm in pain . Telephone interview with LPN #2 on 7/30/19 at 8:18 AM, revealed the 9:00 PM medication administration is sometimes late .it does take me a while sometimes .I'm the only nurse on that unit .max (maximum census) is 54 but the census now is 53 sometimes it may be 10:30 (PM) or 11:30 (PM) . Interview with Resident #266 on 7/30/19 at 10:00 AM, in the resident's room, revealed .my normal pain level is about 7 or 8 Further interview revealed when the 9:00 PM meds are late . oh it may be a 10 by then . it gets worse . Interview with the Medical Director on 7/30/19 at 2:35 PM, in the conference room, revealed Resident #266 had chronic pain and history of a stroke. Further interview revealed his expectation was for all medications to be administered as ordered. Continued interview revealed the pain medications administered late would cause the resident to have increased pain.of course it would .I think I would be complaining too if I was the patient . Further interview revealed the [MEDICATION NAME] and [MEDICATION NAME] administered late would place the resident at .potential risk for arrhythmia (irregular heartbeat) .for anything related to blood pressure .she has already had a stroke . Interview with the DON on 7/31/19 at 9:16 AM, in the conference room, confirmed the facility failed to administer Resident #266's medications timely.",2020-09-01
267,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2018-08-01,761,D,0,1,DS1Q11,"Based on review of facility policy, observation and staff interview, the facility failed to ensure all medications had been labeled with a correct expiration date for 8 bags of medication, in 1 of 10 medication storage rooms observed. The findings include: Review of the facility policy Medication Ordering, Receiving and Storage revealed .The FDA (Food and Drug Administration) requires an expiration date on all medications . Observation with the facility Risk Manager on 8/1/18 at 8:40 AM, in the 300 hall medication room, revealed 8 reconstituted 100 ml (milliliter) bags of Tazicef (antibiotic) 1 gram available for use. Continued observation revealed the 8 bags of antibiotics delivered on 7/30/18 had an expiration date of 7/30/18. Interview with the facility Pharmacist on 8/1/18 at 10:01 AM, in the conference room, confirmed the facility failed to ensure the policy for medication storage was followed by not ensuring the bags of antibiotics were labeled correctly.",2020-09-01
268,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2017-10-11,323,D,1,0,19XQ11,"**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 ensure fall interventions were in place for 1 resident (#3) of 4 residents reviewed for falls. The findings included: Review of the facility's policy, Falls Prevention, revised dated 9/25/14, revealed .3. Interventions .d. implement appropriate interventions immediately . Medical record review revealed Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the post fall assessment dated [DATE], at 7:45 AM, revealed staff responding to alarm sounding. Resident was found on the floor with wheelchair tipped, supine position. Resident reports that he was trying to get back in bed. Head to toe assessment negative for obvious deformity or injury at this time. However, he does c/o (complain) pain in back, his hips, and a headache. ROM (range of motion) NCB (no change base line) .Interventions .assess for need for anti-tip bars for w/c(wheelchair), add sensor pad to w/c . Review of the care plan updated on 9/11/17, revealed the new intervention for falls was the sensor pad alarm to the w/c. Observation on 10/9/17, at 2:20 PM, in the room of Resident #3, revealed the sensor pad alarm was not in the resident's wheelchair. Interview with a Licensed Practical Nurse (LPN) #1 at the time of observation confirmed the sensor pad alarm was not in the resident's wheelchair. Continued interview with the LPN confirmed the sensor pad alarm was to be in place as part of the falls intervention.",2020-09-01
269,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2018-10-17,580,D,1,0,RHRF11,"**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 immediately report a fall to the supervising nurse and failed to immediately report a fall with injury to the responsible party for 1 Resident (#1) of 8 residents reviewed for falls, of 10 sampled residents on 1 of 11 nursing units observed. The findings included: Review of the facility policy Resident Condition Change Notification (revised 1/7/2010) revealed .an acute patient status change .are reported to the medical staff immediately .resident .patient representative are to be notified when there is a patient status change .resident's condition, medical staff notification and orders .interventions .effectiveness .patient .or patient representative notification is documented . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15/15 (cognitively intact); had no symptoms of [MEDICAL CONDITION]; had limited range of motion in the upper and lower extremities; had urinary and fecal incontinence; was non-ambulatory; and was dependent on staff with maximum assistance of one person for all activities of daily living. Continued review revealed Resident #1 had a history of [REDACTED]. Review of the facility investigation dated 10/11/18 at 5:45 AM revealed during incontinence care Certified Nurse Aide (CNA) #1 ran out of supplies and left the resident lying on her back on the bed while she went to retrieve more supplies from outside the room. Continued review revealed when CNA #1 returned to the room to (2 minutes later) she observed Resident #1 seated on the floor, to the right side of the bed, with her back against the bedframe. Further review of the investigation revealed CNA #1 did not immediately notify her supervising nurse when she found Resident #1 in the floor, but instead summoned a co-worker (CNA #2) to assist her with lifting Resident #1 back onto the bed. Continued review revealed neither CNA #1 nor CNA #2 reported the resident's fall to the supervising nurse or to the off-going or oncoming nurse or oncoming CNA during the shift report. Further review revealed Resident #1 exhibited symptoms of swelling and skin discoloration to the right leg on 10/11/18 around 4:45 PM (approximately 11 hours later). Continued review revealed Licensed Practical Nurse (LPN) #1 did not notify the responsible party for Resident #1 of the resident's change in condition until 10/12/18 around 7:00 AM (12 hours after the swelling and discoloration was noted). Telephone interview with CNA #1 on 10/16/18 at 8:15 PM confirmed the CNA did not immediately report finding Resident #1 on the floor to her supervising nurse or to the oncoming nurse or oncoming CN[NAME] Further interview confirmed CNA #1 failed to follow facility policy. Telephone interview with LPN #1 on 10/17/18 at 10:05 AM revealed she was first aware of Resident #1's change in condition on 10/11/18 at 4:45 PM and was unaware the resident had fallen earlier that day. Continued interview confirmed LPN #1 failed to notify the resident's responsible party of the change in condition until the following morning (12 hours after the change in condition had been identified and treatment initiated). Interview with the Director of Nursing (DON) and the Risk Manager on 10/17/18 at 5:05 PM, in the conference room, confirmed the facility failed to follow facility policy, failed to notify Resident #1's responsible party of the change in the condition, and failed to report Resident #1's fall to the supervising nurse.",2020-09-01
270,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2019-12-16,580,D,1,0,DCNE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility documentation, and interview, the facility failed to notify the responsible party of a fall for 1 resident (#2) of 3 residents reviewed for change in condition. The findings included: Review of the facility policy, Resident Condition Change Notification, last revised 11/2016, revealed .The medical staff .and .patient (resident) representative are to be notified when there is a patient status change . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a facility fall investigation dated 11/21/19 revealed Resident #2 fell on [DATE] at approximately 4:00 AM. Review of a facility document dated 11/23/19 revealed the responsible party for Resident #2 was not notified of the fall until 11/23/19 at approximately 6:30 PM (2days after the fall). Interview with the Director of Nursing on 12/16/19 at 7:15 PM, in the conference room, confirmed the facility failed to notify the responsible party for Resident #2 of the resident's fall on 11/21/19. Further interview confirmed the responsible party was not notified until 11/23/19 (2 days later) and the facility failed to follow facility policy.",2020-09-01
271,TREVECCA CENTER FOR REHABILITATION AND HEALING LLC,445112,329 MURFREESBORO RD,NASHVILLE,TN,37210,2018-03-14,725,D,0,1,6Z4211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility staffing schedules and interview, the facility failed to provide sufficient staffing to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident on 3/11/18 for 1 floor (5th) of 4 floors reviewed. Findings include: Record review of the facility staffing for 3/11/18 revealed 4 Certified Nurse Aides (CNAs) were scheduled for the 7:00 PM to 11:00 PM shift with 56 residents on the 5th floor. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #63 had a Brief Interview for Mental Status (BIMS) score of 15/15, (cognitively intact), and required total 1 person assistance for toileting. Interview with Resident #63 on 3/12/18 at 8:29 AM in the resident's room on the fifth floor revealed .they are not answering the call light .takes 40-45 minutes to answer and I can't hold it and wet myself . Medical record review of the Quarterly MDS dated [DATE] revealed Resident #54 had a BIMS score of 13/15, (cognitively intact), and required 2 person assistance for bed mobility and transfers. Interview with Resident #54 on 3/13/18 between 2:10 PM and 2:50 PM during the Resident Council interviews in the Cafe revealed .this pass weekend I had to wait to be put in bed .I usually go to bed between 8:00 PM - 9:00 PM but I had to wait and was put to bed between 10:00 PM - 11:00 PM . Medical record review revealed Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #5 had a BIMS score of 13 (cognitively intact). The resident needed extensive assist with 1 person for bed mobility, total dependent with 2 persons for transfer. Interview with Resident #5 on 3/12/18 at 2:48 PM in the resident's room revealed .last night I did not get to bed until 11:00 PM and was told by the tech (CNA) she had many other people that needed same care I did .I normally get to bed 9:00 PM-9:30 PM . Interview with CNA #3 on 3/14/18 at 6:00 PM on the 5th floor revealed they had 4 CNAs on each shift for the week-end. Further interview revealed if they are giving showers or taking care of other residents then the residents had to wait until they are finished to get care. Interview with CNA #2 on 3/14/18 at 5:45 PM on the 5th floor revealed she worked this past week-end and they had 4 CNAs on the floor for the 7:00 PM -11:00 PM shift. Further interview revealed on 3/11/18 on the 7:00 PM-11:00 PM shift Resident #5 had to wait 45 minutes to be put to bed because CNA #2 and another CNA were assisting 2 other residents at the time and couldn't put her to bed as she requested. Continued interview confirmed Resident #5 had to wait 45 minutes to be put to bed and the facility failed to provide adequate staffing to meet the needs of the resident.",2020-09-01
272,TREVECCA CENTER FOR REHABILITATION AND HEALING LLC,445112,329 MURFREESBORO RD,NASHVILLE,TN,37210,2018-03-14,921,D,0,1,6Z4211,"Based on facility policy review, observation and interview, the facility failed to maintain a clean environment for 1 of 5 observed fans on the 5th floor. Findings include: Review of the facility policy Infection Control Standard Precautions effective date 11/1/07 revealed .Environmental Control .Ensure that environmental equipment and other frequently touched surfaces are appropriately cleaned . Observation on 3/12/18 at 3:12 PM in the room of Resident # 5 revealed a table top fan on the bed side table in operation and directed at the resident seated in power wheelchair. Further observation revealed the fan grate had a heavy accumulation of hanging debris. Interview with Assistant Director of Nursing #2 on 3/12/18 at 3:19 PM in Resident #5's room confirmed the fan was dirty and was directed toward the resident.",2020-09-01
273,TREVECCA CENTER FOR REHABILITATION AND HEALING LLC,445112,329 MURFREESBORO RD,NASHVILLE,TN,37210,2019-04-10,550,D,0,1,TZD611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to respectfully address 1 resident (#212) out of 45 residents requiring feeding assistance, referred to as a feeder. The findings include: Facility policy review, Quality of Life-Dignity, dated 2001 and revised 2009, revealed .Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs . Medical record review revealed Resident #212 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #212's Quarterly Minimum Data Set ((MDS) dated [DATE], the Significant Change MDS dated [DATE], and the Annual MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicated the resident was cognitively intact. Further record review of the MDS revealed the resident required extensive assistance for Activities of Daily Living (ADL's) including total dependence for eating. Medical record review of Resident #212's Care Plan (Nutrition) dated 3/26/19 revealed .Assist with meals as needed . Medical record review of Resident #212's Certified Nurse Technician (CNT) Notes dated 3/1/19-4/10/19 revealed .Eating: Total Dependence-full staff performance every time . Interview with Resident #212 on 4/8/19 at 9:30 AM in the room revealed resident has heard staff calling resident and other residents a feeder and has to wait to be fed last. Further interview revealed that multiple staff members have told her that the trays on the hall are passed first to residents who can feed themselves and then they bring the trays up for the feeders. Continued interview on 4/9/19 at 8:30 AM stated the resident has heard the CNT's talking in the hallway and in the resident's room referring to residents when trays are being passed as feeders. Examples given by resident were .who's got this feeder? .who's the next feeder? . Interview with CNT #1 on 4/10/19 at 4:30 PM in the 3rd floor hallway when asked how feeding assistance for residents was coordinated at mealtimes revealed .there are 9 feeders on the floor .they're (CNT's) assigned based on how long it takes the feeders to eat .usually the first cart is delivered to the floor for the self-feeders and then the 2nd cart has the feeders trays . Interview with Registered Nurse (RN) #1, identified as the facility Staff Educator in charge of training Paid Feeding Assistants and CNT's, on 4/10/19 at 4:35 PM in her office, confirmed .We (our facility) teach all staff to refer to residents as total assist or monitored assistance for feeding . Interview with the Administrator on 4/10/19 at 4:38 PM in the facility lobby confirmed residents requiring assistance for eating should be referred to as .total assistance for feeding or total assist diners. Interview with the Director of Nursing on 4/10/19 at 5:50 PM in the facility dining room confirmed .I expect all staff to refer to residents that require total assistance for feeding as total assist diners.",2020-09-01
274,TREVECCA CENTER FOR REHABILITATION AND HEALING LLC,445112,329 MURFREESBORO RD,NASHVILLE,TN,37210,2019-04-10,689,D,1,1,TZD611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, observation and interview, the facility failed to investigate an incident which involved a non-facility [MEDICATION NAME] syringe for 1 resident (#13) of 69 reviewed. The findings include: Review of the facility policy Accidents/Incidents Investigations dated 10/7/17 revealed .An investigation of the accident/incident will be made by the designated staff person . Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated no cognitive impairment. Medical record review of the physician orders dated 2/16/19 revealed .Urine Drug Screen . Continued review revealed no orders for [MEDICATION NAME]. Medical record review of the Urine Drug Screen dated 2/16/19 revealed .[MEDICATION NAME] Positive . Medical record review of the physician progress notes [REDACTED].Pt (patient) seen at administrator's request regarding recent + (positive) drug test for [MEDICATION NAME] after finding a syringe in pts bed. Pt continues to deny any drug use, but has a long history of drug dependence and addiction and agrees that (pt) needs drug rehabilitation and treatment for [REDACTED]. Review of the facility investigation revealed no investigation addressing the incident for Resident #13. Observation on 4/8/19 at 9:46 AM in Resident #13's room revealed the resident in bed eating breakfast and appeared very slow to respond and sluggish in movement. Interview with Resident #13 on 4/8/19 at 4:03 PM in Resident #13's room revealed .I just got [MEDICAL CONDITION]. I looked at it (syringe) and the nurse said I had it in my arm. I did not have any blood on me. I found the needle it was up under one of those boxes and I picked it up and looked at it. I never stuck that in my arm ever. It was up under the box and it looked like it was opened and not closed very well . Continued interview revealed .she (nurse) said what in the world are you doing, are you sticking that in your arm? I told her I was just looking at it and was going to give it back to her. I was cleaning in the box . Interview with the Administrator on 4/9/19 at 2:02 PM confirmed the [MEDICATION NAME]- needle did not belong to the facility. Continued interview revealed .It was not our needle. We did not leave it in there at all . Interview with Licensed Practical Nurse (LPN) #1 on 4/9/19 at 2:17 PM in the conference room revealed, LPN #1 was the weekend supervisor on the alleged date of the incident. Continued interview with LPN #1 when asked if a facility report was completed confirmed .I just wrote it on a piece of paper and placed it in a file. I did not feel it was appropriate to place it in the resident record . Interview with the Administrator 4/10/19 at 6:10 PM in her office confirmed, the [MEDICATION NAME] needle was found in Resident #13's room. Continued interview confirmed the facility failed to investigate an incident which involved a non facility [MEDICATION NAME] needle. Continued interview revealed .we need to make sure we are documenting everything we do .",2020-09-01
275,TREVECCA CENTER FOR REHABILITATION AND HEALING LLC,445112,329 MURFREESBORO RD,NASHVILLE,TN,37210,2019-10-23,609,D,1,0,2B9Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility document review, medical record review, and interview, the facility failed to report an incident of misappropriation of resident property to the appropriate agency within the prescribed time frame. The findings included: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 14 Day Minimum (MDS) data set [DATE] revealed Resident #2 scored 15 on the Brief Interview for Mental Status indicating she was alert, oriented, and able to make her needs known. Continued review of the MDS revealed Resident #2 required extensive assistance of 1 person with transfers, dressing, toileting, grooming, and bathing; and was always continent of bowel and bladder. Review of a summary dated 8/9/19 by the Administrator revealed .(named Resident #2) came to my office today to let me know that she had misplaced $350 that her son brought her. She said that he brought her the money so that she could go to her pain clinic. I asked her why she had that much money and she said that the clinic only took cash. She said that she thought she put it in her drawer. I asked her to see if we could help her find it and she said that she needed the money asap. I told her that it was not the responsibility of the facility to reimburse monies that are lost. She was very upset because she did not have extra money for the doctor's office . Interview with the Administrator and DON on 10/23/19 at 11:40 AM in the conference room revealed the resident was talking loudly in the foyer about missing money so the Administrator asked the resident into her office. The resident stated she had lost her money she needed to pay the pain clinic. The resident had not spoken to Social Services. The resident said she initially put the money in her bra then into the locked top drawer of her bedside cabinet. The resident is the only one who has a key to the top drawer. The Administrator and DON looked at the video footage and saw no one enter or leave the room other than staff. They investigated the incident but did not report it since the resident had stated she lost the money and was not at that point accusing anyone of taking it.",2020-09-01
276,TREVECCA CENTER FOR REHABILITATION AND HEALING LLC,445112,329 MURFREESBORO RD,NASHVILLE,TN,37210,2019-10-23,610,D,1,0,2B9Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility documents, medical record review, and interview the facility failed to conduct a thorough investigation of an alleged misappropriation of resident property. The findings included: Review of facility policy, Abuse Prevention, revised 3/27/13, revealed .The facility has a zero tolerance for abuse .The resident will not be subjected to mistreatment, neglect, or misappropriation of property .A criminal background check shall be initiated on any potential employee .All new employees will receive training on Abuse Prevention policies and procedures during the initial orientation period .Existing employees will receive ongoing training regarding Abuse Prevention .Employees who have been accused of resident abuse will be suspended from resident care duties until the investigation has been completed .An individual observing an incident of Resident abuse or suspected Resident abuse must immediately report the incident to their supervisor . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 14 Day Minimum (MDS) data set [DATE] revealed Resident #2 scored 15 on the Brief Interview for Mental Status indicating she was alert, oriented, and able to make her needs known. Continued review of the MDS revealed Resident #2 required extensive assistance of 1 person with transfers, dressing, toileting, grooming, and bathing; and was always continent of bowel and bladder. Review of a summary dated 8/9/19 by the Administrator revealed .(named Resident #2) came to my office today to let me know that she had misplaced $350 that her son brought her. She said that he brought her the money so that she could go to her pain clinic. I asked her why she had that much money and she said that the clinic only took cash. She said that she thought she put it in her drawer. I asked her to see if we could help her find it and she said that she needed the money asap. I told her that it was not the responsibility of the facility to reimburse monies that are lost. She was very upset because she did not have extra money for the doctor's office . Review of a summary from the Administrator dated 8/15/19 revealed .Over the next few days we looked in her room and in laundry but could not find the money. She discharged home. I called to see if she had found it but she had not. I decided that I would help her out. I bought her a $350 VISA gift card and took it to her at her apartment. She declined the gift card and said she didn't know how to use it. I told her I would get her the cash. Her son came and picked it up today. I called her and she was very happy about being reimbursed . Interview with the Administrator and DON on 10/23/19 at 11:40 AM in the conference room revealed the resident was talking loudly in the foyer about missing money so the Administrator asked the resident into her office. The resident stated she had lost her money she needed to pay the pain clinic. The resident had not spoken to Social Services. The resident said she initially put the money in her bra then into the locked top drawer of her bedside cabinet. The resident is the only one who has a key to the top drawer. The Administrator and DON looked at the video footage and saw no one enter or leave the room other than staff. They investigated the incident but did not report it since the resident had stated she lost the money and was not at that point accusing anyone of taking it.",2020-09-01
277,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2020-01-29,689,D,1,0,7MVB11,"**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 prevent an accident for 1 resident (Resident #1) of 3 sampled residents, resulting in the resident falling out of bed. The findings included: Review of the facility's policy titled Bed Bath, last revised 2/2018, showed .Place the clean equipment on the bedside stand. Arrange the supplies so they can be easily reached . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] showed Resident #1 had short and long term memory problems and was severely impaired for daily decision making skills. The resident was incontinent of bowel and bladder and was totally dependent on staff for bed mobility and personal hygiene with 1 person assist. Review of a facility investigation dated 1/23/2020 showed Certified Nurse Assistant (CNA) #3 was giving Resident #1 a bed bath. When the CNA turned away from the resident to get a brief for the resident, the resident rolled out of the bed onto the floor. The resident had a hematoma on the right side of her head and scrapes on both knees and was sent to the Emergency Department (ED) for evaluation. The resident was discharged from the hospital to a different long term care facility on 1/28/2020. Review of a handwritten statement dated 1/23/2020 and signed by CNA #3 showed .I had turned her (Resident #1) over on her side then I was getting .brief .I turned back around her legs was (were) hanging off the bed. I tried to grab her but wasn't strong enough to pull her back .she rolled on the floor . During an interview on 1/28/2020 at 11:00 AM, Licensed Practical Nurse (LPN) #1 stated CNA #3 placed Resident #1 on her left side with her back to the CN[NAME] The CNA needed items that were placed behind her and when the CNA turned to obtain the needed items, the resident started to fall off of the bed. The CNA was unable to catch the resident; resulting in the resident falling on the floor.",2020-09-01
278,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2018-07-14,580,J,1,0,K2OF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, interview, and observation, the facility failed to immediately notify the resident's physician when there was a significant change in the resident's physical, mental and psychosocial status for 1 resident (#7) of 6 residents reviewed for accidents and incidents, of 8 sampled residents. The facility's failure to immediately inform the physician or Nurse Practitioner (NP) of a significant change in the resident's pain intensity and the resident's physical condition (swollen and bruised bilateral knees and resulting fractures) placed Resident #7 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 Immediate Jeopardy (IJ) was effective [DATE] and is ongoing. The findings include: Review of the facility's policy titled Change in a Resident's Condition or Status dated [DATE] revealed .1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician and the resident's representative when there has been .d. A significant change in the resident's physical/emotional/mental condition; that is a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications .2. A significant change of condition is a decline or improvement in the resident's status . Medical record review revealed Resident #7 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 was coded 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance of 2 staff for bed mobility (how resident moves to and from lying position, turns side to side). Medical record review of the resident's Medication Administration Record (MAR) and nursing notes for (MONTH) (YEAR) revealed Resident #7 was to have a pain assessment every shift (7:00 AM - 7:00 PM and 7:00 PM - 7:00 AM), and had an order for [REDACTED]. Further review of the MAR and nursing notes revealed the resident rated her pain as 0 daily and did not require any of the as needed [MEDICATION NAME] until [DATE], after she was diagnosed with [REDACTED]. Review of the facility's incident report dated [DATE] at 6:45 AM, revealed Resident #7 .was noted to slide off air mattress on to the floor during a bed change. Head to toe assessment performed, no injury noted .Sister .Dr (physician) .notified. Review of the facility's investigation revealed a written statement completed by Certified Nursing Assistant (CNA) #8 dated [DATE], which stated .I was in the middle of changing patient sheets, when patient rolled over. She slid out of the bed and landed on her knees and fell toward her left side and did not hit her head . Medical record review of Resident #7's MAR revealed on [DATE] the resident's pain was 6 out of 10 (with 10 being the most severe pain) on the 7:00 AM to 7:00 PM shift and was administered [MEDICATION NAME] 7.5 mg at 8:00 AM. Medical record review of a telephone order dated [DATE] at 10:45 AM, revealed .Bilateral hips & (and) L (left) shoulder x-ray .fall .VORB (verbal order read back) (name of the former Director of Nursing) . Continued review of the order revealed the order was a verbal order written by a Registered Nurse (RN) and received from the former Director of Nursing (DON). Further review revealed the order was signed by the Nurse Practitioner (NP) on [DATE]. Medical record review of nurse's notes dated [DATE] at 11:00 AM, revealed the resident complained of bilateral hip and left shoulder pain and x-rays were ordered. Medical record review of the radiology report dated [DATE] revealed no fracture or dislocation of the shoulder or hips was present. Medical record review of the nursing notes and the resident's MAR from [DATE] - [DATE] revealed the resident complained of pain daily that was rated between 5 and 7 on a scale of ,[DATE], with 10 being the worse pain and [MEDICATION NAME] 7.5 mg was given. Further review revealed no documentation the physician or NP was notified of the resident's increased pain or increased need for pain medication. Medical record review of nurse's notes dated [DATE] at 12:30 PM, revealed Resident #7's bilateral knees were swollen and bruised. Further review revealed .on Dr.'s (physician) Board for today (indicating the resident needed to be seen by the physician or the NP) . Medical record review of the resident's MAR and nursing notes for [DATE] and [DATE] revealed the resident continued to rate her pain at 6 out of 10, with [MEDICATION NAME] 7.5 mg administered for pain. Further review revealed no documentation the physician or NP was notified of the resident's increased pain, increased need for pain medication, or of the swollen and bruised knees. Medical record review of a physician's telephone order dated [DATE] at 1:30 PM, revealed a verbal order for x-ray of bilateral knees was written by an RN, verbally given by the NP. Medical record review of the radiology report dated [DATE] revealed .Impacted right knee fracture involving the distal femoral metaphysis .Impacted fracture (left) involving the distal femoral metaphysis (fracture in the area where the long bone femur of the upper leg meets the knee) .Old internally fixated proximal tibial fracture . Continued review of the report revealed documentation the DON and a family member of the resident were notified of the results of the x-ray on [DATE] at 9:10 PM and 9:20 PM. Medical record review of a nursing note dated [DATE], with no time, revealed, Called results to (former DON) and sister .Re: (regarding) knee film . Further medical record review revealed no documentation the physician or NP were notified the resident had fractures in both legs. Medical record review of the resident's MAR and nursing notes from [DATE] through [DATE] revealed the resident continued to have pain daily, rated at ,[DATE] on a ,[DATE] scale, and was given [MEDICATION NAME] 7.5 mg. Further review revealed no documentation the NP or physician was notified of the resident's increased pain, increased need for pain medication, bruising or swelling in the knees, or the x-ray results indicating the resident had bilateral fractures. Medical record review of the office visit History and Physical completed by the orthopedic physician dated [DATE] revealed Resident #7 was complaining of pain only in her knees and legs, but it was quite significant. Continued review revealed both knees were swollen and deformed with some flexion. Resident #7 had some mild ecchymosis (bruising) around the knees. The resident had bilateral distal femur fractures. The resident was admitted to the hospital due to the severity of the knee fractures. Medical record review of the hospital Death Summary completed by the orthopedic surgeon dated [DATE], revealed Resident #7 .sustained bilateral distal femur fractures. She was in extreme pain at the time of admission .the fractures were extremely painful and they were repaired for palliative reasons .Palliative Care was consulted to discuss goals of care with the patient's family due to her severe debility and multiple comorbidities . The resident expired [DATE]. Telephone interview with the NP on [DATE] at 9:25 AM, revealed she remembered she gave the order for the x-ray on [DATE] because the resident was still having pain. Telephone interview with CNA #8 on [DATE] at 10:55 AM, revealed she was making her last round around 6:45 AM on [DATE], and went in to change the resident's bed sheet. CNA #8 stated when she turned Resident #7 over to change the sheet, the resident fell to the floor and landed on her knees. CNA #8 stated she screamed for help and the nurse came in to assess the resident and then the staff put the resident back to bed. CNA #8 stated the resident grabbed her knees after she fell . Interview with RN #2 on [DATE] at 11:30 AM, at a location outside the facility, revealed when she came in [DATE] for the 7:00 AM to 7:00 PM shift, she was informed Resident #7 rolled out of bed and had fallen to the floor. RN #2 stated she assessed the resident who complained of pain in the left shoulder and left hip. RN #2 stated the resident was in pain and would scream when moved or turned. Further interview with RN #2 revealed when she worked Sunday [DATE], the resident was still complaining of pain and she gave the resident pain medication to try to keep her comfortable. Continued interview with RN #2 revealed she was not working [DATE], [DATE], and [DATE]. RN #2 stated on [DATE] when she returned to work, the resident still had not been seen by the Nurse Practitioner or the physician, but stated the NP was at the nurses' station so she asked if she could get x-rays of the knees of Resident #7. Further interview with RN #2 confirmed the NP had not been made aware of the resident's complaints of knee pain until [DATE]. Telephone interview with RN #4 on [DATE] at 1:00 PM, revealed the resident was alert with confusion at times. RN #4 stated on [DATE] the resident was in so much pain the CNAs reported the resident would scream when she was turned. RN #4 stated she went in to talk with Resident #7 who stated her knees hurt her badly. RN #4 stated both knees were swollen and black and blue. RN #4 stated at this time there was a sign posted at the nurse's station to notify the supervisor before calling the physician or NP so she went to the Assistant Director of Nursing (ADON) and reported the resident was in severe pain. RN #4 stated the ADON said they had done x-rays and they were all negative. RN #4 then replied .no, we have not x-rayed the knees . The ADON replied it was too late to call the physician and just place it on the Dr.'s Board (used to list residents who need to be seen by the physician or NP on the next visit) for the resident to be seen the next day. RN #4 stated on [DATE] she saw the physician and the NP in the facility but they never came to the floor to see Resident #7 and when she reminded the ADON Resident #7 needed to be seen, the ADON replied to her the physician and NP were not seeing residents that day. RN #4 confirmed the resident was not seen by the physician or NP on [DATE] or [DATE] when she was on duty. Interview with CNA #4 on [DATE] at 10:50 AM, in the Resting Lounge, revealed after the fall the resident was in a lot of pain all the time. CNA #4 stated when she turned the resident, she would scream out in pain in her knees. The resident's knees were swollen and bruised. When asked if the complaint of pain was different after the fall the CNA replied .absolutely . CNA #4 stated the nurses told the CNAs they had been instructed to put the resident on the doctor's board and the resident could wait until the physician came. Interview with the DON (who was the ADON at the time of the incident) on [DATE] at 11:00 AM, in the Resting Lounge, revealed she could not remember the nurses saying anything to her about the resident having swollen or bruised knees, and if they had told her, she would have told them to call the physician or NP. During observation and interview with RN #4 on [DATE] at 12:10 PM, in the Resting Lounge, the nurse presented a piece of paper, which she stated she had taken down from the nurses' station, .Staff are never to call Dr. (Medical Doctor) or his NP until contact has been made with the on-call Nurse Mgr. (manager). If you have questions about this see (DON) or (ADON). The sign had the DON's name at the bottom. RN #4 also presented a copy of the physician board sheet which revealed a notation dated [DATE] for Resident #7 XXX,[DATE] S/P (status [REDACTED]. Continued interview with RN #4 revealed the nurses were to call management before calling the physician. When asked when the sign was taken down from the nurses' station, the nurse replied when they found out they were being sued. Interview with the Regional Quality Specialist (RQS) on [DATE] at 3:20 PM, in the Resting Lounge, revealed, when asked what she would have expected the nursing staff to do when the resident continued to complain of pain, the Regional Quality Specialist replied .would have expected a call placed to the provider . Telephone interview with the resident's physician on [DATE] at 3:45 PM, revealed when asked what he would have expected the nursing staff to do for any change in resident status including increased pain, the physician stated he would expect to be called for any changes. The physician further confirmed he did not remember the facility calling him for any changes to Resident #7. Interview with CNA #17 on [DATE] at 4:00 PM, in the upper 400 hall shower room, revealed when she took care of Resident #7 she observed the knees swollen and the resident told the CNA she had fallen out of bed. CNA #17 reported to RN #4 the resident's pain on turning and was informed the RN had been instructed to put it on the doctor's board by the ADON. CNA #17 asked nursing again on [DATE] and was told the doctor had still not seen the resident. Interview with RN #2 on [DATE] at 5:45 PM, at the 400 hall nurses' station, revealed when she left on [DATE] the results of the x-rays of the bilateral knees for Resident #7 had not returned. She returned to work on [DATE], read the x-ray results, and was in contact with the DON per text messaging. Further interview confirmed she did not call the physician or NP with the results of the x-rays. Telephone interview with the Medical Director, who was the resident's attending physician, on [DATE] at 5:59 PM, revealed, when asked when he became aware of the bilateral fractures of Resident #7, he replied .this is the first I've heard right now . When asked if he would expect the physician to be notified, the Medical Director replied all fractures should be called to the physician or the person on call. Telephone interview with the NP on [DATE] at 6:20 PM, revealed she could not remember clearly if she was notified of the results of the bilateral knee x-rays and replied .I'm sorry I don't . The NP stated when she got home she would look at her notes and see if she had any notations of notification of the results. Telephone interview with the NP on [DATE] at 9:11 PM, revealed the NP had reviewed her notes for Resident #7 and found no notation of being notified of the results of the bilateral knee x-rays. Interview with the Administrator on [DATE] at 9:00 AM, in the Administrator's Office, revealed during review of nursing notes for [DATE] and [DATE], the Administrator confirmed she did not see documentation the physician or NP had been notified of the results of the bilateral knee x-rays. When asked when she became aware of the fall and fractures related to Resident #7, the Administrator replied when Adult Protective Services came in (MONTH) of (YEAR).",2020-09-01
279,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2018-07-14,600,J,1,0,K2OF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policies, medical record review, review of the facility's investigation, interview, and observation, the facility failed to prevent neglect for 1 resident (#7) of 6 residents reviewed for neglect, of 8 residents reviewed. The facility's failure to prevent neglect resulted in a delay in receiving services and treatment after a fall with fractures, with Resident #7 experiencing intense pain, and placing Resident #7 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 was cited F600 at a scope and severity of J which constitutes Substandard Quality of Care (SQC). The Immediate Jeopardy (IJ) was effective [DATE] and is ongoing. The findings include: Review of the facility's policy titled Change in a Resident's Condition or Status dated [DATE] revealed .1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician and the resident's representative when there has been .d. A significant change in the resident's physical/emotional/mental condition; that is a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications . Review of the facility's policy titled Abuse Prevention/Reporting Policy and Procedure dated (YEAR) revealed .7. Neglect: the failure of the facility, its employees or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish or emotional distress . Medical record review revealed Resident #7 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 was coded 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance of 2 staff for bed mobility (how resident moves to and from lying position, turns side to side). Review of the facility's incident report dated [DATE] at 6:45 AM, revealed Resident #7 .was noted to slide off air mattress on to the floor during a bed change .no injury noted . Review of the facility's investigation revealed a written statement completed by Certified Nursing Assistant (CNA) #8 dated [DATE], which stated .I was in the middle of changing patient sheets, when patient rolled over. She slid out of the bed and landed on her knees and fell toward her left side . Medical record review of the Medication Administration Record [REDACTED]. Continued review revealed Resident #7 was prescribed [MEDICATION NAME]-APAP 7XXX,[DATE] milligrams (mg) every 4 hours as needed (PRN) for pain on [DATE]; [MEDICATION NAME] 50 mg every 12 hours for pain on [DATE]; and [MEDICATION NAME] 12 mcg (micrograms)/HR (per hour) patch every 72 hours for pain on [DATE] prior to the fall. Medical record review of the (MONTH) MAR indicated [REDACTED]. Medical record review of nurse's notes dated [DATE] at 11:00 AM, revealed the resident complained of bilateral hip and left shoulder pain and x-rays of the hips and shoulder were ordered. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of the radiology report for the bilateral hips and left shoulder x-rays dated [DATE] revealed no fracture or dislocation. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of nurse's notes dated [DATE] at 12:10 PM, revealed the resident still had complaints of pain related to the fall and pain medications were given as ordered. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of nurse's notes dated [DATE] at 12:30 PM revealed Resident #7's bilateral knees were swollen and bruised. Further review revealed .on Dr.'s (physician) board for today (indicating the resident was to be seen by the physician or Nurse Practitioner) . Further medical record review revealed no documentation the resident was seen by the physician or Nurse Practitioner (NP) on [DATE]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of nurse's notes dated [DATE] at 2:30 AM, revealed the resident woke up at night complaining of pain in the legs and knees and pain medication was given. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of a physician's telephone order dated [DATE] at 1:30 PM, revealed an order for [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of the radiology report dated [DATE] revealed .Impacted right knee fracture involving the distal femoral metaphysis .Impacted fracture (left) involving the distal femoral metaphysis (fracture in the area where the long bone femur of the upper leg meets the knee) .Old internally fixated proximal tibial fracture . Medical record review of the radiology report and nursing notes dated [DATE] revealed the x-ray results was reported to the Director of Nursing (DON). Further review revealed no documentation the physician or NP were notified of the bilateral fractures. Further review revealed the nurse scheduled an appointment for Resident #7 to be seen by an orthopedic physician on [DATE]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of nurse's notes dated [DATE] revealed Resident #7's bilateral knees remained bruised. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review revealed the first documentation the resident was seen by a physician following the fall on [DATE] was on [DATE] when the resident was sent to the orthopedic physician's office. Medical record review of the History and Physical completed by the orthopedic physician dated [DATE] revealed Resident #7 was complaining of pain only in her knees and legs, but it was quite significant. Continued review revealed both knees were swollen and deformed with some flexion. Resident #7 had some mild ecchymosis (bruising) around the knees. Further review revealed Resident #7 had significant osteoporotic appearing bone with significant arthritis and previous tibial hardware in both legs. The resident had bilateral distal femur fractures. The resident was admitted to the hospital because of the severity of the knee fractures. Medical record review of the hospital Death Summary completed by the orthopedic surgeon dated [DATE] revealed Resident #7 .sustained bilateral distal femur fractures. She was in extreme pain at the time of admission .She was normally non ambulatory however the fractures were extremely painful and they were repaired for palliative reasons .Palliative Care was consulted to discuss goals of care with the patient's family due to her severe debility and multiple comorbidities . The resident expired [DATE]. Telephone interview with the NP on [DATE] at 9:25 AM, revealed she remembered Resident #7 had a fall. The NP stated she gave the order for x-ray of both knees on [DATE] because the resident was still hurting. Telephone interview with CNA #8 on [DATE] at 10:55 AM revealed she was making her last round around 6:45 AM on [DATE] and went into Resident #7's room to change the resident. CNA #8 stated when she turned Resident #7 over to change the sheet, the resident fell to the floor and landed on her knees. CNA #8 stated she screamed for help, the nurse came in to assess the resident, and they put the resident back to bed. CNA #8 stated the resident grabbed her knees after she fell . Interview with Registered Nurse (RN) #2 on [DATE] at 11:30 AM, at a location outside the facility, revealed when she came in to work on [DATE] for the 7:00 AM to 7:00 PM shift, she was told Resident #7 rolled out of bed and had fallen to the floor. RN #2 stated she assessed the resident who complained of pain in the left shoulder and left hip, so she texted the Director of Nursing (DON) at 9:30 AM, and was given verbal permission to get x-rays of the shoulder and bilateral hips. RN #2 stated the resident was in pain and would scream when moved or turned. Further interview with RN #2 revealed when she worked Sunday [DATE], the resident was still complaining of pain. RN #2 further stated she knew the resident was in pain. Continued interview with RN #2 revealed she did not work [DATE], [DATE], and [DATE]. On [DATE], when she returned to work, the resident still had not been seen by either the doctor or the Nurse Practitioner (NP), but the NP was at the nurses' station, so she asked if she could get x-rays of the knees for Resident #7. The nurse stated when she got the x-ray report on [DATE] she scheduled an appointment with an orthopedic surgeon for [DATE]. Further interview with RN #2 confirmed the NP had not been made aware of the resident's complaints of knee pain prior to [DATE]. Telephone interview with RN #4 on [DATE] at 1:00 PM, revealed the resident was alert with confusion at times. RN #4 stated Resident #7 was not a complainer and usually would not volunteer to tell you she was hurting. RN #4 stated on [DATE] the resident was in so much pain, the CNAs reported the resident would scream when she was turned. RN #4 stated she then went in to talk with Resident #7, who stated her knees hurt badly. RN #4 stated both knees were swollen and black and blue. RN #4 stated on [DATE] there was a sign posted at the nurses' station to go to the supervisor before calling the physician, so she went to the Assistant Director of Nursing (ADON). The RN told the ADON the resident was in severe pain and the ADON asked .from what . RN #4 replied, .probably from the fall she had . According to RN #4, the ADON stated they had performed x-rays and they were all negative. RN #4 informed the ADON, .no, we have not x-rayed the knees . The ADON replied it was too late to call the physician and to place the resident on the Dr.'s Board (place to notify the physician or NP residents who need to be seen on next visit) for the resident to be seen the next day. RN #4 stated on [DATE], she saw the physician and the NP in the facility, but they never came to the floor to see Resident #7. RN #4 revealed when she spoke to the ADON on [DATE], she reminded her Resident #7 needed to be seen. The ADON replied the physician and NP were not seeing residents that day. RN #4 stated she did not work on [DATE], [DATE], and [DATE]. RN #4 confirmed the resident was not seen by the physician or NP on [DATE] or [DATE] when she was on duty and she had reported to the ADON the resident needed to be seen. RN #4 further confirmed Resident #7 was never a good eater, but was not eating as much since the accident, and the resident was in pain. RN #4 further confirmed she administered the resident pain medication as much as possible to keep her comfortable. Interview with the Restorative Aide on [DATE] at 9:50 AM, in the Resting Lounge, revealed she had worked with Resident #7 multiple times doing Range of Motion (ROM). The Restorative Aide stated after the fall on [DATE], the resident didn't want her to do ROM on her legs at all. The Restorative Aide stated the resident told her she had a fall and was in .so much pain . The Restorative Aide further stated the resident was also moaning, and her complaint of pain was different from her normal baseline and .enough to get my attention . Interview with CNA #4 on [DATE] at 10:50 AM, in the Resting Lounge, revealed Resident #7 was never really one to complain of pain but would close her eyes and crunch up her face when in pain. CNA #4 stated before the fall when she would turn the resident, she would complain of pain and may complain more on rainy or cold days. After the fall, the resident was in a lot of pain all the time. CNA #4 stated when she turned the resident, she would scream out in pain and complained her knees were hurting. The CNA stated the resident's knees were swollen and bruised. CNA #4 stated she was working [DATE], and it was either [DATE] or [DATE], when she first noticed the bruising and swelling of both knees of Resident #7 and notified the nurse. When asked if the resident's complaints of pain were different after the fall, the CNA replied .absolutely . CNA #4 stated the resident was screaming with intense pain, especially on turning. CNA #4 stated the nurses told the CNAs nursing had been instructed to put it on the doctor's board and the resident's condition could wait until the physician came. CNA #4 stated she felt the nurses on the floor and the CNAs did everything they could do, but she .laid there several days in pain . Telephone interview with the former DON (who was DON at the time of the incident) on [DATE] at 10:15 AM, revealed he did not remember anything about the incident. The DON confirmed several days after the fall, when he was told the resident was complaining of knee pain and the nurses had seen bruising, he told the nurse to obtain x-rays of the knees and an orthopedic appointment. During observation and interview with RN #4 on [DATE] at 12:10 PM, in the Resting Lounge, the nurse presented a piece of paper, which she stated she had taken down from the nurses' station, .Staff are never to call Dr. (Medical Director) or his NP until contact has been made with the on-call Nurse Mgr. (manager). If you have questions about this see (DON) or (ADON). The sign had the DON's name typed at the bottom. RN #4 also presented a copy of the physician board sheet which revealed a notation dated [DATE] for Resident #7 XXX,[DATE] S/P (status [REDACTED]. Continued interview with RN #4 revealed the nurses were to call management before calling the physician. When asked when the sign was taken down from the nurses' station, the nurse replied when they found out they were being sued. RN #4 confirmed she saw a big change in Resident #7after the fall where she didn't eat as well and she didn't want to be changed by the CNAs. Interview with the Regional Quality Specialist on [DATE] at 3:20 PM, in the Resting Lounge, revealed, when asked what she would have expected the nursing staff to do when the resident continued to complain of pain, and especially knee pain, the Regional Quality Specialist replied .would have expected a call placed to provider . Telephone interview with the attending physician (medical doctor) on [DATE] at 3:45 PM revealed, when asked what he would have expected the nursing staff to do for any change in resident status including increased pain or swelling and bruising of both knees, the physician stated he would have expected to be called regarding these changes. The physician further confirmed he did not remember the facility calling him for any changes to Resident #7. Interview with CNA #17 on [DATE] at 4:00 PM, in the upper 400 hall shower room, revealed when she took care of Resident #7, she observed the knees swollen and the resident stated she had fallen out of bed. The CNA informed RN #4 the resident's knees were swollen and painful on turning. The CNA stated RN #4 said she had been told to put it on the doctor's board. CNA #17 confirmed both knees were swollen and the resident complained of a lot of pain on [DATE]. The CNA stated she asked nursing again on [DATE] about the resident being seen by the physician and was told the doctor had still not seen the resident. Interview with CNA #18 on [DATE] at 4:15 PM, in the upper 400 hall shower room, revealed Resident #7's legs and knees were swollen and she .screamed . when turned and would say .Oh Please, Please, Please . during ADL (activities of daily living) care. The CNA further stated she asked staff everyday if anything had been done for the resident, such as an x-ray, and was told no. Interview with RN #2 on [DATE] at 5:45 PM, at the 400 hall nurses' station, revealed when she left work on [DATE] the results of the x-rays of the bilateral knees for Resident #7 had not returned. RN #2 stated when she came in on [DATE], she read the x-ray results and was in contact with the DON per text messaging. RN #2 stated she received a text from the DON, ortho (orthopedic physician) appointment ? When the RN was asked who gave the order for Resident #7 to go to the orthopedic physician's office, the nurse replied the DON. The RN stated she then started calling around to orthopedics and many did not want to see the resident due to the resident's previous surgery and hardware in her leg. The RN stated she talked to the resident, who could not remember the name of the orthopedic she had previously seen. RN #2 stated she kept calling and finally got in touch with the orthopedic who had done the previous surgery and made an appointment for Monday,[DATE]. When RN #2 was asked if she had given the resident or the Power of Attorney (POA) the option of going to the hospital or waiting to go to the orthopedic surgeon, the RN replied she did not but didn't know if anyone else had. When RN #2 was asked how Resident #7 was from [DATE] until the doctor appointment on [DATE], the RN replied the same. RN #2 stated they kept the resident comfortable with the [MEDICATION NAME], and [MEDICATION NAME] the resident had been prescribed prior to the accident on [DATE]. Telephone interview with the Medical Director, who was the resident's attending physician, on [DATE] at 5:59 PM, revealed, when asked did he know about the bilateral fractures of Resident #7, he replied .this is the first I've heard right now . When asked if he would have expected to be notified, the physician replied all fractures should be called to the physician or the person on call. When asked what would be his plan of care, the physician replied he would ask the resident and/or family if they wanted to go to the hospital, go to the physician, or did they need to be seen now. Telephone interview with the NP on [DATE] at 9:11 PM, revealed the NP had reviewed her notes for Resident #7 and found no notation of being notified of the results of the bilateral knee x-rays. Interview with the Administrator on [DATE] at 9:00 AM, in the Administrator's Office, revealed during review of nursing notes for [DATE] and [DATE], the Administrator did not see the physician or NP had been notified of the results of the bilateral knee x-rays. When asked when she became aware of the fall and fractures related to Resident #7, the Administrator replied when Adult Protective Services came in (MONTH) of (YEAR). Continued interview with the Administrator confirmed when asked if the documentation showed the physician or the NP had been made aware of the results of the bilateral knee x-rays the Administrator shook her head back and forth and stated .no .",2020-09-01
280,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2018-07-14,656,J,1,0,K2OF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, facility investigation review, and interview, the facility failed to implement a comprehensive care plan for 1 resident (#7) of 6 residents reviewed for accidents and incidents, of 8 sampled residents. The facility's failure to implement the care plan interventions resulted in impacted fractures of both lower extremities and placed Resident #7 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 Immediate Jeopardy (IJ) was effective 11/11/17 and is ongoing. The findings include: Medical record review revealed Resident #7 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 scored 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance of 2 staff for bed mobility (how resident moves to and from lying position, turns side to side). Medical record review of Resident #7's care plan, reviewed and updated 9/1/17, revealed for the problem of self-care deficit related to bedbound status, the resident's approach included .Bed mobility extensive assist of two . Medical record review of the Interdisciplinary Care Plan (used by the Certified Nurse Assistants (CNAs)), not dated, revealed Resident #7 was a two person assist for bed mobility. Review of the facility's incident report dated 11/11/17 at 6:45 AM revealed Resident #7 .was noted to slide off air mattress on to the floor during a bed change. Resident did not strike her head. Head to toe assessment performed, no injury noted .Two CNAs will be needed to turn resident on air mattress to prevent further falls . Review of the resident's care plan and assessment revealed the resident required a two person assist for bed mobility prior to the accident on 11/11/17. Review of the facility's investigation revealed a written statement completed by CNA #8 dated 11/11/17, which stated .I was in the middle of changing patient sheets, when patient rolled over. She slid out of the bed and landed on her knees and fell toward her left side and did not hit her head . Medical record review of nursing notes dated 11/11/17 revealed the resident complained of pain in the hips and left shoulder and x-rays of the bilateral hips and left shoulder were ordered. Medical record review of the radiology report dated 11/11/17 revealed .Minimal to moderate [MEDICAL CONDITION] changes to the right hip .Moderate to severe [MEDICAL CONDITION] changes of the left hip . No fracture, dislocation, [MEDICAL CONDITION] changes or destructive [MEDICAL CONDITION] of the left shoulder were present. Medical record review of the resident's care plan revealed on 11/13/17 .noodles to bed . had been added as an intervention for at risk for falls due to decrease in mobility. Medical record review of a physician's telephone order dated 11/16/17 at 1:30 PM revealed an order for [REDACTED]. Medical record review of the radiology report dated 11/16/17 revealed .Impacted right knee fracture involving the distal femoral metaphysis .Impacted fracture (left) involving the distal femoral metaphysis (fracture in the area where the long bone femur of the upper leg meets the knee) .Old internally fixated proximal tibial fracture . Interview with the Administrator on 7/10/18 at 9:00 AM, in the Conference Room, revealed Resident #7 did have a fall in (MONTH) of (YEAR) when a CNA turned the resident in the bed and the resident fell to the floor. Continued interview with the Administrator revealed the resident should have been turned by 2 staff members. When asked if the resident was care planned for 2 staff members the Administrator stated yes. Telephone interview with CNA #8 on 7/10/18 at 10:55 AM revealed she was making her last round around 6:45 AM on 11/11/17 when she went into Resident #7's room. The CNA stated when she went to change the resident she noticed something on her sheet, so she decided she would change the sheet. CNA #8 stated the resident had always grabbed the hand rail to hold when she turned but for some reason she did not get a grip on the hand rail. The CNA stated when she turned Resident #7 over to change the sheet, the resident fell to the floor and landed on her knees. CNA #8 stated she screamed for help and the nurse came in to assess the resident and then they put the resident back to bed. CNA #8 stated the resident grabbed her knees after she fell . When CNA #8 was asked had she been turning Resident #7 by herself, the CNA responded she had always turned the resident by herself. When CNA #8 was asked how did she know if a resident was a 1 person or a 2 person assist for bed mobility or transfer, the CNA stated .by word of mouth .asked other CNAs . Interview with Registered Nurse (RN) #3 on 7/10/18 at 12:05 PM, in the Conference Room, revealed each nurses' station had a CNA binder book which had the Interdisciplinary Care Plans for the CNAs to follow and included assistance needed for Activities of Daily Living (ADL). Interviews with 16 CNAs on 7/10/18 and 7/11/18 revealed all but 2 (CNA #8 and #11) knew about the CNA binders at each nurses' station. Interview with CNA #11 on 7/10/18 at 5:18 PM, at the 300 Hall nurses' station, revealed when asked about the CNA binder, he replied .never used it . Telephone interview with the former Director of Nursing (DON) on 7/11/18 at 10:15 AM, revealed when he was asked if he was aware Resident #7 was care planned for a 2 person assist during bed mobility, he replied no, she was a 2 person assist only for transfer from bed to chair. The DON stated he did remember implementing a practice change to deflate the air mattress before doing care and turning. Interview with the Regional Quality Specialist on 7/11/18 at 3:20 PM, in the Resting Lounge, revealed when the Regional Quality Specialist was asked what she would have expected when a CNA stated she was not aware of the CNA Care Guides, which documented assistance needed for ADLs, the Regional Quality Specialist replied .would have expected all CNAs would have been in-serviced on the Care Guides . Refer to F-689",2020-09-01
281,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2018-07-14,658,J,1,0,K2OF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based review of facility's policies, review of Rules and Regulations of Registered Nurses, review of Tennessee Code Annotated, medical record review, facility investigation review, interview, and observation, the facility failed to assure the services provided met professional standards of quality and acceptable standards of clinical practice for 1 resident (#7), of 8 residents reviewed. The facility's failure to ensure care was provided within professional scope of practice resulted in Resident #7 sustaining bilateral fractures, nursing staff ordering interventions without consulting with physician services, and placed Resident #7 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, impairment or death to a resident). The Immediate Jeopardy (IJ) was effective 11/11/17 and is ongoing. The findings include: Review of the facility's policy titled Change in a Resident's Condition or Status dated 12/28/16 revealed .1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician .when there has been .d. A significant change in the resident's physical/emotional/mental condition; that is a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications .2. A significant change of condition is a decline or improvement in the resident's status . Review of the Tennessee Rules and Regulations of Registered Nurses Chapter 1000-01 revised June, (YEAR) revealed .3 .(a) Responsibility .Registered nurses are liable if they perform delegated functions they are not prepared to handle by education and experience and for which supervision is not provided. In any patient care situation, the registered nurse should perform only those acts for which each has been prepared and has demonstrated ability to perform, bearing in mind the individual's personal responsibility under the law . Review of the Tennessee Code Annotated 63-7-103 Practice of professional nursing and professional nursing defined revealed .(F) .(b) Notwithstanding subsection (a), the practice of professional nursing does not include acts of medical [DIAGNOSES REDACTED]. Medical record review revealed Resident #7 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 was coded 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Review of the facility's investigation revealed a written statement completed by Certified Nursing Assistant (CNA) #8 dated 11/11/17, which stated .I was in the middle of changing patient sheets, when patient rolled over. She slid out of the bed and landed on her knees and fell toward her left side and did not hit her head . Medical record review of nurse's notes dated 11/11/17 at 11:00 AM, revealed the resident complained of bilateral hip and left shoulder pain and x-rays had been ordered. Medical record review of a telephone order dated 11/11/17, at 10:45 AM, revealed .Bilateral hips & (and) L (left) shoulder x-ray .fall .VORB (verbal order read back) (name of the former Director of Nursing) Continued review of the order revealed the order was a verbal order written by a Registered Nurse (RN) and given by the former Director of Nursing (DON). Medical record review of the radiology report for the hips and left shoulder dated 11/11/17 revealed no fracture or dislocation of left shoulder or hips was present. Medical record review of nurse's notes dated 11/14/17 at 12:30 PM, revealed the resident's bilateral knees were swollen and bruised. Further review revealed .on Dr.'s (physician) Board (meaning the resident was on the list to be seen by the physician) for today . Medical record review of a physician's telephone order dated 11/16/17 at 1:30 PM, revealed a verbal order for x-ray of bilateral knees given by the Nurse Practitioner (NP). Medical record review of the radiology report dated 11/16/17 revealed .Impacted right knee fracture involving the distal femoral metaphysis .Impacted fracture (left) involving the distal femoral metaphysis (fracture in the area where the long bone femur of the upper leg meets the knee) .Old internally fixated proximal tibial fracture . Medical record review of a nursing progress note dated 11/16/17 revealed the DON was notified of the results of the x-ray on 11/16/17 at 9:10 PM. Continued review of the nursing progress note and the radiology report revealed no documentation the physician or NP had been notified. Medical record review of a nurse's note dated 11/17/17 revealed .spoke to resident's sister .to notify her of resident's orthopedic appt (appointment) . Medical record review revealed there was no documentation of an order for [REDACTED].>Telephone interview with the Nurse Practitioner (NP) on 7/10/18 at 9:25 AM, confirmed she gave the order for the x-ray of the knees on 11/16/17 because the resident was still in pain. Interview with RN #2 on 7/10/18 at 11:30 AM, at a location outside the facility, revealed when she came to work on 11/11/17 for the 7:00 AM to 7:00 PM shift, she was told Resident #7 rolled out of bed and had fallen to the floor. RN #2 stated she assessed the resident who complained of pain in the left shoulder and left hip, so she texted the DON at 9:30 AM and was given verbal permission by the DON to order x-rays of the shoulder and bilateral hips. Continued interview with RN #2 revealed when she returned to work on 11/16/17 the resident still had not been seen by the Nurse Practitioner (NP) or the physician, but the NP was at the nurses' station, so she asked if she could get x-rays of the knees of Resident #7. Telephone interview with RN #4 on 7/10/18 at 1:00 PM, revealed on 11/13/17 and 11/14/17 there was a sign posted at the nurses' station to notify the supervisor before calling the physician or NP, so she reported to the Assistant Director of Nursing (ADON) Resident #7 was having knee pain and x-rays of the knees had not been done. The ADON instructed RN #4 to place the resident on the Dr.'s Board. RN #4 confirmed Resident #7 was not seen by the physician or the NP on 11/13/17 or 11/14/17. Telephone interview with the former DON (who was DON at time of the incident) on 7/11/18 at 10:15 AM, revealed he didn't remember anything about the incident. The DON confirmed several days after the fall, when he was made aware the resident was having a lot of pain and swelling and bruising of both knees, he instructed the nurses to get x-rays and an orthopedic appointment. Observation and interview with RN #4 on 7/11/18 at 12:10 PM, in the Resting Lounge, revealed she presented a sign she stated she took down from the nurses station which read .Staff are never to call Dr. (Medical Director) or his NP until contact has been made with the on-call Nurse Mgr. (manager). If you have questions about this see (DON) or (ADON). The DON's name was typed on the bottom. Continued interview with RN #4 revealed the nurses were to call management first. Interview with the Regional Quality Specialist on 7/11/18 at 3:20 PM, in the Resting Lounge, revealed she was in the building at least monthly 2-3 days at a time. When asked if she had ever seen the sign regarding not to call the physician or NP, the Regional Quality Specialist stated she had not seen it and the DON (who was ADON at time of incident) had told her there was no sign. When asked what she would have expected the nursing staff to do when the resident continued to complain of pain, and especially knee pain, the Regional Quality Specialist replied .would have expected a call placed to the provider . Interview with RN #2 on 7/13/18 at 5:45 PM, at the 400 hall nurses' station, revealed when she left work on 11/16/17, the results of the x-rays of the bilateral knees for Resident #7 had not returned. RN #2 stated when she returned to work on 11/17/18 she read the x-ray results and was in contact with the DON per text messaging. RN #2 stated she received a text from the DON regarding .ortho (orthopedic physician) appointment? . When the RN was asked who gave the order for Resident #7 to go to the orthopedic's office, the nurse replied the DON. Telephone interview with the Medical Director, attending physician, on 7/13/18 at 5:59 PM, revealed when asked did he know about the bilateral fractures of Resident #7, he replied .this is the first I've heard right now . Interview with the Administrator on 7/13/18 at 6:05 PM, at the 400 hall nurses' station, revealed when shown the nurses' notes of 11/16/17, of the results of the x-rays and the physician was not noted as being notified, and on 11/17/17 when the staff made an appointment with an orthopedic surgeon without a physician's orders [REDACTED].(DON) is not a Doctor .",2020-09-01
282,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2018-07-14,689,J,1,0,K2OF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, facility investigation review, and interview, the facility failed to prevent an avoidable accident for 1 resident (#7) of 6 residents reviewed for accidents, of 8 sampled residents. The facility's failure to prevent an avoidable accident resulted in a fall, in which Resident #7 sustained bilateral impacted knee fractures, and placed Resident #7 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 was cited F689 at a scope and severity of J, which constitutes Substandard Quality of Care (SQC). The Immediate Jeopardy (IJ) was effective [DATE] and is ongoing. The findings include: Medical record review revealed Resident #7 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 was coded 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance of 2 staff for bed mobility (how resident moves to and from lying position, turns side to side). Medical record review of the Fall Risk Evaluation dated [DATE] revealed Resident #7 scored 16 (score of 10 or higher placed the resident at risk for falls). Medical record review of Resident #7's care plan reviewed and updated [DATE], revealed for the problem of self-care deficit, related to bedbound status, the resident's approach included .Bed mobility extensive assist of two . Medical record review of the Interdisciplinary Progress Notes dated [DATE] revealed Resident #7 required extensive assist of two persons for bed mobility. Medical record review of the Interdisciplinary Care Plan (used by the Certified Nursing Assistants), not dated, revealed Resident #7 was a two person assist for bed mobility. Review of the facility's incident report dated [DATE] at 6:45 AM, revealed Resident #7 .was noted to slide off air mattress on to the floor during a bed change. Resident did not strike her head. Head to toe assessment performed, no injury noted .Sister .Dr (physician) .notified. Two CNAs (Certified Nursing Assistants) will be needed to turn resident on air mattress to prevent further falls . Continued review revealed the resident was care planned and assessed as a 2 staff assist for bed mobility prior to the accident. Review of the facility's investigation revealed a written statement completed by CNA #8 dated [DATE], which stated .I was in the middle of changing patient sheets, when patient rolled over. She slid out of the bed and landed on her knees and fell toward her left side and did not hit her head . Medical record review of nurse's notes dated [DATE] at 11:00 AM, revealed the resident complained of bilateral hip and left shoulder pain and x-rays were ordered. Medical record review of the radiology report dated [DATE] revealed .Minimal to moderate [MEDICAL CONDITION] changes to the right hip .Moderate to severe [MEDICAL CONDITION] changes of the left hip . No fracture or dislocation of the left shoulder was present. Medical record review of the Fall Risk Evaluation dated [DATE] revealed Resident #7 scored 18 (score of 10 or higher placed the resident at risk for falls). Review of the 5 WHYs worksheet (a worksheet used to ask 5 why questions to determine the root cause of a problem and implement interventions to prevent recurrence) revealed the worksheet was incomplete for the resident's accident. Further review revealed Define the problem: Resident slid out of bed . Further review revealed 5 boxes on the worksheet under why is it happening? with an area to answer why it happened, followed by why is that? and then a space to continue answering until the root cause was found. Further review revealed only 1 of the 5 why boxes was completed with, Air mattress unstable on edge of bed and then an arrow drawn to the side stating, use two CNAs to change or reposition resident, an intervention that was already to be done. Medical record review of nurse's notes dated [DATE] at 12:10 PM, revealed the resident still had complaints of pain related to the fall. Medical record review of the Interdisciplinary Progress Notes dated [DATE] revealed, IDT (Interdisciplinary Team) clinical post fall [DATE], slide from air mattress during care. 0 (no) injurys (injuries) .foam noodles added to bed . Medical record review of the resident's care plan revealed on [DATE] .noodles to bed . had been added as an intervention for at risk for falls due to decrease in mobility. Medical record review of nurse's notes dated [DATE] at 12:30 PM, revealed Resident #7's bilateral knees were swollen and bruised. Further review revealed .on Dr.'s (physician) Board for today (indicating the resident was to be seen by the physician or Nurse Practitioner) . Medical record review of a physician's telephone order dated [DATE] at 1:30 PM, revealed an order for [REDACTED]. Medical record review of the radiology report dated [DATE] revealed .Impacted right knee fracture involving the distal femoral metaphysis .Impacted fracture (left) involving the distal femoral metaphysis (fracture in the area where the long bone femur of the upper leg meets the knee) .Old internally fixated proximal tibial fracture . Continued review revealed the Director of Nursing (DON) was notified of the results of the x-ray on [DATE] at 9:10 PM, and the family was notified of the results at 9:20 PM. Medical record review of nurse's notes dated [DATE] revealed the bilateral knees remained bruised. Medical record review of the office History and Physical completed by the orthopedic physician dated [DATE] revealed Resident #7 was complaining of pain only in her knees and legs, but it was quite significant. Continued review revealed both knees were swollen and deformed with some flexion. Resident #7 had some mild ecchymosis (bruising) around the knees. Further review revealed Resident #7 had significant osteoporotic appearing bone with significant arthritis and previous tibial hardware in both legs. The resident had bilateral distal femur fractures. The resident was admitted to the hospital due to the severity of the knee fractures. Medical record review of the hospital Death Summary dated [DATE], revealed Resident #7 .sustained bilateral distal femur fractures. She was in extreme pain at the time of admission and was initially admitted .She was normally non ambulatory however the fractures were extremely painful and they were repaired for palliative reasons .Palliative Care was consulted to discuss goals of care with the patient's family due to her severe debility and multiple comorbidities . The resident expired [DATE]. Interview with the Administrator on [DATE], at 9:00 AM, in the Conference Room, confirmed Resident #7 had a fall in (MONTH) (YEAR). Continued interview with the Administrator revealed when asked if the resident was assisted by 1 or 2 people, the Administrator stated only one. When asked how many staff members were to assist the resident the Administrator replied .2 . Telephone interview with the Nurse Practitioner (NP) on [DATE] at 9:25 AM, revealed she remembered Resident #7 had a fall. The NP stated she gave the order for the x-ray of the knees on [DATE] because the resident was still hurting. Telephone interview with CNA #8 on [DATE] at 10:55 AM, revealed she was making her last round around 6:45 AM on [DATE], and went to change Resident #7 when she noticed something on her sheet, so she decided she would change the sheet. CNA #8 stated the resident had always grabbed the hand rail to hold onto when she turned, but for some reason she did not get a grip on the hand rail. CNA #8 stated when she turned Resident #7 over to change the sheet, the resident fell to the floor and landed on her knees. CNA #8 stated she screamed for help and the nurse came in to assess the resident and then the staff put the resident back to bed. CNA #8 stated the resident was .shaking really bad and I couldn't even get her vital signs . CNA #8 stated the resident grabbed her knees after she fell . When CNA #8 was asked had she been turning Resident #7 by herself, the CNA responded she had always turned the resident by herself. When CNA #8 was asked how did she know if a resident was a 1 person or a 2 person assist for bed mobility or transfer, the CNA stated .by word of mouth .asked other CNAs . Interview with Registered Nurse (RN) #3 on [DATE] at 12:05 PM, in the Conference Room, revealed each nurses' station had a CNA binder book which had the Interdisciplinary Care Plans for the CNAs to follow, and included assistance needed for Activities of Daily Living (ADL). Interviews with 16 CNAs on [DATE] and [DATE] revealed all but 2 (CNA #8 and #11) knew about the CNA binders at each nurses' station and where to find the information needed for resident care. Interview with CNA #11 on [DATE] at 5:18 PM, at the 300 hall nurses' station, revealed he didn't use the care guides and didn't know anything about them. Interview with RN #2 on [DATE] at 11:30 AM, at a location outside the facility, revealed when she came to work on [DATE] for the 7:00 AM to 7:00 PM shift, she was informed Resident #7 rolled out of bed and had fallen to the floor. RN #2 stated she assessed the resident who complained of pain in the left shoulder and left hip, and obtained x-rays of the shoulder and hips. RN #2 stated the resident was in pain and would scream when moved or turned. Further interview with RN #2 revealed when she worked Sunday [DATE], the resident was still complaining of pain. Further interview with RN #2 confirmed the NP had not been made aware of the resident's complaints of knee pain until [DATE], when an order to obtain x-rays of the bilateral knees was given by the NP. Telephone interview with RN #4 on [DATE] at 1:00 PM, revealed the resident was alert with confusion at times. RN #4 stated on [DATE] the CNAs reported the resident would scream when she was turned. RN #4 stated she went in to talk with Resident #7 who stated her knees hurt her badly. RN #4 confirmed the resident was not seen by the physician or NP on [DATE] or [DATE]. Interview with CNA #4 on [DATE] at 10:50 AM, in the Resting Lounge, revealed when she turned the resident she would scream out in pain in her knees. The resident's knees were swollen and bruised. When she was working [DATE] and it was either [DATE] or [DATE] when she notified the nurse of the swelling and bruising of both knees of Resident #7. Telephone interview with the former DON (who was DON at time of the incident) on [DATE] at 10:15 AM, revealed he didn't remember anything about the incident. When asked if he was aware the resident was care planned for a 2 person assist during bed mobility, he replied she was a 2 person assist only for transfer from bed to chair. The former DON stated he did remember they implemented a practice change to deflate the air mattress before doing care and turning residents. Interview with the Regional Quality Specialist on [DATE] at 3:20 PM, in the Resting Lounge, revealed she was in the building at least monthly ,[DATE] days at a time. The duties of the Regional Quality Specialist included survey readiness, compliance, review of policies and procedures, and performance improvement plans. When asked when she became aware of the accident of [DATE], the Regional Quality Specialist stated on Monday [DATE] when she came into the facility. When the Regional Quality Specialist was asked what she would have expected when a CNA stated she was not aware of the CNA Care Guides which documented assistance needed for ADLs, the Regional Quality Specialist replied .would have expected all CNAs would have been in-serviced on the Care Guides . Interview with CNA #17 on [DATE] at 4:00 PM, in the upper 400 hall shower room, revealed when she took care of Resident #7 she observed the knees swollen and the resident told the CNA she had fallen out of bed. CNA #17 reported to RN #4 about the knees being swollen and pain on turning and was informed the RN had been instructed to add the resident to the doctor's board by the ADON. CNA #17 confirmed both knees were swollen and the resident complained of a lot of pain on [DATE]. Interview with CNA #18 on [DATE] at 4:15 PM, in the upper 400 hall shower room, revealed Resident #7's legs and knees were swollen and she .screamed . when turned and would say .Oh Please, Please, Please . begging during changing. The CNA further stated she asked nursing everyday if anything had been done for the resident, such as an x-ray and was told no. Interview with the Administrator on [DATE] at 8:10 AM, in the Resting Lounge, revealed the facility discussed falls during the morning meetings and reviewed the 24 hour reports. The facility conducted a Risk Management meeting weekly where they went through all falls for the week. The Administrator stated their process .now . during the risk meeting was to look at interventions to see if the intervention was appropriate, pulling each chart, reviewing the nursing notes and trying to do a better and thorough job. The Administrator confirmed they were not doing this in-depth meeting at the time of Resident #7's accident. The Administrator confirmed if they had been doing the type of risk meeting they were doing now, including reading the nurses notes, they would have been aware of the accident. They would have included a teachable moment for the CNA regarding use of the Care Guides and provided more staff education. The Administrator further stated she could not say at the time of the incident that they read the accident reports out loud or discussed the interventions during the meetings but .We do now . When asked when they started doing the new process regarding incident reports the Administrator stated it was after [DATE] when the previous DON left. Telephone interview with the Medical Director on [DATE] at 5:59 PM, revealed, when asked did he know about the bilateral fractures of Resident #7, he replied .this is the first I've heard right now . The MD confirmed all fractures should be called to the physician or the person on call. Interview with the Administrator on [DATE] at 9:00 AM, in the Administrator' Office, confirmed she became aware of the fall and fractures for Resident #7 when Adult Protective Services (APS) came in (MONTH) of (YEAR). The Administrator confirmed the incident resulting in bilateral fractures involving Resident #7 was not discussed for implementation of a corrective action plan.",2020-09-01
283,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2018-07-14,697,J,1,0,K2OF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, facility investigation review, interview, and observation, the facility failed to ensure pain management was provided to 1 resident (#7) of 6 residents reviewed for accidents, after a fall which resulted in bilateral impacted knee fractures. The facility's failure to identify the cause of pain and provide interventions placed Resident #7 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 was cited F697 at a scope and severity of J, which constitutes Substandard Quality of Care (SQC). The Immediate Jeopardy (IJ) was effective [DATE] and is ongoing. The findings include: Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Rheumatology Consultation dated [DATE] revealed .has symptoms of chronic widespread pain. She is exquisitely sensitive to any sort of palpation of her extremities, particularly her lower extremities .would put her under pain amplificatio[DIAGNOSES REDACTED] . Medical record review of the Medication Administration Record [REDACTED]. Medical record review of psychiatric recommendations and progress notes dated [DATE] revealed Resident #7 complained of pain as a 10 (extreme pain) on a scale of 1 to 10. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was coded 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Medical record review of Resident #7's MAR for (MONTH) (YEAR) revealed the resident had a pain assessment completed every shift (7:00 AM - 7:00 PM and 7:00 PM - 7:00 AM) and the resident's pain was 0 every day until [DATE], after the resident was diagnosed with [REDACTED]. Review of the facility's incident report dated [DATE] at 6:45 AM, revealed Resident #7 .was noted to slide off air mattress on to the floor during a bed change. Review of the facility's investigation revealed a written statement completed by Certified Nursing Assistant (CNA) #8 dated [DATE], which stated .I was in the middle of changing patient sheets, when patient rolled over. She slid out of the bed and landed on her knees . Medical record review of the MAR indicated [REDACTED]. Medical record review of the (MONTH) MAR indicated [REDACTED]. Medical record review of Resident #7's (MONTH) (YEAR) MAR indicated [REDACTED]. Medical record review of nurse's notes dated [DATE] at 11:00 AM, revealed the resident complained of bilateral hip and left shoulder pain and x-rays were ordered. Medical record review of the radiology report dated [DATE] revealed no fracture or dislocation of the shoulder or hips was present. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of nurse's notes dated [DATE] at 12:10 PM, revealed Resident #7 still had complaints of pain related to the fall. Continued review revealed pain medication was given as ordered. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of nurse's notes dated [DATE] at 12:30 PM, revealed Resident #7's bilateral knees were swollen and bruised. Further review revealed .on Dr.'s (physician) Board for today (indicating the resident needed to be seen by the physician or the Nurse Practitioner) . Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of the (MONTH) MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of a physician's telephone order dated [DATE] at 1:30 PM, revealed an order for [REDACTED]. Medical record review of the radiology report dated [DATE] revealed .Impacted right knee fracture involving the distal femoral metaphysis (fracture in the area where the long bone femur of the upper leg meets the knee) .Impacted fracture (left) involving the distal femoral metaphysis .Old internally fixated proximal tibial fracture . Continued review revealed the Director of Nursing (DON) was notified of the results of the x-ray on [DATE] at 9:10 PM. Review of the radiology report and nursing notes revealed no documentation the physician was notified. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Medical record review of the office History and Physical completed by the orthopedic physician dated [DATE] revealed Resident #7 was complaining of pain only in her knees and legs, but it was quite significant. The resident had bilateral distal femur fractures. The resident was admitted to the hospital due to the severity of the knee fractures. Medical record review of the hospital Death Summary dated [DATE], revealed Resident #7 .sustained bilateral distal femur fractures. She was in extreme pain at the time of admission and was initially admitted .the fractures were extremely painful and they were repaired for palliative reasons .Palliative Care was consulted to discuss goals of care with the patient's family due to her severe debility and multiple comorbidities . The resident expired [DATE]. Telephone interview with the Nurse Practitioner (NP) on [DATE] at 9:25 AM, revealed she remembered she gave the order for the x-ray of the knees on [DATE] because the resident was still having pain. Telephone interview with CNA #8 on [DATE] at 10:55 AM, revealed she was making her last round around 6:45 AM on [DATE], and went in to change the resident's bed sheet. CNA #8 stated when she turned Resident #7 over to change the sheet, the resident fell to the floor and landed on her knees. CNA #8 stated she screamed for help and the nurse came in to assess the resident and then they put the resident back to bed. CNA #8 stated the resident was .shaking really bad and I couldn't even get her vital signs . CNA #8 stated the resident grabbed her knees after she fell . Interview with Registered Nurse (RN) #2 on [DATE] at 11:30 AM, at a location outside the facility, revealed when she came in [DATE] (for the 7:00 AM to 7:00 PM shift) she was told Resident #7 rolled out of bed and had fallen to the floor. RN #2 stated she assessed the resident in the resident's room who complained of pain in the left shoulder and left hip. RN #2 stated the resident was in pain and would scream when moved or turned. Further interview with RN #2 revealed when she worked Sunday [DATE], the resident was still complaining of pain and she gave the resident pain medication to try to keep her comfortable. RN #2 further stated she knew Resident #7 was in pain. Continued interview with RN #2 revealed she was not working [DATE], [DATE], and [DATE]. RN #2 stated on [DATE] when she returned to work the resident still had not been seen by the Nurse Practitioner or the physician, but stated the NP was at the nurses' station so she asked if she could get x-rays of the knees of Resident #7. The nurse further revealed when she read the report on [DATE] from the bilateral knee x-rays she scheduled an appointment with an orthopedic surgeon for [DATE]. Further interview with RN #2 confirmed the NP had not been made aware of the resident's complaints of knee pain until [DATE]. Telephone interview with RN #4 on [DATE] at 1:00 PM, revealed the resident was alert with confusion at times. RN #4 stated Resident #7 was not a complainer and usually would not volunteer to tell you she was hurting. RN #4 stated on [DATE] the resident was in so much pain the CNAs reported the resident would scream when she was turned. RN #4 stated she went in to talk with Resident #7 who stated her knees hurt her badly. RN #4 stated both knees were swollen and black and blue. RN #4 stated at this time there was a sign posted at the nurse's station to notify the supervisor before calling the physician or NP so she went to the Assistant Director of Nursing (ADON) and reported the resident was in severe pain. RN #4 stated the ADON said they had done x-rays and they were all negative. RN #4 then replied .no, we have not x-rayed the knees . The ADON replied it was too late to call the physician and just place it on the Dr.'s Board (which is used to list residents who need to be seen by the physician or NP on the next visit) for the resident to be seen the next day. RN #4 stated on [DATE] she saw the physician and the NP in the facility but they never came to the floor to see Resident #7 and when she reminded the ADON Resident #7 needed to be seen, the ADON replied to her the physician and NP were not seeing residents that day. RN #4 confirmed the resident was not seen by the physician or NP on [DATE] or [DATE] when she was on duty. RN #4 further revealed Resident #4 was never a good eater, but after the incident the resident was not eating as much and the resident was in a lot of pain. RN #4 further confirmed she administered the resident pain medications that had been previously prescribed as much as possible to keep her comfortable. Interview with the Restorative Aide on [DATE] at 9:50 AM, in the Resting Lounge, revealed she had worked with Resident #7 multiple times doing Range of Motion (ROM). The Restorative Aide stated after the fall on [DATE] the resident didn't want her to do ROM on her legs at all because of the pain. The Restorative Aide stated the resident told her she had a fall and was in .so much pain . The Restorative Aide further stated the resident was also moaning and her complaint of pain was different from her normal baseline and .enough to get my attention . Interview with CNA #4 on [DATE] at 10:50 AM, in the Resting Lounge, revealed Resident #7 was never really one to complain of pain but would close her eyes and crunch up her face. CNA #4 stated before the fall when she would turn the resident, the resident would complain of pain, and maybe even more on rainy or cold days. But after the fall, the resident was in a lot of pain all the time. CNA #4 stated when she turned the resident, she would scream out in pain in her knees. The resident's knees were swollen and bruised. When asked if the complaint of pain was different after the fall the CNA replied .absolutely . CNA #4 stated the resident was screaming with intense pain especially on turning. CNA #4 stated the nurses told the CNAs they had been instructed to put the resident on the doctor's board and the pain could wait until the physician came. CNA #4 stated she felt the nurses on the floor and the CNAs did everything they could do but the lady .laid there several days in pain . Telephone interview with the former DON (who was DON at time of the accident) on [DATE] at 10:15 AM, confirmed he was notified several days after the fall the resident was having a lot of pain. During observation and interview with RN #4 on [DATE] at 12:10 PM, in the Resting Lounge, RN #4 presented a copy of the physician board sheet which revealed a notation dated [DATE] for Resident #7 XXX,[DATE] S/P (status [REDACTED]. RN #4 confirmed she saw a big change in Resident #4 after the fall where she didn't eat as well and she didn't want to be changed because of the pain. Interview with the Regional Quality Specialist on [DATE] at 3:20 PM, in the Resting Lounge, revealed she was in the building at least monthly ,[DATE] days at a time. When asked what she would have expected the nursing staff to do when the resident continued to complain of pain the Regional Quality Specialist replied .would have expected a call placed to the provider . Telephone interview with the attending physician (Medical Doctor) on [DATE] at 3:45 PM, revealed when asked what he would have expected the nursing staff to do for any increased pain, the MD stated he would expect to be called for any changes. The MD further confirmed he did not remember the facility calling him for any changes to Resident #7. Interview with CNA #17 on [DATE] at 4:00 PM, in the upper 400 hall shower room, revealed when she took care of Resident #7 she observed the knees swollen and the resident told the CNA she had fallen out of bed. CNA #17 reported to RN #4 about the resident's pain on turning and was informed the RN had been instructed to put it on the doctor's board by the ADON. CNA #17 confirmed the resident complained of a lot of pain on [DATE]. CNA #17 asked nursing again on [DATE] and was told the doctor had still not seen the resident. Interview with CNA #18 on [DATE] at 4:15 PM, in the upper 400 hall shower room, revealed Resident #7's legs and knees were swollen and she .screamed . when turned and would say .Oh Please, Please, Please . begging during changing. The CNA further stated she asked nursing everyday if anything had been done for the resident, and was told no. Interview with RN #2 on [DATE] at 5:45 PM, at the 400 hall nurses' station, revealed when she left on [DATE] the results of the x-rays of the bilateral knees for Resident #7 had not returned. She returned to work on [DATE], read the x-ray results, was in contact with the DON per text messaging, and an appointment was made for [DATE]. When RN #2 was asked how Resident #7 was during [DATE] until the doctor appointment on [DATE], the RN replied the same. RN #2 stated they (nursing) kept the resident comfortable with the [MEDICATION NAME], and [MEDICATION NAME] the resident was prescribed prior to the fall. In summary, Resident #7 experienced an avoidable accident on [DATE]. From [DATE] until [DATE] Resident #7 experienced significant increase in pain from her baseline level. On [DATE] an x-ray was completed on the bilateral knees indicating bilateral knee fractures. Resident #7 was not seen by a physician at the facility from [DATE] through [DATE], when she was sent out to see an orthopedic physician, and the facility failed to provide interventions to address the cause of newly increased pain, bilateral leg fractures from a fall on [DATE]. Resident #7 was admitted to the hospital from the orthopedic physician's office for repair of the fractures and palliative care. The resident expired on [DATE].",2020-09-01
284,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2018-07-14,777,J,1,0,K2OF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review a facility incident report, interview, and observation, the facility failed to obtain an order by the physician or Nurse Practitioner (NP) prior to obtaining x-rays and failed to promptly notify the ordering physician or NP the results of the x-rays, for 1 resident (#7) of 8 sampled residents. Failure to obtain a physician's orders [REDACTED].#7 experiencing pain, and placed Resident #7 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 Immediate Jeopardy (IJ) was effective 11/11/17 and is ongoing. The findings include: Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's incident report dated 11/11/17 at 6:45 AM, revealed Resident #7 .was noted to slide off air mattress on to the floor during a bed change .no injury noted . Medical record review of nurse's notes dated 11/11/17 at 11:00 AM, revealed the resident complained of bilateral hip and left shoulder pain and x-rays had been ordered. Medical record review of a telephone order dated 11/11/17, at 10:45 AM, revealed Bilateral hips & (and) L (left) shoulder x-ray .fall .VORB (verbal order read back) (name of the Director of Nursing). Continued review of the order revealed the order was a verbal order written by a Registered Nurse and given by the Director of Nursing (DON). Further review revealed the order was signed by the Nurse Practitioner (NP) on 11/16/17. Medical record review of the radiology report for the shoulder and hip x-rays dated 11/11/17 revealed no fracture or dislocation. Medical record review of a physician's telephone order dated 11/16/17 at 1:30 PM, revealed a verbal order from the NP for x-ray of bilateral knees. Medical record review of the radiology report dated 11/16/17 revealed .Impacted right knee fracture involving the distal femoral metaphysis .Impacted fracture (left) involving the distal femoral metaphysis (fracture in the area where the long bone femur of the upper leg meets the knee) .Old internally fixated proximal tibial fracture . Medical record review of a nursing progress note dated 11/16/17 revealed the DON was notified of the results of the x-ray on 11/16/17 at 9:10 PM, and the family was notified of the results at 9:20 PM. Further review of the radiology report and nursing notes revealed no documentation the physician or NP were notified of the results of the radiology report indicating the resident had fractures. Telephone interview with the Nurse Practitioner (NP) on 7/10/18 at 9:25 AM, revealed she remembered giving the order for the x-ray of the knees on 11/16/17 because the resident was still hurting. Interview with RN #2 on 7/10/18 at 11:30 AM, at a location outside the facility, revealed when she came to work 11/11/17 for the 7:00 AM to 7:00 PM shift she was told Resident #7 rolled out of bed and had fallen to the floor. RN #2 stated she assessed the resident who complained of pain in the left shoulder and left hip, so she texted the DON at 9:30 AM and was given verbal permission to obtain x-rays of the shoulder and bilateral hips from the DON. Continued interview with RN #2 revealed she was not working 11/13/17, 11/14/17, and 11/15/17. RN #2 stated on 11/16/17, when she returned to work, the resident still had not been seen by the NP or the physician, but the NP was at the nurses' station so she asked the NP if she could get x-rays of the knees of Resident #7. Telephone interview with the former DON (who was DON at time of the incident) on 7/11/18 at 10:15 AM, revealed he did remember several days after the fall, when he was made aware the resident was having a lot of pain and her knees were swollen and bruised, he instructed the nurses to get x-rays. Observation and interview with RN #4 on 7/11/18 at 12:10 PM, in the Resting Lounge, revealed she presented a sign she stated she took down from the nurses station which read .Staff are never to call Dr. (Medical Doctor) or his NP until contact has been made with the on-call Nurse Mgr. (manager). If you have questions about this see (DON) or (ADON). The DON's name was typed on the bottom. Continued interview with RN #4 revealed the nurses were to call management first. Telephone interview with the attending physician on 7/11/18 at 3:45 PM, revealed he did not remember the facility calling him for any changes to Resident #7 or for any further orders. Interview with RN #2 on 7/13/18 at 5:45 PM, at the 400 hall nurses' station, revealed when she left work on 11/16/17, the results of the x-rays of the bilateral knees for Resident #7 had not returned. RN #2 stated when she returned to work on 11/17/18, she read the x-ray results and was in contact with the DON per text messaging. Further interview revealed she did not contact the physician or the NP with the results. Telephone interview with the Medical Director, who was the resident's attending physician, on 7/13/18 at 5:59 PM, revealed when asked did he know about the bilateral fractures of Resident #7 he replied .this is the first I've heard right now . When asked if he would have expected to be notified, the physician replied all fractures should be called to the physician or the person on call. Interview with the Administrator on 7/13/18 at 6:05 PM, at the 400 hall nurses' station, revealed when shown the nurses' notes dated 11/16/17, with the results of the knee x-rays, the Administrator confirmed the physician was not noted as being notified. Telephone interview with the NP on 7/13/18 at 9:11 PM, revealed the NP had researched her notes related to Resident #7 and found no notation of being notified of the results of bilateral knee x-rays. Interview with the Administrator on 7/14/18 at 9:00 AM, in the Administrator's Office, confirmed during review of nursing notes for 11/16/17 and 11/17/17, the Administrator did not see any documentation the physician or NP had been notified of the results of the bilateral knee x-rays. The Administrator replied .don't see anything .",2020-09-01
285,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2018-07-14,835,J,1,0,K2OF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, facility investigation review, interview, and observation, the Administrator failed to ensure facility policies were implemented, physicians were notified timely of changes in condition, and residents were free from neglect, avoidable accidents, and pain. The Administrator's failure resulted in a resident having an avoidable accident and a delay in receiving services and treatment after a fall with fractures, with Resident #7 experiencing intense pain, and placing Resident #7 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 Immediate Jeopardy (IJ) was effective [DATE] and is ongoing. The findings include: Review of the facility's policy Change in a Resident's Condition or Status dated [DATE] revealed .1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician and the resident's representative when there has been .d. A significant change in the resident's physical/emotional/mental condition; that is a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications .2. A significant change of condition is a decline or improvement in the resident's status . Review of the facility's policy titled Abuse Prevention/Reporting Policy and Procedure dated (YEAR) revealed .7. Neglect: the failure of the facility, its employees or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish or emotional distress . Medical record review revealed Resident #7 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 was coded 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance of 2 staff for bed mobility (how resident moves to and from lying position, turns side to side) Review of the facility's incident report and investigation dated [DATE] at 6:45 AM, revealed Certified Nursing Assistant (CNA) #8 was changing Resident #7's bed linen without assistance of a second staff person, and Resident #7 fell in the floor landing on her knees. Medical record review of the resident's nursing notes and Medication Administration Record [REDACTED]. Further review revealed the physician nor Nurse Practitioner (NP) was notified of the resident having pain, bruising or swelling in her knees and was not assessed at any time after the fall by the physician or NP. Medical record review of a physician's telephone order dated [DATE] at 1:30 PM, revealed an order for [REDACTED]. Medical record review of the radiology report dated [DATE] revealed .Impacted right knee fracture involving the distal femoral metaphysis (fracture in the area where the long bone femur of the upper leg meets the knee) .Impacted fracture (left) involving the distal femoral metaphysis .Old internally fixated proximal tibial fracture . Medical record review of nursing notes, radiology reports, and physician's orders revealed the Director of Nursing (DON) was notified of the results of the x-ray on [DATE] at 9:10 PM, and the family was notified of the results at 9:20 PM, but there was no documentation the physician or NP was notified of the results. Further review revealed Registered Nurse (RN) arranged an appointment with an orthopedic physician for [DATE] and there was no physician's order for the orthopedic consult. Medical record review of the nursing notes and MAR for [DATE] through [DATE] revealed the resident continued to experience pain, swelling, and bruising in her knees and legs. Further review revealed no documentation the physician or NP was notified of the pain or results of the x-rays, and no documentation the resident was assessed by the physician or NP. Medical record review of the office History and Physical completed by the orthopedic physician dated [DATE] revealed Resident #7 was complaining of pain only in her knees and legs, but it is quite significant. Continued review revealed both knees were swollen and deformed with some flexion. Resident #7 had some mild ecchymosis (bruising) around the knees. The resident had bilateral distal femur fractures. The resident was admitted to the hospital due to the severity of the knee fractures. Medical record review of the hospital Death Summary by the orthopedic surgeon dated [DATE] revealed Resident #7 .sustained bilateral distal femur fractures. She was in extreme pain at the time of admission and was initially admitted .She was normally non ambulatory however the fractures were extremely painful and they were repaired for palliative reasons .Palliative Care was consulted to discuss goals of care with the patient's family due to her severe debility and multiple comorbidities . The resident expired [DATE]. Interviews with CNA #8, RN #2, RN #4, CNA #4 during investigation [DATE] - [DATE] revealed the resident continued to complain of severe pain and staff reported the resident's condition to the DON and Assistant Director of Nursing (ADON), who failed to ensure the physician or NP was notified of the resident's condition and assessed the resident. Staff interviews revealed the physician and NP were not notified of the resident's pain or results of the x-rays indicating the resident had bilateral fractures, and the physician and NP did not assess the resident. Telephone interview with the former DON (who was DON at time of the incident) on [DATE] at 10:15 AM, revealed he didn't remember anything about Resident #7's accident. Continued interview with the DON revealed he did remember several days after Resident #7's fall when he was made aware the resident was having a lot of pain. Observation and interview with RN #4 on [DATE] at 12:10 PM, in the Resting Lounge, revealed she presented a sign she stated she took down from the nurses station which read .Staff are never to call Dr. (Medical Director) or his NP until contact has been made with the on-call Nurse Mgr. (manager). If you have questions about this see (DON) or (ADON). The DON's name was typed on the bottom. RN #4 also presented a copy of the physician board sheet which revealed a notation dated [DATE] for Resident #7 XXX,[DATE] S/P (status [REDACTED]. Continued interview with RN #4 revealed the nurses were to call management first. Telephone interview with the attending physician on [DATE] at 3:45 PM, revealed when asked what he would have expected the nursing staff to do for any change in resident status including increased pain or swelling and bruising of both knees, the physician stated he would expect to be called for any changes. The MD further confirmed he did not remember the facility calling him for any changes to Resident #7. Interview with the Administrator on [DATE] at 8:10 AM, in the Resting Lounge, revealed she had not seen the sign hanging at the nursing station to call the nurse supervisor before calling the physician or NP. Telephone interview with the Medical Director, who was the resident's attending physician, on [DATE] at 5:59 PM, revealed when asked when did he know about the bilateral fractures of Resident #7, he replied .this is the first I've heard right now . When asked if he would have expected to be notified, the physician replied all fractures should be called to the physician or the person on call. Interview with the Administrator on [DATE] at 9:00 AM, in the Administrator' Office, confirmed during observation of nursing notes for [DATE] and [DATE] the Administrator did not see any documentation the physician or NP had been notified of the results of the bilateral knee x-rays. The Administrator replied .don't see anything . When asked when she became aware of the fall and fractures related to Resident #7, the Administrator replied when Adult Protective Services (APS) came in (MONTH) of (YEAR). The Administrator stated she didn't remember if she was present or not at the facility for the morning meeting when the fall should have been discussed, but at the time of the fall they were not reading the incidents out loud and the assumption was the DON was looking at all nursing notes of residents with falls. Continued interview with the Administrator confirmed, when asked if the documentation showed the physician or the NP had been made aware of the results of the bilateral knee x-rays, the Administrator shook her head back and forth and said .no . Further interview with the Administrator revealed QA meetings were conducted on [DATE] and [DATE] at which time only number of incidents and location of the incidents were presented. Continued interview revealed no fractures were reported during these meetings.",2020-09-01
286,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2018-07-14,837,J,1,0,K2OF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, facility investigation review, observation, and interviews, the governing body failed to ensure implemention of policies regarding the management and operation of the facility. The governing body's failure placed 1 resident (#7) of 6 residents of 8 residents reviewed for accidents and incidents 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 Immediate Jeopardy (IJ) was effective [DATE] and is ongoing. The findings include: Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident required extensive assist of 2 staff for bed mobility which include turning from side to side. Medical record review of the care plan updated [DATE] revealed Resident #7 required extensive assistance of 2 for bed mobility. During the survey conducted [DATE] - [DATE], investigation revealed on [DATE] at 6:45 AM, Resident #7 was turned in bed by 1 Certified Nursing Assistant (CNA), instead of 2 CNAs as required, and the resident fell to the floor, landing on her knees. The nurse gave the resident Tylenol for knee pain. X-rays were completed on [DATE] of bilateral hips and left shoulder. The results of the x-rays were negative. Resident #7 continued to complain of pain, especially on turning. Interview with Registered Nurse (RN) #4 on [DATE] revealed on [DATE] Resident #7 was in so much pain the CNAs reported the resident would scream when she was turned. RN #4 assessed Resident #7 and found both knees to be swollen and bruised. According to RN #4 on [DATE] a sign was posted at the nurses station to call the supervisor before calling the physician or the Nurse Practitioner (NP), so RN #4 reported to the Assistant Director of Nursing (ADON) who instructed the nurse to place a note on the Dr's Board (list for physician or NP know the residents needed to be seen the next visit). The physician and the NP were in the facility on [DATE] but did not see Resident #7. Resident #7 continued to have pain on turning from [DATE] until on [DATE], when RN #2 approached the NP, who was at the nursing station and bilateral knee x-rays were ordered. Results of the bilateral knee x-rays revealed bilateral knee fracture involving the distal femoral metaphysis (fracture in the area where the long bone femur of the upper leg meets the knee). Neither the physician nor the NP were notified of the results of the bilateral knee x-rays. The Director of Nursing (DON) instructed RN #2 by text messaging to make an orthopedic physician's appointment without a physician's orders [REDACTED]. Resident #7 expired on [DATE]. Interview with the Regional Quality Specialist on [DATE] revealed she was in the facility monthly at least ,[DATE] days at a time. Continued interview with the Regional Quality Specialist revealed her duties while in the facility included survey readiness, compliance of policies and procedures, system breakdown, and performance improvement plans. Further interview revealed the Regional Quality Specialist was unaware of the sign hanging at the nurses' station not to call the physician or NP before calling the nursing supervisor. Continued interview revealed the Regional Quality Specialist was to be notified of all fractures but was unaware of the fractures to Resident #7 until [DATE]. When the Regional Quality Specialist was asked what she would have expected the nursing staff to do when the resident continued to complain of pain and especially with the knees swollen and bruised, the Regional Quality Specialist replied she .would have expected a call placed to the provider . When the Regional Quality Specialist was asked what she would have expected when a CNA stated she was not aware of the CNA Care Guides which documented assistance needed for Activities of Daily Living, the Regional Quality Specialist replied .would have expected all CNAs would have been in-serviced on the Care Guides .",2020-09-01
287,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2018-07-14,867,J,1,0,K2OF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, review of facility investigation, review of Quality Assurance and Performance Improvement (QAPI) meeting documentation, and interview, the QAPI committee failed to identify and correct quality deficiencies resulting in an avoidable accident where Resident #7 rolled out of bed during care and received bilateral leg fractures that were not identified for 5 days and the resident was not assessed and treated by a physician for another 4 days after x-ray results. The QAPI's failure placed 1 resident (#7) of residents reviewed 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 Immediate Jeopardy (IJ) was effective on [DATE] and is ongoing. The findings include: Review of the facility's policy titled Abuse Prevention/Reporting Policy and Procedure dated (YEAR) revealed .7. Neglect: the failure of the facility, its employees or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish or emotional distress . Review of the facility's policy titled Change in a Resident's Condition or Status dated [DATE] revealed .1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician and the resident's representative when there has been .d. A significant change in the resident's physical/emotional/mental condition; that is a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications .2. A significant change of condition is a decline or improvement in the resident's status . Medical record review revealed Resident #7 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 was coded 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance of 2 staff for bed mobility (how resident moves to and from lying position, turns side to side). Review of the facility's incident report dated [DATE] at 6:45 AM, revealed Resident #7 .was noted to slide off air mattress on to the floor during a bed change .Two Certified Nursing Assistants (CNAs) will be needed to turn resident on air mattress to prevent further falls . Further review revealed Resident #7 required 2 person assist with bed mobility prior to the incident. Review of the facility's investigation revealed a written statement completed by CNA #8 dated [DATE], which stated .I was in the middle of changing patient sheets, when patient rolled over. She slid out of the bed and landed on her knees and fell toward her left side and did not hit her head . Medical record review of a physician's telephone order dated [DATE] at 1:30 PM, revealed an order for [REDACTED]. Medical record review of the radiology report dated [DATE] revealed .Impacted right knee fracture involving the distal femoral metaphysis .Impacted fracture (left) involving the distal femoral metaphysis (fracture in the area where the long bone femur of the upper leg meets the knee) .Old internally fixated proximal tibial fracture . Medical record review of the office History and Physical completed by the orthopedic physician dated [DATE] revealed Resident #7 was complaining of pain only in her knees and legs, but it was quite significant. Continued review revealed both knees were swollen and deformed with some flexion. Resident #7 had some mild ecchymosis (bruising) around the knees. The resident had bilateral distal femur fractures and was admitted to the hospital due to the severity of the knee fractures. Medical record review of the hospital Death Summary dated [DATE] revealed Resident #7 .sustained bilateral distal femur fractures. She was in extreme pain at the time of admission and was initially admitted .She was normally non ambulatory however the fractures were extremely painful and they were repaired for palliative reasons .Palliative Care was consulted to discuss goals of care with the patient's family due to her severe debility and multiple comorbidities . The resident expired [DATE]. Interview with the Administrator on [DATE] at 8:10 AM, in the Resting Lounge, revealed the facility conducted Quality Assurance meetings monthly with the Administrator, Director of Nursing (DON), Staff Development Coordinator, Medical Director, Dietary Manager, Social Services, Activities, Infection Control Director, Rehab Director, Human Resources, Medical Records Director, Registered Dietician, MDS Coordinator, Maintenance Director, a CNA, a Nurse, Respiratory Therapist, Wound Care Nurse, and Pharmacy Consultant (at least quarterly). The Administrator stated they go through each department, investigations, customer satisfaction, family satisfaction, revised policies, discharges, falls, and trends. The Administrator stated they discussed falls during the morning meetings and reviewed the 24 hour reports. The facility conducted a Risk Management meeting weekly where they go through all falls for the week. The Administrator stated .now . during the risk meeting they were looking at interventions to see if the intervention was appropriate, pulling each chart, reviewing the nursing notes, and trying to do a better and through job. The Administrator stated they were not doing this in-depth meeting when the previous DON was at the facility at the time of Resident #7's fall. The Administrator confirmed if they had been doing the type of risk meeting they were doing now, including reading the nurses notes, they would have been aware of the accident and the days following the accident, including the resident's continued complaints of pain with the swelling and bruising of both knees. Further interview with the Administrator confirmed if they had been doing the new process at the time of the incident they would have also included a teachable moment for the CNA regarding use of the Care Guides and provided more staff education. The Administrator further stated she was not sure at the time if they read the incident reports out loud or discussed the interventions during the meetings but .We do now . When asked when the new process for reviewing incidents started the Administrator replied after [DATE] when the prior DON left. The Administrator stated we review verbally now, including nursing notes for days after an incident, but the previous DON did not see the value in doing this process. Telephone interview with the Medical Director on [DATE] at 5:59 PM, revealed when asked did he know about the bilateral fractures of Resident #7, he replied .this is the first I've heard right now . Interview with the Administrator on [DATE] at 9:00 AM, in the Administrator's Office, revealed when asked when she became aware of the fall and fractures related to Resident #7, the Administrator replied when Adult Protective Services came in (MONTH) of (YEAR). The Administrator stated she didn't remember if she was present or not at the facility for the morning meeting when the fall should have been discussed, but at the time of the fall they were not reading the incidents out loud, and the assumption was the DON was looking at all nursing notes of residents with falls. Continued interview revealed the facility conducted QA meetings on [DATE] and [DATE], at which time only numbers and locations of accidents and incidents was presented. Further interview confirmed no fractures were reported to the committee at either committee meeting and the facility had not made any type of systemic correction or performance improvement related to the events involving Resident #7 on [DATE].",2020-09-01
288,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2019-08-21,609,D,1,1,V5UN11,"**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 ensure an alleged violation involving abuse was reported to the State Survey Agency within the required timeframe for 1 resident (#108) of 17 residents reviewed for abuse. The findings include: Review of the facility policy Abuse Prevention/Reporting Policy and Procedures, dated (YEAR), revealed .If the events that caused the allegation involve abuse and/or result in serious bodily injury, reporting must be within 2 hours of the allegation being made or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury . Medical record review revealed Resident #108 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Certified Nursing Assistant Interdisciplinary Care Plan dated 1/15/19 revealed .Mood .short-tempered .Behavior Symptoms .physical behavioral symptoms directed at others . Medical record review of a Quarterly Minimum (MDS) data set [DATE] revealed the resident was severely cognitively impaired. Review of a facility investigation dated 8/13/19 revealed Resident #108 was observed slapping another resident on 8/10/19 at 7:10 PM, in the secure unit. Further review revealed the incident was reported to State Survey Agency on 8/12/19 at 11:44 AM (2 days later). Interview with the Director of Nursing on 8/21/19 at 7:51 AM, in the Conference Room revealed she was notified of an allegation of abuse late at night on 8/10/19. Further interview confirmed the allegation of abuse was not reported to the State Survey Agency until 8/12/19 at 11:44 AM. Continued interview confirmed the facility failed to report the allegation of abuse within the required time frame.",2020-09-01
289,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2019-08-21,755,D,0,1,V5UN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation and interview the facility failed to ensure expired medications were not available for resident use in 1 of 4 medication carts observed. The findings include: Review of the facility policy, Storage of Medication, revised 4/2007, revealed .Drugs and biologicals shall be stored in the packing, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers . Further review revealed .The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed . Observation with Licensed Practical Nurse (LPN) Unit Manager #1 on 8/21/19 at 3:20 PM, at the 300 lower end medication cart, in the 300 hallway revealed the following expired items: 6 [MEDICATION NAME] (nausea medication) 4 milligram (mg) tablets, individually packaged with the expiration date of 8/3/19 in zip-lock bag labeled [MEDICATION NAME] 4mg with expiration label of 9/4/19. Further observation revealed 3 individually packaged [MEDICATION NAME] 4mg tablets with the expiration date of 9/4/19 were combined in the labeled zip lock bag. Interview with LPN Unit Manager #1 on 8/21/19 at 3:25 PM, at the 300 lower end medication cart, confirmed the expired 6 [MEDICATION NAME] 4mg tablets were available for resident use. Interview with the Director of Nursing (DON) on 8/21/19 at 4:05 PM, in the conference room, confirmed expired medications were available for resident use and the facility failed to discard of the expired medications per facility policy.",2020-09-01
290,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2019-08-21,812,F,0,1,V5UN11,"Based on review of the facility policy, observation, and interview the facility failed to serve food at a palatable temperature, maintain a temperature log for 1 of 2 nourishment room freezers, ensure undated, unlabeled food and drink items were not available for resident use in 1 of 2 nourishment refrigerators potentially affecting 113 residents. The findings include: Review of the facility policy Refrigerators and Freezers, revised 12/2014 revealed .This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitization .2. Monthly tracking sheets for all .freezers will be posted to record temperatures .4. Food Service Supervisors or designated employees will check and record .freezer temperatures daily .7. All food shall be appropriately dated . Observation with the Dietary Manager (DM) on 8/19/19 at 12:00 PM, in the kitchen, revealed the DM calibrated the thermometer and obtained the food temperatures on the tray line. Further observation and interview revealed fish at 147 degrees Fahrenheit, rice at 165 degrees Fahrenheit, mechanical chicken at 155 degrees Fahrenheit, and pureed green beans at 145 degrees Fahrenheit. Observation and interview with the DM on 8/20/19 at 7:47 AM, in the conference room, revealed the DM calibrated the thermometer and obtained the temperature of the food on the breakfast test tray sent on the meal cart to the 200 hall. Further observation and interview revealed gravy at 127 degrees Fahrenheit and scrambled eggs 125.8 degrees Fahrenheit. Continued interview confirmed the gravy and eggs were below the holding temperature of 140 degrees Farenheit. Observation and interview with the DM on 8/21/19 at 12:40 PM, on the 100 hall, revealed the DM calibrated the thermometer and obtained the temperatures of the food on the lunch test tray sent on the meal cart to the 100 hall. Further observation and interview revealed a hamburger patty at 106 degrees Fahrenheit. Continued interview confirmed the hamburger patty was below the holding temperature of 140 degrees Farenheit. Observation with the Assistant Housekeeping Supervisor and DM on 8/21/19 at 1:30 PM, in the 400 hall nourishment room, revealed a nourishment refrigerator for resident use containing the following items: 1. One 5.5 ounce bag of barbeque chips, opened, undated, and unlabeled. 2. One quart-sized plastic water bottle, 1/2 used, undated, and unlabeled. 3. Two 16 ounce plastic water bottles, 1/2 used, undated, and unlabeled. 4. Two plastic-wrapped peanut butter and jelly sandwiches, undated and unlabeled. 5. One 16 ounce bottle of soda, 3/4 used, undated, and unlabeled. 6. One 7 ounce bowl of corn flakes cereal, undated. 7. One 6 ounce glass bowl containing clear and brown liquid, undated and unlabeled. 8. One Styrofoam to-go box inside a white plastic bag, undated and unlabeled. 9. Three 6 ounce bowls of cereal, undated. 10. One quart-sized plastic bag 1/4 full of fruit, undated and unlabeled. 11. One quart-sized plastic bottle containing a purple liquid, undated and unlabeled. Observation with the DM on 8/21/19 at 2:00 PM, in the 400 hall nourishment room, revealed a nourishment freezer for resident use with no temperature log and containing the following items: 1. One 32 ounce blue 1/2 used shaved ice drink, undated and unlabeled. 2. One 12 ounce restaurant cup, undated. Interview with the Assistant Housekeeping Supervisor, DM, and Unit Manager #1 on 8/21/19 at 2:05 PM, outside the 400 hall nourishment room, confirmed the items should have been both dated and labeled and needed to be thrown away. Further interview confirmed a thermometer was not kept in the 400 unit nourishment room freezer and a temperature log had not been maintained.",2020-09-01
291,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2019-08-21,925,F,0,1,V5UN11,"Based on review of facility policy, review of pest control documentation, observation, and interview the facility failed to maintain an effective pest control program in 1 of 1 kitchens, potentially affecting 113 residents. The findings include: Review of facility policy, Pest Control, revised (MONTH) 2008, revealed .Our facility shall maintain an effective pest control program .to ensure that the building is kept free of insects . Observation with the Dietary Manager (DM) on 8/19/19 at 8:55 AM, in the kitchen, revealed 2 roaches crawling inside an out-of-order side-by-side refrigerator. Interview with the DM on 8/19/19 at 8:55 AM, in the kitchen, confirmed .it was obviously a cockroach . Observation with the DM on 8/19/19 at 9:00 AM, in the kitchen, revealed a roach crawling along the kitchen floor. Interview with the DM on 8/19/19 at 9:00 AM, in the kitchen, confirmed .there's another cockroach . Observation with the DM on 8/19/19 at 9:05 AM, in the kitchen, revealed a roach crawling along the kitchen floor. Observation with the DM on 8/19/19 at 9:20 AM, in the dish room of the kitchen, revealed a dead roach underneath the dishwasher and a live roach crawling up the center section of the dishwasher line where clean dishes come out, crawling towards the sanitization compartment. Interview with the DM on 8/19/19 at 9:20 AM, in the dish room of the kitchen, confirmed .yeah (I see it too) . Observation with the DM on 8/19/19 at 9:30 AM, in the dish room of the kitchen, revealed a partially decomposed dead roach on top of the dishwasher. Interview with the DM on 8/19/19 at 9:30 AM, in the dish room of the kitchen, confirmed .it looks like a dead roach . Observation with the DM on 8/20/19 at 11:45 AM, in the dish room of the kitchen, revealed a dead roach underneath the dishwasher in the same place as observed on 8/19/19. Interview with the DM on 8/20/19 at 11:45 AM, in the dish room of the kitchen, confirmed the observation. Observation with the DM on 8/21/19 at 8:50 AM, in the dish room of the kitchen, revealed a dead roach underneath the dishwasher in the same place as observed on 8/19/19 at 9:20 AM and at 11:45 AM. Interview with the DM on 8/21/19 at 8:50 AM, in the dish room of the kitchen, confirmed the observation. Observation with the DM on 8/21/19 at 8:52 AM, revealed a dead roach on the floor in the corner of the dish room. Interview with the DM on 8/21/19 at 8:52 AM, in the dish room of the kitchen, confirmed the observation. Interview with the Registered Dietician on 8/21/19 at 9:15 AM, outside the kitchen confirmed the kitchen had a pest control problem and .needs more pest control . Interview with the Maintenance Director on 8/21/19 at 8:13 AM, in the conference room, confirmed prior to the survey, the facility was unaware of the roach problem in the kitchen.",2020-09-01
292,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2017-09-27,315,D,0,1,L2NH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure medical justification, and obtain a physician's order for the use of [REDACTED] The findings included: Medical record review revealed Resident #194 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #194 had an indwelling urinary catheter. Medical record review of Nurse's Notes dated 6/26/17 revealed .Resident has (urinary) catheter 18fr (French) .insertion date 6/22/17 . Medical record review of admission orders [REDACTED]. Medical record review of facility documentation revealed no order for Resident #194's urinary catheter. Medical record review of Urinary Continence Evaluation dated 6/26/17 revealed no documentation of medical justification for the use of the urinary catheter. Interview with the Director of Nursing (DON) on 9/27/17 at 9:40 AM, in the facility class room, confirmed .The physician does the orders on what hospital orders the resident comes with . Continued interview confirmed the facility did not require an order for [REDACTED].>Interview with the DON on 9/27/17 at 10:40 AM in the DON's office, confirmed .Don't need a cath (catheter) order like if a resident came with [MEDICAL CONDITION] would just follow those previous orders . Interview with the MDS Coordinator on 9/27/17 at 11:08 AM, in the facility classroom, confirmed an overactive bladder was not an indication for use of an urinary catheter based upon MDS guidelines. Interview with the Regional Quality Specialist on 9/27/17 at 11:15 AM, in the facility classroom, confirmed the facility failed to provide a medical justification for Resident #194's (urinary) catheter.",2020-09-01
293,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2017-09-27,431,D,0,1,L2NH11,"Based on review of facility policy, observation, and interview, the facility failed to separate medications and food in 1 of 3 medication refrigerators. The findings included: Review of the facility policy Storage of Medications, revised 4/2007, revealed .medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location . Medications must be stored separately from food and must be labeled accordingly . Observation with Licensed Practical Nurse #1 on 9/27/17 at 10:55 AM, in the 100 Medication Storage Room, revealed in the locked medication refrigerator, 2 cartons of liquid nutritional supplement, 1 bowl of pudding, and 1 large box of white wine. Further observation revealed medications including narcotics stored in the refrigerator. Interview with the Director of Nursing on 9/27/17 at 11:00 AM, in the Conference Room, confirmed the facility failed to store medications separately from food in the medication refrigerator.",2020-09-01
294,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2018-10-11,584,D,0,1,SM1F11,"**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 readily accessible soap products for 1 resident (#107), on 1 of 4 hallways observed, of 33 sampled residents. The findings include: Review of the facility policy Handwashing/Hand Hygiene, revised 8/2015, revealed .hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use .residents, family members and/or visitors will be encouraged to practice hand hygiene . Medical record review revealed Resident #107 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 of Mental Status of 15, indicating the resident was cognitively intact, the resident was independent for ambulation and toileting, and performed hygiene with limited assistance. Observation on 10/9/18 at 8:15 AM, of the resident's room on the 400 hallway, revealed the soap dispenser above the sink did not have a cover and there was no soap in the dispenser. Continued observation revealed there was no soap or sanitizer at the sink. Interview with Resident #107 on 10/9/18 at 8:20 AM, in the Activity Room, confirmed the resident did not have soap to wash her hands at the sink in her room. Interview with the Director of Nursing and the Maintenance Director on 10/9/18 at 8:30 AM, in the resident's room on the 400 hallway, confirmed there was no cover for the soap dispenser and there was no soap available in the dispenser or next to the sink for the resident, staff, or visitors for handwashing. Continued interview confirmed the facility failed to have soap readily available for use in the resident's room.",2020-09-01
295,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2018-10-11,656,D,0,1,SM1F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to implement the plan of care for diabetic management for 1 resident (#96) of 33 residents sampled. The findings include: Medical record review revealed Resident #96 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 for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Medical record review of the Care Plan dated 6/13/18 revealed .Potential for [DIAGNOSES REDACTED] (low blood sugar)/[MEDICAL CONDITION] (high blood sugar) secondary to [DIAGNOSES REDACTED].Administer medication as ordered . Medical record review of the physicians orders dated 6/6/18 revealed .sliding scale (amount of insulin given dependent on blood sugar result) over 450 (blood sugar result) give 12 units (of insulin) recheck (blood sugar) in 2 (hours) if still above 450 give 12 units Q (every) 2 (hours) until under 450 . Medical record review of the Medication Record dated 10/1/18 through 10/31/18 revealed .[MEDICATION NAME] (insulin) R (regular) .Accuchecks (blood sugar check) BID (twice a day) .250-300/4 units (for blood sugar result of 250-300 give 4 units of insulin) 301-350/ 6 units 351-400/8 units 401- 450/10 units > (greater than) 450/12 units Recheck in 2 (hours) and repeat . Medical record review of the Diabetic Monitor Log dated 10/2018 revealed blood glucose levels were ordered for 6:30 AM and 4:30 PM. Continued review revealed blood glucose levels were greater than 450 on 10/1/18, 10/2/18, 10/5/18, 10/6/18, and 10/7/18 at the 4:30 PM check, and there was no documentation of the blood glucose recheck in 2 hours or repeated insulin administration. Telephone interview with the hospice physician on 10/10/18 at 1:56 PM, confirmed it was her expectation the facility would recheck blood sugar and administer insulin coverage as ordered by the physician. Interview with the Director of Nursing (DON) on 10/10/18 at 2:40 PM, in the conference room, confirmed the facility failed to follow the physician's orders [REDACTED].#96's blood glucose and provide insulin coverage for blood glucose greater than 450.",2020-09-01
296,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2018-10-11,679,D,0,1,SM1F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of medical records, observation, and interview, the facility failed to provide individual 1 on 1 activities for 1 resident (#72) of 33 residents reviewed. The findings include: Review of the facility policy Activities and Social Services, revised 12/2006, revealed .a resident .considered to lack sufficient decision making capacity, mental incompetence, or physical capacity to participate .the facility will provide activities . Medical record review revealed Resident #72 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan, Resident prefers to stay in door for activities, dated 6/1/18 revealed .provide one on one activities as indicated .continue to encourage outer room activity for social stimulation . Medical record review of the Record of One-to One Activities for Resident #72 revealed 6 entries of one-to-one activities from 3/1/18 to 7/22/18. Continued review revealed no further documentation of one-to-one activities. Medical record review of the quarterly Minimum (MDS) data set [DATE] revealed a Brief Interview of Mental Status of 99, indicating severe cognitive impairment, and the functional status for ambulation, toileting, and hygiene was total dependence. Observations of Resident #72 on 10/8/18 and 10/9/18 throughout the day, revealed 1 occurrence of the resident being taken to a weight scale and then returned to the room. Continued observations revealed the resident in the private room with the blinds closed and the lights off over the 2 days observed. Interview with the Director of Nursing and the Activity Assistant on 10/9/18 at 5:00 PM, in the Conference Room, confirmed Resident #72 did not attend organized activities, was care planned for 1 on 1 activities, and no 1 on 1 activities were provided by the facility on 10/8/18 or 10/9/18. Interview with the Administrator on 10/9/18 at 5:35 PM, in the Conference Room, confirmed the facility had not provided 1 on 1 activities for Resident #72 since 7/22/18.",2020-09-01
297,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2018-10-11,755,D,0,1,SM1F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to timely order, obtain, and administer medications for 1 resident (#15) of 33 residents sampled. The findings include: Review of the facility policy Administering Medications, revised 12/2012, revealed .If a medication is ordered and not available from the pharmacy, the ordering physician or Nurse Practitioner/Physician Assistant should be notified for an alternative order until medication is available . Medical record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician's orders dated 10/1/18-10/31/18 revealed .[MEDICATION NAME] (an antibiotic) .100 mg (milligrams) .Take 1 capsule by mouth once daily *Nurse to reorder* .(give at) 8 AM .Artificial tear drops instill 1 drop in right eye four times a day .(give at) 8 AM .12 PM .4 PM .8 PM . Medical record review of the Medication Record dated 10/1/18 -10/31/18 revealed [MEDICATION NAME] had not been given from 10/1/18 through 10/9/18. Further review revealed the artificial tears had not been administered on 10/9/18 for the 8:00 AM dose. Interview with Licensed Practical Nurse (LPN) #1 on 10/9/18 at 3:45 PM, in the nurses lounge/nurses station, confirmed the [MEDICATION NAME] and artificial tears were not available for administration. Continued interview confirmed the physician had not been notified of the unavailable medications. Interview with the Medical Director (the resident's physician) on 10/9/18 at 3:59 PM, at the 300 hall nurse's station, confirmed the Medical Director was unaware the artificial tears and [MEDICATION NAME] had been unavailable and was not administered to the resident. Continued interview revealed it was his expectation to be made aware of any missed doses of medication. Interview with the Director of Nursing (DON) on 10/10/18 at 2:38 PM, in the conference room, confirmed the facility failed to notify the Medical Director the [MEDICATION NAME] and artificial tears were unavailable for administration.",2020-09-01
298,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2018-10-11,756,D,0,1,SM1F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility pharmacy services failed to report irregularities to the physician for 1 resident (#96) of 3 residents reviewed for insulin administration of 33 residents reviewed. The findings include: Medical record review revealed Resident #96 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physicians orders dated 6/6/18 revealed .sliding scale (amount of insulin given dependent on blood sugar result) over 450 (blood sugar result) give 12 units (of insulin) recheck (blood sugar) in 2 (hours) if still above 450 give 12 units Q (every) 2 (hours) until under 450 . Medical record review of the Medication Record dated 10/1/18 through 10/31/18 revealed .[MEDICATION NAME] (insulin) R (regular) .Accuchecks (blood sugar check) BID (twice a day) .250-300/4 units (for blood sugar result of 250-300 give 4 units of insulin) 301-350/ 6 units 351-400/8 units 401- 450/10 units > (greater than) 450/12 units Recheck in 2 (hours) and repeat . Medical record review of the Diabetic Monitor Log dated 10/2018 revealed blood glucose levels were ordered for 6:30 AM and 4:30 PM. Continued review revealed blood glucose levels were greater than 450 on 10/1/18, 10/2/18, 10/5/18, 10/6/18, and 10/7/18 at the 4:30 PM check, and there was no documentation of the blood glucose recheck in 2 hours or repeated insulin administration. Telephone interview with the hospice physician on 10/10/18 at 1:56 PM, confirmed it was her expectation the facility would recheck blood sugar and administer insulin coverage as ordered by the physician. Interview with the Consultant Pharmacist on 10/10/18 at 1:26 PM, in the Conference Room, confirmed it was his responsibility to review the charts monthly to ensure the physician's orders [REDACTED].#96 and the Consultant Pharmacist had failed to identify the irregularity during the monthly chart reviews.",2020-09-01
299,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2018-10-11,770,D,0,1,SM1F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to obtain laboratory (lab) services as ordered by the physician for 1 resident (#46) of 33 residents sampled. The findings include: Medical record review revealed Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED].LABS .TSH ([MEDICAL CONDITION] level), Lipid (cholesterol), CMP (Complete Metabolic Panel) yearly in (MONTH) .[MEDICATION NAME], CBC (Complete Blood Count), LFT (Liver Function Test), CRCL (Creatinine Clearance, a test for kidney function) , K+ (Potassium) every 6 months (May/Nov) . Medical record review of the lab results for Resident #46 revealed no documentation of a TSH, LIPID, CBC, or LFT level for (MONTH) (YEAR). Interview with the Director of Nursing (DON) on 10/11/18 at 10:14 AM, at the 200 hallway, confirmed the facility failed to obtain the labs for (MONTH) including the TSH, LIPID, CBC, and LFT.",2020-09-01
300,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2018-10-11,812,E,0,1,SM1F11,"Based on review of facility policy, observation, and interview, the facility failed to maintain sanitation of 3 of 3 ice machines observed, and failed to maintain sanitary pans to serve resident food for 9 of 15 pans observed. The findings include: Review of the facility's policy Sanitization revised 2008, revealed .Food preparation equipment and utensils that are manually washed will be allowed to air dry . Observation and interview with the Dietary Manager on 10/8/18 from 9:20 AM to 10:00 AM, in the kitchen, revealed the ice machine had brown and black debris on the top frame of the ice bin, and white debris on the side wall of the ice bin; and three 4 inch quarter pans, four 8 inch quarter pans, and two 2 inch quarter pans were stored and ready to use to serve resident food. Interview with the Dietary Manager confirmed the ice bin had debris and the 9 pans were stored wet and were available for use to serve resident food. Observation and interview with Licensed Practical Nurse (LPN) #3 on 10/9/18 at 6:05 PM, in the ice machine closet on the 300 unit, revealed the ice bin had brown and black debris on the top frame of the ice machine and on the metal frame on the sides. Interview with LPN #3 confirmed the brown and black debris in the ice machine bin was unsanitary. Observation and interview with LPN #2 on 10/9/18 at 6:10 PM, in the ice machine closet on the 100 unit, revealed the ice bin had brown/black debris and rust on the top frame and on the side metal frame. Interview with LPN #2 confirmed the black/brown debris and rust in the ice machine bin was unsanitary.",2020-09-01
301,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2018-10-11,814,C,0,1,SM1F11,"Based on observation and interview, the facility failed to maintain a lid on 1 of 1 dumpster to prevent vermin from entering the dumpster. The findings include: Observation and interview on 10/8/18 at 9:55 AM, with the Dietary Manager outside of the facility at the dumpster site, revealed the garbage dumpster did not have a lid to prevent possible vermin from entering the dumpster. Interview with the Dietary Manager confirmed the dumpster did not have a lid in place.",2020-09-01
302,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2018-10-11,842,D,0,1,SM1F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, and interview, the facility failed to maintain an accurate and complete medical record of wound care treatment documentation for 1 Resident (#65) and for medication administration for 1 Resident (#96) of 33 residents sampled. The findings include: Review of the facility policy Wound Care, revised 10/2010, revealed .Documentation .The following information should be recorded in the resident's medical record .The date and time the wound care was given .If the resident refused the treatment and the reason(s) why .The signature and title of the person recording the data . Medical record review revealed Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician/Prescriber Telephone Order dated 9/18/18 revealed .cleanse (right) gluteal abscess site (with) (wound cleanser), apply Dakins ([MEDICATION NAME] solution) 1/2 strength, wet to dry dressing bid (twice a day). Cover (with) [MEDICATION NAME] (type of foam dressing) . Review of the Treatment Record dated 9/1/18-9/30/18 revealed the treatment to the right gluteal abscess site had not been completed on the 2nd shift on 9/23/18, 9/26/18, and 9/28/18. Interview with the Wound Care Licensed Practical Nurse (LPN) on 10/10/18 at 2:57 PM, in the conference, room confirmed the treatment for [REDACTED]. Interview with the Director of Nursing on 10/11/18 at 9:05 AM, in the conference room, confirmed Resident #65's medical record was incomplete and the facility failed to follow the facility wound care policy. Medical record review revealed Resident #96 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the care plan dated 6/13/18 revealed .Potential for [DIAGNOSES REDACTED] (low blood sugar) /[MEDICAL CONDITION] (high blood sugar) secondary to [DIAGNOSES REDACTED].Administer medication as ordered . Medical record review of the Physicians Orders dated 10/1/18 through 10/31/18 revealed .[MEDICATION NAME] (insulin) .10 UNITS .ONCE DAILY . Medical record review of the Medication Record dated 10/1/18 through 10/31/18 revealed no documentation the resident received the [MEDICATION NAME] on 10/1/18, 10/2/18, 10/5/18, 10/6/18, and 10/7/18. Interview with the Director of Nursing on 10/9/18 at 5:21 PM, at the 400 hall nurses station, confirmed the facility failed to document [MEDICATION NAME] administration on 10/1/18, 10/2/18, 10/5/18, 10/6/18, and 10/7/18.",2020-09-01
303,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2019-11-27,569,D,1,0,GP5R11,"> Based on review of facility policy, review of resident funds accounts, and interviews, the facility failed to provide conveyance of personal funds within 30 days of discharge, transfer, or death for 4 residents (#5, #7, #8 and #9) of 39 residents reviewed for resident funds accounts. The findings included: Review of the facility policy Resident Refund Policy, last revised 3/20/17 revealed .To ensure that all resident accounts reconciled and maintained according to federal and state regulations .Any Resident refunds due shall be submitted, via email, with the appropriate documentation, to the Regional Field Controller (RFC) for approval . Review of resident funds accounts on 11/26/19 revealed the following: Resident #5 had $2631.50 remaining in a resident funds account. Further review revealed the resident was discharged from the facility on 9/6/19 (81 days earlier). Resident #7 had $497.00 remaining in a resident funds account. Further review revealed the resident was discharged from the facility on 9/16/19 (71 days earlier). Resident #8 had $175.75 remaining in a resident funds account. Further review revealed the resident was discharged from the facility on 9/25/19 (62 days earlier). Resident #9 had $40.00 remaining in a resident funds account. Further review revealed the resident was discharged from the facility on 9/29/19 (58 days earlier). Interview with the Administrator on 11/27/19 at 9:30 AM, in her office, revealed .it was brought to my attention in (MONTH) (2019) we (facility) had multiple outstanding past due refunds .contacted the Regional Director of Operations .to prevent a hardship on the corporation it was decided to pay a couple of the largest refunds monthly . Interview with the Business Office Manager on 11/27/19 at 9:45 AM, in the Administrator's office, revealed .I send a list of discharges to the corporate office at the end of each month . In summary, the facility failed to provide conveyance of resident funds within 30 days of discharge for Residents #5, #7, #8, and #9.",2020-09-01
304,TENNOVA LAFOLLETTE HEALTH AND REHAB CENTER,445115,200 TORREY ROAD,LAFOLLETTE,TN,37766,2020-01-23,684,D,0,1,5Y8I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to follow Physician Orders for wound care and failed to follow Physician Orders for sliding scale insulin for 1 resident (#59) of 3 residents reviewed for wound care and sliding scale insulin. The findings include: Review of the facility's policy titled, Medication Administration, dated 10/20/2018, showed .Medications will be administered only upon the orders of physicians . Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Physician Telephone Order dated 12/16/2019, showed .Apply Z-guard (ointment to treat pressure wound) BID/PRN (twice daily and as needed) . Review of a Treatment Flow Sheet dated 12/1/2029-12/31/2019, showed Z-guard had been applied daily 12/16/2019-12/31/2019, and not BID/PRN as ordered. Review of a Treatment Flow Sheet dated 1/1/2020-1/31/2020, showed the Z-guard had been applied daily 1/1/2020, 1/2/2020, 1/3/2020 and 1/6/2020-1/21/2020. And not BID/PRN as ordered. The Z-guard had not been applied on 1/1/2020, 1/4/2020 and 1/5/2020 as ordered. Review of the Weekly Wound Assessment Sheet dated 12/16/2019, showed a sacrum stage II wound, onset 11/2019 measuring 1x (by)1 x 0.1 centimeter (cm). Review of the Weekly Wound Assessment Sheet dated 1/20/2020, showed the wound measured 1 x 1 x 0.1cm and did not increase in size. Observation of the resident on 1/22/19 at 1:30 PM, revealed the resident lying on her back with the head of bed elevated at 30 degrees and an air mattress in place. During an interview on 1/22/2020 at 4:00 PM, the Wound Nurse confirmed the wound care had been provided daily 12/16/2020-12/31/2020 and had been provided daily 1/2/2020, 1/3/2020, and 1/6/2020-1/21/2020. There was no documentation that wound care had been provided to Resident #59 as ordered. During an interview on 1/23/2020 at 8:20 AM, the Director of Nursing (DON) confirmed the facility failed to follow physician orders for wound care for Resident #59. Observation of Resident #59's wound on 1/23/2020 at 9:20 AM, with the Lead Supervisor showed an open area to the sacrum, pink wound bed, with no odor or drainage, and the area was blanchable (skin blanches with pressure). The resident was lying in the bed with an air mattress in place. Review of the Physician Recapitulation Orders for 1/1/2020-1/31/2020 showed, .[MEDICATION NAME] (medication to treat Diabetes) .BEFORE MEALS & (AND) AT BEDTIME .LOW DOSE SLIDING SCALE . Review of an Insulin Administration Documentation record dated 1/20/2020 8PM-1/23/2020 5AM showed the resident had a moderate dose sliding scale in place, and not the low dose sliding scale as ordered for Resident #59. The Insulin Administration Documentation record showed the resident had a total of 8 incorrect doses of insulin administered from 1/20/2020-1/23/2020. During an interview on 1/23/2020 at 12:20 PM, the DON confirmed the facility failed to follow physician orders for sliding scale insulin for Resident #59. During an interview on 1/23/2020 at 12:50 PM, Licensed Practical Nurse (LPN) #2 confirmed she failed to administer the correct dose of sliding scale insulin to Resident #59 on 1/22/2020 at 12:00 PM and 5:00PM. During a telephone interview on 1/23/2020 at 2:08 PM, Resident #59's Physician stated the resident used to be on a moderate dose sliding scale and he changed it to low dose sliding scale.",2020-09-01
305,TENNOVA LAFOLLETTE HEALTH AND REHAB CENTER,445115,200 TORREY ROAD,LAFOLLETTE,TN,37766,2020-01-23,758,E,0,1,5Y8I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview the facility failed to attempt a Gradual Dose Reduction (GDR) of [MEDICAL CONDITION] medications for 1 resident (#14), and failed to provide a rationale for the continued use of an as needed (PRN) antianxiety and antipsychotic medication beyond 14 days for 1 resident (#40) of 5 residents reviewed for unnecessary medications. The findings include: Review of the medical record showed Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], showed Resident #14 received antidepressant medications on all 7 days of the assessment look back period. Review of the Physician Recapitulation Orders for 1/1/2020 - 1/31/2020, showed [MEDICATION NAME] (antidepressant) 30 milligrams (mg) by mouth twice daily with an order date of 2/7/2018 and [MEDICATION NAME] (antidepressant) 50 mg 1and 1/2 tablets by mouth daily with an order date of 2/11/2019. Observation of the resident on 1/22/2020 at 10:16 AM, Resident #14 was seated outside of the beauty shop interacting with staff with no behaviors. During an interview on 1/23/2020 at 11:50 AM, the Director of Nursing (DON) confirmed that a GDR had not been attempted for [MEDICATION NAME] or [MEDICATION NAME] since the medications were first prescribed. Review of the medical record showed Resident #40 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] showed Resident #40 scored a 6 on the Brief Interview for Mental Status (BIMS) indicating the resident had severe cognitive impairment. The resident had no moods or behaviors and the resident received antianxiety, antidepressant and opioid medications. Review of the hospital Discharge Medication List dated 1/1/2020 showed [MEDICATION NAME] 0.5 mg (antianxiety medication) every 8 hours PRN with no stop date and [MEDICATION NAME] disintegrating tablet (antipsychotic medication) 5 mg every 6 hours PRN with no stop date. Review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Observation of Resident #40 on 1/22/2020 at 3:25 PM and 1/23/2020 at 8:40 AM revealed the resident lying in his bed with no behaviors exhibited. During an interview on 1/23/2020 at 11:50 AM, the DON confirmed the PRN [MEDICATION NAME] and the PRN [MEDICATION NAME] did not have a discontinue date or end date ordered and the medications continued beyond the 14 day time frame.",2020-09-01
306,TENNOVA LAFOLLETTE HEALTH AND REHAB CENTER,445115,200 TORREY ROAD,LAFOLLETTE,TN,37766,2020-01-23,760,D,0,1,5Y8I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Facility policy review, medical record review, and interview, the facility failed to prevent a significant medication error for 1 resident (#59) of 3 residents reviewed for insulin administration. The findings include: Review of the facility's policy titled, Medication Administration, dated 10/20/2018, showed .Medications will be administered only upon the orders of physicians . Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician Recapitulation Orders for 1/1/2020-1/31/2020 showed, .[MEDICATION NAME] (insulin medication to treat Diabetes) .BEFORE MEALS & (AND) AT BEDTIME .LOW DOSE SLIDING SCALE . Review of a blank Insulin Administration Documentation form undated showed: Low Dose Regimen (blood glucose ranges) - Less than 40= initiate [DIAGNOSES REDACTED] protocol and call MD (Medical Doctor) - 41-50= 0 units - 151-200= 0 units - 201-250= 3 units - 251-300= 4 units - 301-350= 6 units - 351-499= 9 units - Greater than 500= 12 units of insulin and call MD The Moderate Dose Regimen (blood glucose ranges) - Less than 40= initiate [DIAGNOSES REDACTED] protocol and call MD - 41-150= 0 units -151-200= 4 units - 201-250= 8 units - 251- 300= 10 units -301-350= 12 units - 351-499= 16 units - Greater than 500= 18 units and call MD Review of Resident #59's Insulin Administration Documentation form dated 1/20/2020 at 8PM-1/23/2020 5AM showed Resident #59 had a moderate dose sliding scale in place, and not the low dose sliding scale as ordered. The form showed the following: - 1/20/2020 at 8PM, blood sugar 310, [MEDICATION NAME] 10 units administered. The resident was to receive [MEDICATION NAME] 6 units as per ordered sliding scale. - 1/21/2020 at 5AM, blood sugar 245, [MEDICATION NAME] 8 units administered. The resident was to receive [MEDICATION NAME] 3 units as per ordered sliding scale. - 1/21/2020 at 8PM, blood sugar 267, [MEDICATION NAME] 10 units administered. The resident was to receive [MEDICATION NAME] 4 units as per ordered sliding scale. - 1/22/2020 at 5AM, blood sugar 155, [MEDICATION NAME] 4 units administered. The resident was to receive [MEDICATION NAME] 0 units as per ordered sliding scale. - 1/22/2020 at 12PM, blood sugar 197, [MEDICATION NAME] 4 units administered. The resident was to receive [MEDICATION NAME] 0 units as per ordered sliding scale. - 1/22/2020 at 5PM, blood sugar 221, [MEDICATION NAME] 4 units administered. The resident was to receive [MEDICATION NAME] 3 units as per ordered sliding scale. - 1/22/2020 at 9PM, blood sugar 251, [MEDICATION NAME] 10 units administered. The resident was to receive [MEDICATION NAME] 4 units as per ordered sliding scale. - 1/23/2020 at 5AM, blood sugar 176, [MEDICATION NAME] 4 units administered, The resident was to receive [MEDICATION NAME] 0 units as per ordered sliding scale. A total of 8 wrong doses had been administered to Resident #59. The resident did not experience hypoglycemic episodes due to the incorrect doses being administered. During an interview on 1/23/2020 at 12:20 PM, the Director of Nursing confirmed the facility follows the Insulin Administration Documentation record for insulin low dose regimen. The DON confirmed Resident #59 had received 8 incorrect doses of insulin and the facility failed to follow physician orders [REDACTED].#59. During an interview on 1/23/2020 at 12:50 PM, Licensed Practical Nurse (LPN) #2 confirmed she failed to administer the correct dose of sliding scale insulin to Resident #59 on 1/22/2020 at 12:00 PM and 5 PM. During a telephone interview on 1/23/2020 at 2:08 PM, Resident #59's Physician stated the resident used to be on a moderate dose sliding scale and he changed it to low dose sliding scale. The Physician stated there were no adverse side effects to the resident due to the incorrect insulin doses administered.",2020-09-01
307,TENNOVA LAFOLLETTE HEALTH AND REHAB CENTER,445115,200 TORREY ROAD,LAFOLLETTE,TN,37766,2020-01-23,842,D,0,1,5Y8I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure a physician had signed the Physician's Orders for Scope of Treatment (POST) (a physician's order which indicates end of life care preferences) for 1 (#46) of 24 sampled residents for POST forms. The findings include: Review of the medical record showed Resident #46 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the POS [REDACTED]. Review of the Physician's Recapitulation Orders dated 1/2020 showed the resident had a Do Not Resuscitate (DNR) status. During an interview on 1/23/2020 at 8:30 AM, the Director of Nursing confirmed the POST dated 9/12/2019 had not been signed by a physician.",2020-09-01
308,TENNOVA LAFOLLETTE HEALTH AND REHAB CENTER,445115,200 TORREY ROAD,LAFOLLETTE,TN,37766,2020-01-23,880,D,0,1,5Y8I11,"**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 follow contact isolation precautions for 1 resident (#60) of 4 residents observed for contact isolation. The findings include: Review of the facility's policy titled, Isolation Policy, revised 4/5/2016, showed .Contact Precautions .Personal Protective Equipment .Wear gloves and gown when entering the room .a mini-stop sign will be placed outside the door . Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Physician's Telephone Order dated 1/14/2020 showed contact precaution for Urinary Tract Infection [MEDICAL CONDITION] Multidrug Resistant Organism (MDRO). Observation at Resident #60's room on 1/21/2020 at 11:00 AM, showed a large metal box placed on the resident's entrance door with no signage on the door. During an interview on 1/21/2020 at 11:20 AM, Licensed Practical Nurse (LPN) #1 stated the resident was on contact isolation due to MDRO UTI. Observation on 1/21/2020 at 12:46 PM, showed LPN #1 entered the resident's room, donned gloves, and administered medication to Resident #60. Observation on 1/21/2020 at 12:48 PM, showed the Unit Secretary entered the resident's room without donning gloves or gown. During an interview on 1/21/2020 at 12:50 PM, the Unit Secretary stated she was not aware Resident #60 was on contact isolation .there is not a sign on the door . During an interview on 1/21/2020 at 12:55 PM, LPN #1 stated the staff had to don gloves prior to entering the resident's room and wear a gown if the staff came in contact with bodily fluids or .up close care . LPN #1 confirmed there was no contact isolation sign on Resident #60's door. Observation of the resident on 1/23/2020 at 9:40 AM, showed the resident sitting in a chair in her room with Certified Nursing Assistant (CNA) #1 present. Continued observation showed the staff member was not wearing a gown or gloves in the resident's room. During an interview on 1/23/2020 at 9:45 AM, with CNA #1 stated she had not applied gloves or gown prior to entering Resident #60's room, I know I should wear gloves but I was never told to wear a gown. During an interview on 1/23/2020 at 8:26 AM, the Director of Nursing confirmed the facility failed have contact isolation precautions in place for Resident #60 and failed to follow their facility policy.",2020-09-01
309,TENNOVA LAFOLLETTE HEALTH AND REHAB CENTER,445115,200 TORREY ROAD,LAFOLLETTE,TN,37766,2018-05-03,602,D,1,0,IO8511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation, observation, and interview, the facility failed to prevent misappropriation of a narcotic patch for 1 resident (#1) of 6 residents reviewed for misappropriation of property. The findings included: Review of the facility policy Abuse Prevention Program dated 8/17 revealed .Our residents have the right to be free from abuse, neglect, misappropriation of resident property .Protect our residents from abuse by anyone . Medical record review revealed Resident #1 was admitted to the facility on [DATE], and was readmitted on [DATE], with the [DIAGNOSES REDACTED]. Review of a Quarterly Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. Review of the facility's investigation dated 4/8/18 at 5:30 PM, revealed Resident #1 called for LPN #2, and reported the other nurse had told her she was sent to change her pain patch. When LPN #2 checked the patch she discovered the pain patch missing but the [MEDICATION NAME] (clear dressing) was intact. When the facility was able to contact LPN #1 she stated she was trying to replace the torn [MEDICATION NAME] covering the patch, and accidently removed the patch with the torn [MEDICATION NAME]. She had discovered it in her scrub pocket late that night when doing laundry. On 4/9/18 at approximately 7:00 AM, LPN #1 reported to the Director of Nurses office, and was escorted to HR (Human Resources). At this time LPN #1 returned the patch to the facility. The facility noted the LPN had red eyes and unusual speech patterns. She was taken to the lab for a drug screen, which was failed due to urine failing to have a temperature with in the acceptable range. This was considered a positive and LPN #1 was terminated. Observation and interview with Resident #1 on 5/1/18 at 10:00 AM, in her room revealed on Sunday morning 4/8/18, LPN #1 was a new nurse her hair was blue, she asked me to stand up and I told her I couldn't. She said I'll have to put your pain patch on in the bed. I told her I didn't think it was time for it to be changed, but she said (LPN #2) said it was. She took off the old patch and folded it up in a small piece of gauze. Then she put something on my back, but when (LPN #1) checked she said she didn't put a new patch on. Interview with LPN #2 on 5/1/18 at 10:15 AM, on the 200 Central Hall revealed Resident #1 told her that girl told me you sent her in here to change my patch. I asked her if the girl had blue hair and she said yes that's her. I checked her patch. There was a [MEDICATION NAME] with the date and her (LPN #1's) initials but no patch. The old patch had been removed but she did not put on a new patch. Continued interview revealed somewhere between 9:45 AM, and 10:00 AM, she had observed LPN #1 flipping through my MAR (Medication Administration Record), and around 10:00 AM, (LPN #1) told me (Resident #4) wanted her 12:00 PM, pain pills and asked me if I had given them. She asked me if I wanted her to take the medicine to her and I told her no. Then about 11:30 AM, she told me (Resident #6) wanted a pain pill, and asked me if I wanted her to take it to him, again I told her no. Further interview revealed she had reported both incidents to the RN supervisor. She stated I went and told (RN #1) that she kept asking me if I wanted her to give my residents their pain medications. Interview with RN #1 on 5/1/18 at 12:10 PM, via telephone revealed, (LPN #2) came to me and said (Resident #1) had stated (LPN #1) had removed her patch. The [MEDICATION NAME] was there but there was not patch. It was dated and (LPN #1's) initials were on it. She identified her as the blue haired girl. (LPN #1) was working as a CNA (certified nurse aide) that day; she had no business in the MAR, or dealing with the medications. I told her to just be a CNA for today, and to forget about passing medication, just to do patient care. I had to redirect her a couple of times. She took the [MEDICATION NAME] (pain medication) patch off and kept it. Further interview revealed (LPN #1) had been complaining of being sick, and not long after she took the patch off, she said she was sick, and asked to leave and he had told her to go ahead and leave. Interview with LPN #1 on 5/1/18 4:30 PM, via telephone revealed When I took off the old [MEDICATION NAME], the patch must have come off with it. I reapplied the new [MEDICATION NAME] initialed and dated it. I didn't realize the patch was still on the old [MEDICATION NAME] until I found it in my scrub pocket. Further interview revealed LPN #1 stated as a CNA I should have reported to the nurse, but I am used to being the nurse and I had never worked as a CNA before. I didn't think anything about fixing the [MEDICATION NAME]. Review of facility documents, Daily Assignment Sheets for 3/29/18 through 4/8/18 revealed LPN #1 had worked as a CNA on 3/29, 3/30, 3/31, 4/1, 4/7 and 4/8/2018. Interview with CNA #2 on 5/2/18 at 8:45 AM, in the conference room revealed at approximately 2:00 PM, she (LPN #1) was in (Resident #1's) room, I walked down the hall, the resident's back was towards the door, and she (LPN #1) was standing at her back, as I walked by I heard her say (LPN #2) told me to come in and change your patch. Interview with the Administrator on 5/2/18 at 1:48 PM, in the conference room confirmed the facility failed to prevent misappropriation of a narcotic patch for Resident #1.",2020-09-01
310,TENNOVA LAFOLLETTE HEALTH AND REHAB CENTER,445115,200 TORREY ROAD,LAFOLLETTE,TN,37766,2018-09-07,609,D,1,0,OSU511,"> Based on review of the facility policy, facility investigation review, and interviews the facility failed to ensure staff report an allegation of abuse in a timely manner. The findings include: Review of the facility policy Abuse Investigation and Reporting dated 8/13/17, revealed .Reporting .2. Suspected abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported within two hours . Review of afacility investigation dated 7/4/18, revealed while the facility was interviewing staff for an alleged allegation, CNA #4 made an allegation of abuse regarding CNA #3. During the interview CNA #4 revealed the allegation happened late (MONTH) or early June, and CNA #4 had not reported the allegation. Interview with the Director of Nursing (DON) on 9/4/18, at 10:40 AM, in the DON's office, confirmed CNA #4 had not reported the allegation of abuse regarding CNA #3 in a timely manner.",2020-09-01
311,TENNOVA LAFOLLETTE HEALTH AND REHAB CENTER,445115,200 TORREY ROAD,LAFOLLETTE,TN,37766,2018-12-05,686,D,0,1,2QW911,"**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 maintain infection control practices during a dressing change for 1 resident (#4) of 2 residents reviewed for pressure ulcers of 22 residents sampled. The findings include: Review of the facility policy Hand Washing With and Without Water Policy, revised 12/3/14 revealed, .Purpose .B. To reduce overall infection rates .I. Policy: [NAME] Handwashing will be utilized as a method of prevention and control of infection. Thorough handwashing is the most important factor in the control of infection. Handwashing should be done by clinical staff often when providing care. When hands are visibly dirty or contaminated wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water .B. If hands are not visibly soiled, use an alcholol- based .hand rub for routinely decontaminating hands. Handrubs should be used before care and after completion of care for each patient. C. Wear gloves when contact with blood or other potentially infectious materials, mucous membranes, and nonintact skin could occur. Change gloves during patient care if moving from a contaminated body site to a clean body site .Procedure: A Indications for handwashing and antisepsis .1. Before giving direct care to patient; 2. After giving direct care to a patient .7 .after glove removal .9. After contact with body fluids or excretions, mucous membrames, non-intact skin, and wound dressings if hands are not visibly soiled .11. If moving from a contanimated body site to a clean body (site) during patient care . Medical record review revealed Resident #4 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 (BIMS) score of 6 indicating the resident was severely cognitively impaired. Further review revealed the resident had a pressure ulcer. Observation of Resident #4's wound care with Registered Nurse (RN) #1 on 12/4/18 at 2:07 PM, in the resident's room, revealed RN #1 applied clean gloves and removed the soiled dressing from the resident's pressure wound. Further observation revealed the RN then removed the soiled gloves, and applied clean gloves without performing hand hygiene. Continued observation revealed RN #1 cleaned the wound, and without changing gloves and performing hand hygiene, picked up clean 4 x 4 (size of bandage) bandages, and applied wound cleanser to the clean 4 x 4 bandages with the contaminated gloves. Further observation revealed RN #1 removed the dirty gloves, and applied clean gloves without performing hand hygiene. Continued observation revealed the RN then used the 4 x 4 bandages the RN had wet with wound cleanser while wearing the dirty gloves, and packed the resident's wound with the contaminated 4 x 4 bandages. Further observation revealed RN #1 then removed the gloves worn while packing the pressure wound, did not perform hand hygiene, and applied a clean dressing with the bare hands. Interview with the Director of Nursing (DON) on 12/5/18 at 9:05 AM, in the conference room, confirmed it was the facility policy for nurses to perform hand hygiene between glove changes. Further interview confirmed it is the facility policy for the nurses to wear gloves with the application of a clean dressing. Continued interview confirmed RN #1 failed to maintain infection control practices during a dressing change.",2020-09-01
312,TENNOVA LAFOLLETTE HEALTH AND REHAB CENTER,445115,200 TORREY ROAD,LAFOLLETTE,TN,37766,2018-12-05,756,D,0,1,2QW911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to act timely on pharmacy recommendations for 2 residents (#12 and #13) of 5 residents reviewed for unnecessary medications, of 22 residents reviewed. The findings include: Medical record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a pharmacy recommendation dated 8/23/18 revealed .Drug, dosage and schedule presently on [MEDICATION NAME] (medication to treat depression) 50mg (milligrams) .(one tablet) HS (at bedtime) .tapered dosage and schedule [MEDICATION NAME] 25mg .(one tablet) HS (at bedtime) Further review revealed the Physician agreed with and signed the recommendation on 11/13/18 (sixty-six days later) and the order was not written and acted upon until 11/26/18 (seventy-nine days later). Interview with the Director of Nursing (DON) on 12/05/18 at 2:01 PM, in the conference room, confirmed the pharmacy recommendation had not been acted upon timely. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Pharmacy Recommendation dated 8/29/18 revealed .Drug, dosage and schedule presently on [MEDICATION NAME] (medication to treat depression) 20 mg daily tapered dosage and schedule [MEDICATION NAME] 10 mg daily . Continued review of the Pharmacy Recommendation revealed the Physician agreed with and signed the recommendation on 11/13/18 (sixty-six days later) and the physician's orders [REDACTED]. Interview with the DON on 12/5/18 at 2:01 PM, in the conference room, confirmed the Pharmacy Recommendation was not acted upon timely.",2020-09-01
313,"NHC HEALTHCARE, SMITHVILLE",445116,825 FISHER AVE P O BOX 549,SMITHVILLE,TN,37166,2018-10-31,684,D,0,1,GGS111,"**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 evaluate and implement an appropriate positioning device for 1 resident (#24) of 2 residents reviewed for positioning and mobility of 33 sampled residents. The findings include: Review of the facility's Repositioning Policy, revised 5/30/14, revealed .Assessment for Appropriate Repositioning .Assess residents who sit or recline in a chair .Does the resident need intervention to maintain postural alignment .When a resident is up in a chair .supporting of feet . Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a care plan dated 10/9/17 and updated 8/27/18 revealed the resident utilized a .(specialized wheelchair) . (a wheelchair that tilts, rocks and reclines) for mobility. Continued review revealed the resident required assistance with all activities of daily living (ADL). Medical record review of the annual Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10 indicating the resident had moderate cognitive impairment. Continued review revealed the resident required extensive assistance of 2 staff for bed mobility, dressing, toileting and hygiene, and total dependence of 2 staff with transfers. Further review revealed the resident was on pain management and utilized a wheelchair for mobility with extensive 1 staff assistance. Observation of Resident #24 on 10/29/18 at 11:05 AM, 12:19 PM, and 2:05 PM, on the 100 hall activity room, revealed Resident #24 was sitting in a specialized wheelchair in a reclined position without a foot pedal on the right side of the wheelchair. Continued observation revealed the bilateral lower extremities (BLE) dangled freely from the wheelchair. Further observation revealed the foot pedal that was in place on the left side of the specialized wheelchair was extended further than the foot and did not allow the foot to rest on the pedal. Observation of Resident #24 on 10/30/18 at 8:00 AM, 8:47 AM, 9:05 AM, 1:20 PM, and 3:30 PM, on the 100 hall activity room, revealed Resident #24 was sitting in a specialized wheelchair in a reclined position. Continued observation revealed there was no support for the BLE which allowed the BLE to dangle freely from the wheelchair. Observation of Resident #24 and interview with Licensed Practical Nurse (LPN) #1 on 10/31/18 at 8:45 AM, on the 100 hall, revealed .we lost one of her foot pedals . Interview with Resident #24 on 10/31/18 at 11:45 AM, on the 100 hall activity room, revealed the resident preferred her lower legs elevated. Interview with the Director of Nursing (DON) on 10/31/18 at 11:55 AM, in the resident's room, confirmed the resident did not have a foot pedal on the right side of the wheelchair or BLE support. Further interview confirmed the specialized wheelchair needed foot rests, support or cushions to elevate the BLEto aid in the resident's positioning and comfort.",2020-09-01
314,"NHC HEALTHCARE, SCOTT",445117,2380 BUFFALO ROAD,LAWRENCEBURG,TN,38464,2019-05-01,812,E,0,1,YI4711,"Based on policy review, observation, and interview, the facility and failed to ensure meal trays were served under sanitary conditions when 3 of 7 (Certified Nursing Assistant (CNA) # 1, #2, and #3) staff members failed to perform proper hand hygiene during dining. The findings include: The facility's undated Hand Washing and Hand Sanitizer policy documented, .Hand hygiene is the primary means to prevent the spread of infection . Observations in Resident #3's room on 4/29/19 at 11:57 AM, revealed CNA #1 delivered Resident #3's meal tray into her room. CNA #1 repositioned Resident #3. CNA #1 and CNA #2 then pulled Resident #3 up in the bed. CNA #1 opened the meal tray, poured Resident #3's milk, touched items on the tray, opened Resident #3's straw, touched the straw with his bare hands, and inserted it into Resident #3's drink without performing hand hygiene. Observations in Resident #5's room on 4/30/19 at 7:32 AM, revealed CNA #3 delivered Resident #5's meal tray, moved a garbage can, then set up the meal tray, and stirred the food with the utensils, without performing hand hygiene. Observations in Resident #21's room on 4/30/19 at 7:39 AM, revealed CNA #3 delivered Resident #21's meal tray, pulled Resident #21 up in the bed, opened the silverware, opened the juice, and put the straw into the juice, without performing hand hygiene. Observations in Resident #23 and Resident #6's room on 4/30/19 at 8:01 AM, revealed CNA #3 and CNA #2 pulled Resident #23 up in the bed. CNA # 2 then removed her gloves and went to Resident #6 and set up her meal tray, opened her jelly and spread it on her food, opened the juices, opened the straw and put it into Resident #6's drink, without performing hand hygiene. Observations in Resident #303's room on 4/30/19 at 8:05 AM, revealed CNA #3 delivered Resident #303's meal tray, raised the head of the bed, adjusted Resident #303's oxygen on her face, moved a cord on the floor under the bed, moved the over-bed table in front of the resident, opened and sprinkled sweetener over the food, opened the carton of milk, opened the straw and put it into the drink, without performing hand hygiene. Interview with the Director of Nursing (DON) on 4/30/19 at 9:36 AM, in the Community Room, the DON was asked if it was appropriate to reposition residents, touch articles in the room such as garbage cans and things on the floor, then set up meal trays without performing hand hygiene. The DON stated, They should perform hand hygiene before setting up the tray.",2020-09-01
315,"NHC HEALTHCARE, SCOTT",445117,2380 BUFFALO ROAD,LAWRENCEBURG,TN,38464,2019-05-01,880,D,0,1,YI4711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview the facility failed to store an ice scoop under sanitary conditions for 1 of 2 (200 Hall) ice storage areas and failed to ensure practices were followed to maintain infection control for 1 of 1 (Resident #25) sampled residents observed during perineal care. The findings include: 1. The facility's Safety & (and) Sanitation Best Practice Guidelines policy dated 11/2017 documented .the handle of the scoop must be stored so that it does not touch the ice . 2. Observations in the 200 Hall nourishment room on 4/29/19 at 11:30 AM and at 3:39 PM, revealed the ice scoop was stored inside the portable ice bin on top of the ice. Interview with the Director of Nursing (DON) on 4/30/19 at 11:40 AM. in the 100 Hall, the DON was asked if it was acceptable for the ice scoop to be stored inside the ice bin. The DON stated, No. 3. The facility's undated Perineal Care policy documented, .To provide cleanliness and comfort to the patient .prevent infections .Remove gloves and discard. Wash and dry your hands . 4. Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #25's room on 4/29/19 at 11:37 AM, revealed Certified Nursing Assistant (CNA) #2 provided perineal care to Resident #25. CNA #2 did not remove the soiled gloves used during the perineal care. After performing the perineal care, CNA #2 assisted the resident to sit on the bedside, took the resident's hairbrush, and began brushing and touching Resident #25's hair. Interview with the DON on 4/30/19 at 9:36 AM, in the Community Room, the DON was asked if it was appropriate to perform perineal care and wear the same gloves to brush a resident's hair. The DON stated, No.",2020-09-01
316,"NHC HEALTHCARE, SCOTT",445117,2380 BUFFALO ROAD,LAWRENCEBURG,TN,38464,2018-06-19,761,D,0,1,CB2S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured in 1 of 1 (Clean Utility Room) clean utility rooms. The findings included: 1. The facility's MEDICATION STORAGE IN THE FACILITY policy documented .The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access . 2. Observations in the unlocked Clean Utility Room on 6/18/18 at 6:45 AM, 7:43 AM, 12:19 PM, and 2:34 PM, revealed 5 unsecured syringes containing 5 milliliters of [MEDICATION NAME] 100 units/milliliter (an anticoagulant medication). Interview with the Director of Nursing (DON) on 6/18/18 at 2:42 PM, in the Clean Utility Room, the DON was asked if the residents should have access to the [MEDICATION NAME] syringes. The DON stated, No. The DON confirmed the medication was not secured.",2020-09-01
317,"NHC HEALTHCARE, SCOTT",445117,2380 BUFFALO ROAD,LAWRENCEBURG,TN,38464,2018-06-19,921,D,0,1,CB2S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation and interview, the facility failed to ensure the environment was free from accident hazards as evidenced by unsecured and accessible chemicals and needles stored in 1 of 1 (Clean Utility Room) clean utility rooms. The findings included: 1. The facility's .Storage of Hazardous Chemicals policy documented, Hazardous chemicals are to be stored out of the reach of patients. Examples of hazardous materials are .[MEDICATION NAME] . 2. The facility's .EQUIPMENT AND SUPPLIES FOR ADMINISTERING MEDICATIONS policy documented, .The following equipment and supplies are .maintained by the facility for the proper storage, preparation and administration of medication .needles . 3. Observations in the unlocked Clean Utility Room on 6/18/18 at 6:45 AM, 7:43 AM, 12:19 PM, and 2:34 PM, revealed a bottle of nail polish remover ([MEDICATION NAME]), 4 bottles of shave cream labeled Keep out of Reach of Children, 5 bottles of anti-perspirant deodorant labeled, Keep out of Reach of Children, 3 denture cleanser tablets, (9) 24-gauge needles, and (2) 23-gauge needles, all unsecured. Interview with the Director of Nursing (DON) on 6/18/18 at 2:42 PM, in the Clean Utility Room, the DON was asked if the residents should have access to the nail polish remover, the items labeled Keep out of reach of children, or the needles. The DON stated, No. The DON confirmed the chemicals and sharps were not secured.",2020-09-01
318,"NHC HEALTHCARE, SOMERVILLE",445119,"308 LAKE DRIVE, PO BOX 550",SOMERVILLE,TN,38068,2019-05-15,658,D,0,1,XL3E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, Manufacturer Guidelines, medical record review, observation, and interview, 2 of 4 (Licensed Practical Nurse (LPN) #1 and #2) nurses failed to follow the facility policy for the destruction of a medication and failed to follow facility policy for the application of a [MEDICATION NAME] during medication administration. The findings include: 1. The facility's Controlled Substance Disposal policy dated (MONTH) (YEAR) documented, .It (Controlled Substance) is destroyed in the presence of two licensed nurses, and the disposal is documented on the accountability record/book on the line representing that dose . The (Named Manufacturer's) instructions for the [MEDICATION NAME] Patch, with a revision date of 12/2018 documented, .Do not apply to a skin area where cream, lotion, or powder has recently been applied . The facility's Specific Medication Administration Procedures IIB13: [MEDICATION NAME] Drug Delivery System (Patch) Application policy dated (MONTH) (YEAR) documented, .Identify the clean, hairless location on the body for patch placement . 2. Medical record review revealed Resident #61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] - Schedule V (5) capsule; 400 mg (milligram) .po (by mouth) three times a day . Observations at the North Hall Medication Cart 2 on 5/14/19 beginning at 9:52 AM, revealed LPN #1 dropped Resident #61's [MEDICATION NAME] on top of the medication cart. LPN #1 discarded the pill into the sharps container, on her medication cart, without obtaining a witness to waste the narcotic. Interview with LPN #1 on 5/14/19 at 10:27 AM, at the North Hall Medication Cart 2, LPN #1 was asked what was the facility policy regarding medication destruction. LPN #1 stated, .I should have had another nurse witness that I had destroyed the [MEDICATION NAME]. Interview with the Director of Nursing (DON) on 5/14/19 at 1:25 PM, in the DON office, the DON was asked how she expected her nursing staff to destruct [MEDICATION NAME]. The DON stated, .it ([MEDICATION NAME]) is considered a narcotic and it should be witnessed by 2 nurses when destructing . 3. Medical record review revealed Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].rivastigmine patch 24 hour; 13.3 mg / 24 hour .[MEDICATION NAME] .Once a day . Observations in Resident #21's room on 5/14/19 at 9:56 AM, revealed LPN #2 removed Resident #21's old [MEDICATION NAME] from her left arm and placed a new [MEDICATION NAME] on her right back. The right back was not cleaned prior to the new [MEDICATION NAME] application. Interview with LPN #2 on 5/14/19 at 9:56 AM, at the North Hall Medication Cart 2, LPN #2 was asked if she should have cleaned the right back area prior to administering the patch. LPN #2 stated, .No, you don't do that . Interview with the DON on 5/14/19 at 1:25 PM, in the DON office, the DON was asked what the procedure was for applying a [MEDICATION NAME]. The DON stated, .clean the site it's ([MEDICATION NAME]) going on . Interview with Certified Nursing Assistant (CNA) #3 on 5/15/19 at 1:29 PM, at the North Hall Nurses Station, CNA #3 was asked what activities she did with Resident #21. CNA #3 stated, .I provide personal care . lotion her up . CNA #3 was asked if she applied lotion to her back after a shower or bath. CNA #3 stated, .sometimes I do put lotion on her back .and massage too .",2020-09-01
319,"NHC HEALTHCARE, SOMERVILLE",445119,"308 LAKE DRIVE, PO BOX 550",SOMERVILLE,TN,38068,2019-05-15,812,F,0,1,XL3E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Lippincott Manual of Nursing Practice, 10th Edition, policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by undated, unlabeled, and unsealed food items, expired food items, carbon build up on a pan, improper cleaning of a food thermometer, dented cans, and improper thawing of frozen food, and when 2 of 19 (Certified Nursing Assistant (CNA) #1 and #2) staff members failed to perform hand hygiene during dining. The facility had a census of 70 residents with 68 of those residents receiving a tray from the kitchen. The findings include: 1. The Lippincott Manual of Nursing Practice,10th EDITION documented, Hand hygiene is the single most recommended measure to reduce the risks of transmitting microorganisms .Hand hygiene should be performed between patient contacts .after contact with .contaminated equipment or articles . 2. The facility's Safety & (and) Sanitation Best Practice Guidelines policy revised ,[DATE] documented, .Thawing .Store raw foods on pans on the lowest shelves to prevent them from dripping or splashing on other foods .Herbs and spices .A best practice is to use herbs and spices within 2 years of purchase date .Foods will be stored in their original packages .If opened, packages should be closed securely to protect the product .A designated area in or near the storeroom should be labeled for dented cans and damaged product temporary storage .dented cans should be placed in the designated area . 3. Observations in the kitchen on [DATE] beginning at 8:50 AM, revealed the following: a. An undated bag of salmon in the walk-in freezer b. An undated bag of meatballs in the walk-in freezer c. An undated bag of bar-b-que in the walk-in freezer d. An undated bag of beef steaks in the walk-in freezer e. 9 undated rolls of ground beef in the walk-in freezer f. An undated bag of lima beans in the walk-in freezer g. An undated bag of tortilla shells in the walk-in freezer h. An undated, unlabeled, and unsealed package of tater tots in the walk-in freezer i. 2 undated packages of waffles in the walk-in freezer j. An undated package of pancakes in the walk-in freezer k. An undated, unlabeled piece of cake in aluminum foil in the walk-in freezer l. 6 undated containers of strawberries in the walk-in freezer m. 1 loaf of bread with a green colored substance on the bread with a best by date of [DATE] n. 1 loaf of bread with a best buy date of [DATE] o. 2 loafs of bread with a best buy date of [DATE] p. 4 loafs of bread with a best buy date of [DATE] n. 1 loaf of wheat bread with a best buy date [DATE] o. 4 bags of hoagie sandwich buns with a green colored substance on the buns p. 2 undated packages of hot dog buns q. 1 undated plastic container of cocoa in the dry storage room r. 3 undated jars of cherries in the dry storage room s. 1 pan with carbon build up on the bottom of the pan t. 1 undated plastic container of corn flakes on the prep table Observations in the kitchen on [DATE] beginning at 11:10 AM, revealed the following: a. 2 jars of cherries not dated in the dry storage room b. 1 dented can of cream of coconut on the shelf with other canned foods in the dry storage room c. 1 dented can of green beans on the shelf with other canned foods in the dry storage room d. 1 dented can of potatoes on the shelf with other canned foods in the dry storage room e. 1 dented can of tomatoes on the shelf with other canned foods in the dry storage room f. 3 rolls of ground beef thawing on a tray above cartons of milk in the walk-in refrigerator g. 1 container of nutmeg with a delivery date of [DATE] in the dry storage room Observations in the kitchen on [DATE] beginning at 11:55 AM, revealed the following: The Dietary Manager was performing tray line temperatures and placed the thermometer on the shelf with the tip of the thermometer touching a black bag lying next to the thermometer, then placed the thermometer in a tray of pork chops to obtain a temperature without cleaning the thermometer. Interview with the Dietary Manager on [DATE] at 10:45 AM, in the Dietary Manager Office, the Dietary Manager was asked if a thermometer should be used to obtain the temperature of a pork chop after it has touched the thermometer bag, without cleaning the thermometer probe. The Dietary Manager stated, No, ma'am. The Dietary Manager was asked if dented cans should be on the shelf with the other canned items. The Dietary Manager stated, No, ma'am. The Dietary Manager was asked if food should be dated and labeled. The Dietary Manager stated, Yes, ma'am. The Dietary Manager was asked should food be sealed. The Dietary Manager stated, Yes, ma'am. The Dietary Manager was asked should frozen ground beef that was thawing be on a tray above crates of milk. The Dietary Manager stated, No, ma,am. The Dietary Manager was asked if bread should have mold on it. The Dietary Manager stated, No, ma,am. The Dietary Manager was asked if bread should be used by the best by date. The Dietary Manager stated, If not used by the best by date it won't have the quality. Interview with the Dietary Manager [DATE] at 3:50 PM, in the Kitchen, the Dietary Manager was asked if carbon should be on pans. The Dietary Manager stated, No, ma'am. 4. Observations in the Dining Room on [DATE] beginning at 12:50 PM, revealed the following: CNA #1 moved a chair, prepared the meal tray for Resident #54, and fed Resident #54 without performing hand hygiene. CNA #2 moved a chair, prepared the meal tray, and fed Resident #1 without performing hand hygiene. Interview with the Director of Nursing (DON) on [DATE] at 3:00 PM, in the DON Office, the DON was asked should staff move a chair and then feed a resident without performing hand hygiene. The DON stated, No .",2020-09-01
320,"NHC HEALTHCARE, SOMERVILLE",445119,"308 LAKE DRIVE, PO BOX 550",SOMERVILLE,TN,38068,2019-05-15,880,D,0,1,XL3E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the Lippincott Manual of Nursing Practice, 10th Edition, policy review, medical record review, observation, and interview, the facility failed to ensure 2 of 4 (Licensed Practical Nurse (LPN) #3 and #4) nurses followed practices to prevent the potential spread of infection when nebulizing equipment was not properly stored and overfill of a liquid medication was poured back into the dispensing bottle during medication administration. The findings include: 1. The Lippincott Manual of Nursing Practice, 10th Edition, documented, .Disassemble and clean nebulizer after each use .a thorough proper cleaning, sterilization, and storage of equipment, organisms can be prevented from entering the lungs . 2. The facility's Specific Administration Procedures policy dated (MONTH) (YEAR) documented, .When treatment is complete, turn off nebulizer and disconnect T-piece, mouth piece and medication cup . 3. Medical record review revealed Resident #67 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME]-[MEDICATION NAME]; 0.5 mg (milligram) - 3 mg .3 ml (milliliter) .inhalation four times a day . Observations in Resident #67's room on 5/13/19 at 3:58 PM, revealed LPN #3 removed Resident #67's nebulizer mask with the reservoir after a breathing treatment had been administered. LPN #3 placed the nebulizer mask and the reservoir into a plastic bag without disconnecting the T-piece, mouth piece and reservoir. There was moisture in the mask and medicine cup when she placed the equipment into the plastic bag. 4. Medical record review revealed Resident #172 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] acid liquid .250 mg / 5 ml .3.5 ml - 125 mg; gastric tube every 8 hours . Observations at the North Hall Medication Cart 1 on 5/14/19 at 10:10 AM, revealed LPN #4 overfilled the medication cup with [MEDICATION NAME] Acid. LPN #4 poured the overfill of [MEDICATION NAME] Acid back into the Resident #172's medication bottle. Interview with the LPN #4 on 5/14/19 at 10:20 AM, at the North Hall Medication Cart 1, LPN #4 was asked if it was appropriate to pour the overfill of medication back into the original dispensing bottle. LPN #4 stated, .probably not . Interview with the Director of Nursing (DON) on 5/14/19 at 1:25 PM, in the DON office, the DON was asked what she expected her nursing staff to do when too much liquid medication was poured in the medicine cup. The DON stated, .dispose of the overfill medication in a sharps container . The DON was asked if it was appropriate to pour the overfill of medication back into the dispensing bottle of medication. The DON stated, .No, not appropriate .",2020-09-01
321,"NHC HEALTHCARE, SOMERVILLE",445119,"308 LAKE DRIVE, PO BOX 550",SOMERVILLE,TN,38068,2017-06-28,241,D,0,1,3XG211,"Based on observation, and interview the facility failed to provide care in a manner that ensured the residents' dignity, respect, and quality of life was maintained when 1 of 21 (Licensed Practical Nurse (LPN) #1) staff members observed during dining stood over a resident while assisting them to eat. The findings included: Observations in Resident #66's room on 6/26/17 at 12:22 PM, revealed LPN #1 stood over Resident #66 while assisting him to eat. Interview with the Director of Nursing (DON) on 6/28/17 at 9:45 AM, in the DON office, the DON was asked if it was acceptable to stand over a resident while assisting them to eat. The DON stated, No, ma'am.",2020-09-01
322,"NHC HEALTHCARE, SOMERVILLE",445119,"308 LAKE DRIVE, PO BOX 550",SOMERVILLE,TN,38068,2017-06-28,279,D,0,1,3XG211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview the facility failed to ensure a resident with a contracture had a comprehensive care plan addressing the contracture for 1 of 16 (Resident #25) residents reviewed. The findings included: Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE], and the annual MDS dated [DATE] revealed the resident was severely cognitively impaired for daily decision making. Review of the Range of Motion section revealed, Resident #25 was limited in her upper and lower extremity on one side, required extensive assistance of two for bed mobility and was totally dependent of two persons for all other activities of daily living (ADL). Review of the care plan dated 6/15/17 revealed, Self-care deficit; requires total staff assist for all ADL needs. One of the approaches was Resident #25 would receive passive range of motion (PROM) and active assist range of motion (AAROM) exercises daily. There was no care plan found regarding her one sided upper and lower limitation. Observations on 6/27/17 at 10:38 AM Resident #25 was observed in her bed sleeping. Her right and left hand were in a fist like position. Observations on n 6/28/17 at 9:00 AM, 10:00 AM, 11:45 AM and 1:21 PM the resident was observed to be lying in bed with both of her hands to be held in a fist like position her legs were bent at the knees. Observations on 6/28/17 at 10:54 AM Resident #25 was observed in bed, pillow between legs, bilateral heel protector boots and she facing towards the door. Both of her hands remained in a fist like position and her legs were bent at the knee. During an interview on 6/26/17 at 1:51 PM, Registered Nurse (RN) 2 stated that Resident #25 had bilateral upper and lower extremity contractures. During an interview on 6/28/17 at 10:04 AM Certified Nursing Assistance (CNA) #4 stated Resident #25' s lower extremities were contracted as well as her left hand contracted. During an interview on 6/28/17 at 10:45 AM Licensed Practical Nurse (LPN) #4 stated she has worked with Resident #25 on and off for the past five years and Resident #25 has been contracted of her left hand and bilateral lower extremities since this time. During an interview on 6/28/17 at 4:25 PM with the MDS coordinator, The MDS coordinator stated she must have made an error in coding the MDS as Resident #25 has limited ROM in the bilateral upper and lower extremities. During an interview on 6/28/17 at 4:30 PM with the Assistant Director of Nursing (ADON), the ADON confirmed when a resident has contractures a care plan should be in place. There was no care plan found regarding the resident's contractures.",2020-09-01
323,"NHC HEALTHCARE, SOMERVILLE",445119,"308 LAKE DRIVE, PO BOX 550",SOMERVILLE,TN,38068,2017-06-28,371,D,0,1,3XG211,"Based on policy review, observation, and interview the facility failed to ensure food was served under sanitary conditions when 4 of 21 (Certified Nursing Assistant (CNA) #5, 6, and 7 and Licensed Practical Nurse (LPN) #1) staff members observed during dining failed to perform proper hand hygiene. The findings included: 1. The facility's Blood-Borne Pathogen Exposure Control Plan policy documented, .HANDWASHING PR[NAME]EDURES .When to wash hands .Before passing out trays or handling food . 2. Observations in Resident #24's room on 6/26/17 at 11:55 AM, revealed CNA #5 raised the head of the bed, opened the salad dressing and placed it on the salad without performing hand hygiene. Observations in Resident #59's room on 6/26/17 at 11:57 AM, revealed CNA #5 raised the head of the bed, opened the silverware, placed the clothing protector around the resident's neck, opened the straw and placed it in the tea, then opened the salad and the cake without performing hand hygiene. Observations in Resident #10's room on 6/26/17 at 12:00 PM, revealed CNA #5 touched the lettuce in the bowl with her bare hand, set up Resident #10's meal tray, and then served the meal to Resident #10 without performing hand hygiene. Observations in Resident #48's room on 6/28/17 at 12:05 PM, revealed CNA #6 pulled the bed linens over Resident #48 and then opened the silverware, took the lid off the glass of milk,and opened a container of ice cream without performing hand hygiene. Observations in Resident #66's room on 6/26/17 at 12:07 PM, revealed CNA #6 raised the head of the bed, then opened the silverware, placed a clothing protector around the resident's neck, opened the straw and placed in the drink, opened the ice cream, took the lid off the salad and then placed salad dressing on the lettuce without performing hand hygiene. Observations in Resident #66's room on 6/26/17 at 12:22 PM, revealed LPN #1 raised the head of the bed, then opened the containers of liquids and fed Resident #66 without performing hand hygiene. Observations in Resident #24's room on 6/28/17 at 8:10 AM, revealed CNA #7 turned her name badge over to the back of her uniform with her hand, then placed butter and jelly on a biscuit, opened a sugar package and placed the sugar over the cereal, and poured the milk over the cereal without performing hand hygiene. Observations in Resident #59's room on 6/28/17 at 8:13 AM, CNA #7 raised the head of the bed, then took the lids off the drinks, took the cover off the plate, then cut up a biscuit and opened the orange juice without performing proper hand hygiene. Observations in Resident #66's room on 6/28/17 at 8:35 AM, LPN #1 raised the head of the bed, moved a chair close to the bed, then began to assist Resident #66 with the meal, then lowered the bed and fed the resident more food without performing hand hygiene. Interview with the Director of Nursing (DON) on 6/28/17 at 9:45 AM, in the DON office, the DON was asked if it is acceptable to touch objects in the environment and then assist the resident or feed the resident without performing hand hygiene. The DON stated, No, not without washing their hands",2020-09-01
324,ALEXIAN VILLAGE OF TENNESSEE,445123,671 ALEXIAN WAY,SIGNAL MOUNTAIN,TN,37377,2017-07-19,223,D,1,0,POC011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, facility investigation review, time detail review, and interviews, the facility failed to ensure 1 resident (#1) was free from verbal abuse of 4 residents reviewed for abuse of 4 sampled residents. The findings included: Review of the facility's policy titled Reporting Abuse to Community Management last revised 12/2016, revealed .It is the responsibility of our employees, community consultants, Attending Physicians, family members, visitors .to promptly report any incident or suspected incident of neglect or resident abuse including injuries of unknown origin and theft or misappropriation of resident property to community management .Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability .Mental abuse is defined as, but is not limited to humiliation, harassment . 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 scored 10/15 (moderately cognitive impaired) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance for transfer, dressing, eating, and hygiene/bathing, and limited assistance for ambulation. Review of a facility investigation revealed a statement from the Director of Nursing (DON) dated 6/20/17 at approximately 2:00 PM. Further review revealed while the DON was reviewing emails received the previous week (while on vacation), one of the email messages stated VERY URGENT from Certified Nursing Assistant (CNA) #4. Continued review revealed the email was dated 6/17/17 at 12:01 AM. Further review revealed CNA #4 was told by CNA #2 she (CNA #2) overheard Licensed Practical Nurse (LPN) #2 tell Resident #1 to Shut the f*** up. Continued review revealed CNA #2 was in the resident's room talking with the sitter for the resident LPN #2 the room and said .'with the two of yawl in here he's still yelling' then (LPN#2) approached the resident to yell at him saying SHUT THE F*** UP . Further review of a telephone interview conducted with CNA #2 by the Director of Quality (DQ) on 6/20/17 revealed on the evening of 6/16/17 CNA #2 was visiting residents and staff at the facility. Continued review revealed CNA #2 was friends with the sitter and was in the resident's room talking with the sitter when LPN #2 entered the room and stated .there are two of you in this damn room and you can't keep him (Resident #1) quiet .(LPN #2) .went over to (Resident #1) and got in his face and told him to 'shut the f*** up' . Further review of a signed statement from the sitter for Resident #1 revealed the sitter was in the room at the time of the alleged incident and .On (MONTH) 16, (YEAR) a nurse by the name of (LPN #2) came into (Resident #1) room yelling at (CNA #2) and myself about shutting (Resident #1) up. Then she (LPN #2) walked up to (Resident #1) and told him to 'shut the f*** up' before storming out of the room . Continued review revealed the facility investigation began on 6/20/17 (4 days later) and LPN #2 was notified by voicemail of an alleged allegation and was told she was not allowed on the premises until further notice. Interview with LPN #1 on 7/18/17 at 2:00 PM, in the conference room, revealed at times the resident would continually yell and you could hear him outside yelling Help, Help, Help. Further interview revealed LPN #1 would .assess the resident for pain, offer food, and offer a quiet environment .some days nothing seemed to help . Telephone interview with CNA #2 on 7/18/17 at 4:00 PM revealed she was on medical leave and was in the facility to visit because she was bored and the facility was her second home. Continued interview revealed the CNA knew Resident #1's sitter so she went in to chat with her and while she was talking to the sitter LPN #2 came in to give Resident #1 his medications. Further review revealed a .few minutes later the resident was still yelling .the door flew open and (LPN #2) walked in and stated 'there are 2 of you in here I don't understand why you can't keep him quiet' .and then (LPN #2) walked over to the (resident) and was in his face and said 'I need you to shut the f*** up and be quiet' .You are irritating me and getting on my damn nerves . Continued interview revealed CNA #2 and the sitter discussed who they should report this to and CNA #2 decided to report the incident to CNA #4, who stated he would email the DON. Further interview confirmed Resident #1 was verbally abused by LPN #2 and CNA #2 was aware she needed to report the incident immediately to a supervisor or charge nurse but failed to do so. Continued interview revealed LPN #2 remained in the facility for the rest of her shift. Interview with the DON on 7/18/17 at 5:00 PM, in the DON's office, confirmed the resident was verbally abused by LPN #2 and the facility failed to investigate the allegation timely.",2020-09-01
325,ALEXIAN VILLAGE OF TENNESSEE,445123,671 ALEXIAN WAY,SIGNAL MOUNTAIN,TN,37377,2017-07-19,225,D,1,0,POC011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on the review of facility policy, medical record review, review of a facility investigation, and interviews, the facility failed to promptly report and investigate an allegation of abuse to the appropriate facility staff for 1 resident (#1) of 4 residents reviewed for abuse of 4 sampled residents. The findings included: Review of the facility's policy titled Reporting Abuse to Community Management last revised 12/2016, revealed .It is the responsibility of our employees, community consultants, Attending Physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse including injuries of unknown origin and theft or misappropriation of resident property to community management .Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability .Mental abuse is defined as, but is not limited to humiliation, harassment .Employees, community consultants and/or Attending Physicians must immediately report any suspected abuse or incidents of abuse to the Director of Nursing Services. In the absence of the Director of Nursing Services such reports may be made to the Nursing Supervisor on duty .any individual observing an incident of resident abuse or suspected resident abuse must immediately report such incident to the Administrator, Director of Nursing Services, or Charge Nurse . 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 scored 10/15 (moderately cognitive impaired) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance for transfer, dressing, eating, and hygiene/bathing, and limited assistance for ambulation. Review of a facility investigation revealed a statement from the Director of Nursing (DON) dated 6/20/17 at approximately 2:00 PM. Further review revealed while the DON was reviewing emails received the previous week (while on vacation), one of the email messages stated VERY URGENT from Certified Nursing Assistant (CNA) #4. Continued review revealed the email was dated 6/17/17 at 12:01 AM. Further review revealed CNA #4 was told by CNA #2 she (CNA #2) overheard Licensed Practical Nurse (LPN) #2 tell Resident #1 to Shut the f*** up. Continued review revealed CNA #2 was in the resident's room talking with the sitter for the resident LPN #2 the room and said .'with the two of yawl in here he's still yelling' then (LPN#2) approached the resident to yell at him saying SHUT THE F*** UP . Further review of a telephone interview conducted with CNA #2 by the Director of Quality (DQ) on 6/20/17 revealed on the evening of 6/16/17 CNA #2 was visiting residents and staff at the facility. Continued review revealed CNA #2 was friends with the sitter and was in the resident's room talking with the sitter when LPN #2 entered the room and stated .there are two of you in this damn room and you can't keep him (Resident #1) quiet .(LPN #2) .went over to (Resident #1) and got in his face and told him to 'shut the f*** up' . Further review of a signed statement from the sitter for Resident #1 revealed the sitter was in the room at the time of the alleged incident and .On (MONTH) 16, (YEAR) a nurse by the name of (LPN #2) came into (Resident #1) room yelling at (CNA #2) and myself about shutting (Resident #1) up. Then she (LPN #2) walked up to (Resident #1) and told him to 'shut the f*** up' before storming out of the room . Continued review revealed the facility investigation began on 6/20/17 (4 days later) and LPN #2 was notified by voicemail of an alleged allegation and was told she was not allowed on the premises until further notice. Telephone interview with CNA #2 on 7/18/17 at 4:00 PM revealed CNA #2 was aware she needed to report the incident immediately to a supervisor or charge nurse, but failed to do so. Interview with the DON on 7/18/17 at 5:00 PM revealed she was out of the facility and did not review her email until 6/20/17. Continued interview revealed staff had been educated to verbally tell someone of any allegations of abuse. Continued interview confirmed the facility failed to report and investigate an allegation of abuse timely.",2020-09-01
326,ALEXIAN VILLAGE OF TENNESSEE,445123,671 ALEXIAN WAY,SIGNAL MOUNTAIN,TN,37377,2017-09-08,224,D,1,0,HIQ011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility investigation, review of personnel files, observation, and interview, the facility failed to prevent neglect of 1 resident (#1) of 3 residents reviewed for neglect. The findings included: Review of the facility policy, Care Rounding & Risk Prevention Continuous And Responsive Engagement Rounding Review, undated, revealed .Actively, not passively, provide care and do so continuously. Hourly rounding is not as important as continuous rounding that moves with purposeful intent .Round at shift change .Typically, a round includes checking on the status of the 4 Ps: Pain Assessment Potty (toileting) needs Positioning Possessions (in reach of the Resident, including call button) . Medical record review revealed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the care plan dated 2/6/17 revealed .Reposition every 2 hours during the day when in bed or chair. Reposition during the night every 2 hours . Further review revealed the resident required supervision with transfer, mobility using a walker, bed mobility (and at times 1 staff support with bed mobility) and toileting. Medical record review of the Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Medical record review of the MDS, Functional Abilities dated 7/14/17 revealed bed mobility, transfer, and toilet use coded 2 (limited assistance); walk in room and corridor, locomotion on and off unit, dressing and personal hygiene coded 1 (supervision, oversight). Medical record review of the Medication Record for 8/2017 revealed .[MEDICATION NAME] 3 mg (milligrams) tablet- 1 tab by mouth at bedtime ([MEDICAL CONDITION]) .[MEDICATION NAME] 30 mg tablet- 1 tab by mouth at bedtime .Major [MEDICAL CONDITION] .[MEDICATION NAME] (anti-anxiety medication) 2 mg tablet .Hour of Sleep For Anxiety .Monitor for [MEDICAL CONDITION]- Hour of sleep . Continued review revealed on 8/18/17 the nurse had initialed the resident had been monitored for [MEDICAL CONDITION] after receiving medications for anxiety and sleep. Review of the Safety Event Entry dated 8/19/17 at 7:30 AM revealed the resident was found on the floor, covered with a blanket, by the Day Nurse. The resident told her she had been .laying there all night . The resident was not harmed and the family and physician were notified with neuro (neurolgical) checks initiated. Review of the personnel files for Registered Nurse (RN) #1 dated 8/19/17 revealed .Written Warning .Medication was documented as being given to Resident #1 at 2116 (9:16) pm and was actually given at approximately 10 pm. Per [MEDICAL CONDITION] flow sheet, nurse documented that resident was not having difficulty sleeping without having physically checked the patient who had fallen in the floor . Review of the Associate Corrective Action Form for Certified Nursing Assistant (CNA) #3 dated 8/19/17 revealed .Final Written Warning .CNA failed to make walking rounds with night shift and physically check on residents. One of the residents (#1) she was accepting care for had fallen onto the floor. This patient was not found for another 1.5 hrs . Continued review revealed CNA #1 was terminated for not following the facility's policy for rounding. Review of the General Investigation Form dated 9/3/17 revealed Resident (#1) was on the floor for an undetermined about (amount) of time. She had not been rounded on since 10 pm the previous night. CNAs did not do walking rounds. Resident found at 0730ish (around 7:30 AM). No injury. Formal investigation done by DON (Director of Nursing) and ED (Executive Director) .what led to this event .Laziness on the part of CNAs involved. They did not check on resident for 10 hours .Per .night shift RN, she was still in her regular clothes when she received her night meds . Observation and interview of Resident #1 on 9/5/17 at 11:25 AM, in the resident's room, revealed the resident was sitting in her chair with her son present. Interview confirmed she did have a fall during the night of 8/18/17 but was not injured. Continued interview confirmed she was unable to get herself up or get to the call light and she laid on the floor until the next morning when a nurse entered her room. Further interview confirmed she expected a staff member would check on her during the night. Interview with CNA #1 on 9/5/17 at 1:12 PM, by telephone, confirmed she was one of the two CNAs responsible for the care of Resident #1 on 8/18/17 on night shift. Continued interview confirmed Resident #1 was independent and rang the call bell if she needed assistance. Further interview confirmed the nurse gave her medication at 10:00 PM and her door was closed. Continued interview confirmed no one told her she had to go into every room on every round. Further interview confirmed she did not enter Resident #1's room after 10:00 PM on 8/18/17. Interview with RN #1 on 9/5/17 at 3:50 PM, by telephone, confirmed she was working the night shift on 8/18/17 and was responsible for the care of Resident #1. Further interview confirmed she administered medications to the resident at 10:00 PM and neither she or the 2 CNAs entered the residents room for the duration of the night shift. Continued interview confirmed she checked on every resident when the shift started and the CNAs were to make rounds on every resident every 2 hours and at shift change. Interview with CNA #2 on 9/5/17 at 4:00 PM, by telephone, confirmed she was pulled from the 7th floor to work on the 5th floor on 8/18/17 for the night shift to help out. Continued interview confirmed CNAs were expected to check on all residents every 2 hours. Further interview confirmed they went in residents' rooms to do rounds together, but did not enter Resident #1's room to check on her because CNA #1 knew the residents so, I just followed her lead. Interview with the Director of Nursing (DON) on 9/6/17 at 12:35 PM, in the conference room, confirmed Resident #1 had a fall on 8/18/17, sometime after 10 PM, and was found in her room lying on the floor by the day nurse at approximately 7:30 AM on 8/19/17. Continued interview confirmed CNA #1 and CNA #2 did not check on the resident all night. Further interview confirmed RN #1 administered medication to the resident at approximately 10:00 PM and did not check on the resident after that time. Continued interview confirmed CNA #1 and #2 were suspended pending the investigation and then terminated because they did not follow the facility protocol. Further interview confirmed CNAs were expected to make Continuous and Responsive Engagement Rounding, which assessed the 4 P's and were to see each resident approximately every 2 hours.",2020-09-01
327,ALEXIAN VILLAGE OF TENNESSEE,445123,671 ALEXIAN WAY,SIGNAL MOUNTAIN,TN,37377,2017-09-08,280,G,1,0,HIQ011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility protocol review, medical record review, review of facility falls investigations, and interview, the facility failed to develop and implement interventions to prevent falls for 5 residents (#7, #3, #4, #5, and #6), of 7 residents reviewed for falls, of 69 residents assessed as at risk for falls. The facility's failure resulted in a fractured ankle (harm) for Resident #7. The findings included: Review of the facility policy, Care Plans - Comprehensive Person-Centered revised 5/2017 revealed .The comprehensive, person-centered care plan will .Incorporate identified problem areas .Reflect currently recognized standards of practice for problem areas and conditions .Identifying problem areas and their causes, and developing interventions .are the endpoint of an interdisciplinary process .Care planning interventions are chosen only after careful data gathering, proper sequencing of events .and relevant clinical decision making .The Interdisciplinary Team must review and update the care plan .When the desired outcome is not met .When the resident has been readmitted to the community from a hospital stay; and at least quarterly . Medical record review revealed Resident #7 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Safety Event Entries (facility investigation conducted post falls) dated 7/6/17, 7/7/17 (2 of 3 falls on this date), 8/24/17, 9/3/17, and 9/4/17, revealed the resident sustained [REDACTED]. Continued review revealed the resident sustained [REDACTED]. Review of a Safety Event Entry dated 7/7/17 4:06 PM revealed .Resident found on floor beside her bed. 3rd fall this shift .What type of injury(s) was sustained? Fracture (Major) . Medical record review of a nurses note dated 7/7/17 at 4:44 PM revealed .Call received from Dr (physician) .stating .resident has a left tibular (ankle) fx (fracture) . Medical record review of the care plan dated 7/7/17 revealed the care plan was not revised or updated to reflect new interventions to prevent falls after the falls on 7/7/17. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Safety Event Entry dated 7/8/17 revealed the resident sustained [REDACTED]. Medical record review of the care plan dated 9/5/17 revealed the care plan was updated on 9/5/17 to include .Falls .Resident re-education to call for assistance with transfers post fall 7/8/17 .start date 9/5/17 . Continued review revealed the care plan was not updated until 60 days after the fall occured. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Safety Event Entry dated 8/7/17 revealed the resident had an unwitnessed fall in her room on this date. Medical record review of the care plan dated 4/17/17 revealed the care plan was not revised to include a new intervention to prevent falls after the fall on 8/7/17. Medical record review revealed Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a Safety Event Entry dated 8/13/17 revealed the resident had an unwitnessed fall and was sent to the hospital for evaluation. Medical record review of the care plan dated 8/21/17 revealed the care plan had not been revised to include a new fall intervention after the resident's fall on 8/13/17. Medical record review revealed Resident #6 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of a Safety Event Entry dated 8/18/17 revealed the resident sustained [REDACTED]. Medical record review of the care plan dated 8/23/17 revealed .Falls .at risk for falls r/t (related to) hx (history) of falls with fx (fracture) . Continued review revealed the care plan was not revised to reflect new interventions after returning to the facility from a hospitalization . Interview with the Director of Quality on 9/8/17 at 8:20 AM, in the conference room, confirmed Resident #6 had alarms ordered previously for fall prevention on 6/14/17. Continued interview confirmed the resident was discharged to the hospital on [DATE], and the alarm was discontinued at that time. Further interview confirmed the facility failed to revise the resident's care plan when she returned from the hospital, and the current care plan was not accurate. Continued interview confirmed the care plans for Residents #3, #4, #5, and #7 were not revised to include new interventions to prevent further falls after the post-falls investigations had been completed. The facility's failure resulted in Resident #7 sustaining a fractured ankle (tibula). Refer to F-323",2020-09-01
328,ALEXIAN VILLAGE OF TENNESSEE,445123,671 ALEXIAN WAY,SIGNAL MOUNTAIN,TN,37377,2017-09-08,323,G,1,0,HIQ011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility protocol review, medical record review, review of facility falls investigations, interview, and observation, the facility failed to provide supervision to prevent falls for 5 residents (#7, #3, #4, #5, and #6), of 7 residents reviewed for falls, of 69 residents assessed as at risk for falls. The facility's failure resulted in a fractured ankle (harm) for Resident #7. The findings included: Review of the facility protocol, Falls Clinical Protocol, dated 12/2016 revealed .Treatment/Management .the associate and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of consequences of falling. If underlying causes cannot be readily identified or corrected, associates will try various relevant interventions, based on assessment of the nature or category of falling .Monitoring and follow-up .The community associates will monitor and document the individuals response to interventions intended to reduce falling .If the individual continues to fall, the nursing associate and physician will re-evaluate the situation and .will re-evaluate the continued relevance of current interventions . Medical record review revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 6 indicating the resident had severe cognitive impairment. Continued review of the functional status revealed the resident required limited assistance for toileting and dressing and supervision for bed mobility, transfer, ambulation and personal hygiene. Medical record review of a Falls Risk assessment dated [DATE] revealed a score of 8, indicating the resident was at high risk for falls, and .A Score of 5 or greater = (equals) High Risk . Medical record review of a nurses note dated 7/6/17 at 3:39 PM, revealed .Witnessed fall at 1530 (3:30 PM) Resident tripped on the carpet as she was walking toward her room No s/s (signs or symptoms) or c/o (complaints of) pain or discomfort .Walker was being used for assistance . Review of a Safety Event Entry (entries for falls investigations) dated 7/6/17 revealed .Witnessed fall. Resident was using walker for assistance to her room but tripped on the carpet. No injuries noted .Event increased the need for monitoring or evaluation . Continued review revealed no documentation the increased monitoring or evaluation was completed. Continued review revealed no other new interventions were implemented after the fall to prevent future falls. Medical record review of a nurse's note dated 7/7/17 at 8:25 AM revealed .Witnessed fall from standing position with walker to couch then slid off edge to floor .no visible injury . Review of a Safety Event Entry dated 7/7/17 8:36 AM, revealed .Resident attempting to sit on couch from standing position, sat on edge of couch and slid to floor .Location where the event occurred? Reception Area .No Harm .Event increased the need for monitoring or evaluation . Continued review revealed no documentation the increased monitoring or evaluation had been completed, and there were no other new interventions implemented to prevent future falls. Medical record review of a nurse's note dated 7/7/17 at 12:09 PM revealed .Resident having extreme agitation. Found walking down hall with no pants on. Nonsensical word salad (incoherent jumble of words), crying, received order .to administer 1 mg (milligram) lorazepam (anti-anxiety medication, same as Ativan) IM (intramuscular) q 6h PRN (every 6 hours as needed). First dose administered at this time . Medical record review of a nurses note dated 7/7/17 at 1:55 PM, revealed .Resident fell in bathroom. All clothes had been removed and she soiled herself. Gotten up off the floor with a gait belt and assist x 3 (with 3 persons) .Left ankle xray (swollen and painful) .Additional dose of 1 mg Ativan (anti-anxiety medication) IM also given at this time . Medical record review revealed no interventions were implemented after the fall on 7/7/17 to prevent future falls. Medical record review of a nurses note dated 7/7/17 at 3:59 PM, revealed .Resident found on floor by her bed. Third fall this shift .Resident is now in wheelchair at the nurse's station . Review of a Safety Event Entry dated 7/7/17 at 4:06 PM revealed .Resident found on floor beside her bed. 3rd fall this shift. 2nd fall occurred 4 hours prior in the bathroom. Resident was naked and had urinated on herself at that time. Unknown why she fell the third time. She is unable to articulate .What type of injury(s) was sustained? Fracture (Major) . Medical record review of a nurses note dated 7/7/17 at 4:44 PM revealed .Call received from Dr (physician) .stating .resident has a left tibular fx (fracture) .1640 (4:40 PM)- resident transported by EMS (emergency medical services) . Medical record review of a nurses note dated 7/7/17 at 11:59 PM, revealed .Resident arrived back from hospital via EMS .No new orders given. Resident has boot on broken ankle and is now resting in bed . Medical record review revealed no new interventions to prevent further falls had been implemented after the third fall on 7/7/17 at 4:06 PM. Medical record review revealed the resident was hospitalized from [DATE] to 7/13/17, and again on 8/4/17 to 8/24/17. Continued review revealed Resident #7 was readmitted to the facility on [DATE]. Medical record review of a falls risk assessment dated [DATE] revealed a score of 14 (score of 5 or higher indicates High Risk). Review of a Safety Event Entry dated 8/24/17 at 5:08 PM revealed .Witnessed fall. Resident was attempting to transfer without assistance . Medical record review revealed no new interventions were implemented after the fall on 8/24/17 to prevent future falls. Review of a Safety Event Entry dated 9/3/17 at 4:32 PM revealed .Resident attempting to stand from wheelchair, with non-weight bearing status d/t (due to) LLE (left lower extremity) fracture .fell to floor .denies injuries . Continued medical record review revealed no new interventions were implemented after the fall to prevent future falls. Review of a Safety Event Entry dated 9/4/17 at 3:57 PM revealed . Unwitnessed fall. Resident attempted to ambulate/transfer without assistance . Continued medical record review revealed no new interventions were implemented to prevent future falls. Interview with the Quality Director on 9/7/17 at 11:30 AM, in the conference room, confirmed Resident #7 had suffered a fractured ankle as a result of the 2nd fall that occurred on 7/7/17. Continued interview confirmed no new interventions were implemented after the fall to address safety concerns, and Resident #7 continued to have falls on 8/24/17, 9/3/17, and 9/4/17, with no new interventions implemented to prevent falls. Continued interview confirmed the facility failed to adequately assess the safety needs and implement interventions to prevent falls for Resident #7, which resulted in harm to the resident. 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 the resident had a BIMS score of 15, indicating the resident was cognitively intact. Continued review revealed the resident required limited assistance of 1 for bed mobility, transfers, and ambulation in the room and hallway. Review of a Safety Event Entry dated 5/18/17 at 12:44 PM, revealed .unwitnessed fall. Resident assisted to her w/c (wheelchair) x 3 staff .No Injury . Medical record review of a Falls assessment dated [DATE] revealed score of 4, indicating the resident was a low risk for falls. Medical record review revealed no new interventions were implemented to prevent future falls after the fall on 5/18/17. Medical record review of an Interdisciplinary Note dated 7/8/17 revealed .Resident was in the sitting position without her 02 (oxygen) when this nurse arrived. Resident had fallen on the floor while attempting to use her potty chair unassisted .small abrasions on the 1st and 2nd toe on the left foot and to the 2nd toe on the right foot . Review of Resident #3's Care Plan revealed, .Resident reeducation to call for assistance with transfers post fall 7/8/17 . Continued review revealed the intervention was implemented on 9/5/17, two months after the resident's fall, and no other new interventions were implemented in a timely manner. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Significant Change MDS dated [DATE] revealed the resident required extensive assistance of 2 staff for bed mobility, transfers, dressing and toilet use and the resident used a wheelchair for mobility. Continued review revealed the resident had a history of [REDACTED]. Review of a Safety Event Entry dated 8/7/17 revealed .Was informed by .Rehab Tech that resident was in (on) the floor .W/C (wheelchair) was on it's side .no injuries noted . Medical record review of a Falls assessment dated [DATE] revealed a score of 8, indicating the resident was a high risk for falls. Medical record review revealed no interventions were implemented after the fall on 8/7/17 to prevent future falls. Observation of Resident #4 on 9/7/17 at 11:30 AM, revealed the resident seated in a wheelchair in the resident's room with her daughter visiting. Attempted interview was unsuccessful as the resident was unable to answer questions. Medical record review revealed Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed a BIMS score of 14, indicating the resident was cognitively intact. Continued review revealed the resident required extensive assistance of 2 staff for bed mobility and transfers. Medical record review of a Falls Risk assessment dated [DATE] revealed a score of 9, indicating the resident was a high risk for falls. Review of the Safety Event Entry dated 8/13/17 revealed .Writer .heard alarm start sounding and went .to residents room .resident lying on the floor on right side .alert and oriented x 2 (oriented to person and place) stated that she was trying to get up and walk to BR (bathroom) (resident does not walk) .large pumpknot noted to right side of forehead, skin tears x 2 to LUE (left upper extremity), red area around eye .order received to transfer to ED (emergency department) for evaluation and treatments . Medical record review of an Interdisciplinary Note dated 8/13/17 revealed .@ (at) 250 (2:50) pm Resident returned to facility .Large purple/red area noted to right side face . Medical record review revealed no new interventions were implemented after the fall on 8/13/17 to prevent future falls. Medical record review revealed Resident #6 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of an Admission MDS dated [DATE] revealed the resident had short and long term memory impairment and severe cognitive impairment. Continued review revealed the resident required extensive assistance of 2 staff for bed mobility, transfer, and required extensive assistance of 1 staff for locomotion using a wheelchair or walker. Medical record review of a CT Scan (type of xray) report dated 7/14/17 revealed .There is diffuse bone demineralization . Medical record review of a Falls Risk assessment dated [DATE] revealed a score of 8, indicating the resident was at high risk for falls. Medical record review of an Interdisciplinary Note dated 8/18/17 at 10:50 AM, revealed .Resident noted to be on back .resident was attempting to ambulate from her w/c when her leg buckled and she fell on to the floor . Review of a Safety Event Entry dated 8/18/17 revealed The resident stood up from her w/c, her leg buckled and she fell on to the floor. Her left leg was deformed and she was sent to the ER (emergency room ) . Medical record review of an xray report dated 8/18/17 revealed .displaced fracture of the proximal left femur .Underlying generalized demineralization . Medical record review revealed no new interventions were implemented after the fall on 8/18/17, or after Resident #6 returned to the facility on [DATE], to prevent future falls. Interview with the Director of Quality on 9/8/17 at 8:20 AM, in the conference room, confirmed the facility failed to follow the falls protocol to identify and implement pertinent interventions to prevent future falls for Residents #7, #3, #4, #5, and #6. The facility's failure resulted in a fractured ankle for Resident #7.",2020-09-01
329,ALEXIAN VILLAGE OF TENNESSEE,445123,671 ALEXIAN WAY,SIGNAL MOUNTAIN,TN,37377,2017-10-25,253,B,0,1,QBNE11,"Based on observation and interview, the facility failed to maintain the walls in good repair in 4 of 19 rooms on 1 of 4 floors. The findings included: Observation of room 505 on 10/23/17 at 2:15 PM revealed there were several areas with white mudding (compound to smooth drywall) on the painted green wall at the head of the bed. Observation and interview with the Maintenance Director on 10/24/17 at 3:50 PM of the wall in room 505 revealed there were 9 areas of mudding on the wall, with the largest area measuring approximately 36 inches in length. Continued interview confirmed the wall was in need of repair/painting. Interview with the facility's painter with the Maintenance Director present on 10/24/17 at 4:00 PM, in the hallway revealed the wall had been mudded 6 months ago and confirmed the green wall had not been repainted after the mudding. Observation and interview with the Maintenance Director on 10/25/17 at 9:30 AM of the walls in rooms 503, 513, and 519, confirmed the walls had areas of sheetrock showing and were in need of repair.",2020-09-01
330,ALEXIAN VILLAGE OF TENNESSEE,445123,671 ALEXIAN WAY,SIGNAL MOUNTAIN,TN,37377,2017-10-25,315,D,0,1,QBNE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to assess 1 resident (#123) for a toileting program of 2 residents reviewed for urinary incontinence of 28 residents reviewed. The findings included: Review of the facility's policy Restorative Nursing - Toileting Program, revised 12/2016, revealed .Residents who are incontinent are assessed by Nursing and/or Therapy for a Toileting program to promote independence and quality of life by maintaining or improving a resident's continence .[NAME] Appropriate residents for the program may include the following: 1. Residents who are incontinent .4. Residents who require limited to extensive assistance in toilet use; 5. Residents who have difficulty notifying staff when they have the urge to void .B. Resident continence is assessed on admission, with significant changes and quarterly: 1. Check resident approximately hourly and document in the resident's medical record as continent, incontinent or soiled and level of assistance. 2. During the assessment period, associates honor the resident's request to toilet, but do not offer to take them as this interferes with the results of the incontinence pattern. 3. After 3 days analyze data .Determine patterns in frequency, volume, duration, and time of day . Medical record review revealed Resident #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission Minimum Data Set ((MDS) dated [DATE] revealed the resident scored a 4 on the Brief Interview for Mental Status, indicating the resident had severely impaired cognitive skills, required extensive assistance of 1 person with transfers, walking in room, and toilet use, and was frequently incontinent of bladder. Medical record review of the significant change of status MDS dated [DATE] revealed the resident had a BIMS of 6, indicating the resident had severely impaired cognitive skills, required extensive assistance of 1 person with transfers, walking in room, and toilet use, and was always incontinent of bladder. Medical record review revealed no documentation the resident's continence pattern had been documented approximately hourly for 3 days then assessed to determine a pattern of incontinence or the type of incontinence after the resident's decline in urinary incontinence. Interview with Registered Nurse (RN #1) on 10/24/17 at 3:30 PM, in the conference room, confirmed the continence pattern was not completed after Resident #123's decline in continence identified on the 6/15/17 MDS to determine if the resident would benefit from a toileting program.",2020-09-01
331,ALEXIAN VILLAGE OF TENNESSEE,445123,671 ALEXIAN WAY,SIGNAL MOUNTAIN,TN,37377,2017-10-25,441,E,0,1,QBNE11,"Based on facility policy review, manufacturer's recommendation, observation, and interview, the facility failed to ensure staff maintained infection control for the glucose meter and to disinfect the glucose meters with appropriate disinfectant for 3 of 6 nurses observed. The findings included: Review of the facility's policy, Obtaining a Fingerstick Glucose Level, revised date 12/2016, revealed .Steps in the Procedure Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice . Review of the manufacturer's recommendation user guide revealed .page 42/43. Cleaning and disinfecting meter and lancing device is very important in the prevention of infectious disease .The following products are validated for disinfecting the (product name) (named cleaning wipe) . Observation on 10/24/17, at 7:50 Am, revealed Licensed Practical Nurse (LPN) #1, was preparing to perform a blood glucose test. Continued observation revealed the LPN#1 removed the glucose meter from medication cart and placed the meter in her uniform pocket. Observation revealed the LPN entered the resident's room, removed the glucose meter from uniform pocket, placed the glucose meter on the resident's overbed table. Continued observation revealed after the LPN obtained the resident's blood glucose, she placed the glucose meter in her uniform pocket. Observation revealed the LPN returned the glucose meter to the medication cart and placed the meter on top. Further observation revealed the LPN disinfected the glucose meter with alcohol pads. Observation on 10/25/17, at 7:50 AM, revealed LPN#2 was preparing to check a blood glucose for a resident. Continued observation revealed LPN#2 took the glucose meter in the resident's room, obtained blood glucose, returned the glucose meter to the medication cart. Observation revealed LPN #2 disinfected the glucose meter with alcohol pads. Observation on 10/25/17, at 8:00 AM, revealed LPN #3 was preparing to check a blood glucose for a resident. Observation revealed LPN #3 took the glucose meter in the resident's room, placed meter on the resident's bed, and obtained the blood glucose. Continued observation revealed LPN #3 returned the glucose meter to medication cart and placed in the drawer without disinfecting. Interview with LPN #3 at the time of observation confirmed LPN #3 had not disinfected the glucose meter before placing in the medication cart. Interview with the Director of Nursing (DON) on 10/24/17, at 1:30 PM, in the DON's office, confirmed the glucose meter was to be disinfected using the manufacturer's recommendation, (named cleansing wipe) and staff were not to carry the glucose meter in their uniform pocket. Interview with the DON on 10/25/17, at 8:25 AM, in the conference room, confirmed the facility had failed to follow policy and manufacturers' recommendation for disinfecting the glucose meter.",2020-09-01
332,ALEXIAN VILLAGE OF TENNESSEE,445123,671 ALEXIAN WAY,SIGNAL MOUNTAIN,TN,37377,2018-11-07,561,D,0,1,G97W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to honor representative care choices for bathing for 1 resident (#7) of 13 residents reviewed of 26 residents sampled. The findings include: Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the annual Minimum Date Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score could not be completed due to the resident being rarely or never understood. Interview with Resident #7's legal representative on 11/5/18 at 11:42 AM, in the resident's room, revealed . he should receive 3 showers weekly, but most weeks, he only gets one . Medical record review of Resident #7's Care Plan revealed, .Start 01/20/2017 .need total assistance with bathing/showering .Assist of 2 .3x (times) a week . Interview with Certified Nursing Assistant #1 on 11/6/18 at 4:04 PM, in the 6th floor nurse's station revealed, . he requires assistance of 2 .today is his bath day, and I haven't given him one yet until the nurse can help me . Medical record review of the Monthly Flow Sheet for (MONTH) (YEAR) of Resident #7's bathing schedule revealed 4 baths were missed. Further review revealed baths/showers were not given as requested per Resident #7's legal representative for (MONTH) (YEAR). Interview with the Director of Nursing on 11/7/18 at 9:42 AM, in the conference room, confirmed the facility failed to honor representative care choices for bathing for Resident #7.",2020-09-01
333,ALEXIAN VILLAGE OF TENNESSEE,445123,671 ALEXIAN WAY,SIGNAL MOUNTAIN,TN,37377,2018-11-07,644,D,0,1,G97W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview the facility failed to resubmit a PASSAR Level 1 referral with [DIAGNOSES REDACTED].#86) of 3 residents reviewed for PASARR (Pre Admission Screening and Resident Review) evaluation of 26 residents reviewed. The findings include: Review of the facility policy, PASARR (Pre Admission Screening and Resident Review) with a revised date of 7/2018, revealed .The purpose of this policy is to outline the screening of residents with a history of serious mental illness .The community will not admit any new resident who is suspected of having .A serious mental illness unless .The state mental health authority determines that the physical and mental condition of the individual requires the level of services provided by the facility .The state mental health authority determines whether or not the individual requires specialized services for mental illness .The community must incorporate communication from PASARR Level 2 determination into a resident's assessment, care planning and to his/her level of care . Medical record review revealed Resident #86 was admitted on [DATE] with [DIAGNOSES REDACTED]. Further review revealed Resident #86 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the PASARR dated 7/13/16 revealed a PASARR Level 1 screening was conducted on Resident #86. Continued review revealed .PASRR (PASARR) (LEVEL I) screen for Mental Illness & Mental [MEDICAL CONDITION] .Mental Illness (check YES or NO for each question) .NO Does the individual have a [DIAGNOSES REDACTED].g.(for example) including .[MEDICAL CONDITION] disorder .atypical [MEDICAL CONDITION] .[MEDICAL CONDITION] .NO .Does the individual have any presenting evidence of MENTAL ILLNESS .including disturbance in orientation affect or mood . Medical record review revealed no documentation a PASARR Level 2 had been conducted on Resident #86 with mental [DIAGNOSES REDACTED]. Medical record review of a Psychiatric Consult dated 9/14/18 revealed Resident #86 was followed by psychiatric services for [DIAGNOSES REDACTED]. Medical record review of a Psychiatric Consult dated 10/19/18 revealed .Continue [MEDICATION NAME] . I believe that hypomania (mood state characterized by persistent disinhibition and elevation (euphoria) it may involve irritation, but less severely than full mania) is probably related to recent trauma .Problem .Delusions .Status: Worsening . Medical record review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #86 had a Brief Interview for Mental Status Score (BIMS) of 15 indicating the resident was cognitively intact. Medical record review of Resident #86's Care Plan dated 10/24/18 revealed . (Resident #86's) psychosocial well-being is impaired related to GAD (Generalized Anxiety Disorder) and [MEDICAL CONDITION] disorder .(Resident #86) has alteration in mood related to h/o (history of) GAD and [MEDICAL CONDITION] disorder .(Resident #86) has impaired behavior related to h/o GAD and [MEDICAL CONDITION] disorder . Medical record review of Resident #86's Care Plan with a start date of 11/6/18 revealed .Level 1 PASRR (PASARR) is Negative .(Resident #86) will have PASRR (PASARR) completed per regulation . Medical record review of the Physician Orders and Medication Record dated 11/2018 revealed Resident #86 was ordered [MEDICATION NAME] (mood stabilizer) 125mg (miligrams) tablet delayed release by mouth every day at noon for [MEDICAL CONDITION] Disorder. Interview with the Director of Nursing (DON) on 11/07/18 at 9:33 AM, in the conference room, confirmed the facility failed to resubmit a PASARR Level 1 for Resident #86 with [DIAGNOSES REDACTED]. Interview with the MDS Coordinator on 11/07/18 at 9:45 AM, in the conference room, confirmed the facility failed to resubmit a PASARR Level 1 for Resident #86 with [DIAGNOSES REDACTED].",2020-09-01
334,ALEXIAN VILLAGE OF TENNESSEE,445123,671 ALEXIAN WAY,SIGNAL MOUNTAIN,TN,37377,2018-11-07,656,D,0,1,G97W11,"**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 implement a comprehensive care plan related to falls for 1 resident (#33) of 3 residents reviewed for falls of 26 residents sampled. Review of the facility policy, Using the Care Plan, last revised 7/2018, revealed .The care plan shall be used in developing the resident's daily care routines and will be available to associates who have the responsibility for providing care or services to the resident .Policy Interpretation and Implementation .The daily/weekly work assignments are driven from the Care Plan . Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the resident's current care plan revealed .Falls .(Resident #33) has potential for falls related to fall history .Anti rollbacks to w/c (wheelchair) .(updated) 10/31/18 . Observation and interview with Licensed Practical Nurse (LPN) #3 on 11/07/18 at 2:42 PM, in the resident's room, revealed the resident was seated in his wheelchair and anti-rollback wheels were not in place. Interview with LPN #1 confirmed the resident was in his personal wheelchair and the anti-rollback wheels should have been in place. Interview with the Director of Nursing (DON) on 11/07/18 at 3:05 PM, in the conference room, confirmed an intervention such as anti-rollback wheels should immediately be put in place. Continued interview confirmed .if they're not on the wheelchair .clearly it's not happening . Further interview confirmed the facility failed to implement Resident #33's care plan for a fall on 10/31/18.",2020-09-01
335,ALEXIAN VILLAGE OF TENNESSEE,445123,671 ALEXIAN WAY,SIGNAL MOUNTAIN,TN,37377,2018-11-07,689,D,0,1,G97W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, review of the facility fall program documentation, medical record review, observation, and interview, the facility failed to implement falls interventions for 1 resident (#33) identified as high risk for falls of 3 residents reviewed for falls of 26 sampled residents. The findings include: Review of the facility policy, Falls Prevention, revised 1/2018, revealed, .Policy Statement/Overview .Early identification of the risk for falls and reduction of falls, encourage residents to maintain the highest level of independence in a safe environment without significant risk of injury. Based on previous evaluations and current data, the associates may identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling . Review of the facility's Fall Program documentation, undated revealed, .Post Fall Follow-up .Daily Clinical Huddle .Day following fall, Nurse Manager to check if interventions are in place and being used properly . Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status score of 8, indicating Resident #33 had a moderate cognitive impairment, and required extensive assistance for bed mobility and transfers with assistance from 1 staff member. Medical record review of Resident #33's Falls Risk assessment dated [DATE] and 11/1/18, revealed the resident was at high risk for falls. Review of the facility Safety Event Entry dated 10/31/18, revealed Resident #33 had an unwitnessed fall on this date, and was observed sitting in the floor in front of his wheelchair beside his bed. Medical record Review of the POS [REDACTED].New Intervention .Anti-rollbacks to w/c (wheelchair) . Medical record review of the resident's current comprehensive care plan revealed, .Falls (Resident #33) has potential for falls related to fall history .Anti-rollbacks to w/c .10/31/18 . Observation and interview with Licensed Practical Nurse #3 on 11/7/18 at 2:42 PM, in the resident's room, revealed the resident was seated in his wheelchair and anti-rollback wheels were not in place. Interview confirmed the resident was in his personal wheelchair and the anti-rollback wheels should have been in place. Interview with the Director of Nursing on 11/7/18, at 3:05 PM in the conference room, confirmed an intervention such as anti-rollback wheels should be immediately put in place. Continued interview confirmed .if they are not on the wheelchair .clearly it is not happening . Further interview confirmed the facility failed to follow their policy for falls prevention.",2020-09-01
336,ALEXIAN VILLAGE OF TENNESSEE,445123,671 ALEXIAN WAY,SIGNAL MOUNTAIN,TN,37377,2018-11-07,756,D,0,1,G97W11,"**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 the Physician reviewed and acted upon irregularities identified by the pharmacist for 2 residents (#38 and #62) of 5 residents reviewed for unnecessary medications of 26 residents sampled. The findings include: Review of facility policy, Medication Regimen Reviews, revised 12/2016 revealed .The Pharmacist shall review the medication regimen of each resident at least monthly .Pharmacist will provide a written report or electronic via the electronic medical record to Physicians for each resident with an identified irregularity .If the Physician does not provide a pertinent response, or the Pharmacist identifies that no action has been taken .then contact the Medical Director .Copies of the drug/medication regimen review reports, including Physician responses will be maintained as a part of the permanent medical record . Medical record review revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Consultation Report dated 6/25/18 revealed . (Resident #38) .has a PRN (as needed) for an anxiolytic without a stop date: [MEDICATION NAME] (Anti Anxiety) 0.5 mg (Milligram) .since 6/22/18 .Recommendation: Please add a stop date . Continued review revealed the Physician did not respond to the Pharmacist recommendation. Medical record review of a Consultation Report dated 7/17/18 revealed .6/25/2018 .please add a stop date. This order ([MEDICATION NAME]) is out of compliance with CMS Regulations . Continued review revealed the Physician did not respond to the Pharmacist recommendation. Medical record review of the Physician order [REDACTED].[MEDICATION NAME] 0.5 mg tablet .4 times a day PRN . Interview with the Director of Nursing (DON) on 11/7/18 at 2:50 PM in conference room confirmed .Physician failed to follow up with Pharmacy Recommendations . Continued interview confirmed .I am responsible for following up with Physician for Pharmacy Review Recommendations . Telephone interview with the Medical Director on 11/7/2018 at 4:26 PM, in conference room, confirmed he was not aware the attending Physician was not reviewing pharmacy recommendations. Resident #62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment, required extensive assistance with 1 staff member for activities of daily living, and did not experience behaviors Medical record review of the Medication Records dated 5/2018 - 7/2018 revealed .abhrp gel (compounded antipsychotic medication) .Apply 1 ML (milliliter) to inner wrist every 4 hours as needed for agitation .Start date 04/26/18 .End Date 07/26/18 . Medical record review of the Consultation Report dated 5/2/18 revealed .(Resident #62) has a PRN (as needed) order for an antipsychotic without a stop date: ABHR gel q (every) 4h (hour) prn since 4/25/18. This RX (prescription) is only good for 14 days. Recommendation .Please discontinue PRN ABHRP . Continued review revealed no documentation Resident #62's Physician responded to or acknowledged the recommendation. Interview with the DON on 11/07/18 at 12:28 PM, in the conference room, confirmed Resident #62's Physician had not responded to the pharmacy recommendations made on 5/2/18 and 6/25/18. Continued interview confirmed the facility failed to have Resident #62's Physician follow up with a pharmacy recommendation.",2020-09-01
337,ALEXIAN VILLAGE OF TENNESSEE,445123,671 ALEXIAN WAY,SIGNAL MOUNTAIN,TN,37377,2018-11-07,761,D,0,1,G97W11,"Based on facility policy review, observation, and interview, the facility failed to ensure all expired medications, medication related supplies, and biologicals were discarded in 2 of 5 medication storage areas and 1 of 3 medication carts observed of 6 medication storage rooms and 6 medication carts in use. The findings include: Review of the facility policy, .Storage of Medications last revised 12/2017 revealed .The nursing associates shall be responsible for maintaining medication storage .not use discontinued, outdated, or deteriorated drugs or biologicals . Observation with Licensed Practical Nurse (LPN) #1 on 11/7/18 at 3:20 PM, in the 5th floor medication storage room, of the medication cart, revealed 44 Tylenol (medication to treat pain) 325 mg (milligram) tablets with expiration date of 10/31/18. Continued observation revealed the following expired supplies: * 2 light blue top laboratory tubes 2.7 ml (milliliter) with an expiration date of 7/31/18 * 2 blood transfer devices with an expiration date of 10/2018 Interview with LPN #1 on 11/7/18 at 3:20 PM, in the 5th floor medication room, confirmed the expired medications and supplies were available for resident use. Observation with LPN #2 on 11/7/18 at 3:42 PM, in the 6th floor medication room, revealed the following expired supplies: * 39 red top laboratory tubes 10 ml with an expiration date of 9/30/18 Interview with LPN #2 on 11/7/18 at 3:42 PM, in the 6th floor medication room, confirmed the expired supplies were available for patient use. Interview with the Director of Nursing on 11/7/18 at 5:10 PM, in the conference room, confirmed .The expired supplies should not be in the medication rooms or carts .Every Sunday night supervisors check for expired medication and supplies .we split up and go through each medication room . Continued interview confirmed the facility failed to ensure all expired medications, medication related supplies, and biologicals were discarded appropriately.",2020-09-01
338,ALEXIAN VILLAGE OF TENNESSEE,445123,671 ALEXIAN WAY,SIGNAL MOUNTAIN,TN,37377,2018-11-07,812,F,0,1,G97W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation, and interview, the facility failed to properly clean and store kitchen equipment, separate cooking utensils from personal items, failed to discard expired food items, failed to secure, label and date opened food items, and failed to provide thermometers for 2 of 12 refrigerators and freezers possibly affecting 92 of 93 residents in the 1 of 1 kitchen and failed to secure, date, and label opened food items for 1 of 4 floor kitchens. The findings include: Review of the facility policy Food Purchasing and Storage, revised ,[DATE] revealed .food storage areas shall be clean and dry at all times . Review of the facility policy Food Preparation Area Safety and Sanitation retrieved [DATE] revealed .cleaning schedules governing daily, weekly, and monthly cleaning procedures should be followed . Review of the facility policy Food and Supply Storage Procedures revised ,[DATE] revealed .cover, label and date unused portions and open packages .remove from storage any items for which the expiration date has expired .foods that must be opened must be stored .approved containers that have tight-fitting lids .hang scoop .scoops may be stored in bins on a scoop hanger . Review of the facility policy Food Contact Surfaces revised ,[DATE] revealed .cooking equipment shall be kept free of encrusted grease deposits and other accumulated soil . Review of the facility policy Food Handling Guidelines revised ,[DATE], revealed .protect food from contamination with covers or shield .do not store food directly on ice . Review of the facility policy Equipment Temperature Monitoring and Documentation dated [DATE] revealed .document temperatures for all refrigerators and freezers used to store resident's food . Observation and interview with the Executive Chef and the Dietician on [DATE] at 10:35 AM, in the kitchen revealed a covered stand-up mixer. Continued observation revealed dried white debris on the back, sides, and top of the mixer. Interview with the Executive Chef at this time confirmed the mixer was not used on [DATE] and the facility failed to properly clean and store the stand-up mixer. Observation and interview with the Executive Chef and the Dietician on [DATE] at 10:40 AM, at the prep station of the kitchen revealed a set of keys on a lanyard (cloth necklace) in a utensil drawer, along with cooking utensils. Further observation of the shelf over the prep table revealed sandwich rolls with an expiration date of ,[DATE]. Interview with the Executive Chef confirmed the facility failed to separate cooking utensils from personal items and to discard expired food items. Observation and interview with the Executive Chef and the Dietician on [DATE] at 10:43 AM, in the Produce Walk-in Cooler, of the kitchen, revealed 1 opened, half-loaf of wheat bread expired '',[DATE]'', 1 unlabeled, undated submarine roll, and 1 unlabeled, undated, half-loaf of raisin bread. Interview with the Executive Chef confirmed the facility failed to discard the expired wheat bread and to label and date the submarine roll and the raisin bread. Observation and interview with the Executive Chef and the Dietician on [DATE] at 11:00 AM, in the Vegetable Walk-in Freezer of the kitchen, revealed 1 open to air, unsecured box of frozen peanut butter cookies (approximately half full) and 1 open to air, unsecured box of frozen oatmeal raisin cookies (approximately half full). Further observation revealed the opened cookie boxes were not dated or labeled. Interview with the Executive Chef confirmed the facility failed to secure, date, and label the opened boxes of frozen cookies. Observation and interview with the Executive Chef and the Dietician on [DATE] at 11:05 AM, in the Milk Cooler of the kitchen, revealed no thermometer. Interview with the Executive Chef confirmed the facility failed to ensure the placement of a thermometer for the cooler. Observation and interview with the Executive Chef and the Dietician on [DATE] at 11:08 AM, in the Meat Walk-In Freezer of the kitchen, revealed no thermometer. Interview with the Executive Chef confirmed the facility failed to ensure the placement of a thermometer for the Meat Freezer. Observation and interview with the Executive Chef and the Dietician on [DATE] at 11:10 AM, in the Dry Storage room of the kitchen, revealed approximately 3 pounds (lbs.) of opened, unlabeled, and undated bag of couscous (small grain) and approximately one-half ( 1/2) lb. of opened, unlabeled, and undated bag of tube noodles. Interview with the Executive Chef cofirmed the couscous and tube noodles were opened, unlabeled, and undated. Observation and interview with the Executive Chef and the Dietician on [DATE] at 11:15 AM, in the Ice Cream Walk-In Freezer of the kitchen, on the top shelf, revealed a large metal pan with prepared hash brown casserole covered with plastic wrap. Further observation revealed a large ice block sitting on top of the casserole. Interview with the Executive Chef confirmed the facility failed to properly cover and monitor frozen prepared foods. Observation and interview with the Executive Chef and the Dietician on [DATE] at 11:20 AM, at 3 of 3 double ovens in the kitchen revealed: Double oven number (#) 1: three of 3 crumb trays with a heavy amount of black and brown debris Double oven #2: one of 2 crumb trays with a heavy amount of black and brown debris Double oven #3: four of 5 crumb trays with a heavy amount of black and brown debris Interview with the Executive Chef confirmed the facility failed to properly clean the crumb trays of the 3 double ovens. Observation and interview with the Executive Chef and the Dietician on [DATE] at 11:25 AM, of the Line Freezer in the kitchen revealed the following open to air, unsecured, unlabeled, and undated food items: 15 frozen country fried steaks, 10 frozen breaded catfish nuggets, and 1/2 box of frozen sweet potato wedges. Interview with the Executive Chef confirmed the steaks, catfish, and sweet potatoes were opened to air, unsecured, unlabeled, and not dated. Observation and interview with the Executive Chef and the Dietician on [DATE] at 11:30 AM, of 1 of 3 bulk food storage bins revealed a scoop resting in the fish breading. Interview with the Executive Chef confirmed the facility failed to properly store the scoop. Interview with the Director of Dietary on [DATE] at 11:15 AM, in the Conference Room, confirmed the facility failed to properly clean kitchen equipment, separate cooking utensils from personal items, failed to discard expired foods, failed to secure, date, and label opened foods, and failed to provide thermometers for 1 refrigerator and 1 freezer. Observation with the Dietary Server #1 on [DATE] at 12:34 PM, in the 8th floor kitchen, revealed: A) One 10 ounce plastic bottle containing approximately 2 ounces of ranch dressing with the top of bottle cut off, ranch dressing contents open to air, and available for resident use. B) One 14 ounce container approximately 1/2 full of coffee ice cream, with ice crystals scattered throughout the inside of the ice cream container, undated, and unlabeled with the resident's name, and available for resident use. Interview with the Service Manager on [DATE] at 12:34 PM, in the 8th floor kitchen area, confirmed the facility failed to maintain a sanitary kitchen evidence by food items covered with ice buildup, undated, unlabeled, and open to air food items available for resident use.",2020-09-01
339,ALEXIAN VILLAGE OF TENNESSEE,445123,671 ALEXIAN WAY,SIGNAL MOUNTAIN,TN,37377,2019-11-20,880,D,0,1,WOBN11,"Based on facility policy review, observation, and interview, the facility failed to follow infection control practices during medication administration observations for 1 of 4 nurses observed administering medications to 1 (#7) of 5 residents. The findings include: Review of the policy, Administering Medications, dated 2/2019, revealed .Associates shall follow established community infection control procedures (e.g., handwashing, antiseptic technique, gloves) .for the administration of medications, as applicable . Observation of a medication administration with Registered Nurse (RN) #1 on 11/19/19 at 8:15 AM, on the 5th floor revealed RN #1 opened a drawer to the medication cart. Continued observation revealed the RN pulled the medication packets, removed the medications from the packets, each time placing medication in her bare hand, for a total of 11 medications. Further observation revealed RN #1 administered the medications to Resident #7. Interview with RN #1 on 11/19/19 at 8:59 AM, on the 5th floor, confirmed she had touched the medications with the bare hands during medication administration for Resident #7. Interview with Quality Assurance Director on 11/19/19 at 8:59 AM, on the 5th floor, confirmed RN #1 was to have worn gloves when touching medications for administration to Resident #7.",2020-09-01
340,"THE WATERS OF GALLATIN, LLC",445124,555 EAST BLEDSOE STREET,GALLATIN,TN,37066,2019-01-09,800,D,0,1,X6DS11,"Based on facility policy review, observation, and interview, the facility failed to serve hot food at or greater than 135 degrees Fahrenheit (F) for 1 of 5 halls. The findings include: Review of the facility policy dated 12/16/06 .Resident Dining Services revealed .Hot foods are served at 135 degrees or higher . Review of the resident council minutes dated 12/3/18 revealed .Dietary Food being served cold . Interview with the Resident Council on 1/7/18 at 10:30 AM in the dining room revealed hall 400 was served cold food. Observation on 1/7/19 at 1:09 PM on hall 400 revealed 18 trays on the meal cart. Further observation revealed the test tray consisted of chicken, mashed sweet potatoes, and mixed vegetables. Further observation at 1:11 PM revealed the Assistant Dietary Manager obtained the temperature of the mixed vegetables which were 112 degrees Fahrenheit. Interview with Resident #85 on 1/7/19 at 2:52 PM in her room stated .when meals are served on hall 400 they are not hot and always cold when delivered to her room . Interview with the Dietary Manager on 1/8/19 at 10:01 AM in her office confirmed .the food should be appealing, accommodating, and hot foods should be hot .",2020-09-01
341,"THE WATERS OF GALLATIN, LLC",445124,555 EAST BLEDSOE STREET,GALLATIN,TN,37066,2017-10-11,223,D,1,1,AQJ411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, and interview, the facility failed to prevent abuse/exploitation for 1 residents (#81) of 5 resident reviewed for abuse. The findings included: Review of facility policy, Cell Phone Policy, undated, revealed .It is Facility's policy that representatives of our organization do not use cell and /or smart phones while performing work tasks. Further, video and or pictures should not be taken of residents, PHI (Protected Health Information) and ePHI (electronic Protected Health Information) . Medical record review revealed Resident #81 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #81 discharged from the facility on 7/28/17. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview for Mental Status score of 15, indicating she was cognitively intact. Review of the facility investigation revealed a written statement from Certified Nurse Aide (CNA) #2 dated 6/27/17 .I was shown a picture by (CNA #1). It was an inappropriate picture of the resident in 408B. I also witnessed (CNA #1) showing the picture at the nurse's station one night & laughing about it . Telephone interview with CNA #1 on 10/11/17 at 6:35 PM revealed she admitted taking a picture of Resident #81 while the resident was transferring from the bedside commode to the bed. It was unknown when this picture was taken. Further interview revealed the resident was not clothed from the waist down. Further interview revealed approximately 2 months later the CNA sent the picture to CNA #2 and denied showing the picture to any other staff. Interview with the Administrator on 10/11/17 at 4:30pm in her office revealed confirmed the facility failed to prevent abuse/exploitation for Resident #81.",2020-09-01
342,"THE WATERS OF GALLATIN, LLC",445124,555 EAST BLEDSOE STREET,GALLATIN,TN,37066,2017-10-11,225,D,1,1,AQJ411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, and interview, the facility failed to thoroughly investigate 2 allegations for 1 resident (#81) of 5 residents reviewed for abuse. The findings included: Review of facility policy, Abuse Prevention Program, dated 1/19/17 revealed .Once the Administrator or designee determines that there is a reasonable cause for suspecting abuse, the Administrator or designee will investigate the allegation and obtain a copy of any documentation relative to the incident . Medical record review revealed Resident #81 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #81 discharged from the facility on 7/28/17. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #81 had a Brief Interview for Mental Status score of 15, indicating she was cognitively intact. Review of the facility investigation regarding abuse/exploitation of Resident #81 revealed no statement from the identified staff who took the picture or from Resident #81. Review of the facility investigation of an undated hand written document revealed .Res (resident) reported to nurse that $80 was missing fr (from) wallet. It has been 2-3 days since she saw it . Further review of the facility's investigation revealed 5 witness statements were obtained from staff. Interview with the Administrator on 10/11/17 at 4:30 PM in her office revealed the resident was having hallucinations when she reported the money missing. The Administrator stated the hallucinations worsened as the day progressed, resulted in the resident being sent to local hospital for evaluation. The Administrator confirmed no additional witness statements were obtained nor was a statement obtained from Resident #81. The Administrator confirmed she wrote the hand written document in the investigation. The Administrator confirmed the facility failed to thoroughly investigate 2 allegations of abuse/exploitation and misappropriation of funds for Resident #81. Interview with the Assistant Director of Nursing (ADON) on 10/11/17 at 4:45 PM in the conference room revealed the statements in the investigations were obtained by the Director of Nursing, the Administrator and the ADON. The ADON confirmed no additional statements were obtained from any additional staff, from the identified staff who took the picture of Resident #81 or from Resident #81 about either investigation. The ADON confirmed the facility failed to thoroughly complete both investigations. The facility failed to obtain statements from staff who worked prior to the money being reported missing and from Resident #81 thus the facility failed to completed a thorough investigation of the missing money per the facility. The facility failed to obtain statements from the identified staff who took the picutre of Resident #81 and from the resident thus the facility failed to complete a thorough investigation of abuse/exploitation per the facility policy.",2020-09-01
343,"THE WATERS OF GALLATIN, LLC",445124,555 EAST BLEDSOE STREET,GALLATIN,TN,37066,2017-10-11,278,D,0,1,AQJ411,"**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 oral status of 1 resident (#34) of 20 residents reviewed. The findings included: Medical record review revealed Resident #34 was admitted to the facility on [DATE] and readmitted on [DATE] and 11/9/15 with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], the Annual MDS dated [DATE], and the Quarterly MDS dated [DATE] of the Oral/Dental Status section revealed the resident had no concerns. Observation on 10/10/17 at 9:53 AM in the Main Dining Room, on 10/10/17 at 12:40 PM in the 600 Hall area, and on 10/11/17 at 7:20 AM in the 600 Hall dining area revealed Resident #34 had several missing front teeth at the top and bottom of the mouth. Interview with the MDS Corrdinator on 10/11/17 at 12:10 PM in her office revealed she was responsible for completing the dental status section of the MDS for Resident #34. The MDS Cordinator confirmed Resident #34's dental status section on the Quarterly MDS dated [DATE], the Annual MDS dated [DATE] and the Quarterly MDS dated [DATE] were not coded accurately.",2020-09-01
344,"THE WATERS OF GALLATIN, LLC",445124,555 EAST BLEDSOE STREET,GALLATIN,TN,37066,2017-10-11,516,D,0,1,AQJ411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation, and interview, the facility failed to safeguard medical record information against loss or unauthorized use. The findings included: Review of facility policy, Controlled Substance Prescriptions, undated revealed .In compliance with applicable state and federal regulations, and to prevent diversion of controlled substances, the following steps must be taken when a provider completes and signs a prescription for a controlled substance in the skilled nursing facility: .Original paper prescription to be placed in a sealed envelope and delivered to pharmacy . Observation on 10/10/17 at 4:00 PM at the 600 Hall nurses station revealed the station door open, the desk top computer was logged into a resident's chart and a paper prescription for [MEDICATION NAME] was stored on the desk. Further observation revealed no facility staff in the nurses station or the immediate area. Observation and interview on 10/10/17 at 4:02 PM at the 600 Hall nurses station, with the Assistant Director of Nursing (ADON) present, revealed the station door open, the desk top computer was logged into a resident's chart and a paper prescription for [MEDICATION NAME] was stored on the desk. Interview with the ADON confirmed it was not facility procedure for the computer to be logged on and the paper prescription to be stored on the desk without facility staff present. Further interview confirmed the facility failed to safeguard the medical record information against loss or unauthorized use.",2020-09-01
345,"THE WATERS OF GALLATIN, LLC",445124,555 EAST BLEDSOE STREET,GALLATIN,TN,37066,2019-12-18,600,D,1,1,BPQR11,"**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 1 (#66) of 94 residents was free from abuse. Facility policy review Resident Rights & Facility Responsibilities, undated, revealed .The right to live in a caring environment free from abuse, mistreatment and neglect . Facility policy review Abuse Prevention Program, dated 1/19/17, revealed .It is the policy of this facility to prevent resident abuse, neglect, mistreatment and misappropriation of resident property .This facility will not tolerate resident abuse or mistreatment by anyone, including staff members, other residents, consultants, volunteers, staff of other agencies, family members, legal guardians, friends or other individuals . Review of facility investigation initiated on 11/11/19 revealed Resident #24 was observed with his hand on Resident #66's torso. Continued review revealed Resident #24 was removed and placed on 1 on 1 supervision and both residents were assessed by staff with no skin issues noted. Resident #24 was sent to local hospital for further evaluation with medication adjustments made; upon return to facility the resident was moved to a different unit to a private room. Continued review revealed staff were educated on abuse from 11/11/19 through 11/22/19. Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident received a [DIAGNOSES REDACTED]. Medical record review of Resident #24's Order Summary Report dated (MONTH) 2019 revealed .[MEDICATION NAME] Sprinkles 125 MG (milligram) give 1 tablet at bedtime for sexual impulsivity 11/15/19 .Flutamide 250 mg one time daily at bedtime for sexual inappropriate behaviors 11/12/19 . Medical record review of Resident #24's History and Physical dated 11/12/19 revealed .Pt (patient) is being seen per nursing request. Pt has had an episode of sexually inappropriate behavior with another resident. Pt sent to ED (emergency department) for evaluation. He was found to have mild PNA (pneumonia) and is taking [MEDICATION NAME] 750 mg by mouth daily. He returned back to the facility and has been moved to another wing away from other resident . Medical record review of Resident #24's Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 6 indicating the resident had severe cognitive impairment. Continued review revealed the resident exhibited physical behaviors directed toward others 1-3 days of the 7 day look back period. Medical record review of Resident #24's comprehensive care plan dated 5/5/19 and revised on 10/15/19 revealed .the resident exhibits sexually inappropriate behavioral symptoms related to dementia. Behavioral symptoms are manifested by: making inappropriate comment toward staff members, attempting to get females to lie down in bed with him, grabbing staff members during care. Grabs nurses and sexual remarks . Medical record review revealed Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #66's MDS dated [DATE] revealed the resident was severely impaired for decision making. Continued review revealed the resident exhibited no behaviors. Medical record review of Resident #66's comprehensive care plan revealed the resident had communication impairment. Medical record review of an incident note for Resident #24 and #66 dated 11/11/19 revealed .around 17:20 - 17:25, I walked by female resident's room (Resident #66) (she was lying in bed) and noticed the resident (Resident #24) was in her room sitting in his w/c (wheel chair) beside the bed. The lights were off, so I turned the lights on as I walked in. the blanket was at the female resident's waist, her gown was around her neck and the resident had his left hand on her left breast. I immediately pulled him away, pulled the female resident's gown down and covered her with the blanket. I comforted and reassured the female resident, she was unable to tell me what happened, no obvious skin injury or other injury noted . Continued review revealed Resident #24 was taken to the nurse station and placed on 1 on 1 supervision. Interview with Resident #24 on 12/16/19 at 12:08 PM in his room revealed when asked if he touched Resident #24 on her breast he stated no, I don't remember that. Interview with the Administrator on 12/17/19 at 8:15 AM in her office revealed the facility unsubstantiated the allegation of abuse between Residents #24 and #66 due to both residents' cognition and there was no intent identified. Continued interview revealed the facility deemed the incident as a wandering, rummaging type of behavior. Telephone interview with Licensed Practical Nurse (LPN) #2 on 12/17/19 at 11:32 AM confirmed I was walking down the hall past (named) Resident #66's room when I saw another resident sitting in her room in a wheelchair beside her bed; I went into the room and turned on the light and she had her gown up close to her neck and (named) Resident #24 had his left hand on her left breast; I addressed him and he moved his hand. Continued interview she stated she removed the male resident to the hall way and assessed the female resident's skin with no issues identified. Continued interview revealed she placed the male resident in the main nurse station and notified the Assistant Director of Nursing. Continued interview revealed Resident #24 was placed on 1 on 1 supervision and was transferred to the hospital for further evaluation. Interview with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) on 12/17/19 at 1:14 PM in the DON's office revealed staff notified them of the incident on 11/11/19 with Resident #24 and #66. Continued interview the ADON confirmed (named) LPN #2 came to me and reported she found (named) Resident #24 in (named) Resident #66's room with his hand on her chest with her covers pulled back; I immediately notified the DON and the Administrator; (named) Resident was placed on 1 on 1 supervision and then sent to the hospital for evaluation.",2020-09-01
346,"THE WATERS OF GALLATIN, LLC",445124,555 EAST BLEDSOE STREET,GALLATIN,TN,37066,2019-12-18,641,D,0,1,BPQR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to accurately assess 1 (#87) resident of 32 residents reviewed for Minimum Data Set (MDS) accuracy. The findings include: Medical record review revealed Resident #87 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #87's physician order [REDACTED].D/C (discharge) home 11/29/19 . Medical record review of Resident #87's Care Plan Summary Progress Note dated 11/27/19 revealed .Care plan meeting held .resident is scheduled for discharge on Friday . Medical record review of Resident #87's Progress Note dated 12/2/19 revealed Resident discharged home Friday (11/29/19) . Medical record review of Resident #87's Discharge MDS dated [DATE] revealed .Discharge Status .acute hospital . Interview with the MDS Coordinator on 12/18/19 at 9:24 AM in her office confirmed Resident #87's discharge MDS was coded to reflect the resident was discharged to the hospital; she stated I just miscoded it.",2020-09-01
347,"NHC HEALTHCARE, SEQUATCHIE",445126,"360 DELL TRAIL, PO BOX 878",DUNLAP,TN,37327,2017-06-14,371,E,0,1,SEPB11,"Based on observation and interview, the facility failed to serve hot food at or above 135 degrees Fahrenheit (F) and failed to serve cold food at or less than 41 degrees F for 1 of 2 resident meal services observed. The findings included: Observation on 6/12/17 beginning at 12:14 PM in the dietary department revealed the resident mid-day meal service was in progress and one resident meal delivery cart had left the dietary department. Further observation revealed the Assistant Dietary Manager obtained 113 degrees F for the grilled chicken. Further observation revealed a pan containing shredded lettuce, chopped tomatoes, and shredded cheese stored in a chilled pan on the counter behind the steam table and was available to be served to the residents. Further observation revealed the Assistant Dietary Manager obtained 56 degrees F for the shredded cheese. Interview with the Assistant Dietary Manager confirmed the facility failed to serve hot food at or above 135 degrees F and failed to serve cold food at or less than 41 degrees F.",2020-09-01
348,"NHC HEALTHCARE, FRANKLIN",445127,216 FAIRGROUND ST,FRANKLIN,TN,37064,2018-02-28,637,D,0,1,L0V711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual v1.15R (MONTH) 1, (YEAR), medical record review, and interview, the facility failed to ensure a significant change in status assessment (SCSA) was completed and completed timely related to hospice services for 2 of 20 (Resident #35 and 74) sampled residents reviewed. The findings included: 1. The MDS 3.0 RAI Manual v1.15R p. 23-24 documented .A SCSA is required to be performed when a terminally ill resident enrolls in a hospice program .The MDS completion date (Item Z0500B) must be .no later than 14 days after the determination that the criteria for a SCSA were met . 2. Medical record review revealed Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].(Named) Hospice . Medical record review revealed there was no significant change MDS assessment completed when Resident #35 was admitted to hospice. Interview with the MDS Coordinator on 2/28/18 at 12:00 PM, in the MDS office, The MDS Coordinator was asked if a change of status MDS was completed when Resident #35 was admitted to hospice. The MDS Coordinator stated, No, I do not have one. 3. Medical record review revealed Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change MDS, related to hospice services, with an Assessment Reference Date (ARD) of 10/10/17 documented a completion date of 10/23/17. A physician's orders [REDACTED].>Interview with the MDS Coordinator on 1/28/17 at 2:30 PM, in the MDS office, the MDS Coordinator was asked if the 10/10/17 MDS was completed within 14 days of the resident being admitted to hospice. The MDS Coordinator stated No, Ma'am",2020-09-01
349,"NHC HEALTHCARE, FRANKLIN",445127,216 FAIRGROUND ST,FRANKLIN,TN,37064,2018-02-28,657,D,0,1,L0V711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure each resident was involved in developing the care plan and making decisions about his or her care for 2 of 2 (Resident #34 and 44) sampled residents reviewed of the 11 residents interviewed about participation in care planning. The findings included: 1. Medical Record review revealed Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] and the quarterly MDS dated [DATE] documented a Brief Interview for Mental Status score of 15, indicating Resident #34 was cognitively intact. Medical record review revealed no documentation Resident #34 participated in care planning meetings. Interview with Resident #34 on 2/26/18 at 3:45 PM, in Resident #34's room, Resident #34 was asked if she participated in her care planning meetings. Resident #34 stated, No .I have asked to be there, but have not been invited yet. Resident #34 was asked if she wanted to go to the meetings. Resident #34 stated, Yes. 2. Medical record review revealed Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS dated [DATE] and the quarterly MDS dated [DATE] documented a Brief Interview for Mental Status score of 15, indicating Resident #44 was cognitively intact. Review of the facility's Focus Meeting Form dated 6/1/17 revealed no interdisciplinary team signatures. Resident #44 had not signed the form. Review of the care plan for Resident #44 revealed that the care plan was revised on 1/26/18. Interview with Resident #44 on 2/26/18 at 5:04 PM, on the front lawn of the facility, Resident #44 stated that he had not been invited to participate in care planning meetings. Interview with the Social Services Director on 2/28/18 and 8:25 AM, in the Social Services office, the Social Services Director confirmed that there were no interdisciplinary team signatures on the Focus Meeting Form and confirmed that Resident #44 had not signed the form. The Social Services Director confirmed that Resident #44 had not participated in any care planning meetings since that time. 3. Interview with the Director of Nursing (DON) on 2/28/18 at 9:10 AM, in the DON office, the DON was asked if she expected alert and oriented residents to participate in their care planning meetings. The DON stated, Yes, absolutely. The DON was asked if residents or family members should be invited to care planning meetings on a quarterly basis. The DON stated, Yes. Interview with the MDS Coordinator on 2/28/18 at 8:35 AM, in MDS office, the MDS Coordinator was asked if residents and family members should be invited to the care plan meetings. The MDS Coordinator stated, Yes, Absolutely.",2020-09-01
350,"NHC HEALTHCARE, FRANKLIN",445127,216 FAIRGROUND ST,FRANKLIN,TN,37064,2018-12-20,689,D,0,1,776311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, review of fall investigation reports, and interview, the facility failed to ensure that fall investigations were completed for 1 of 18 (Resident #57) sampled residents reviewed for falls. The findings included: 1. The facility's PROTECTION/PREVENTION PROGRAMS-FALLS PREVENTION PROGRAM policy revised 8/13/13 documented, . (Named facility) takes a person centered approach to falls prevention. Comprehensive assessment and root cause analysis are two very important tools in the prevention of falls and the recurrence of falls .a Falls Committee .monitors falls and utilizes data to systemically address falls . 2. The facility's INCIDENT AND ACCIDENT PR[NAME]ESS revised 8/13/13 documented, .Investigation into the incident/accident: -Obtain information on what happened-what was actually seen or heard. If not witnessed, get patient's statement about what happened .Document all known facts, results of assessment including complete description of injuries, treatment, notification of physician and family. Gather statements from persons having information that may be pertinent . 3. Medical record review revealed Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of fall investigations for resident #57 dated 11/13/18, 12/2/18, and 12/10/18 revealed the fall investigation was incomplete. Interview with the Director of Nursing (DON) on 12/20/18 at 6:17 PM, in the 300 hall, the DON confirmed that the fall scene investigation was not attached to the 11/13/18, 12/2/18, and 12/10/18. The DON was asked if the fall investigations were complete. The DON stated, .no these are not complete .",2020-09-01
351,"NHC HEALTHCARE, FRANKLIN",445127,216 FAIRGROUND ST,FRANKLIN,TN,37064,2018-12-20,880,E,0,1,776311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure practices were maintained to prevent the potential spread of infection when 1 of 3 (Registered Nurse (RN) #1) nurses failed to properly clean the nebulizer equipment after use during medication administration, 2 of 16 (Certified Nursing Assistant (CNA) #1) and (Licensed Practical Nurse (LPN) #2) staff members touched the residents' food during dining, and Respiratory Therapist (RT) #1 failed to perform appropriate infection control practice during [MEDICAL CONDITION] care. The findings included: 1. The facility's SPECIFIC MEDICATION ADMINISTRATION PR[NAME]EDURES policy dated 6/2016 documented, .Rinse and disinfect the nebulizer equipment .Wash pieces (except tubing) with warm, soapy water .Rinse with hot water .Allow to air dry completely on paper . Observations in Resident #174's room on 12/18/18 at 8:34 AM, RN #1 washed her hands and performed the nebulizer treatment as ordered. RN #1 failed to clean the nebulizer equipment after use, and placed the uncleaned nebulizer equipment into a plastic bag at the resident's bedside. Interview with the Director of Nursing (DON) on 12/18/18 at 2:24 PM, at the nursing station, the DON was asked if it was acceptable to not clean the nebulizer equipment after use during medication administration. The DON stated, .No. 2. Observations on the 200 hall during dining on 12/17/18 at 11:51 AM, CNA #1 set up Resident #9's meal tray. CNA #1 removed a roll with his bare hands from the resident's meal plate and placed it on the tray. Observations in the restorative dining room on 12/17/18 at 12:23 PM, revealed Resident #27 was seated at the table when LPN #2 put the chicken patty on the bun with a fork and then with her bare hands, LPN #2 cut the chicken sandwich in half. LPN #2 picked up half of the sandwich with her bare hands and placed the sandwich in Resident #27's hand. Interview with the DON on 12/20/18 at 6:36 PM, on the 300 hall, the DON was asked if it was appropriate for the staff to touch the resident's food with their bare hands. The DON stated No, it is not, never. 3. The facility's .Tracheotomy Care policy revised 7/14 documented, .procedures are sterile and are performed by the RT, RN or LPN .Put a sterile glove on the dominant hand and a nonsterile glove on the nondominant hand . The facility's policy .Using Gloves revised 9/2010 documented .To prevent the spread of infection .Putting on Sterile Gloves .with one hand, grasp a glove by the inside of the cuff. Insert the opposite hand into the glove .Pick up the remaining glove with gloved hand. Insert ungloved hand into the second glove .Pull up cuffs of the glove .Removing Gloves .Wash hands. The facility's policy Handwashing/Hand Hygiene with a revised date of 8/2015 documented, .When applying, remove one glove from the dispensing box at a time . 4. Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].CLEAN WITH TRACHE ([MEDICAL CONDITION]) CARE KIT ONCE DAILY AND AS NEEDED . Observations in Resident #8's room on 12/19/18 at 9:25 AM, RT #1 removed the breakfast tray and other items from the bedside table, laid her [MEDICAL CONDITION] care kit and a package containing a split 4 x 4 gauze dressing on the bedside table without sanitizing the table and putting down a barrier. RT #1 removed a pair of gloves from her [NAME]et pocket, donned the pair of unsterile gloves, opened the pack of sterile gloves, donned the sterile gloves on top of the unsterile gloves and continued with [MEDICAL CONDITION] care. Interview with the DON on 12/20/18 at 4:12 PM, in the DON's office, the DON was asked if it was acceptable when preparing for [MEDICAL CONDITION] care not to sanitize the bedside table and not to lay a barrier down before putting supplies down for [MEDICAL CONDITION] care. The DON stated, .No. The DON was asked if it was acceptable to pull a pair of gloves out of your pocket and use them. The DON stated No. The DON was asked is it acceptable to don sterile gloves over a pair of unsterile gloves. The DON stated, No.",2020-09-01
352,"NHC HEALTHCARE, OAK RIDGE",445128,300 LABORATORY RD,OAK RIDGE,TN,37831,2017-02-01,161,B,0,1,CP8M11,"Based on facility records review and interview, the facility failed to provide a Surety Bond to cover the residents' personal funds account. The findings included: Review of the daily ledger balance summary for the residents' personal funds dated 12/1/16 through 12/31/16 revealed the following balances: 1) 12/2/16 with a balance of $42,126.24 2) 12/5/16 with a balance of $41,265.53 3) 12/6/16 with a balance of $41,665.53 4) 12/7/16 with a balance of $19,884.93 5) 12/8/16 with a balance of $19,849.93 Review of a facility letter from the insurance company dated 12/5/16 revealed a bond amount of $18,000.00. Interview with the Administrator on 2/1/17 at 7:45 AM in the conference room, confirmed the Surety Bond amount was $18,000.00 and the resident trust balance had been more than $18,000.00 on 5 occasions in (MONTH) (YEAR).",2020-09-01
353,"NHC HEALTHCARE, OAK RIDGE",445128,300 LABORATORY RD,OAK RIDGE,TN,37831,2017-02-01,309,D,0,1,CP8M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to follow a physician's order for medication administration for 1 resident (#58) of 21 sampled residents. The findings included: Medical record review revealed Resident #58 was admitted to the facility on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Medication Administration Record [REDACTED]. Continued review revealed the medication was signed by the Licensed Practical Nurse (LPN) #1 for 8:00 AM. Observation of Resident #58 on 2/1/17 at 10:30 AM, sitting in a geri-chair in the dining room. Continued observation revealed the Assistant Director of Nursing assisted Resident #58 with breakfast and the resident ate 75% of her meal. Interview with LPN #1 on 2/1/17 at 4:15 PM, at the 200 nurse's station confirmed the LPN failed to follow the physician's order and gave the medication without food.",2020-09-01
354,"NHC HEALTHCARE, OAK RIDGE",445128,300 LABORATORY RD,OAK RIDGE,TN,37831,2017-02-01,431,D,0,1,CP8M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of manufacturer's instructions, observation, and interview the facility failed to ensure laboratory supplies had not expired for 1 of 2 medication rooms and failed to ensure blood glucose control solutions had not expired for 1 of 3 medication carts reviewed. The findings included: Review of the manufacturer's instructions for blood glucose control solution revealed .Use the control solution within 90 days .of first opening .write the date of opening on the control solution bottle label as a reminder to dispose of the opened solution after 90 days . Observation with Licensed Practical Nurse (LPN) #2 on [DATE] at 11:00 AM, in the Wing 2 medication storage room revealed 3 pediatric purple top specimen collection tubes with expiration date of ,[DATE]. Interview with the Assistant Director of Nursing (ADON) on [DATE] at 11:11 AM, in the Wing 2 medication storage room confirmed the facility failed to monitor expired laboratory supplies. Observation with LPN #3, of the medication cart B on [DATE] at 11:30 AM, in the Wing 1 medication storage room revealed 2 bottles of the test solution for testing the accuracy of the blood glucose machine had an opened date of [DATE]. Continued observation revealed 2 bottles of test solution was open and undated. Interview with the ADON on [DATE] at 2:53 PM, in the Wing 1 medication storage room confirmed the facility failed to ensure blood glucose control solutions had not expired.",2020-09-01
355,"NHC HEALTHCARE, OAK RIDGE",445128,300 LABORATORY RD,OAK RIDGE,TN,37831,2019-02-27,558,D,0,1,HTMF11,"**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 a call light within reach of 1 resident (#53) of 36 residents observed. The findings include: Review of the facility policy Answering Call Lights, dated 3/2018, revealed .when the resident is confined to the bed or confined to a chair be sure the call light is within easy reach of the resident . Medical record review revealed Resident #53 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 of Mental Status of 15 indicating intact cognition. Further review revealed functional status required total dependence for toileting needs. Medical record review of the ADL (Activities of Daily Living) Functional/Rehabilitation Care Plan dated 2/5/19 revealed .set up necessary equipment and place within patient's reach .assist with toileting needs . Observation and interview with Resident #53 on 2/25/19 at 10:00 AM, in the resident's room, revealed the resident in her recliner yelling out .I'm wet . Further observation and interview revealed the call light wrapped around the assist railing attached to the bed located behind the resident's recliner .I can't reach it (call light) . Observation and interview with the Assistant Director of Nursing on 2/25/19 at 10:08 AM, in the resident's room, confirmed the facility failed to ensure the resident's call light was within the resident's reach.",2020-09-01
356,"NHC HEALTHCARE, OAK RIDGE",445128,300 LABORATORY RD,OAK RIDGE,TN,37831,2018-02-28,698,D,0,1,4KZD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure ongoing communication between the facility and the [MEDICAL TREATMENT] clinic for 1 resident (#21) of 1 resident reviewed for [MEDICAL TREATMENT] of 31 sampled residents. The findings included: Medical record review revealed Resident #21 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].RESIDENT TO RECEIVE [MEDICAL TREATMENT] ON MONDAY, WEDNESDAY, and FRIDAY . Interview with the Director of Nursing (DON) on 2/28/18 at 11:20 AM, in the conference room, revealed a Post [MEDICAL TREATMENT] Report which included: date of service; pre/post [MEDICAL TREATMENT] weights; pre/post [MEDICAL TREATMENT] vital signs; lab work ordered or preformed during [MEDICAL TREATMENT]; problems that occured pre/post treatment or with shunt or catheter; and a line for the nurse to sign and date. The form was to be sent with the resident to [MEDICAL TREATMENT] and returned to the facility with the resident. Continued interview revealed the Post [MEDICAL TREATMENT] Report should be located in the resident's medical record. Medical record review from 1/18/17 to 2/28/18 revealed no Post [MEDICAL TREATMENT] Reports were present in Resident #21's medical record. Interview with the DON in the DON's office on 2/28/18 at 2:40 PM confirmed no Post [MEDICAL TREATMENT] Reports had been completed for Resident #21 from 1/18/17 to 2/28/18.",2020-09-01
357,"NHC HEALTHCARE, OAK RIDGE",445128,300 LABORATORY RD,OAK RIDGE,TN,37831,2018-02-28,881,C,0,1,4KZD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility Center Statement, review of the Antibiotic Stewardship Notebook and Infection Control Records, and interview, the facility failed to implement an Antibiotic Stewardship program for 98 of 98 residents in the facility. The findings included: Review of the facility Center Statement: Antibiotic Stewardship undated revealed .( Name of facility) is committed to establish and implement practices to maximize treatment of [REDACTED]. Review of the Antibiotic Stewardship Notebook and Infection Control Records with the Infection Control Nurse on 2/28/18 at 3:00 PM, in the Assistant Director of Nursing office, revealed no system was in place to monitor antibiotic usage in the facility for residents with infections. Interview with the Infection Control Nurse on 2/28/18 at 3:00 PM, in the ADON's office, confirmed .I don't surveillance antibiotics .There is no written antibiotic protocol .I review labs and cultures at the end of the month .We have no antibiotic policy just a mission statement . Continued interview confirmed she was not aware of the specific infections and the antibiotic medications prescribed in the facility. Further interview confirmed the facility had not developed, promoted or implemented a system to monitor use of antibiotics in the facility.",2020-09-01
358,"NHC HEALTHCARE, OAK RIDGE",445128,300 LABORATORY RD,OAK RIDGE,TN,37831,2017-09-06,225,D,1,0,KIGC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of a facility investigation, medical record review, and interview, the facility staff failed to report an allegation of abuse timely for 1 resident (#1) of 3 residents reviewed for abuse. Review of the facility policy Patient Protection and Response to Policy for Allegations/Incidents of Abuse, Neglect and Misappropriation of Property, dated 11/28/16, revealed .Reporting Policy .Any partner having either direct or indirect knowledge of any event that might constitute abuse, neglect, or misappropriation of patient property must report the event immediately . Review of a facility investigation revealed a witness statement completed by Certified Nursing Assistant (CNA) #3 dated 8/10/17. Further review revealed CNA #3 alleged she witnessed CNA #4 stuff a wash cloth in the mouth of Resident #1 on 8/6/17 (4 days prior) and .(CNA #4) told her (Resident #1) that she better shut up because she had[***]all over her and we were cleaning her up . Continued review revealed CNA #3 reported the allegation to CNA #2 and Registered Nurse (RN) #1 on 8/10/17. Further review revealed CNA #2 and CNA #3 reported the allegation to Licensed Practical Nurse (LPN) #2 on 8/10/17 before the start of the evening shift (7:00 PM) and LPN #2 immediately called the Director of Nursing. Medical record review revealed resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum (MDS) data set [DATE] revealed Resident #1 had a Brief Interview Mental Status score of 8 (moderate cognitive impairment). Continued review revealed the resident was resistant with care 1-3 days during the 7 day look back period. Further review revealed the resident required maximum assist with transfers, dressing, and personal hygiene with 2 person assist. Interview with the Director of Nursing (DON) on 9/5/17 at 11:35 AM, in the conference room, confirmed she was notified by LPN #2 on 8/10/17 at approximately 7:00PM of the allegation of abuse (4 days after the alleged incident). Interview with CNA #2 on 9/6/17 at 7:00 AM, in the conference room, revealed .was working with (CNA #3) on Sunday (8/10/17) .she (CNA 3#) told me would not believe what (CNA #4) had done to (Resident #1) .ask if she reported it .she said no . Interview with RN #1 on 9/6/17 at 7:15 AM, in the conference room, revealed . was leaving work (8/10/17) that morning .had clocked out . (CNA #2) called me over to the table and made (CNA #3) tell me what (CNA #4) had done on Wednesday (8/6/17) .DON was not there that morning so I planned to catch her the next morning . Telephone interview with LPN #2 on 9/6/17 at 11:55 AM revealed .was on break (8/10/17) when 2 night shift CNA's were getting ready to start their shift told me what had happened (on 8/6/17) .immediately called the DON . Interview with the DON on 9/6/17 at 9:00 AM, in the conference room, confirmed she would have expected to have been notified immediately of the allegation of abuse and the facility failed to do so. Interview with the Administrator on 9/6/17 at 9:05 AM, in the conference room, revealed facility staff .should have followed the policy as they were trained . Continued interview confirmed the facility failed to follow facility policy.",2020-09-01
359,FORT SANDERS SEVIER NURSING HOME,445129,731 MIDDLE CREEK RD,SEVIERVILLE,TN,37862,2017-05-18,225,D,1,0,M21J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of the facility investigation, review of employee time punches, and interview the facility failed to report an allegation of abuse to the state agency and failed to suspend an employee after an allegation of abuse for 1 resident (#1) of 3 residents reviewed. The findings included: Review of the facility policy, Abuse-Adult, revised 2/15 revealed .all alleged violations .involving .abuse .are reported immediately or as soon as possible (but not to exceed 24 hours after discovery of the incident) to the administrator (or his/her designated representative) .Any employee suspected or involved in abuse will be sent home immediately and not return to work until the investigation is complete .State survey and certification agency should be notified as soon as possible but not to exceed 24 hours after discovery of the incident . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed Resident #1 was discharged to home on 3/28/17. Medical record review of a Minimum (MDS) data set [DATE] revealed Resident #1 had a Brief Interview for Mental Status score (a test for cognitive ability) of 13/15 indicating the resident was cognitively intact for daily decision making skills. Review of the facility investigation dated 3/27/17 revealed Resident #1 alleged Certified Nursing Assistant (CNA) #1 yelled at the resident when he assisted her in the bathroom on 3/25/17 at 2:30 PM. Review of CNA #1's time punches revealed CNA #1 worked 6:18 AM - 7:00 PM on 3/25/17 and 6:16 AM - 7:09 PM on 3/26/17. Telephone interview with Resident #1 on 5/15/17 at 3:47 PM, confirmed the resident reported the incident with CNA #1 to Licensed Practical Nurse (LPN) #1 on 3/25/17 immediately following the incident. Interview with LPN #1 on 5/16/17 at 4:22 PM, in the conference room confirmed Resident #1 reported CNA #1 had yelled at her while assisting the resident in the bathroom. Further interview confirmed CNA #1 continued to work after the alleged incident on 3/25/17 and on 3/26/17. Continued interview confirmed LPN #1 did not report the incident to the Administrator or the Director of Nursing (DON). Interview with the DON on 5/17/17 at 10:43 AM, in the conference room confirmed the DON was not aware of the alleged incident until Resident #1 told her on the morning of 3/27/17 at 8:30 AM. Interview with the Administrator on 5/17/17 at 11:25 AM, in the conference room confirmed he was not notified of the alleged incident which occurred on 3/25/17 until the morning of 3/27/17. Continued interview confirmed the facility failed to suspend CNA #1 pending the investigation results and failed to report the allegation of abuse to the state agency per facility policy.",2020-09-01
360,FORT SANDERS SEVIER NURSING HOME,445129,731 MIDDLE CREEK RD,SEVIERVILLE,TN,37862,2019-09-18,661,D,0,1,7EIV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, and interview, the facility failed to complete a discharge summary, including a final summary of the resident's status at the time of discharge and a post-discharge plan of care, for 1 resident (#38) of 3 residents reviewed for transfer/discharge. The findings include: Review of the facility policy Discharge Policy and Chart Order, dated 6/2019, revealed .upon discharge of a resident .complete the discharge summary .Discharge Planning Assessment . Medical record review revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Baseline Care Plan dated 6/13/19 revealed .Initial Goals .Discharge to community . and .Discharge Plans .home c (with) husband . Medical record review of the 5 day Minimum (MDS) data set [DATE] for Resident #38 revealed a Brief Interview of Mental Status (BIMS) score of 12, indicating the resident was cognitively intact and received Occupational and Physical Therapy. Medical record review of the Discharge Summary dated 6/19/19 revealed the facility documented the resident left the facility AMA (against medical advice), written on the top of the page, .went out for an apt (appointment) c (with) husband and never returned . Continued review revealed her condition at the time of discharge .unknown went to an appt & (and) never returned . Further review revealed no documentation of any specific plan of care follow-up instructions for discharge home information including home health care, follow up appointments, or post discharge activity. Medical record review of a Progress Note dated 6/19/19 at 7:15 PM, revealed .Resident's husband signed her out .husband unable to tell me who doctor was .has not returned .reported to DON (Director of Nursing) and Social Worker . Interview with the VP (Vice President) Support Services, Administrator, and the Social Worker on 9/18/19 at 10:40 AM, in the Conference Room revealed the husband returned to the facility on [DATE] to pick up Resident #38's belongings. Further interview confirmed Resident #38's medical record contained no documentation or interaction with the family on 6/20/19. Continued interview with the VP Support Services confirmed the facility did not mail a discharge plan of care including home health care and follow up appointments .we should have .we have a lot of work to do . Continued interview confirmed the facility failed to complete the discharge summary with a post discharge plan of care to assist Resident #38 in her return to home.",2020-09-01
361,"NHC HEALTHCARE, SPARTA",445130,34 GRACEY ST,SPARTA,TN,38583,2017-09-20,502,D,0,1,D0BN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure laboratory tests were completed for 1 (#109) resident of 5 residents reviewed for unnecessary medications of 29 residents reviewed. The findings included: Medical record review revealed Resident #109 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].BMP (Basic Metabolic Panel) every week on Thursday .Ammonia Level every week on Thursday . Medical record review revealed no laboratory results for the BMP or Ammonia Level on 8/31/17 (Thursday). Interview with the Director of Nursing on 9/20/17 at 11:15 AM, in the conference room, confirmed the laboratory tests were not completed on 8/31/17.",2020-09-01
362,"NHC HEALTHCARE, SPARTA",445130,34 GRACEY ST,SPARTA,TN,38583,2018-10-02,584,D,0,1,0PSU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, and interview, the facility failed to maintain cleanliness for 10 of 28 privacy curtains observed on 1 of 3 hallways. The findings include: Review of the facility policy un-named (housekeeping), undated, revealed .2. AS REQUIRED .e. Launder cubicle curtains . Observation on 9/30/18 from 9:15 AM to 12:50 PM, on the 200 Hall, revealed soiled or stained privacy curtains in rooms 217-A, 219-B, 221-B, 222-A, 225-A, 226-A, 226-B, 227-A, 229-A and 229-B. Observation and interview on 10/1/18 at 8:30 AM, with the Assistant Director of Nursing (ADON), in room [ROOM NUMBER]-A, confirmed the privacy curtain had 2 brown smudges and was soiled. Observation and interview on 10/2/18 at 10:20 AM, with the Director of Nursing (DON), confirmed the privacy curtains in resident rooms 217-A, 219-B, 221-B, 222-A, and 225-A, were either stained or soiled. Observation and interview on 10/2/18 at 10:30 AM, with the ADON, confirmed the privacy curtains in resident rooms 226-A, 226-B, 227-A, 229-A, 229-B were either stained or soiled. Interview with the Housekeeping Manager on 10/2/18 at 11:15 AM, in the conference room, revealed .if a curtain is stained it would be pitched and a new one would be replaced. Further interview revealed the privacy curtains had not been laundered on the 200 hall.",2020-09-01
363,"NHC HEALTHCARE, SPARTA",445130,34 GRACEY ST,SPARTA,TN,38583,2018-10-02,656,D,0,1,0PSU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to work with 1 resident (#16) in the care plan process to support the resident's choices, and desired outcomes of 36 residents reviewed. The findings include: Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Further review revealed the resident was assessed as having no plans for discharge from the facility. Observation of the resident on 9/30/18 at 10:00 AM, revealed the resident in her wheelchair with the left foot resting on top of the right foot. Continued observation revealed the resident propelled herself with her right foot up and down the hallways. Interview with the resident on 10/1/18 at 9:00 AM, in her room, revealed the resident expressed questions about her diet as ordered and complained about information not being forthcoming related to her discharge plan. Further interview revealed she had not been included in a care plan meeting or had a care plan shared with her. Interview with the Social Services Director on 10/2/18 at 7:45 AM, in her office, confirmed the resident was assisted by an outside resource for housing and a tentative discharge was being planned. Continued interview confirmed the facility's interdisciplinary team (IDT) had not met with the resident, and confirmed the resident was responsible for her own decisions. Interview with the MDS Nurse on 10/2/18 at 11:10 AM, in the conference room, confirmed the IDT met to develop Resident #16's plan of care and did not include the resident. Continued interview confirmed the facility failed to include the resident in the developement of the resident's plan of care.",2020-09-01
364,"NHC HEALTHCARE, SPARTA",445130,34 GRACEY ST,SPARTA,TN,38583,2018-10-02,689,D,0,1,0PSU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, review of Incident/Accident reports, observation and interview, the facility failed to develop and implement an intervention to prevent future falls from a wheelchair for 1 resident (#36) of 4 residents reviewed for falls of 36 sampled residents. The findings include: Review of the facility policy QM (quality management) REVIEW AND REPORTING: DATA SOURCES, revised 8/13/13, revealed .examples of incidents/accidents are: Falls .Potential Hazards: .Equipment .Wheels not locked on wheelchairs .Defective or broken equipment .1. Investigation .Obtain information on what happened .get patient's statement about what happened .Review the Care plan for any possible updates that might be required related to a change/update . Medical record review revealed Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the Brief Interview for Mental Status (BIMS) was 15, indicating the resident was cognitively intact. Continued review revealed the resident was assessed as requiring the assistance of 1 staff member for transfers and used a wheelchair for mobility and locomotion. Further review revealed the resident had 1 fall since previous MDS assessment completed 11/13/17. Review of Incident/Accident reports for Resident #36 revealed the following: 1. A fall on 4/8/18 at 3:10 PM, with no apparent injury .sitting on floor on bottom in front of w/c (wheelchair) .Pt (patient) stated he was trying to reach for his coke when fell .lost his balance .Post incident interventions .Reacher .pt to be provided with a reacher to assist with getting objects .history of falling . 2. A fall on 7/30/18 at 7:10 PM, with no apparent injury .lying on the floor .left side with left arm tucked underneath him .Patient's statement regarding the incident .stated he had dropped his jello onto the floor and was reaching to get it when the wheelchair slipped out from him .Summary .Pt stated the wheelchair slipped out from under him . 3. A fall on 7/31/18 at 10:00 AM, with Type of Injury - Bruise/discoloration, - Abrasion Location of Injury - Upper back, - Lower back, - Left hip .assess patient's w/c noted antiroll back was not working properly and also brakes not working properly .Location of incident - Patient's Bathroom .Patient's statement regarding the incident pt states he was transferring to the toilet when his wheelchair rolled away from him .Post incident interventions .Maintence (maintenance) to Check brakes and antiroll back to w/c . Medical record review of the current Care Plan, last updated 9/27/18 revealed, .Patient is at risk for falls . Continued review revealed 19 interventions were included to address repeated falls over the previous 17 months and none of the interventions included locking the wheelchair brakes when resident was using. Observation and interview with Resident #36 on 9/30/18 at 10:30 AM, in the resident's room revealed the resident seated in his wheelchair in his room. Continued observation revealed no other wheel chairs in the room. Interview with the resident, at the same time, revealed when the resident was asked if he had fallen in the facility, the resident responded, .A few months ago . Observation and interview with Resident #36 on 10/2/18 at 10:35 AM, revealed the resident sitting in his wheelchair with the brakes unlocked. Interview revealed the resident got up before breakfast, spent the majority of the day in his wheelchair, and did not routinely apply the brakes on the wheelchair. Interview with the Director of Nursing (DON) on 10/2/18 at 9:00 AM, in the 200 hall nursing station, confirmed Resident #36 had 2 falls on consecutive days 7/30/18 and 7/31/18. Continued interview revealed the resident's statement on 7/30/18 the wheelchair slipped out from under him was not addressed. Further interview confirmed the wheelchair brakes and antiroll back mechanism were not assessed until after the 2nd fall from the wheelchair on 7/31/18. Continued interview confirmed the wheelchair brakes and antiroll back mechanisms were .not working properly . Interview with the maintenance supervisor on 10/2/18 at 12:20 PM, in the conference room, confirmed the work order to fix Resident #36's wheelchair was received and completed on 7/31/18 (after the 2nd fall from the wheelchair). Continued interview confirmed the wheelchair brak and antiroll back mechanism were not funtioning correctly. wheelchair brake was broken and the antiroll back mechanism had malfunctioned. Further interview revealed .one of the brake handles was completely broken off . Interview with the DON on 10/2/18 at 12:30 PM, in the conference room, confirmed the broken wheelchair brakes, and the antiroll back mechanism malfunction was not addressed until after the second fall on 7/31/18.",2020-09-01
365,"NHC HEALTHCARE, SPARTA",445130,34 GRACEY ST,SPARTA,TN,38583,2018-10-02,761,D,0,1,0PSU11,"Based on observation and interview, the facility failed to ensure expired medications were properly disposed of in 1 of 3 medication rooms. The findings include: Observation with Licensed Practical Nurse (LPN) #1 on 10/2/18, at 10:22 AM, of the 300 hall medication room, revealed the following expired medication stored in the locked cabinet: 1 bottle of 60 stool softener tablets expired 7/18. Interview with LPN #1, on 10/2/18, at 10:22 AM, in the 300 hall medication room, confirmed the medication was expired, available for resident use, and had not been properly disposed of.",2020-09-01
366,"NHC HEALTHCARE, SPARTA",445130,34 GRACEY ST,SPARTA,TN,38583,2019-10-30,689,D,0,1,ZDV511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, fall investigation review, observation and interview, the facility failed to provide interventions to prevent accidents for 1 resident (#15) of 5 residents reviewed for falls. The findings include: Medical record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Comprehensive Care Plan, dated 2/6/19, and edited on 7/29/19 and 10/29/19, revealed Resident #15 had a history of [REDACTED].Reposition/Re-adjust patient in chair when she becomes restless and agitated .alarm to bed and layback (facility's name for the resident's type of chair) . Medical record review of Resident #15's Significant Change Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 5, indicating severe cognitive impairment. The resident required extensive assistance of 2 persons for transfers, extensive assistance with 1 person physical assist for locomotion, and the resident was not steady when moving from a seated to a standing position. Review of an undated Manager Investigation of Incident and an Event Report dated 6/1/19 revealed Resident #15 had a witnessed fall, without injury, on 6/1/19 at 6:07 PM, while seated in a gerichair (type of reclining chair) at the nurse's station. The resident slid to the edge of the foot rest, and then slid from the foot rest to the floor. Continued review revealed .Alarm was not sounding when patient fell , alarm was replaced . Further review revealed .OLD ALARM WAS SOUNDING BUT SEEMS TO HAVE A SHORT FROM PATIENT FREQUENTLY PLAYING WITH DEVICE . Review of a Manager Investigation of Incident and an Event Report dated 6/25/19, revealed Resident #15 fell on [DATE] at 6:33 PM. The resident was seated in front of the dining room listening to her music when she got out of her layback chair and walked independently. The resident's alarm was not sounding and she had been seen playing with the alarm prior to standing up from the chair. Staff witnessed the resident walking, she became unstable, and was lowered to the floor. Medical record review of Resident #15's Significant Change MDS dated [DATE], revealed a BIMS score of 3, indicating severe cognitive impairment. The resident required extensive assistance of 2 persons for transfers, was total dependence with 1 person physical assist for locomotion, and was not steady when moving from a seated to a standing position. Medical record review of Resident #15's Physical Therapy (PT) Plan of Care dated 8/23/19 revealed PT treated the resident from 7/15/19-8/23/19. Continued review revealed .Patient requires frequent verbal cues to stay on task due to poor attention span .Daily Life .condition of confusion . Medical record review of Resident #15s Fall Risk Assessment Tool dated 9/4/19 revealed the resident was a high fall risk. Review of a Manager Investigation of Incident and an Event Report dated 10/9/19 revealed Resident #15 fell on [DATE] at 2:30 PM in the dining room. The resident was participating in a singing activity when she attempted to stand up and fell from her gerichair. The resident's alarm did not sound. Observation and interview on 10/29/19 at 12:30 PM, in Resident #15's room, revealed she was seated in a Geri-chair with her daughter present. Interview with the resident's daughter confirmed .fell recently (10/9/19) .cannot stand or walk independently but will try to . Observation on 10/30/19 at 3:44 PM, at the Unit 3 nurses station, revealed Resident #15 seated in her Geri-chair with the chair with alarm in place. Interview and review of fall investigations with the Unit 3 Manager on 10/30/19 at 1:53 PM, in the conference room, confirmed the chair alarm was not sounding during the resident's fall on 6/1/19. Continued interview confirmed the Unit Manager changes the alarm batteries once a week. Further review revealed .Nurse checks alarm placement and other fall interventions q (every) shift and functionality of alarms . Continued interview confirmed a Geri-chair and a layback chair are the same chair. Further interview confirmed the chair alarm did not sound when Resident #15 exited her chair at the singing activity on 10/9/19. Interview with the Director of Nursing (DON) on 10/30/19 at 4:38 PM, in the conference room, confirmed Resident 15's alarm was not sounding at the time of the 6/1/19 and the 10/9/19 falls.",2020-09-01
367,BEVERLY PARK PLACE HEALTH AND REHAB,445131,5321 BEVERLY PARK CIRCLE,KNOXVILLE,TN,37918,2020-02-21,552,D,1,0,D6D711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, interviews, the facility failed to obtain consent for administration of a medication for 1 resident (Resident #1) of 3 residents reviewed for medication administration, resulting in Resident #1 receiving an appetite stimulant without approval from the resident or the resident's representative. The findings included: Review of the facility's policy titled, Change in a Resident's Condition or Status, dated 11/17/2017 showed .Our facility shall promptly notify the resident .and representative of changes in the resident's medical/mental condition and/or status . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum (MDS) data set [DATE] showed the resident scored a 6 (severe cognitive impairment) on the Brief Interview Mental Status. The resident required extensive assist for bed mobility and transfers with 2 person assist and required extensive assist for Activities of Daily Living with 1 person assist. The resident was always incontinent of urine and frequently incontinent of bowel. Review of a Practitioner's Order dated 1/27/2020, not timed, showed .Orders .[MEDICATION NAME] (appetite stimulant) 7.5 mg (milligrams) PO (by mouth) q (every) hs (hour of sleep) x (times) 7 days then (increase) to 15 mg q hs . Review of the medical record showed no documentation consent for the appetite stimulant was received from the resident or the resident's representative. During an interview on 2/21/2020 at 10:00 AM Resident #1 stated the resident's daughter .takes care of everything . During an interview on 2/21/2020 at 11:55 AM, Registered Nurse (RN) #1 stated an order for [REDACTED].#1 for her to get permission from Resident #1's daughter prior to administration of the medication. During an interview on 2/21/2020 at 12:15 PM, the Nursing Supervisor stated the facility should have obtained family consent prior to administration of the appetite stimulant. During a telephone interview on 2/21/2020 at 2:15 PM, LPN #1 stated she had not been notified a signature was needed prior to administration of Resident #1's appetite stimulant. During a telephone interview on 2/21/2020 at 2:30 PM, the Assistant Director of Nursing confirmed there was no documentation to indicate consent was obtained prior to administration of the appetite stimulant to Resident #1.",2020-09-01
368,BEVERLY PARK PLACE HEALTH AND REHAB,445131,5321 BEVERLY PARK CIRCLE,KNOXVILLE,TN,37918,2018-04-30,569,D,1,0,0TGD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility documentation, and interviews, the facility failed to refund the balance of a Patient Trust Fund, within the required time frame, for one discharged Resident (#2) of 6 residents reviewed for Patient Trust Funds. The findings included: Review of the facility policy Resident AR (Accounts Receivable) Refund Policy not dated revealed . will review and credit balances for appropriate refund, and issue refund within 30 days based on the following: .There are no funds due to the facility by a third party payer, i.e. an insurance secondary to Medicare .Any refund will be payable to the resident, or responsible party when applicable . Medical record review revealed Resident #2 was admitted to the facility on [DATE], and discharged on [DATE] with the [DIAGNOSES REDACTED]. Review of a facility document Trial Balance dated 4/25/18 revealed Resident #2 had a balance of #213.13 in his Patient Trust Fund. Interview with Resident #2's daughter, on 4/25/18 at 11:45 AM, via telephone revealed Resident #2 had discharged from the facility on 1/8/18, and neither she nor Resident #2 had received a refund check, or any notification from the facility in reference to closing his Patient Trust Account. Interview with the Business Office Assistant, on 4/25/18 at 2:00PM, in the conference room confirmed Resident #2 discharged from the facility on 1/8/18. The facility did not send a Resident Fund Management Service statement to the resident within 30 days, disclosing the balance of his Patient Trust Account. Interview with the Business Office Manager, on 4/25/18 at 2:40 PM, in the conference room confirmed Resident #2 had met the criteria for his Patient Trust Fund to be refund as of 2/12/18. Further interview confirmed the facility failed to follow their AR Refund Policy, and had not issued a refund check for Resident #2's Patient Trust Account within the required time frame.",2020-09-01
369,BEVERLY PARK PLACE HEALTH AND REHAB,445131,5321 BEVERLY PARK CIRCLE,KNOXVILLE,TN,37918,2017-08-02,282,D,0,1,QVZY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to implement the Activities of Daily Living (ADL) comprehensive care plan for restorative services for 1 of 3 sampled residents (#326) reviewed for ADLs. The findings included: Medical record review of the [DIAGNOSES REDACTED].#326 revealed [DIAGNOSES REDACTED]. Further review revealed on 6/8/17, a new [DIAGNOSES REDACTED]. Review of the most recent comprehensive Minimum Data Set ((MDS) dated [DATE] and a quarterly MDS dated [DATE] revealed Resident #326 required the assistance of one staff for bed mobility and transfers and was able to walk in his room with limited assistance of one staff member. Further review of the clinical record revealed a Nursing assessment dated [DATE] indicated Resident #326 had no cognitive concerns and required supervision for bed mobility and transfers. A Nursing assessment dated [DATE] revealed the resident was full weight bearing, and self-propelled himself in the wheelchair. Review of the current ADL care plan dated 4/10/17 indicated Resident #326 required the assistance of staff for his ADL's due to his gait instability. An intervention was added to the ADL care plan on 5/18/17 to begin a restorative nursing program as directed. The clinical record had no documentation indicating Resident #326 was currently participating in a restorative nursing program. Observation of Resident #326 on 7/31/17 at 10:08 AM revealed he was ambulating with the assistance of his sister to the bathroom in his room and was ambulating with a steady gait. Observation of Resident #326 on 8/1/17 at 1:28 PM revealed he was in the hallway on the 200 Hall in his wheelchair. An interview conducted with Physical Therapy Staff #1 on 8/1/2017 at 3:40 PM in the physical therapy office revealed Resident #326 was discharged from physical therapy on 5/18/2017 as he had plateaued in his progress towards his physical therapy goals. Continued interviewed confirmed a note had been written on 5/18/2017 for instructions for Resident #326 to begin receiving restorative nursing services after being discharged from physical therapy. Continued interview verified once a resident is released from physical therapy and restorative nursing services is ordered it is the physical therapy departments responsibility to write the restorative plan and have it signed by the physician before the restorative nursing services can begin. Continue interview confirmed Resident #326 was on a restorative program prior to his recent physical therapy so when he was discharged from therapy on 5/18/2017 there had already been a prior program in place so he should have just started back with the restorative program from where he had previously left off. Continued interview confirmed there was no required signature on the back of the physical therapy form to re-initiate the prior restorative services. She verified a signature was never obtained and no new restorative plan was ever written for Resident #326 therefore he failed to receive restorative nursing services for ambulation since being recommended on 5/18/2017. An interview was conducted with the Restorative Nurse Manager Registered Nurse #4 on 8/2/2017 at 10:05 AM outside the lower level conference room. She stated she was not aware of an order to begin any type of restorative program for Resident #326 and he was not currently receiving restorative nursing services from her department. Continued interview confirmed if the therapy department determines a resident requires restorative nursing services they will write a restorative nursing program, and they will advise the restorative staff of the specific program for the resident. Continued interview confirmed Resident #326 had not received any restorative nursing service since 5/18/2017 when he was discharged from physical therapy. An interview was conducted on 8/2/2017 at 11:00 AM with the Director of Nursing (DON) and the Corporate Nurse in the DON office. They verified Resident #326 had an intervention on the current ADL care plan dated 5/18/2017 for restorative services for ambulation and those services were not implemented according to the current compressive care plan.",2020-09-01
370,BEVERLY PARK PLACE HEALTH AND REHAB,445131,5321 BEVERLY PARK CIRCLE,KNOXVILLE,TN,37918,2017-08-02,311,D,0,1,QVZY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to ensure restorative nursing services for ambulation were provided to 1 of 3 sampled residents (#326) reviewed for Activities of Daily Living (ADL). The findings included: Medical record review of the [DIAGNOSES REDACTED].#326 revealed [DIAGNOSES REDACTED]. Further review revealed on 6/8/17 a new [DIAGNOSES REDACTED]. Review of the most recent comprehensive Minimum Data Set ((MDS) dated [DATE] and a quarterly MDS dated [DATE] revealed Resident #326 required the assistance of one staff for bed mobility and transfers and was able to walk in his room with limited assistance of one staff member. Further review of the clinical record revealed a Nursing assessment dated [DATE] that indicated Resident #326 had no cognitive concerns and required supervision for bed mobility and transfers. A Nursing assessment dated [DATE] revealed the resident was full weight bearing and self-propelled himself in the wheelchair. Review of the most current ADL care plan dated 4/10/17 revealed a problem documenting Resident #326 required the assistance of staff for ADL's due to his gait instability. An intervention was added to the ADL care plan on 5/18/17 to begin a restorative nursing program as directed. Review of the Physical Therapy notes provided by the Corporate nurse on 8/1/17 at 10:50 AM revealed Resident #326 had been receiving physical therapy starting on 4/10/17 due to muscle weakness, difficulty walking and was noted to have a [DIAGNOSES REDACTED]. A Physical Therapy note dated 5/18/17 documented Resident #326's goal for ambulation was not met during physical therapy, and he continued to require stand by assistance due to unsteadiness and occasional loss of safety awareness when fatigued. The long-term goal indicated the resident and the staff would be trained in the restorative nursing program upon discharge from physical therapy. Observation of Resident #326 on 7/31/17 at 10:08 AM revealed he was ambulating with the assistance of his sister to the bathroom in his room and was ambulating with a steady gait. Observation of Resident #326 on 8/1/17 at 1:28 PM revealed he was in the hallway on the 200 Hall in his wheelchair. An interview was conducted with Physical Therapy Staff #1 on 8/1/17 at 3:40 PM in the physical therapy office and revealed Resident #326 was discharged from physical therapy on 5/18/17 as he had plateaued in his progress. Continued interview confirmed a note written on 5/18/17 for instructions for Resident #326 to begin receiving restorative nursing services after being discharged from physical therapy. Continued interview confirmed when restorative nursing services are ordered after a resident is released from physical therapy, it is the therapy department's responsibility to write the restorative plan and have it signed by the physician before the restorative nursing services begin. Continued interviewed confirmed a physician signature was never obtained, and a new restorative plan was never written for Resident #326; therefore, he never received restorative nursing services for ambulation after the recommendation was made on 5/18/17. An interview was conducted with Restorative Nurse Manager Registered Nurse #4 on 8/2/17 at 10:05 AM outside the lower level conference room. She stated she was not aware of an order to begin any type of restorative program for Resident #326, and he is currently not receiving any restorative nursing services from her department. Continued interview confirmed if the therapy department determines a resident requires restorative nursing services, they will write a restorative nursing program, and they will advise the restorative staff of the specific program for the resident. She verified Resident #326 had not received any restorative nursing service since 5/18/17 when he was discharged from physical therapy. An interview was conducted with Certified Nurse Aide (CNA) #4 on 8/1/17 at 3:40 PM in the hallway of the 200 Hall. She confirmed Resident #326 had done very well with ambulation in his room but stated he does lose his balance at times, becomes fatigued and is at risk for falls. An interview was conducted on 8/2/17 at 11:00 AM with the Director of Nursing (DON) and the Corporate Nurse in the DON office. They verified Resident #326 had a recommendation on 5/18/17 from physical therapy to begin restorative services for ambulation; the restorative nursing plan was not developed; and services had not been provided.",2020-09-01
371,BEVERLY PARK PLACE HEALTH AND REHAB,445131,5321 BEVERLY PARK CIRCLE,KNOXVILLE,TN,37918,2017-08-02,333,D,0,1,QVZY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to prevent a significant medication error for 1 resident (#438) of 5 residents observed during medication administration. The findings included: Medical record review revealed Resident #438 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's orders [REDACTED]. Further medical record review of the acute care hospital's Patient Summary dated 7/28/17, revealed .Stop Taking These Medicines: [MEDICATION NAME] ([MEDICATION NAME] 125 mcg (micrograms) .oral tablet) 1 tab(s) ORALLY Once Daily . Medical record review of physician's orders [REDACTED].[MEDICATION NAME] 125 mcg tab, take 1 tablet by mouth once daily . Medical record review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Further medical record review revealed the (MONTH) (YEAR) MAR indicated [REDACTED] Observation of Registered Nurse (RN) #1 on 8/1/17 at 8:12 AM, on the main floor, revealed RN #1 administered [MEDICATION NAME] 125 mcg by mouth to Resident #438. Interview with Licensed Practical Nurse (LPN) Unit Manager on 8/1/17 at 8:44 AM, at the main floor nurse's station, confirmed [MEDICATION NAME] had been given without a physician's orders [REDACTED].>Interview with Pharmacist #1 on 8/1/17 at 2:10 PM, in the conference room, revealed the (MONTH) (YEAR) computer generated physician's orders [REDACTED]. Interview revealed A nurse and someone from pharmacy should have caught it . Interview with LPN #2 on 8/2/17 at 3:36 PM, in the conference room, confirmed the LPN checked the pharmacy generated Physician order [REDACTED]. Interview continued and LPN #2 confirmed she had not clarified whether the [MEDICATION NAME], not included in the (MONTH) (YEAR) admission orders [REDACTED]. Interview confirmed the failure to reconcile medication records accurately resulted in Resident #438 receiving [MEDICATION NAME] 125 mcg by mouth on 8/1/17 at 8:12 AM.",2020-09-01
372,BEVERLY PARK PLACE HEALTH AND REHAB,445131,5321 BEVERLY PARK CIRCLE,KNOXVILLE,TN,37918,2017-08-02,425,D,0,1,QVZY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs) for 1 resident (#438) of 5 residents observed during medication administration. The findings included: Medical record review revealed Resident #438 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's orders [REDACTED]. Further medical record review of the acute care hospital's Patient Summary dated 7/28/17, revealed .Stop Taking These Medicines: digoxin (digoxin 125 mcg (micrograms) .oral tablet) 1 tab(s) ORALLY Once Daily . Medical record review of physician's orders [REDACTED].Digoxin 125 mcg tab, take 1 tablet by mouth once daily . Medical record review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Further medical record review revealed the (MONTH) (YEAR) MAR indicated [REDACTED].Take 1 tablet by mouth once daily . Observation of Registered Nurse (RN) #1 on 8/1/17 at 8:12 AM, on the main floor, revealed RN #1 administered Digoxin 125 mcg by mouth to Resident #438. Interview with Pharmacist #1 on 8/1/17 at 2:10 PM, in the conference room, revealed the pharmacy had entered Resident #438's medications by a faxed .New Home Medication List . from the acute care hospital on [DATE] at 1:40 PM that included . digoxin (digoxin 125 mcg . oral tablet) 1 tab ORALLY Once Daily . Interview continued and revealed the procedure was to reconcile the faxed list with the written admission orders [REDACTED]. Interview continued and confirmed the (MONTH) (YEAR) Physician Order's and the (MONTH) (YEAR) MAR indicated [REDACTED]. Interview with Pharmacist #1 confirmed the pharmacy's present procedures had contributed to a medication error.",2020-09-01
373,BEVERLY PARK PLACE HEALTH AND REHAB,445131,5321 BEVERLY PARK CIRCLE,KNOXVILLE,TN,37918,2018-09-12,644,D,0,1,CZPP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to refer 1 resident (#47) after the resident was identified with a possible serious mental disorder, to the state-designated authority for a Level II PASARR (Preadmission Screening and Resident Review) of 4 residents reviewed for PASARR. The findings include: Medical record review revealed Resident #47 was admitted to the facility on [DATE] with diagoses [MEDICAL CONDITION], Diabetes Mellitus, Major [MEDICAL CONDITIONS], and Hypertension. Medical record review of the Pre-Admission Screening and Resident Review (PASARR) form dated 2/27/18 revealed no mental health [DIAGNOSES REDACTED]. Medical record review of a psychiatric progress note dated 9/13/17 revealed the resident had a [DIAGNOSES REDACTED].Psych (psychiatric) medication management for depression, aggression, crying spells .staff reports he is still having occ (occasional) crying spells .Has received scheduled [MEDICATION NAME] (antianxiety medication) and is doing better with his anxiety and restlessness .STM (short term memory) impaired, remote memory impaired, intellectual disability .Current [MEDICAL CONDITION] Medications-[MEDICATION NAME] (antidepressant medication) 10 mg. (milligrams) PO (by mouth) Q (every) day-depression .[MEDICATION NAME] 0.25 mg. PO @ (at) 2PM (and) HS (hour of sleep) for anxiety and may repeat X (times) 1 in 24 hours .[MEDICATION NAME] (antipsychotic medication) 25 mg. PO Q AM (morning) and 50 mg. PO Q HS . Medical record review of a psychiatric progress note dated 8/9/18 revealed the resident had a [DIAGNOSES REDACTED].staff report more depressed, more crying spells and thoughts that he would be better off dead expressed to one of the CNAs (Certified Nursing Assistant), charge nurse questioned him and he stated he had no plan, no intention of harming himself .his [MEDICAL CONDITION] sxs (symptoms) are managed (with) [MEDICATION NAME] and are stable . Interview with Registered Nurse (RN) #1, responsible for completing PASARRs at the facility, on 9/12/18 at 1:05 PM, at the 3rd floor nursing station confirmed the facility had not referred the resident to the state-designated authority for a Level II PASARR evaluation to determine if the resident required specialized services.",2020-09-01
374,BEVERLY PARK PLACE HEALTH AND REHAB,445131,5321 BEVERLY PARK CIRCLE,KNOXVILLE,TN,37918,2018-09-12,842,D,0,1,CZPP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, and interview the facility failed to ensure a complete medical record by failing to document the administration of anticoagulant medication for 1 resident (#184) of 5 sampled residents reviewed for anticoagulation medication of 53 total sampled residents. The findings include: Review of the facility's policy Medication Administration with revision date 3/16/15 revealed .Record the name, dose, route, and time of medication on the Medication Administration Record .Initial the record after the medication is administered to the resident . Medical record review revealed Resident #184 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's orders [REDACTED].xarelto (an anticoagulation medication) is for A Fib ([MEDICAL CONDITION]) - anticoagulation . Medical record review of physician's orders [REDACTED].xarelto 20 milligram (mg) tab (tablet) po (by mouth) at bedtime (a fib) . Medical record review of Resident #184's Medication Record (MAR) dated 9/1/18 through 9/30/18 revealed no documentation Xarelto had been administered on 9/1/18-9/9/18 and 9/11/18. Telephone interview with Licensed Practical Nurse (LPN) #2 on 9/12/18 at 4:00 PM, confirmed she had administered Resident #184's Xarelto on 9/1/18 but had failed to sign the medication administration record (MAR). Telephone interview with LPN #3 on 9/12/18 at 4:02 PM, confirmed she had administered Resident #184's Xarelto on 9/2/18, 9/3/18, 9/4/18, 9/5/18, 9/6/18, 9/8/18, and 9/9/18 but had failed to sign the MAR. Telephone interview with LPN #4 on 9/12/18 at 4:13 PM, confirmed she had administered Xarelto to Resident #184 on 9/11/18 but failed to sign the MAR. Telephone interview with LPN #5 on 9/12/18 at 4:15 PM, confirmed she had administered Xarelto to resident #184 on 9/2/18 but failed to sign the MAR.",2020-09-01
375,BEVERLY PARK PLACE HEALTH AND REHAB,445131,5321 BEVERLY PARK CIRCLE,KNOXVILLE,TN,37918,2019-09-18,600,D,1,1,QLQ211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility abuse policy, medical record review, review of facility documentation, observation and interview, the facility failed to prevent verbal abuse of 1 resident (#17) of 26 residents reviewed for abuse. The findings include: Review of the facility policy Abuse Prevention Policy and Procedure, dated 2/26/18, revealed .The purpose of this written .Prevention Program is to outline the preventive steps taken by the facility to reduce the potential for the mistreatment, neglect and abuse of residents . Medical record review revealed Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set, dated dated [DATE], revealed Resident #17 scored an 8 on the Brief Interview for Mental Status, indicating severe cognitive impairment, with short and long term memory deficits, and was totally dependent on 2 persons to transfer. Review of the facility's documentation, dated 9/5/19, revealed 2 Certified Nursing Assistants (CNA #1 and #2) were providing care to Resident #17 when CNA #1 became upset with the resident and spoke harshly to him, using foul language. Further review revealed CNA #1 was removed from resident care. Continued review revealed CNA #1 confirmed she became upset with the resident and used the F word. Review of the Director of Nursing's (DON) summary statement revealed, Two CNA's were getting (Resident #17) up and the resident became agitated. He started to flail his arms and (CNA #1) said 'Don't you f***ing hit me.' .(CNA #1) admits to saying F***ing in front of the resident and was terminated . Observation of Resident #17 on 9/16/19 from 2:35 PM until 3:15 PM revealed he was in his wheel chair, using his arms to propel himself through the front halls of his unit. Interview with the Charge Nurse on 9/16/19 at 3:15 PM, at the nursing station, revealed .(Resident #17) is normally in the hall .always mild mannered .doesn't normally resist care . Further interview revealed Resident #17 was diagnosed with [REDACTED]. Continued interview revealed the Charge Nurse had not encountered any problems with CNA #1 prior to 9/5/19 and stated .they (referring to the facility administration) don't tolerate foul language . Interview with CNA #2 on 9/18/19 at 11:40 AM, in the conference room, revealed the facility's documentation of the events on 9/5/19 was correct. Interview with the DON on 9/18/19 at 11:50 AM, in the conference room, confirmed the verbal abuse had occurred and he stated his observation and interview of Resident #17 two hours after the incident, revealed the resident had no memory of the verbal abuse.",2020-09-01
376,BEVERLY PARK PLACE HEALTH AND REHAB,445131,5321 BEVERLY PARK CIRCLE,KNOXVILLE,TN,37918,2019-09-18,636,D,0,1,QLQ211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review and interview, the facility failed to complete a Discharge Minimum Data Set (MDS) assessment for one resident (#19) of 3 residents reviewed for discharge MDS assessments. The findings include: Review of the RAI Version 3.0 Manual Chapter 2: Assessments for the RAI revealed .Discharge assessment .Must be completed .within 14 days after the discharge date . Medical record review revealed Resident #19 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Further review revealed the resident was discharged from the facility on [DATE]. Medical record review of the resident's MDS assessments revealed a discharge MDS assessment for Resident #19 had not been completed from the day of discharge, [DATE], to the present day, [DATE]. Interview with the MDS Coordinator on [DATE] at 5:06 PM, in the conference room, confirmed Resident #19 expired on [DATE] in the facility. Continued interview confirmed the facility had not complete a Discharge MDS assessment for Resident #19.",2020-09-01
377,BEVERLY PARK PLACE HEALTH AND REHAB,445131,5321 BEVERLY PARK CIRCLE,KNOXVILLE,TN,37918,2019-09-18,757,D,0,1,QLQ211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility documentation review and interview, the facility failed to ensure unnecessary medications were not administered to 1 resident (#82) of 6 residents reviewed for unnecessary medications. The findings include: Medical record review revealed Resident #82 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physician Order, dated 6/11/19, revealed .DC (discontinue) [MEDICATION NAME] (an antibiotic used to treat infections) 500 mg (milligrams) x (for) 7 days .DC [MEDICATION NAME] (a medication used in a nebulizer machine to prevent, or relieve wheezing, coughing, shortness of breath, and chest tightness) 1.25/3 ml (milliliters) QID (4 times a day) x 10 days orders put in on wrong patient . Medical record review of the Medication Administration Record [REDACTED].Start Date 6/11/19 .Discontinue Date 6/11/19 . Continued review revealed Resident #82 received 1 dose of [MEDICATION NAME] 500 mg on 6/11/19 at 9:00 PM. Further review revealed .[MEDICATION NAME] 1.25 MG/3 ML SOLUTION GIVE TREATMENT 4 TIMES DAY FOR 10 DAYS Order Date: 6/11/19 START DATE 6/11/19 DISCONTINUE DATE 6/11/19 . Further review of the MAR indicated [REDACTED]. Medical record review of the facility's documentation dated 6/11/19 revealed .resident (Resident #82) received a wrong medication, due to the wrong order put in .the medication order belonged to an other (another) resident . Record review of the facility's documentation, dated 6/13/19, written by Registered Nurse (RN) #1 revealed .On Tuesday an order was received for (Resident #178) for antibiotic and Neb treatments .They were put in under (Resident #82) by accident . Interview with RN #1 on 9/17/19 at 3:27 PM, in the conference room, confirmed Resident #82 and #178 had similar names. Continued interview confirmed RN #1 selected the wrong resident in the computer to receive [MEDICATION NAME] and [MEDICATION NAME] on 6/11/19. Interview with Licensed Practical Nurse (LPN) #1 on 9/17/19 at 3:45 PM, in the conference room, confirmed the LPN administrated [MEDICATION NAME] and [MEDICATION NAME] to Resident #82 on 6/11/19 at 9:00 PM. Interview with the Director of Nursing (DON) on 9/18/19 at 9:34 AM, in the DON's office, confirmed Resident #82 received a dose of [MEDICATION NAME] and [MEDICATION NAME] on 6/11/19 which was ordered for Resident #178.",2020-09-01
378,SEVIERVILLE HEALTH AND REHABILITATION CENTER,445132,415 CATLETT RD,SEVIERVILLE,TN,37862,2020-01-16,558,D,0,1,8CXC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure reasonable accommodation of needs for 1 of 1 resident (Resident #33) reviewed for call light accessibility. This failure had the potential to prevent Resident #33 from calling for assistance as desired and potentially prevent Resident #33's needs from being met. Findings include: Review of the Minimum Data Set (MDS) assessment, with an Assessment Reference Date of 12/6/2019, indicated Resident #33 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] from an acute care hospital. Resident #33's [DIAGNOSES REDACTED]. Resident #33 had cognitive impairments, as evidenced by a Brief Interview for Mental Status Score (BIMS) score of 3 out of 15. Resident #33 required total assist from one to two staff members with all Activities of Daily Living (ADLs). Resident #33 had functional limitations in Range of Motion (ROM) and impairment on one side in the upper and lower extremities According to Resident #33's care plan, dated 5/29/2019, Resident #33 was dependent on staff assistance for ADL's related to Weakness, Left-sided [MEDICAL CONDITIONS], and Mild Cognitive Impairment. The care plan included an undated, handwritten intervention that read, Touch pad (touchpad) call light within reach at all times while in bed. On 1/13/2020 at 10:01 AM, Resident #33 was in his room lying in bed with the touchpad call light positioned on Resident #33's right shoulder. There was a note taped to the wall which read, nurse call (call light touchpad) on resident's right side. Resident #33 had contractures noted in both arms and hands. Both arms were flexed upward towards Resident #33's chest. His right hand was flexed inward at the wrist with his fingers in a straight, fixed position. Resident #33's left hand flexed at the wrist, with his fingers bent outward at the knuckles and in a fixed position. When asked, Resident #33 was unable to reach his touchpad call light. On 1/13/2020 at 3:30 PM, an interview with Resident #33's family member, in Resident #33's room, revealed there were previous issues with Resident #33's call light not being in place. Resident #33's family member said the note was posted on the wall to remind staff where to place the call light so Resident #33 could reach it. On 1/14/2020 at 9:45 AM, Resident #33 was observed in his room, lying in bed. The touchpad call light was on the floor behind the head of the bed. Resident #33 said, this happens all the time. On 1/15/2020 at 8:46 AM, Resident #33 was observed in his room, in bed sleeping. The touchpad call light was out of reach, positioned upon Resident #33's right shoulder. On 1/15/2020 at 10:33 AM, Resident #33 was observed in his room, lying in bed. The touchpad call light was up near Resident #33's right shoulder. When asked if he could reach the touchpad call light, Resident #33 attempted to reach for the touchpad call light but was unsuccessful. Resident #33 said he lost a lot of his dexterity and was unable to reach the touchpad call light. On 1/15/2020 at 10:39 AM, in the presence of Licensed Practical Nurse (LPN) #17, Resident #33 was observed in his room, lying in bed with the touchpad call light on Resident #33's right shoulder. LPN #17 said the call light was placed too high, asked Resident #33 where a good spot would be, and repositioned the call light. On 1/15/2020 at 11:20 AM, Certified Nursing Assistant (CNA) #12 was interviewed at the nursing station on Unit 200. The interview revealed Resident #33's touchpad call light should be on his chest. If not, Resident #33 was unable to reach the touchpad call light. CNA #12 indicated the touchpad call light was sometimes on Resident #33's right shoulder and at other times on Resident #33's chest. Staff made sure Resident #33 could reach his touchpad call light, which she reported doing that morning during breakfast. CNA #12 indicated staff used the resident's Activities of Daily Living (ADL) Assistance Legend to know what was going on with the resident. CNA #12 reviewed the ADL Assistance Legend and said the ADL assistance Legend did not provide direction regarding placement of Resident #33's touchpad call light, but said that information was in Resident #33's care plan, which staff should follow. On 1/15/2020 at 11:29 AM, Registered Nurse (RN) #21 was interviewed in the activity room on Unit 100. RN #21 said resident call lights should be in place to allow residents to call for assistance. RN #21 said she would expect staff to follow Resident #33's care plan. On 1/15/2020 at 12:04 PM, during a second interview with RN #21 in the nourishment room on Unit 200, RN #21 said on 12/9/19, staff changed out the call light for a soft-touch call light (touchpad call light). Review of the care plan with RN #21 revealed the touchpad call light should be within Resident #33's reach at all times when in bed. On 1/15/2020 at 12:20 PM, Nursing MDS #5 was interviewed in the conference room adjacent to Nursing MDS #5's office. The interview revealed that Resident #33 had returned to the facility from the hospital with increased contractures, and an inability to use his hands. Within a few days of Resident #33's return to the facility, staff determined Resident #33 could no longer use a regular call light and switched the call light out for a touchpad call light. Nursing MDS #5 said she went into Resident #33's room today (1/15/20) and asked Resident #33 to use the touchpad call light, and he was unable to. Since the placement of the touchpad call light, Nursing MDS #5 acknowledged she had not reassessed whether Resident #33 was capable of using the touchpad call light since it was changed. Nursing MDS #5 said LPN #17 reported to her that Resident #33 could use the touchpad call light sometimes, but not today. Nursing MDS #5 said the touchpad call light should be within Resident #33's reach. On 1/16/2020 at 2:00 PM, Quality Assurance Infection Prevention (QA/IP) Nurse #10 was interviewed a second time, in the presence of the Director of Nursing (DON), in the conference room adjacent to the MDS Coordinators office. The interview revealed Resident #33 was recently hospitalized and returned to the facility. Resident #33 had been slowly declining, and the staff initiated a touchpad call light since Resident #33 was unable to use a regular call light. QA/IP Nurse #10 indicated she had seen Resident #33 use the touchpad call light and the CNAs checked to make sure the call light was in place daily. Review of the care plan with QA/IP Nurse #10 showed the touchpad call light should be within Resident #33's reach at all times when in bed.",2020-09-01
379,SEVIERVILLE HEALTH AND REHABILITATION CENTER,445132,415 CATLETT RD,SEVIERVILLE,TN,37862,2020-01-16,582,C,0,1,8CXC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide 2 of 3 residents (Resident #20 and Resident #33) with the Advanced Beneficiary Notice, Center for Medicare and Medicaid Services (CMS)- when they ended therapy services and remained in the facility for long-term care services. This failure left residents without information related to the cost of therapy services if they desired to continue them in the facility and did not allow for them to have informed choice. Findings include: Resident #20 was admitted on [DATE] for a Medicare A stay. He had [DIAGNOSES REDACTED]. He received physical therapy, occupational therapy, and speech language therapy. The Social Service Director (SSD) issued the Notice of Medicare Non-Coverage (CMS- ) on 10/2/2019 informing him therapy services would end on 10/7/2019. The SSD did not issue the CMS- Advance Beneficiary Notice to the resident. The resident remained in the facility for long-term care and had Medicare benefit days remaining. Resident #33 was re-admitted on [DATE] after a hospital stay. His admitting [DIAGNOSES REDACTED].#33 received speech language therapy upon returning to the facility. The SSD issued the CMS- informing him that therapy would be ending on 12/20/2019. The CMS- was not issued to the resident or Family Member #33 indicating why the Medicare therapy services would no longer be covered and the cost of the therapy services, and the resident and representative were not provided with the choice to continue the services, pay privately for the services, or to stop the services. Interview with the SSD on 1/14/2020 at 12:01 PM revealed she was responsible for issuing all beneficiary notices. She stated she did not issue the CMS- to any residents remaining in the facility that had Medicare days remaining. She further stated the interdisciplinary team reviewed all Medicare residents and determined as a team that the individual no longer met Medicare requirements. She stated she was unaware that residents coming off Medicare and remaining in the facility as long-term care with benefit days remaining were supposed to receive the CMS- . Interview with Family Member #33 on 1/14/2020 at 12:35 PM revealed that they were not provided the CMS- . Interview with Resident #20 on 1/15/2020 at 3:11 PM revealed he had not been issued the CMS- detailing why his Medicare therapy was ending or the cost of the services.",2020-09-01
380,SEVIERVILLE HEALTH AND REHABILITATION CENTER,445132,415 CATLETT RD,SEVIERVILLE,TN,37862,2020-01-16,625,D,0,1,8CXC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, review of facility Admission packet, medical record review, and interviews, the facility failed to issue bed hold notices within 24 hours after transfer to the hospital for 2 of 27 sampled residents (Resident #27 and Resident #1). Findings include: Review of the facility policy titled, Attachment F-Bed Hold Policy, last revised (MONTH) (YEAR), revealed, At the time the Resident is to leave the Center for a temporary stay in a hospital or for therapeutic leave, (or within 24 hours in care of an emergency transfer) the Resident/Resident Representative will be given a written copy of the Bed Hold Policy which specifies the duration of the bed-hold and may elect to hold open the Resident's room and bed until the Resident returns. At this time, the Resident/Resident Representative will indicate in writing whether the Resident desires or declines the bed hold. Review of the facility's Admission packet revealed the initial notice of the bed hold policy was provided to residents upon admission. This bed hold policy specified, At the time the resident is to leave the center for a temporary stay in a hospital or for therapeutic leave (or within 24 hours of an emergency transfer), the resident/resident representative will be given a written copy of the bed hold policy which specifies the duration of the bed-hold and may elect to hold open the resident's room and bed until the resident returns. At this time, the resident/resident representative will indicate in writing whether the resident desires or declines the bed hold. Resident #27 was admitted to the facility on [DATE]. Review of his clinical record revealed [DIAGNOSES REDACTED]. He had two unplanned transfers to the hospital on [DATE] returning 10/18/2019, and on 11/14/2019 readmitting on 11/18/2019. The Business Office Manager (BOM) was interviewed on 1/15/2020 at 2:09 PM in the conference room. She said she was responsible for completing the second bed hold notifications to the family members when the resident transferred to the hospital. The BOM said when a resident was transferred to the hospital, she usually found out about it the following day, and would contact the family via phone and ask if they wanted to hold the bed for the resident. She said she did not provide written notification to the family members. The BOM said there was no one else who sent bed hold notices to the residents or their representatives, and no one responsible for completing this task in her absence. The BOM said she had 3 days to send a bed hold notice to the resident or resident representatives. Review of the bed hold's policy notification binder, provided by the BOM, revealed Resident #27's representative (Family Member #1) was contacted by phone on 10/17/2019 and declined to hold the bed for the resident. The binder revealed there was no bed hold notice given (either written or via telephone) to Family Member #1 related to the 11/14/2019 emergent transfer to the hospital. Family Member #1 was interviewed on 1/16/2020 at 10:30 AM by telephone. Family Member #1 said she was not familiar with what a bed-hold notice was, and that the BOM never calls me. The Director of Nursing (DON) was interviewed on 1/16/2020 at 1:50 PM in the conference room. The DON said the BOM was responsible for contacting residents and resident representatives to provide the second bed hold notice. The DON said she did not think there was anyone assigned to provide bed hold notification to the resident or resident representatives in the BOM's absence. She said the bed hold notifications should be sent within 24 hours according to the regulations and facility policy. Resident #1 was admitted to the facility on [DATE] and was sent to the hospital on [DATE] for chest pain. Review of the clinical record revealed there was no documentation the resident was provided a bed hold notice upon transfer or within 24 hours of the transfer. During an interview on 1/15/2020 at 2:08 PM, the BOM stated when a Medicare resident was sent to the hospital, the resident had a 3 day leave of absence and after the third midnight, during the hospital admission, a bed hold notice was provided to the resident and/or the family. She further stated the bed hold notice for Resident #1 was not issued until 12/20/2019. During an interview on 1/15/2020 at 2:45 PM, with Resident #1 and Family Member #1, they stated they did not receive a bed hold notice when he was sent out on 12/17/2019.",2020-09-01
381,SEVIERVILLE HEALTH AND REHABILITATION CENTER,445132,415 CATLETT RD,SEVIERVILLE,TN,37862,2020-01-16,684,D,0,1,8CXC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interviews, and review of the Hospice Cooperative Agreement, the facility failed to implement a Bowel Movement (BM) protocol and failed to ensure effective coordination of hospice care for one resident (Resident #11) out of 15 sampled residents. These failures placed Resident #11 at risk for complications related to constipation and potential fecal impaction (a large mass of dry, hard stool that can develop in the rectum due to chronic constipation). Findings include: Review of the Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/31/2019, indicated Resident #11 was receiving hospice services and had moderate cognitive impairment, as evidenced by a Brief Interview for Mental Status (BIMS) score of 9 out of 15. Review of the facility's Physician's Routine Orders for constipation, signed by the Medical Director on 1/1/2019, specified, If no BM (bowel movement) in three (3) days: Milk of Magnesia (or generic equivalent) 30 cc (cubic centimeter) by mouth every day PRN (as needed) constipation (notify MD (medical doctor) if [MEDICAL TREATMENT] resident). [MEDICATION NAME] (or generic equivalent) 5 mg (milligram) tabs (tablets) 1 (one) tab by mouth every day PRN constipation. [MEDICATION NAME] (or generic equivalent) 10 mg suppository 1 (one) PR (per rectum) PRN constipation. (Fleets) enema PR PRN if constipation not relieved with any two (2) of the above and notify the physician. Review of the BM Detail option 2 Roster dated 9/1/2019 through 1/16/2020 indicated Resident #11 did not have a documented BM for more than 3 consecutive days on 4 separate occasions as follows: 1. 9/19/2019 through 9/24/2019, 6 days without a documented BM: Review of the Medication Administration Records (MARs) and Treatment Administration Records (TARs) dated (MONTH) 2019, showed the Physician's Routine Orders for constipation signed by the physician on 1/1/2019 were not on the MARs or TARs. The MARs and TARS did not indicate staff initiated the BM protocol on 9/22/2019 (after 3 days with no BM), 9/23/2019, or 9/24/2019. Review of the Department Notes dated 9/19/2019 through 9/24/2019 did not indicate Resident #11 had a BM or that staff initiated the facility's BM protocol. 2. 9/26/2019 through 10/3/2019, 8 days without a documented BM: Review of the MARs and TARS dated (MONTH) 2019, indicated the staff did not initiate the BM protocol on 9/29/2019, after 3 days with no BM. On 9/30/2019, 5 days after the last documented BM, staff received an order to administer Mirilax 17 gm PRN and Senna 8.6 mg daily. The [MEDICATION NAME] and Senna were not administered to Resident #11 on 9/30/2019. Review of the Department Note dated 9/30/2019, 5 days after Resident #11's last documented BM, indicated Resident #11 was ON NO BM LIST, PRUNE JUICE GIVEN, NEW ORDERS RECEIVED FOR [MEDICATION NAME] PRN AND SENNA DAILY. The nursing note did not indicate why the nurse gave prune juice instead of MOM, as outlined in the facility's BM protocol. Review of the Department Note dated 10/4/2019, 8 days after Resident #11's last documented BM, indicated Resident #11 was ON NO BM LIST, PRUNE JUICE WAS GIVE. WILL MONITOR FOR RESULTS. The nursing note did not indicate why the nurse gave prune juice instead of MOM as outlined in the facility's BM protocol. Review of the MARS and TARS dated (MONTH) 2019, indicated staff started administering Senna, ordered 9/30/2019, on 10/1/2019. The staff did not initiate the facility's BM protocol on 10/1/2019. On 10/3/2019, 8 days after Resident #11's last documented BM, staff received and initiated new orders for Senna Plus 8.6-50 mg tablets BID (twice daily). 3. 10/18/2019 through 10/23/2019, 5 days without a documented BM: Review of the MARS and TARS dated (MONTH) 2019, indicated Resident #11 received scheduled Senna 8.6 mg once a day from 10/1/2019 through 10/3/2019. On 10/3/2019 through 10/23/2019, Resident #11 received scheduled Senna Plus 8.6-50mg BID, except on 10/3/19 at 8:00 PM when the resident refused. The staff did not initiate the facility's BM protocol on 10/21/19 (after 3 days with no BM), 10/22/19, or 10/23/19. Review of the Department Notes dated 10/18/2019 through 10/23/2019, did not indicate Resident #11 had a BM or that staff initiated the facility's BM protocol. 4. 11/12/2019 through 11/15/2019, 4 days without a documented BM: Review of the MARs and TARs for (MONTH) 2019, indicated Resident #11 received scheduled Senna Plus 8.6 mg-50 mg BID from 11/1/2019 through 11/15/2019. Resident #11 refused one dose of Senna Plus on 11/11/2019 at 8:00 AM. The staff did not initiate the facility's BM protocol and did not administer PRN Mirilax or MOM on 11/15/19, after 3 days with no BM. On 1/13/2020 at 11:48 AM, Resident #11 was interviewed in her room. The interview revealed Resident #11 reported only having a BM once a week and had issues with constipation. Resident #11 said that her last BM was last night (1/12/2020); the staff had to give her MOM and an enema. On 1/15/2020 at 1:09 PM, Licensed Practical Nurse (LPN) #17 was interviewed at the nurses' station on Unit 200. The interview revealed the nurses run a No BM List each morning. If a resident was on the No BM List, nurses confirmed no BM with the resident. If the resident had not had a BM in 3 days, nurses administered MOM. If the resident was still on the No BM List, nurses administered a [MEDICATION NAME] suppository. LPN #17 said Resident #11 had issues with constipation; however, MOM or a suppository would usually work. LPN #17 reported initiating the facility's BM protocol on several occasions, which she reported to Hospice. LPN #17 added, sometimes, Resident #11 refused her medications and did not always eat a lot, which may contribute to her decreased BMs. On 1/15/2020 at 1:35 PM, the Assistant Director of Nursing (ADON) was interviewed in the conference room adjacent to the MDS office. The ADON said that if a resident did not have a BM in 3 days, the staff should initiate the facility's BM protocol. On 1/16/2020 at 11:06 AM, the Director of Nursing (DON) was interviewed in the main conference room across from the Administrator's office. The DON acknowledged the staff did not initiate the BM protocol when the resident did not have a documented BM within 3 days. The DON said the expectation was for staff to follow the facility BM protocol. Failure to follow the bowel protocol could potentially lead to an obstruction. Review of the Home Health and Hospice Nursing Home Cooperative Agreement, dated 8/15/2013, revealed the facility was responsible for coordinating services with the hospice provider to meet the patient's daily personal, medical, and emotional needs through utilization of the combined care plans of the facility and hospice provider. The hospice provider was responsible for communicating changes in the hospice patient's condition and/or death. The hospice provider was to provide the facility with a pink divider to be placed in the patient's medical record at the facility for hospice documentation. The Hospice guidelines in the nursing home and multidisciplinary progress notes for hospice staff was filed in this section. Review of the hospice Election of Medicare Hospice Benefit form, dated 10/23/2019, revealed Resident #11 elected hospice services effective 10/23/2019. Review of the care plan dated 11/11/2019 indicated Resident #11 chose to receive hospice services with a designated hospice provider. The care plan interventions directed staff to coordinate care with the hospice team. Review of the facility's BM Detail option 2 Roster dated 9/1/2019 through 1/16/2019 indicated Resident #11 did not have a BM on 10/27/2019, 11/4/2019, 11/8/2019, 11/25/2019, 11/29/2019, 12/9/2019, 12/13/2019, 12/19/2019, 12/30/2019, 1/3/2020, and 1/6/2020. Review of Resident #11's clinical record revealed the facility only had Hospice Aide Visit Notes from 12/16/2019 through 1/6/2020. The clinical record did not contain the Hospice Aide Visit Notes from 10/23/2019 through 12/13/2019. On 1/15/2020, the facility contacted the hospice provider and requested copies of the Hospice Aide Visit Notes from the start of hospice services on 10/23/2019. On 1/16/2020, the hospice provider faxed copies of the hospice Aide Visit Notes dated 10/28/2019 through 12/13/2019. Review of the Hospice Aide Visit Notes dated 10/28/2019 through 12/13/2019, (received from the Hospice provider on 1/16/20) revealed Resident #11 had a BM on 10/27/2019, 11/4/2019, 11/8/2019, 11/25/2019, 11/29/2019, 12/9/2019, and 12/13/2019, which did not correlate with the facility's BM Detail option 2 Report. Review of the Hospice Aide Visit Notes dated 12/16/2019 through 1/6/2020, revealed Resident #11 had a BM on 12/13/2019, 12/19/2019, 12/30/2019, 1/3/2020 and 1/6/2020, which did not correlate with the facility's BM Detail option 2 Report. On 1/16/2020 at 12:30 PM, Registered Nurse #21 was interviewed at the nursing station on Unit 200. RN #21 said the hospice provider should have a communication binder for Resident #11 at the facility. RN #21 said when Hospice came in to see the resident, they would come up to the nursing station and verbally communicate the care and services provided, any concerns, and whether the resident had a BM, which facility staff should document in the Electronic Health Record (EHR). On 1/16/2020 at 11:49 AM, LPN #22 was interviewed on Unit 200. LPN #22 said facility staff took care of the resident and provided the overall care, and Hospice was an add-on (offers additional services). Before the hospice aide or nurse left, they would advise staff of any concerns and if the resident had a BM. If hospice staff reported a resident had a BM, LPN #22 would chart the BM in the EHR and let the CNA know. LPN #22 said the facility started hospice binders with all the hospice providers, but she was unsure why Resident #11's hospice provider did not have a binder. On 1/16/2020 at 11:55 AM, CNA #12 was interviewed at the nursing station on Unit 200. CNA #12 said Hospice provided bed baths and made sure Resident #11 had the supplies she needed. CNA #12 said Hospice came in once a week (nurse and CNA) and they would communicate specifics about the resident that staff needed to know, such as BMs, which facility staff was responsible for documenting in the EHR. CNA #12 denied any concerns with hospice staff not providing information regarding the resident. On 1/16/2020 at 12:01 PM, LPN #17 was interviewed at the nursing station on Unit 200. LPN #17 said the hospice aides came in once or twice a week, bathe the resident, provided necessary supplies, and supervised all her medications. LPN #17 said the hospice nurse came in several times a week. The hospice aides and hospice nurse would verbally communicate concerns and the care provided. If the hospice aides or nurse notified her the resident had a BM, LPN #17 notified the resident's CNA, and the CNA was responsible for charting the BM in the EHR. On 1/16/2020 at 12:11 PM, CNA #11 was interviewed at the nursing station on Unit 200. CNA #11 said the Hospice aides came in three times a week, and the nurse may come in once a week. The Hospice aides verbally communicated the care provided and whether the resident had a BM, which she would document in the EHR. CNA #11 denied any concerns with Hospice communicating information on the care provided or when the resident had a BM. On 1/16/2020 at 1:06 PM, the DON was interviewed in the DON's office. The DON said the facility required Hospice to give the facility a binder that included their care plan, signed hospice documents, agreements, signed consents, and all Hospice related documents. The hospice staff verbally communicated any change in the resident, concerns, bathing, and BMs. The DON said the facility staff was responsible for documenting information related to the care and services provided in the EHR. The DON said there was a breakdown in communication and she reached out to Hospice on 1/6/20 to advise them they needed to provide all related documents to the facility. On 1/16/2020 at 3:12 PM, Hospice Director (HD) #20 was interviewed via the phone. She said Hospice provided all new orders and information to the facility. She attended the first care conference last week, which was when she first learned that the facility was requesting Hospice to send information to the facility. HD #20 was not sure whether the hospice notes entered into their Hospice system was sent to the facility. She said there was a hospice tab in the clinical record where the Hospice nurse documented concerns. On 1/16/2020 at 3:34 PM, the Hospice Registered Nurse (RN) #15 was interviewed via the phone. Hospice RN #15 said Hospice did not provide a written note in the clinical record. If there were new orders, Hospice faxed the order over to the facility, and the facility was responsible for transcribing and initiating the orders. She said Hospice provided the facility staff with verbal communication regarding care and services provided, and the facility was responsible for documenting this information in the EHR.",2020-09-01
382,SEVIERVILLE HEALTH AND REHABILITATION CENTER,445132,415 CATLETT RD,SEVIERVILLE,TN,37862,2017-06-15,225,D,1,0,25IX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of the facility investigation, and interview the facility failed to suspend an employee after an allegation of abuse for 1 resident (#1) of 4 residents reviewed. The findings included: Facility Policy review of the Abuse Prevention Policy and Procedure, revised 8/2016, revealed .report all allegations of abuse immediately to the Director of Nursing and Administrator .all employees are required to immediately notify the administrative or nursing supervisory staff that is on duty .so the resident's needs can be attended to immediately and investigation can be undertaken promptly .the charge nurse .will examine the resident .document findings in the clinical records .immediately initiate the Investigation protocol .any employee suspected of abuse, neglect, or mistreatment must be suspended as soon as the incident is reported pending outcome of the investigation .Do not wait . Medical record review revealed Resident #1 was a [AGE] year-old woman admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Continued review revealed the patient was discharged from the facility on 6/8/17. Medical record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact, required extensive assistance of 2 person with transferring, dressing, toileting, and personal hygiene, required extensive assistance of 1 person with walking in room and locomotion on unit, and supervision with eating. Medical record review of a Nursing Note dated 5/23/17 at 4:53 AM revealed .resident rang out for assistance to the restroom .both CNAs (certified nursing assistant) responded to help .resident was very inappropriate towards CNAs by cussing them out and threatening to get them fired .resident accused one CNA of pushing her in the wheelchair .CNA was only guiding .towards the chair .not the first time resident has cussed out these CNAs . Facility investigation review dated 5/23/17 revealed the incident occurred on 5/23/17 at 4:30 AM and at 6:40 AM Licensed Practical Nurse (LPN) #1 (days shift nurse) received the complaint and notified the Director of Nursing (DON) at 6:55 AM. Further review the DON interviewed the resident at 8:30 AM and revealed .stated .she put her light on at about 5:00 or 5:30 am this morning .two nurses came into the room .told them she had .to the bathroom .they (CNAs) wanted her to use the bedpan .she was supposed to be using the toilet .felt this made them mad .one (CNA) was in front of her .one behind the wheelchair .one behind the wheelchair pushed her down into the wheelchair causing her left leg to hurt .she told them nurse behind her .she was going to get her fired .going to tell her son .he would get a lawyer . Review at 10:00 AM the Social Worker interviewed the resident who stated 2 Registered Nurses (RN) came to her room to get her in her wheelchair and assist her to the bathroom .1 RN that was older with dark hair pushed her by her neck . Interview with LPN #1 on 6/13/17 at 11:53 AM in the conference room revealed .work dayshift .when I came in I got report .she (nightshift nurse) only told me the resident was all the time threatening staff with her attorney's .nothing was said about the resident making an allegation of abuse .the two CNAs on dayshift went to do the resident's blood pressure and the resident told them she had 2 CNAs last night and the older one .was helping her into her wheelchair from the bed .the CNA pushed her .said it hurt her and she felt she had been injured all over again .I reported it . Interview with RN #1 on 6/13/17 at 12:08 PM in the conference room revealed .I was assigned to her (resident) .(CNA #3) and (CNA #4) came out and informed me they were getting patient in wheelchair to go to restroom .(CNA #4) was going to assist her .because she was going to miss the wheelchair .I was new .I didn't know (to call supervisor) .(CNA #4) didn't go in room any more that night .I didn't assess her .I didn't know I was suppose to afterward . Interview with the Nurse Practitioner (NP) on 6/13/17 at 1:25 PM in the conference room revealed .she constantly complained .she did not want to be here .she was assessed and there were no signs of abuse .we did order some x-rays and they were negative . Interview with CNA #1 on 6/13/17 at 1:40 PM in the conference room revealed .me and (CNA #2) .had gone in to do her vital signs .said she had been abused .said .that girl last night .tall one .pushed her in her chair .we went and told (LPN #1) . Interview with CNA #2 on 6/13/17 at 2:50 PM in the conference room revealed .me and (CNA #1) .went in to her room cause her light was on .stated she came here for therapy not to be abused .said the CNA had pushed her down and hurt her leg .she didn't name the person .we told the (LPN #1) . Interview with CNA #3 on 6/14/17 at 6:00 AM in the conference room revealed .we had to help her to her wheelchair .I stood in front of her .(CNA #4) stood behind her .when she was fixing to sit she was going to miss the wheelchair .(CNA #4) put her hands on her hips to help assist her into the wheelchair so she would not miss it and fall .she said (CNA #4) pushed her .she was going to get her fired .we assisted her to the bathroom and back to bed .we told (RN #1) about what happened . Interview with CNA #4 on 6/14/17 at 6:15 AM in the conference room revealed .she was cussing .we got her up on the side of the bed .she got up .she was going to miss the wheelchair .I gently helped ease her over into the wheelchair so she would not fall and hurt herself .said you quit shoving me around .she was going to get someone fired .we assisted her to the restroom and back to bed .we mentioned it to the nurse I didn't take it serious .I finished working out the shift . Interview with the Administrator on 6/14/15 at 7:00 AM in the conference room revealed .we did discipline (RN #1) since she did not report the incident immediately and did not send (CNA #4) home . Interview with the Administrator and the DON on 6/15/17 at 9:25 AM in the Administrator's office confirmed the facility failed to report an allegation of abuse immediately to the DON and the Administrator and failed to suspend CNA #4 pending the investigation results per facility policy.",2020-09-01
383,SEVIERVILLE HEALTH AND REHABILITATION CENTER,445132,415 CATLETT RD,SEVIERVILLE,TN,37862,2018-10-30,609,D,1,0,B4T611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on the facility policy review, medical record review, review of facility investigation, and interview, the facility failed to ensure all allegations of abuse or neglect were reported immediately to the Administrator and the State Survey Agency within 2 hours for 1 resident (#1) of 3 residents reviewed for abuse or neglect on 3 of 3 nursing units sampled. The findings included: Review of facility policy Abuse Prevention Policy and Procedure, last revised 2/26/18, revealed .1 .All alleged violations involving abuse, neglect, exploitation or mistreatment .are reported immediately to the Administrator and Director of Nursing . 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 scored a 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Review of a facility investigation dated 10/4/18 revealed Resident #1 told Registered Nurse (RN) #2 on 10/1/18 that RN #1 did not give her all her medications. Continued review revealed RN #2 reported the allegation to the Assistant Director of Nursing (ADON) on 10/1/18, but the allegation was not reported to the Administrator or the Director of Nursing (DON). Further review revealed the incident was reported to the DON by the resident's daughter on 10/4/18. Interview with the Administrator and the DON on 10/29/18 at 2:00 PM, in the Conference Room, confirmed no one reported the allegation to them until 10/4/18 (3 days later). Telephone interview with the Administrator on 10/30/18 at 8:35 AM confirmed the ADON failed to report the allegation to the DON or the Administrator. In summary, the allegation of neglect was not reported to the DON, the Administrator, or State Survey Agency until 10/4/18 (3 days later) and the facility failed to follow facility policy.",2020-09-01
384,SEVIERVILLE HEALTH AND REHABILITATION CENTER,445132,415 CATLETT RD,SEVIERVILLE,TN,37862,2017-11-30,554,D,0,1,AD5V11,"**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 1 resident (#4) of 7 residents reviewed for self-administration of medications. The findings included: Review of facility policy Medication Administration dated 3/16/15 revealed .prepare medications immediately prior to administration .observe that the resident swallows oral drugs .do not leave medications with the resident to self-administer unless the resident is approved for self-administration of the medication . Medical record review revealed Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #4's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident scored 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. Observation and interview with Licensed Practical Nurse (LPN) #1 on 11/28/17 at 8:39 AM, in the resident's private room, revealed Resident #4 was alone in her room and a medication cup containing 8 pills was sitting on the resident's bedside table. Interview with LPN #1 revealed the medication cup contained the following medications: [REDACTED] *two 500 microgram (mcg) [MEDICATION NAME] tablets (medication to treat vitamin B-12 deficiency) *one 80 milligram (mg) [MEDICATION NAME] tablet (medication to treat fluid retention, [MEDICAL CONDITION], and swelling) *two 2,000 unit Vitamin D3 tablets (supplement to improve overall health or for treating [MEDICAL CONDITION]) *one 1,000 unit Vitamin D3 tablet *one 5 mg [MEDICATION NAME] capsule (Vitamin B supplement) *one 800 mg [MEDICATION NAME] tablet (medication to control phosphorus levels in people with [MEDICAL CONDITION]) Continued Interview with LPN #1 confirmed no assessment for self-administration of medications had been completed. Interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 11/30/17 at 9:15 AM, in the Nursing Office, confirmed Resident #4 was assessed for self-administration of medications and the facility failed to follow facility policy.",2020-09-01
385,SEVIERVILLE HEALTH AND REHABILITATION CENTER,445132,415 CATLETT RD,SEVIERVILLE,TN,37862,2017-11-30,812,F,0,1,AD5V11,"Based on facility policy review, observation, and interview, the facility failed to obtain and record temperatures in the ice cream freezer, milk cooler, and the reach-in cooler and failed to maintain dietary equipment in a sanitary manner, in 1 of 3 kitchen observations made, affecting 75 of 75 residents in the facility. The findings included: Review of the facility policy, Record of Refrigeration Temperatures, revised 7/2014, revealed .A daily temperature record is to be kept of refrigerated items .Record temperatures from the internal thermometers . Review of the facility policy, Dietary Department Guidelines, not dated, revealed .The dietary department will be maintained in a clean and sanitary manner to prevent foodborne illness .Refrigerator temperatures will be monitored regularly, and logs will be maintained of all temperatures . Review of the facility policy, Cleaning Schedules, revised 3/2014, revealed .The Dietary staff shall maintain the sanitation of the Dietary Department . Review of the facility policy, Can Opener, revised 9/2011, revealed .Sanitation of equipment .after each meal; more frequently if needed .Scrub the shank, paying special attention to blade . Observation and interview with the CDM on 11/28/17 at 10:15 AM, in the kitchen, revealed no documentation temperatures had been obtained or recorded for the ice cream freezer, milk cooler, or reach-in cooler. Interview with the CDM confirmed the facility failed to obtain and record temperatures for the ice cream freezer, milk cooler and reach-in cooler, and the temperature logs were not maintained. Observation with the CDM on 11/29/17 at 9:30 AM, in the kitchen, revealed a can opener with dried thick debris on the blade. Further observation revealed the convection oven had dried burnt debris on the interior bottom and on the interior doors of the oven. Interview with the CDM on 11/29/17 at 9:35 AM, in the kitchen, confirmed the facility failed to maintain dietary equipment in a clean and sanitary manner.",2020-09-01
386,ALLEN MORGAN HEALTH AND REHABILITATION CENTER,445133,177 NORTH HIGHLAND,MEMPHIS,TN,38111,2018-10-02,812,D,0,1,5TK311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure food was served under sanitary conditions when 1 of 5 (Certified Nursing Assistant (CNA) #1) staff members placed a dirty meal tray on a cart with a clean undelivered meal tray and failed to perform hand hygiene during dining observations. The findings included: The facility's Handwashing/Hand Hygiene policy with a revision date of (MONTH) (YEAR) documented, Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections .Policy Interpretation and Implementation .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .7. Use an alcohol-based hand rub containing at least 62% (percent) alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations .b. Before and after direct contact with residents .l. After contact with objects (e.g. (example), medical equipment) in the immediate vicinity of the resident .o. Before and after eating or handling food . Observations in the Skilled hall on 10/1/18 beginning at 12:43 PM, revealed CNA #1 entered Resident #84's room, delivered a meal tray to this resident, and picked up a dirty tray (Resident #84's tray from breakfast) and placed this tray in the cart with 1 clean tray still left to deliver. CNA #1 then entered Resident #83's room, delivered a meal tray to this resident, and did not perform hand hygiene. CNA #1 removed a pillow and adjusted this resident's bed, and continued to set up the tray without performing hand hygiene. Observations in the Skilled hall on 10/02/18 beginning at at 8:17 AM, revealed CNA #1 delivered a meal tray to Resident #20, adjusted Resident #20's bed, touching the bed, and continued to set up the meal tray without performing hand hygiene. CNA #1 then used hand gel prior to leaving the room. CNA #1 entered Resident #231's room, delivered a meal tray to this resident, adjusted the bed touching the bed, and continued setting up the meal tray without performing hand hygiene. CNA #1 then used hand gel prior to leaving the room. CNA #1 entered Resident #83's room, delivered a meal tray to this resident, adjusted the bed, touching the bed, and moved a pillow from under Resident #83's arm, then continued to set up the tray without performing hand hygiene. Interview with the Director of Nursing (DON) on 10/2/18 at 4:47 PM, in room [ROOM NUMBER], the DON was asked if a tray that had been in a room, had been uncovered, and that a resident had already eaten from the tray, should the tray be placed back on the cart with trays that had not been delivered. The DON stated, No. The DON was asked what should be done after assisting residents, touching objects, and before setting up a meal tray. The DON stated, .hand wash .",2020-09-01
387,ALLEN MORGAN HEALTH AND REHABILITATION CENTER,445133,177 NORTH HIGHLAND,MEMPHIS,TN,38111,2017-11-02,226,E,0,1,WCXB11,"Based on policy review, personnel record review, and interview, the facility failed to follow the facility policy for prescreening of 5 of 5 (Licensed Practical Nurse (LPN) #1 and 2, Registered Nurse (RN) #1, Certified Nursing Assistant (CNA) #1, and Housekeeping staff #1) employees. The findings included: 1. The facility's Background Screening Investigations policy documented .Our facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on individuals making applications for employment .The Personnel/Human Resources Director, or other designee, will conduct employment background checks, reference checks and criminal conviction checks .on persons making application for employment with this facility . 2. Review of personnel records revealed the facility did not complete a reference check on the following: a. Review of the personnel record for LPN #1 revealed a hire date of 10/3/17. There was no documentation a reference check was completed. b. Review of the personnel record for LPN #2 revealed a hire date of 9/25/17. There was no documentation a reference check was completed. c. Review of the personnel record for RN #1 revealed a hire date of 9/25/17. There was no documentation a reference check was completed. d. Review of the personnel record for CNA #1 revealed a hire date of 8/22/17. There was no documentation a reference check was completed. e. Review of the personnel record for Housekeeping Staff #1 revealed a hire date of 10/11/17. There was no documentation a reference check was completed. Interview with the Human Resources Director on 11/1/17 at 12:57 PM, in the conference room, the Human Resources Director was asked if she completed reference checks on new employees. The Human Resources Director stated, No . Interview with the Director of Nursing (DON) on 11/1/17 at 1:03 PM, in the conference room, the DON was asked if she completed reference checks on new employees. The DON stated, .I don't write it anywhere .",2020-09-01
388,ALLEN MORGAN HEALTH AND REHABILITATION CENTER,445133,177 NORTH HIGHLAND,MEMPHIS,TN,38111,2017-11-02,241,D,0,1,WCXB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to provide care in a manner that enhanced the dignity of 1 of 2 (Resident #90) residents observed with a indwelling urinary catheter. The findings included: 1. The facility's Quality of Life-Dignity policy documented, .Demeaning practice and standards of care that compromise dignity are prohibited .Staff shall promote dignity and assist residents as needed by .Helping the resident to keep urinary catheter bags covered . Medical record review revealed Resident #90 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #90's room on 10/30/17 at 12:58 PM, 5:00 PM, and 5:24 PM, revealed Resident #90 had an indwelling urinary catheter with the drainage bag uncovered and in full view. Interview with the Director of Nursing (DON) on 10/30/17 at 5:24 PM, in Resident #90's room the DON was asked if it was acceptable to have the resident's indwelling urinary catheter bag uncovered. The DON stated, No.",2020-09-01
389,ALLEN MORGAN HEALTH AND REHABILITATION CENTER,445133,177 NORTH HIGHLAND,MEMPHIS,TN,38111,2017-11-02,314,D,0,1,WCXB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Prevention and treatment of [REDACTED].#93) sampled residents reviewed with a pressure ulcer. The findings included: The Prevention and treatment of [REDACTED].Suspected Deep Tissue Injury: Depth Unknown .Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear . area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue . Evolution may be rapid exposing additional layers of tissue even with optimal treatment . Medical record review revealed Resident #93 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The ADMISSION EVALUATION AND INTERIM CARE PLAN dated 10/6/17 documented, .break down to heels bilateral .surgical incision .lumber spine . The NURSE'S NOTES documented, .10/9/17 Skin Note: L Heel .3 .cm (centimeters) blisters noted dried up. Floating Heels @ (at) night . The physician order [REDACTED].Apply skin prep to L (left) Heel Daily .Float heels as tolerated while in bed . There were no documentation the physician was notified of the skin breakdown until 10/9/17. The were no documentation of physician's orders [REDACTED]. The care plan dated 10/15/17 documented, .Problem .has impaired skin integrity related to blisters to left heel .Approach .apply skin prep to left heel daily until healed .Start Date 10/15/2017 . The WEEKLY PRESSURE ULCER PROGRESS REPORT documented, .L Heel DTI (deep tissue injury) . Date Identified .10/9/17 .Date Dr. (doctor) Notified 10/9/17 .Date 10/9/17 Length 3x (by) 3 .Black .Stage DTI .Float Heels .Weight 145 .10/11/17 .3x3 .BLK (black) .DTI .Float Heels .10/17/17 .3x3 .BLK .DTI .10/24/17 .3x3 .Weight 153 . Review of the TREATMENT RECORD for the month of (MONTH) revealed Resident #93 received application of skin prep to the left heel daily from (MONTH) 11th through 30th. Observations during wound care in Resident #93's room on 10/31/17 at 2:35 PM, revealed Resident #93 had 3 small unopened black areas on the left heel. Interview with the Treatment Nurse on 10/31/17 at 2:56 PM, in the conference room, the Treatment Nurse was informed that Resident #93 had been assessed on 10/6 with breakdown on her heel and was asked what treatment had been done for her on the 6th. The Treatment Nurse stated, .that would have been (Named Registered Nurse (RN) #2) .I didn't see her till 10/9 . The Treatment Nurse was asked when you saw Resident #93 on 10/9 what was put in place for the left heel DTI. The Treatment Nurse stated, .to float heels and (apply) skin prep .didn't write it (referring to order) till 10/11 . The Treatment Nurse was asked when you saw her on 10/9 why wasn't the order written till 10/11. The Treatment Nurse stated, .I forgot to get the order . Interview with the Director of Nursing (DON) on 10/31/17 at 3:15 PM, at the nurse's station, the DON was asked what she would expect her staff to do for a resident that had been assessed with [REDACTED]. The DON stated, .to put something in place .to notify the physician or nurse practitioner. The DON was asked if it was acceptable to wait 5 days to put a treatment in place for skin breakdown of a heel or DTI. The DON stated, No . Interview with RN #1 on 10/31/17 at 3:36 PM, in the conference room, RN #1 was asked if she completed Resident #93's admission assessment. RN #1 stated, Yes, ma'am. RN #1 was asked did she have breakdown to her heels. RN #1 stated, .yes . RN #1 was asked did you notify the physician. RN #1 stated, .I don't think so .",2020-09-01
390,ALLEN MORGAN HEALTH AND REHABILITATION CENTER,445133,177 NORTH HIGHLAND,MEMPHIS,TN,38111,2017-11-02,315,D,0,1,WCXB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to obtain a physicians order and medical justification for indwelling urinary catheter use for 1 of 2 (Resident #90) sampled residents reviewed with an indwelling urinary catheter. The findings included: 1. Medical record review revealed Resident #90 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #90 was coded for an indwelling urinary catheter. Review of the care plan dated 10/23/17 revealed, Resident #90 had an indwelling urinary catheter. Medical record review revealed no physician's orders or medical justification for the use of the indwelling urinary catheter. Observations in Resident #90's room on 10/30/17 at 12:58 PM, 5:00 PM, and 5:24 PM, revealed Resident #90 had an indwelling urinary catheter. Interview with License Practical Nurse (LPN) #3 on 10/31/17 at 2:15 PM, at the unit 1 medication cart, LPN #3 was asked if there was an order and [DIAGNOSES REDACTED]. LPN #3 stated, No it's not there. Interview with the Director of Nursing (DON) on 10/31/17 at 2:31 PM, at the unit 1 nurse's station, the DON was asked if it was acceptable to not have an order or [DIAGNOSES REDACTED]. The DON stated, .No .we did not get the order .",2020-09-01
391,ALLEN MORGAN HEALTH AND REHABILITATION CENTER,445133,177 NORTH HIGHLAND,MEMPHIS,TN,38111,2017-11-02,323,E,0,1,WCXB11,"Based on policy review, review of the Safety Data Sheets (SDS), review of the Material Safety Data Sheets (MSDS), observation, and interview, the facility failed to ensure the environment was free from the accident hazards of chemicals, aerosol sprays, and sharps, in 6 of 21 (Room #136, 135, 120, 122, 126, and 136) resident rooms. The findings included: 1. The facility's Shaving the Resident policy documented, .Dispose of the razor in a designated sharps container .the razor must be transported .in a puncture-resistant, closed container . 2. The SDS for (brand name) Chlorhexidine Gluconate 4% (percent) Solution documented, .Hazard Statements Causes skin irritation Causes serious eye damage Suspected of causing cancer .Store locked up .May cause irritation of respiratory tract .May cause severe damage to eyes .Prolonged contact may cause redness and irritation .Ingestion may cause irritation to mucous membranes .gastrointestinal irritation, nausea, vomiting and diarrhea . 3. The SDS for (brand name) Mouthwash documented, .Direct Contact with eyes may cause temporary irritation . 4. The SDS sheet for PDI Sani-Cloth Bleach Germicidal Disposable Wipes documented, .Caution: Causes moderate eye irritation. Avoid contact with eyes . 5. The MSDS sheet for (brand name) VapoRub Ointment documented, .Eye contact with the product may produce mild transient, superficial irritation .Possible mild gastrointestinal irritation with nausea and vomiting and diarrhea, if large quantities are ingested . 6. Observations in Room #136 on 10/30/17 at 11:08 AM, 12:25 PM, and 2:27 PM, revealed the following unsecured and unattended hazards: a. a bottle of chlorhexidine gluconate 4% solution skin antiseptic wash on top of the chest of drawers b. a large pair of scissors on top of the over-bed table 7. Observations in Room #135 on 10/30/17 at 11:10 AM, and 2:45 PM revealed the following unsecured and unattended hazards: a. 1 large bottle of aerosol hair spray on the over-bed table b. 1 large bottle of dry mouth rinse on the counter in the bathroom 8. Observations in Room 120 on 10/30/17 at 11:19 AM, 2:27 PM, and 4:43 PM revealed the following unsecured and unattended hazards: a. a jar of vaporub ointment on top of the night stand b. a disposable razor in the bathroom b. 1 can of aerosol deodorant in the bathroom 9. Observations in Room 122 on 10/30/17 at 11:24 AM and 2:49, and 4:48 PM, revealed the following unsecured and unattended hazards: a. 3 disposable razor in the bathroom b. 1 can of aerosol deodorant in the bathroom c. 1 jar of vaporub on the night stand 10. Observations in Room 126 on 10/30/17 at 12:21 PM, revealed the following unsecured and unattended hazards: a. 1 container of sani-cloth germicidal bleach wipes on the bathroom counter b. 1 disposable razor on the bathroom counter 11. Observations in Room #128 on 10/30/17 at 2:52 PM, revealed the following unsecured and unattended hazards: a. 1 container of sani-cloth bleach wipes on top of the chest of drawers Interview with the Director of Nursing (DON) on 10/30/17 at 5:24 PM, in unit 1, the DON was asked if it was acceptable to store chemicals, aerosols, and sharps in the resident rooms. The DON stated, No.",2020-09-01
392,ALLEN MORGAN HEALTH AND REHABILITATION CENTER,445133,177 NORTH HIGHLAND,MEMPHIS,TN,38111,2017-11-02,371,E,0,1,WCXB11,"Based on policy review, observation and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when 1 of 1 (Dietary Staff #1) staff failed to perform hand hygiene during dish washing, 1 of 7 (Certified Nursing Assistant (CNA) #2) staff members observed during dining placed a dirty meal tray from breakfast on the cart with the noon meal trays, a black oven with carbon build up that stored food and kitchen supplies, a dirty oven with black grease build up with clean plates being kept warmed inside, and carbon buildup on skillets and pans. The facility had a census of 21 residents all receiving a meal tray from the kitchen. The findings included: 1. The facility's DISHMACHINE TEMPERATURES policy documented, .Dish area must have a dirty area and a clean area. One associate loads the machine from the dirty area and another associate unloads the machine from the clean area . 2. Observations in the dishwashing area, on 10/30/17 at 9:19 AM, revealed Dietary Staff #1 placed dirty dishes in the dishware, then walked over and removed clean dishes. Dietary Staff #1 failed to perform hand hygiene before removing clean dishes. Interview with Dietary Staff #1 on 10/30/17 at 9:25 AM, in the dishwashing area, Dietary Staff #1 was asked if he washed his hands after putting in the dirty dishes and going to the clean side and removing the clean dishes. Dietary Staff #1 stated, No. 3. Observations during dining in the unit 1 hallway on 10/30/17 at 12:46 PM, revealed CNA #2 removed a dirty breakfast tray from a resident's room and placed it on the top rack of the meal cart that contained a total of 4 other meal trays that hadn't been served. CNA #2 then proceeded to serve the remaining trays from the cart. Interview with the Director of Nursing (DON) on 10/31/17 at 7:38 AM, in the conference room, the DON was asked if it was acceptable for staff to remove a dirty tray from a resident's room and place it in the cart with meal trays that haven't been served. The DON stated, No. 4. The facility's .STORAGE OF POTS, DISHES, FLATWARE, UTENSIL policy documented, .Pots, dishes, and flatware are stored in such a way as to prevent contamination by splash, dust, pest, or other means .Remove carbon build-up from pots . 5. The facility's .CLEANING OF FOOD AND NONFOOD CONTACT SURFACES policy documented, .The food-contact surfaces of all cooking equipment shall be kept free of encrusted grease deposit and other accumulated soil . 6. Observations in the kitchen on 10/31/17 at 3:45 PM, revealed a dirty oven with black buildup and the following items stored inside: 1 small skillet with black carbon buildup 1 open bag of taco season 1 open bag on mashed potatoes 1 unopened bag of mashed potatoes 10 scoops 1 towel 1 box of gloves Interview with the Executive Chief on 11/01/17 at 12:15 PM, in the Executive Chief's office, the Executive Chief was asked should staff store food, utensils, towels, gloves, and skillets in an oven. The Executive Chief stated, No .she was hoarding them . 7. Observations in the kitchen on 10/31/17 at 4:00 PM, revealed a dirty oven with black greased build up and inside was stored 30 clean white plates being kept warmed. Interview with the Executive Chief on 10/31/17 at 4:03 PM, in the kitchen, the Executive Chief was asked why there were clean dishes in a dirty oven. The Executive Chief stated, .to warm the plates .the plate warmer had torn up . The Executive Chief was asked should clean dishes be stored in a dirty oven. The Executive Chief stated, No. 8. Observations in the kitchen on 10/31/17 at 8:30AM, revealed 8 muffin pans with buildup of a black substance on them. Observations in the kitchen on 11/01/17 at 12:00 PM, revealed 6 skillets with buildup of a black substance on them. Interview with the Executive Chief on 11/01/17 at 12:15 PM, in the Executive Chief's office, the Executive Chief was asked what were the black substance on the muffin pans and skillets. The Executive Chief stated, .carbon .",2020-09-01
393,ALLEN MORGAN HEALTH AND REHABILITATION CENTER,445133,177 NORTH HIGHLAND,MEMPHIS,TN,38111,2017-11-02,441,D,0,1,WCXB11,"Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained as evidence by a mop stored in a bucket of water in 1 of 1 biohazard rooms and by a nebulizer mask and a bi-pap mask not properly stored. The findings included: 1. The facility's General Infection Control Practices policy documented, .Infection Control Considerations Related to Medication Nebulizers / Continuous Aerosol .7. Store the circuit in plastic bag, marked with date and resident's name, between uses . 2. Observations in Resident #90's room on 10/30/17 at 2:27 PM, 4:43 PM, and 5:33 PM, revealed an uncovered nebulizer mask resting on the night stand. 3. Observations in Resident #91's room on 10/30/17 at 2:50 PM, 4:52 PM, and 5:34 PM, revealed a bi-pap machine at the bedside with the mask uncovered. Interview with the Director of Nursing (DON) on 10/30/17 at 5:33 PM, in Resident #90's room, the DON was asked if it was acceptable to have a nebulizer mask uncovered on the resident's nightstand. The DON stated, No. Interview with the DON on 10/30/17 at 5:34 PM, in Resident #91's room, the DON was asked if it was acceptable to have a bi-pap mask on the resident's night stand uncovered. The DON stated, No. 4. Observations in unit 1 Biohazard Room on 10/31/2017 at 8:30 AM and 8:52 AM, revealed a mop stored in a bucket of dirty water. Interview with the Laundry/Housekeeping Supervisor on 10/31/17 at 8:50 AM, in unit 1 Biohazard Room, the Laundry/Housekeeping Supervisor was asked if a mop should be stored in a bucket of water. The Laundry/Housekeeping Supervisor stated, No it should not.",2020-09-01
394,"THE WATERS OF CLINTON, LLC",445135,220 LONGMIRE RD,CLINTON,TN,37716,2019-01-09,689,D,0,1,DWFB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, facility records review, observation and interview, the facility failed to investigate the root cause of 7 falls and develop interventions to address the specific cause of 7 falls for 1 resident (#3) of 4 residents reviewed for falls of 21 residents reviewed. The findings include: Review of the facility policy Accident Incident Reporting Policy, undated, revealed .PURPOSE: To ensure accidents .are identified, reported, investigated .To provide a database to study the cause of accidents .to provide assistance in implementing corrective actions to prevent reoccurrence when possible .13. A thorough investigation will be completed within 5 business days . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set ((MDS) dated [DATE], revealed a score of 9 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. Continued review revealed Resident #3 required extensive assistance of 2 persons for transfer, ambulated in the room [ROOM NUMBER]-2 times per week with the assistance of 1 person and was able to move around facility independently with a wheel chair. Review of the facility record Incidents by Incident Type revealed Resident #3 had 11 falls from 8/3/18-12/4/18. Review of the Falls Incident Reports and concurrent review of the Manager Incident Review (identified by the Director of Nurses/DON as the fall investigation) revealed the following: 8/3/18 at 7:45 AM - .lying on bathroom floor on back .abrasion to (L) (left) middle back noted .w/c (wheelchair) in bathroom door way and wheels not locked .Intervention: Bathroom alarm applied to door . Review of the Manager Incident Review dated 8/6/18 revealed .poor safety awareness and has [MEDICAL CONDITION] .door alarm on bathroom door. 8/16/18 at 10:23 AM - .sitting on buttocks in the floor of his bathroom .Scrape noted to back .New batteries placed into bathroom door alarm. Scheduled battery changes began . Review of the Manager Incident Review dated 8/17/18 revealed Why did it happen .Doesn't remember to call for assistance. Battery on alarm going dead and soft chipper sound was heard .What will decrease likelihood of reoccurrence? Schedule door alarm battery (changes). 8/27/18 at 5:00 AM - .Heard someone yelling .entering resident's room, noted resident lying on right side on floor in front of bed .stated he was standing next to his bed to use the urinal and his knee gave out on him causing him to fall . Review of the Manager Incident Review dated 8/27/18 revealed .Stated knee 'gave on him' while using urinal .What will decrease likelihood of reoccurrence? 72 (hour) toileting. 8/31/18 at 6:10 AM - .Heard someone yelling .entered bathroom, noted resident sitting in floor .CNA (Certified Nursing Assistant) notified LPN (Licensed Practical Nurse) resident has been turning bathroom door alarm off. Intervention: Remove bathroom door alarm and apply to inside of bathroom door . Review of the Manager Incident Review dated 9/4/18 revealed .Resident removed door alarm from door. Unable to recall safety measures put into place .door alarm on inside of bathroom door. 9/5/18 at 9:45 AM - .Heard resident yell out .call light had come on .noted resident laying on (L) side with feet toward head of bed .I was trying to use urinal .' Intervention: PT (Physical Therapy) to eval (evaluate) . Review of the Manager Incident Review dated 9/6/18 revealed .Why did it happen? Res (resident) unable to recall safety precautions. He is unable to remember to use call light. He always self transfers .What will decrease likelihood of reoccurrence? Refer to PT for strengthening. 9/23/18 at 7:41 PM - .Resident .yelling from room .noted to be on floor lying on back .w/c unlocked and beside him .Resident stated trying to stand at sink to use his urinal . Review of the Manager Incident Review dated 9/24/18 revealed Why did it happen? Decreased cognition, unable to remember to push call light. Resident had pushed with foot the bedside table to the end of the bed .What will decrease the likelihood of reoccurrence? Place urinal within reach when resident is in bed. 9/26/18 at 8:50 PM - .resident was yelling from the room .lying on the floor .resident said 'I was standing and holding the sink and slipped . Review of the Manager Incident Review dated 9/27/18 revealed Why did it happen? Res has poor safety awareness, resident does not recognize physical limitations .What will decrease the likelihood of reoccurrence? Grip strips in front of sink. 10/23/18 at 9:30 PM - .Witness .Statement .'walking past resident room and noticed resident was going to sit in wheelchair and before could assist he sat in the floor and missed his chair and fell in floor' . Review of the Manager Incident Review dated 10/24/18 revealed, .Why did it happen? Res continues to stand unassisted. Frequent urination. Unable to remember to call for assistance .NP to evaluate (increase) urge in urination. 11/18/18 at 6:34 PM - .Called to resident's room per CNA .Resident stated he was going to get his water pitcher and his knees went out on him, causing him to fall, knocking water pitcher off .offer resident a lighter weight pitcher . Review of the Manager Incident Review dated 11/19/18 revealed, Why did it happen? Res stood and knees weakened causing him to fall .What will decrease likelihood of reoccurrence? Lighter weight water pitcher . 11/28/18 at 12:05 PM - .Resident noted laying in floor on back .in front of sink .Intervention: Therapy to evaluate for correct way to use urinal and if grab bars needed at sink .Other Info (information) Resident stands at sink to use urinal with balance problem noted with standing and unable to stay balanced when trying to hold urinal and to position .correctly in urinal . Review of the Manager Incident Review undated revealed .Resident states he was trying to use urinal and fell . 12/4/18 at 10:00 AM - .LPN entered resident bathroom noted resident with both hands on grab bar, knees in bent position .Noted outer bathroom door alarm with low tone and inner bathroom door alarm was off wall .When LPN asked (resident) how alarm got in floor states, 'I tore that off' . Review of the Manager Incident Review dated 12/5/18 revealed .Res has poor safety awareness, has had TBI ([MEDICAL CONDITION]) .Replaced alarm on top of door frame. Observation of the nursing station, directly across from Resident #3's room, on 1/9/18 at 2:02 PM revealed 2 LPN's and 4 CNA's in the immediate area of the nursing station. Observation included the sounding of Resident #3's bathroom alarm for approximately 1-2 minutes before 1 (#1) of the 4 CNA's in the immediate area responded to the bathroom alarm. Observation of the resident and the resident's room on 1/9/18 at 2:05 PM revealed CNA #1 had transferred Resident #3 from the commode in the bathroom and was wheeling him back to bed. Observation revealed 2 alarms present at the top of the bathroom door casing, 1 on the inside of the door and 1 on the casing. Observation continued and revealed the first alarm placed on the door casing was not working. Observation of the alarm, after it was turned back on, revealed a soft chirping sound. Interview with CNA #1 on 1/9/18 at 2:07 PM, in the resident's room, revealed she stated the alarm had been turned off by her as the resident was being assisted. Interview with CNA #2 on 1/9/18 at 2:10 PM at the nursing station, revealed there was a louder sound alternative for the chirping alarm placed on the resident's bathroom door casing and stated, I put the alarm on the louder sound when I am working . Interview with the Rehabilitation (Rehab) Director on 1/9/18 at 2:15 PM, in the conference room, revealed Resident #3 was treated by P.T. and O.T. (Occupational Therapy) from admission in (MONTH) until 7/11/18. Continued interview confirmed the resident was treated by P.T. for a second period from 9/5/18-11/13/18. Further interview revealed the second treatment period focused on transfers and balance and the therapy department determined the resident was not safe for independent use of a hemi-walker. Further interview revealed the Rehab Director participated in the interdisciplinary meetings to address falls. Interview continued, with concurrent review of rehab screening tools provided, and confirmed the intervention of replacing the resident's water pitcher, developed on 11/19/18, did not address the circumstances of the 11/18/18 fall. Interview with the MDS Registered Nurse (RN) on 1/9/18 at 2:55 PM, in the conference room, included the question of whether providing the resident with a lighter water pitcher addressed the 11/18/18 fall, and the RN responded, It has gotten harder to come up with an intervention . Interview with the Administrator on 1/9/18 at 3:20 PM, in his office, confirmed the facility continued to have difficulty with battery checks and replacement when he arrived 3 weeks prior. Interview with the DON on 1/9/18 at 4:05 PM, in the conference room, revealed 7 of the investigations for the root cause of Resident #3's 11 falls concluded the root cause was due to the resident's cognition. Interview continued and the DON stated I will have to review them. In conclusion, 7 of the 11 falls Resident #3 had from 8/5/18-12/4/18 were not investigated for the immediate circumstances of each fall to aide in the development of an intervention to create a safer environment. Review revealed 7 intervention developed did not address the immediate circumstances of the resident's falls. In addition, the interventions related to the additional alarms, provided at the entry to the resident's bathroom, were not effective when the batteries were not functioning and when the softer alarm setting was not audible outside of the resident's room.",2020-09-01
395,"THE WATERS OF CLINTON, LLC",445135,220 LONGMIRE RD,CLINTON,TN,37716,2019-01-09,865,D,0,1,DWFB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, Provider History Profile Review, medical record review, and interview the facility failed to provide an effective Quality Assurance Performance Improvement Program (QAPI) to ensure care plan interventions were effective, re-evaluate the effectiveness of care plan interventions after each resident fall, and consistently identify the root cause analysis of falls. The QAPI program failed to effectively evaluate, recognize, and monitor falls to ensure the QAPI program was effective in the prevention of repeat deficiencies at F-689 and F-865 (formerly at F-323 and F-520) affecting 1 resident (#3) of 4 residents reviewed for fall of 21 residents reviewed. The findings include: Review of the facility policy, Quality Assurance Performance Improvement, with a copyright date of 2014 revealed .Our Quality Assurance and Performance Improvement Program .represent our facility's commitment to continuous quality improvement .The program ensures a systematic performance evaluation, problem analysis and implementation of improvement strategies to achieve our performance goals .The QAPI committee's oversight responsibilities shall include, but not limited to the following .Utilize facility data to identify opportunities to improve systems and care. Data may include, but is not limited to .medical record review, fall log, incident and accident reports, quality measures, survey outcomes .The QAPI Committee will review the plan annually and make the necessary revisions, Revisions shall reflect the findings, discussions, meetings, surveys, interaction with executive leadership .of the previous year . Review of the Provider History Profile dated 12/2016 revealed the facility was cited at F-323 at a Harm level during the annual Recertification survey on 12/14/16 for failure to ensure a resident was free from accidents resulting in injury. Review of the Provider History Profile dated 11/2017 revealed the facility was cited at F-323 and F-520 at an [NAME] pattern level during the annual Recertification survey on 11/13/17 for failure to complete a thorough investigation of falls, failure to provide supervision for residents to prevent falls, and failure to implement interventions to prevent falls. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility record Incidents by Incident Type revealed Resident #3 had 11 falls from 8/3/18-12/4/18. Medical record review revealed the facility failed to consistently identify and investigate the root cause of Resident #3's falls. Further review revealed the facility failed to create effective interventions to prevent falls. Medical record review of the facility's documentation revealed 7 of the 11 falls Resident #3 had from 8/5/18-12/4/18 were not investigated for the immediate circumstances of each fall to aid in the development of an intervention for creating a safer environment. Review revealed 7 interventions developed had not addressed the immediate circumstances of the resident's falls. In addition, the interventions related to the additional alarms, provided at the entry to the resident's bathroom, were not effective when the batteries were not functioning and when the softer alarm setting was not audible outside of the resident's room. Interview with the Administrator on 01/9/19 at 3:44 PM, in the Administrator's office, confirmed the facility had a repeat deficiency of F-323 on 12/14/16 at a harm level during an annual recertification survey. Continued interview confirmed the facility had a repeat deficiencies of F-323 and F-520 on 11/13/17 during the annual recertification survey related to falls and QAPI. Further interview confirmed the QAPI Committee failed to conduct a thorough and consistent root cause analysis on the facility's resident falls and failed to effectively evaluate, recognize, and monitor their system for managing resident's falls to prevent repeat deficiencies. Further interview confirmed the facility's QAPI program failed to adhere to and follow their policy related to falls to prevent repeat deficiencies related to falls.",2020-09-01
396,"THE WATERS OF CLINTON, LLC",445135,220 LONGMIRE RD,CLINTON,TN,37716,2020-02-25,656,D,0,1,HQTP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to develop a comprehensive care plan for 1 Resident (#61) of 3 residents reviewed for [MEDICAL TREATMENT]. The findings include: Review of medical record review showed Resident #61 was admitted on [DATE], readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the care plan, updated 12/23/2019, showed the resident had [MEDICAL CONDITION] and the potential for complications related to [MEDICAL TREATMENT]. The care plan did not address Resident #61's type of [MEDICAL TREATMENT] access or the location of the access site. Interview Assistant Minimum Data Set (MDS) Coordinator on 2/24/2020 at 2:00 PM, stated Resident #61's care plan was to address the type of [MEDICAL TREATMENT] access and where the access site was located. The resident's care plan does not address the type of [MEDICAL TREATMENT] access or the location of the access site.",2020-09-01
397,"THE WATERS OF CLINTON, LLC",445135,220 LONGMIRE RD,CLINTON,TN,37716,2020-02-25,695,D,0,1,HQTP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record review, observation, and interview, the facility failed to change oxygen tubing and replace humidifier bottles for 2 residents (#60 and #72) of 8 residents reviewed for oxygen use. The findings included: Review of the facility policy titled, O2, (Oxygen) undated, showed .Tubing, humidifier bottles and filters will be changed, cleaned and maintained by the facility . Review of the medical record, showed Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's order dated 4/11/2019, revealed an order for [REDACTED]. Observation of the resident's room on 2/23/2020 at 10:50 AM, showed Resident #60 was wearing oxygen at 3 LPM via nasal cannula and the tubing and water bottle for humidification was dated 2/13/2020. During an interview conducted on 2/23/2020 at 10:50 AM, Licensed Practical Nurse (LPN) #2 confirmed Resident's #60's tubing and humidification bottle was dated 2/13/2020, was to be changed weekly, and had not been changed in a timely manner. Review of the medical record, showed Resident #72 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician Recapitulation Orders for (MONTH) 2020, revealed an order for [REDACTED]. Observation of the resident's room on 2/23/2020 at 9:00 AM, showed Resident #72 wearing oxygen via nasal cannula, oxygen tube dated 1/5/2020, and water bottle for humidification was empty and dated 1/5/2020. During an interview conducted on 2/23/2020 at 9:31 AM, LPN #1, who was assigned to care for Resident #72, stated oxygen tubing is supposed to be changed weekly and the residents tubing had not been changed since the 5th (1/5/2020) and .she's out of water too (humidifier bottle empty and dated 1/5/2020) . During an interview conducted on 2/25/2020 at 9:09 AM, Director of Nursing (DON) confirmed the water bottle used for humidification should have been replaced if it was empty and the oxygen tubing should have been changed.",2020-09-01
398,"THE WATERS OF CLINTON, LLC",445135,220 LONGMIRE RD,CLINTON,TN,37716,2017-07-11,252,D,1,0,RIJH11,"> Based on facility policy review, observation, and interview the facility failed to maintain a homelike environment by eliminating odors in 1 of 2 Television rooms observed in 5 of 5 observations. The findings included: Review of the facility policy, Day Room and Lounge Cleaning, not dated revealed .clean and sanitary, neat appearing and odor-free day rooms and lounges . Observation on 7/10/17 at 11:00 AM, in the South TV room revealed a foul odor, 8 residents present and unable to determine if the odor was related to a particular resident. Observation on 7/10/17 at 12:30 PM, revealed a foul odor present in the South TV room. Observation of the South wing on 7/10/17 at 7:50 PM, revealed a strong foul odor was present in the South wing TV room. Observation/Interview with LPN on 7/10/17 at 8:55 PM, in the South wing TV room confirmed the room had a foul odor described by LPN as an old urine smell. Interview with Director of Environmental Services on 7/11/17 at 10:48 AM, in the South TV room confirmed the room had a foul odor. Further interview revealed the staff had shampooed the carpet 7/10/17 PM, and the upholstery was cleaned 7/11/17 AM.",2020-09-01
399,"THE WATERS OF CLINTON, LLC",445135,220 LONGMIRE RD,CLINTON,TN,37716,2017-07-11,312,D,1,0,RIJH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the facility's policy, medical record review, observation and interview, the facility failed to provide nail care for 1 resident (#1) of 4 residents reviewed. The findings included: Review of the facility policy, Infection Control-Fingernail Maintenance not dated revealed .Necessary attention will be given to residents fingernails to maintain cleanliness as needed .Fingernails should be kept clean .clinical staff will provide fingernail care as necessary . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident scored 3 out of 15 on the Brief Interview for Mental Status indicating severe cognitive impairment, and required extensive assistance for personal hygiene. Observation on 7/10/17 at 12:51 PM, of Resident #1 in the dining room revealed the resident seated at a dining table in a wheel chair. The resident was feeding himself; bilateral hands were observed with dark present on the right hand under the thumbnail and fingernails. Observation of Resident #1 on 7/10/17 at 7:45 PM, in the resident's room revealed his fingers and thumb nails on his right hand with thick dark debris underneath the nails. Interview with Registered Nurse Assistant Director of Nursing (ADON) on 7/10/17 at 7:50 PM, at the North wing nursing station revealed nail care is to be done during showers, or during a bed bath. Observation/Interview with Licensed Practical Nurse on 7/10/17 at 8:25 PM, in Resident #1's room confirmed the resident's fingernails and thumb nail on his right hand had dark thick debris underneath the nails. Further interview confirmed the resident had not received nail care as he should have.",2020-09-01
400,"THE WATERS OF CLINTON, LLC",445135,220 LONGMIRE RD,CLINTON,TN,37716,2017-11-13,157,D,1,1,UJ6N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to notify the physician and family of a fall for 1 resident (#43) of 8 residents reviewed for falls, of 29 residents reviewed. The findings included: Medical record review revealed Resident #43 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. Review of the significant change MDS dated [DATE] revealed the resident required extensive assist of 2 persons for bed mobility, transfers, toilet use; and extensive assist of 1 person for locomotion on the unit, dressing, and eating. Medical record review of a nursing note dated 9/15/17 at 8:45 PM revealed, .Night nurse here for shift report. Night nurse taken to resident's room for report. Night nurse verbalizes understanding to this nurse's shift report. Resident lying on floor mat. Resident's eyes closed, respirations even and unlabored. Skin warm, dry and normal color . Medical record review of a nursing note dated 9/15/17 at 9:30 PM revealed, .This nurse and staff observe resident sitting on mat. Resident offered water per this nurse. Resident refuses to drink water. Resident covered with blanket for comfort. This nurse leaves room with door open due to no residents in hallway . Medical record review of the SBAR - Change of Condition (Situation, Background, Action, Response) created on 9/16/17 at 12:14 AM with an effective date (meaning the time/date of incident) of 9:07 PM, revealed, .Resident observed sitting on floor in her room. Resident was scooting across floor . Medical record review of a nursing noted dated 9/16/17 at 7:32 AM revealed, .Post Fall: Head to toe assessment - greyish/blue colored bruise & (and) swelling across forehead - tissue soft to palpate .Quarter size blue bruise with raised area top of head. Bruise remains bridge of nose; swelling with reddish bruise lt (left) eye. Old bruising both hands & scattered bruises BUE & BLE (bilateral upper extremities and bilateral lower extremities) .Bruise rt (right) side rib area. No c/o (complaint of) pain. Rested quietly during the night in low bed - mattress beside bed . Medical record review of a nursing note dated 9/16/17 at 6:39 PM revealed, .Notified of increase in bruising and [MEDICAL CONDITION] to the nose, forehead, and eyes of this resident S/P (after) fall last night. Spoke with the hospice medical director .Medical director for hospice at this time wants to wait for the hospice nurse to evaluate the resident and speak with the family on their wishes . Medical record review of a nursing note dated 9/16/17 at 7:50 PM revealed, .Talked with D.O.N. (Director of Nursing) regarding resident previous fall. Hospice called and nurse came in .Asked to call family to see if they wanted to send resident to ER (emergency room ) or not .Talked with (family member) . Interview with Registered Nurse (RN) #1 on 11/7/17, at 8:04 AM, at the south nurses' station, revealed RN #1 was notified of Resident #43's facial bruising on 9/16/17, at approximately 6:30 PM, approximately 21 1/2 hours after the fall. The RN then notified the hospice physician and family at that time. Further interview confirmed the facility failed to notify the physician and family of the fall in a timely manner.",2020-09-01
401,"THE WATERS OF CLINTON, LLC",445135,220 LONGMIRE RD,CLINTON,TN,37716,2017-11-13,224,D,1,1,UJ6N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, review of police report, and interview, the facility failed to ensure 1 resident (#101) was free from misappropriation of property of 3 residents reviewed for abuse of 29 sampled residents. The findings included: Review of the facility policy Abuse Prevention Program, updated 1/19/17, revealed .prevent resident abuse .theft .misappropriation of resident property .the deliberate .use of a resident's belongings or money without the resident's consent . Medical record review revealed Resident #101 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #101 had a Brief Interview for Mental Status score of 12, indicating the resident was minimally cognitively impaired. Continued review revealed no behavioral symptoms, hallucinations or delusions and the resident was independent with activities of daily living. Review of a facility investigation revealed Resident #101's daughter discovered several charges to the resident's bank account she believed to be fraudulent and reported the suspicious charges to the facility on [DATE]. Review of Resident #101's Bank Statement dated 8/18/17 revealed a check charge in the amount of $309.15, along with several other charges totaling approximately $1,439. Review of a police report dated 8/18/17 revealed an officer of the local police department interviewed Resident #101 at the facility. Continued review revealed the resident told the officer she kept several checks in a bottom drawer in her room and she did not give permission to anyone to use them. Further review revealed, through the officer's investigation, it was discovered Certified Nursing Assistant (CNA) #5 was identified through surveillance footage to be the person writing the stolen check at a local store. Review of CNA #5's signed statement dated 8/18/17 revealed the CNA confirmed she stole a check from Resident #101 without her consent and used the funds for her own purpose. Interview with Resident #101 on 11/6/17 at 9:40 AM, in the resident's room, confirmed she had been .robbed .a few months ago . Interview with the Administrator on 11/8/17 at 11:44 AM, in the Director of Nursing office, confirmed the facility failed to prevent the misappropriation of property for Resident #101.",2020-09-01
402,"THE WATERS OF CLINTON, LLC",445135,220 LONGMIRE RD,CLINTON,TN,37716,2017-11-13,278,D,0,1,UJ6N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for 1 (#21) resident of 29 residents reviewed. The findings included: Medical record review revealed Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual MDS dated [DATE] revealed the MDS assessment did not indicate the resident was missing any teeth. Observation of the resident on 11/8/17 at 10:10 AM, revealed the resident ambulating in the hall. Continued observation revealed the resident had no natural teeth. Interview with Registered Nurse (RN) MDS Coordinator on 11/8/17 at 4:45 PM, at the nursing station, confirmed the Annual MDS dated [DATE] was inaccurate related to the dental status.",2020-09-01
403,"THE WATERS OF CLINTON, LLC",445135,220 LONGMIRE RD,CLINTON,TN,37716,2017-11-13,280,E,0,1,UJ6N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, interview, and review of falls investigations, the facility failed to develop and implement interventions following falls for 3 residents (#85, #43, and #104) of 8 residents reviewed for accidents. The findings included: Review of the facility policy Falls Management Guideline, last review date 8/10/16, revealed .if a resident triggers at risk for falls .the plan of care is updated .to minimize the risk of falls .appropriate interventions are implemented . Medical record review revealed Resident #85 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Progress Notes dated 10/10/17 at 9:41 PM revealed, .resident found sitting in the floor next to the bed. Small skin tear noted to right forearm. no other injury noted . Medical record review of the Progress Notes dated 10/10/17 at 9:49 PM revealed, .while passing hs (nighttime) medications found resident sitting in the floor next to the sink .no injury noted . Medical record review of the resident's care plan initiated 10/11/17 revealed the resident was care planned for being at risk for falls. Further review revealed the two falls on 10/10/17 were not documented on the care plan with interventions to prevent new falls. Medical record review of the 14 day Minimum Data Set ((MDS) dated [DATE] of Resident #85 revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment, behaviors including physical, verbal, and rejection of care, and requiring extensive assist with 2 staff including transfer, hygiene, and toileting. Medical record review of the Progress Notes dated 10/22/17 at 6:30 AM revealed, Resident found sitting in floor .No injuries noted .Recommendations: Have night shift to make resident last on there last round and perform peri care or take to bathroom if needed . Medical record review revealed the care plan was not updated to reflect the fall on 10/22/17 or the new intervention to be implemented. Medical record review of the Progress notes dated 11/1/17 at 3:12 PM revealed, .Resident was sitting WC (wheelchair) in day room and was reaching for something imagined in the floor. He overextended and slid from his chair and onto floor .no injuries noted . Medical record review revealed the care plan was not updated to reflect the fall on 11/1/17 or the new intervention to be implemented. Interview with the Director of Nursing (DON) on 11/8/17 at 11:55 AM, in the DON's office, confirmed the facility failed to update the care plan after falls for Resident #85. Medical record review revealed Resident #43 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. Review of the significant change MDS dated [DATE] revealed the resident required extensive assist of 2 persons for bed mobility, transfers, toilet use; and extensive assist of 1 person for locomotion on the unit, dressing, and eating. Medical record review the resident's current care plan revealed, .At risk for falls . with the resident's first fall on the care plan dated 9/15/16 and interventions to be utilized to prevent further falls. Medical record review of a nursing progress note dated 7/15/17 at 5:15 PM revealed, .res(resident) observed in the floor in lobby by front door with W/C (wheelchair) on top of her .New interventions: Anti-tippers to W/C (wheelchair) front wheels. Tilt drop seat to W/C . Further review revealed the resident had no injuries. Medical record review of an SBAR - Change of Condition (Situation, Background, Action, Response) dated 7/31/17 at 3:10 AM revealed, .Noted scooting on the floor .sat leaning against door frame of her room .Recommendations: Continue present interventions. Pain monitoring & (and) neuro (neurological) checks with vital signs q (every) shift per facility protocol x 3 (for 3) days . Further review revealed the resident had no injuries. Review of a falls investigation dated 8/3/17 at 7:30 PM revealed, .Resident observed sitting in floor in another residents room .no injuries noted .New intervention: Assist to bed after supper . Review of a falls investigation dated 8/5/17 at 3:15 PM revealed, .Resident observed leaning to the side of her W/C. two nurses assisted to upright position. Resident then observed to quickly lean forward throwing herself out of W/C onto her hands and knees .Immediate action Taken .Tilt drop seat to W/C . Further review revealed the resident had no injuries. Review of a falls investigation dated 8/22/17 at 3:15 AM revealed, .Resident observed to be scooting on buttocks in floor in hallway near her room. No obvious injuries noted New intervention: Scheduled toileting Q 2 hours (every 2 hours) day and night . Review of a falls investigation dated 8/22/17 at 3:49 PM revealed, .Resident was observed lying on left side in floor in the lobby area. W/C cushion had slid down in chair .No injury noted .New Intervention: Anti-skid material in W/C cushion . Review of a falls investigation dated 8/24/17 at 9:39 PM revealed, .Resident was observed lying in the floor in South tv lounge next to her reclining W/C. W/C upright with back of chair reclined. Resident was lying on her left side .No injuries noted .New Intervention: Changed to non-reclining W/C, therapy screen . Review of a falls investigation dated 8/30/17 at 10:51 PM revealed, .Resident was observed crawling on floor in her room .no injury was noted .New Intervention: Psyc NP (Psychiatric Nurse Practitioner) to review meds (medications) again . Review of a falls investigation dated 9/4/17 at 9:41 PM revealed, .Resident was observed sliding out of wheelchair .no injuries noted .Moved closer to nurses desk. New Intervention: Soft Foam Helmet as tolerated . Review of a falls investigation dated 9/9/17 at 2:30 PM revealed, .Resident was observed sitting in w/c in tv lounge. Resident slid out of w/c and landed in a sitting position .no injuries noted .New Intervention: Non slip material to both sides of w/c cushion . Medical record review of the resident's current and active care plan revealed the care plan was not revised to reflect the falls, and the New Interventions to be implemented after the falls, on 7/15/17, 7/31/17, 8/3/17, 8/5/17, 8/22/17, 8/24/17, 8/30/17, 9/4/17, and 9/9/17. Interview with the Regional Nurse Consultant and Registered Nurse (RN) #1 on 11/8/17 at 2:42 PM, in the small conference room, confirmed the facility had failed to update the care plan for each of the falls and new interventions. Medical record review revealed Resident #104 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Progress Note dated 6/1/17 at 11:15 AM, revealed, .pt. (patient) found in floor by bed. Upon assessment found large knot to back of head .denies pain with movement of either upper or lower extremities . Medical record review of Resident #104's plan of care revealed the care plan was not updated to reflect the fall or interventions for the fall on 6/1/17. Interview with the DON on 11/09/17, at 1:48 PM, in the DON's office, confirmed the facility failed to revise the care plan for Resident #104 following a fall on 6/1/17.",2020-09-01
404,"THE WATERS OF CLINTON, LLC",445135,220 LONGMIRE RD,CLINTON,TN,37716,2017-11-13,314,D,1,1,UJ6N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, interview, and observation, the facility failed to ensure weekly skin assessments were completed for 2 (#30, #106) residents of 5 residents reviewed for pressure ulcers of 29 residents reviewed. The findings included: Review of the facility policy, Skin Integrity Guideline, undated, revealed .Licensed nurse will be responsible for performing a skin evaluation/observation weekly, utilizing the Weekly Skin Review . Medical record review revealed Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Medical record review of the Braden Scale dated 8/16/17 revealed .score 13.0 .moderate risk . Medical record review of the Weekly Skin Review dated 8/21/17 revealed .elbows and heels clear . Medical record review of the Weekly Skin Review dated 9/4/17 revealed .Treatment in progress for wounds to coccyx and right hip .Top of right foot, red nonblanchable area 3 (centimeters) x (by) 2 (centimeters) .and purple nonblanchable area to bottom of left heel . Medical record review of a Physician's Order dated 9/4/17 revealed .Apply skin prep to red area to top of right foot Q (every) shift until healed .red non blanchable area .apply skin prep to left heel Q shift .for purple non blanchable area . Medical record review of a Physician's Progress Note dated 9/5/17 revealed .area red and nonblanchable on the top of his right foot and a purple discolored area on the bottom of his heel .he said that he often crosses his feet and he feels like this is what has happened . Medical record review of the Progress Note dated 9/12/17 revealed .Right dorsal foot 2.0 (cm) x 2.4 (cm) unblanchable red area .left foot is 2.0 (cm) x 2.0 (cm) red area now nonblanchable appearing now since initial onset which appeared more bruise in appearance. Skin prep continues . Medical record review of the Progress Notes dated 9/16/17 revealed .Resident .refuses to turn and reposition. Resident request that his feet be placed on pillows . Interview with the Wound Care Nurse on 11/8/17 at 8:20 AM, at the Nursing Station, confirmed there was no documentation a skin assessment had been performed the week of 8/28/17, prior to the identification of the red nonblanchable area to the top of the right foot and the purple area on the left heel. Medical record review revealed Resident #106 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #106 was severely cognitively impaired and required extensive assistance of two person physical assist for bed mobility, transfers, dressing, and personal hygiene, and was totally dependent of two or more physical assist for toileting. Further review revealed Resident #106 was at risk for developing a pressure ulcer, did not have a pressure ulcer at the time of the assessment, and was always incontinent of urine and bowel. Medical record review of Resident #106's plan of care dated 8/29/17 revealed .at increased risk for alteration in skin integrity .impaired mobility . Medical record review revealed a weekly skin assessment was not completed for the week of 10/8/17 - 10/14/17. Medical record review of the weekly skin sheet dated 10/16/17 revealed .open areas .R (right) lateral (side) ankle 1.8 (cm) x 1.6 (cm) x 0.8 (cm) .yellow slough (devitalized tissue) . Medical record review of the Wound report dated 10/27/17 revealed .right ankle .granulation noted to edges of wound with white slough in center .pressure ulcer .unstageable .size of wound .1.9 (cm) x 1.9 . Interview with Registered Nurse (RN) #1 on 11/8/17 at 11:01 AM, in the nursing office, confirmed the facility failed to complete a weekly skin assessment on Resident #106 the week of 10/8/17 - 10/14/17. Interview with Nurse Practitioner (NP) #1 on 11/9/17 at 1:49 PM, in the conference room, confirmed due to the resident's overall condition the development of a pressure ulcer was unavoidable. Observation of Resident #106's right ankle wound on 11/9/17 at 3:42 PM, with RN #1, Licensed Practical Nurse #1, and NP #1 in the resident's room revealed Resident #106 was lying in bed on an air mattress. Continued observation revealed an open area to the right outer ankle approximately the size of a quarter. Further observation revealed the wound bed was red with pink edges. Continued observation revealed RN #1 obtained measurements of the wound which were 2.5 centimeters (cm) x 2.5 cm x 0.5 cm.",2020-09-01
405,"THE WATERS OF CLINTON, LLC",445135,220 LONGMIRE RD,CLINTON,TN,37716,2017-11-13,323,E,1,1,UJ6N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility falls investigations, and interview, the facility failed to complete a thorough investigation and implement interventions to prevent further falls for 3 residents (#85, #43, #104), and failed to provide adequate supervision to prevent falls for one resident (#93) of 8 residents reviewed for accidents of 29 residents reviewed. The findings included: Review of the facility policy Falls Management Guideline, last review date 8/10/16, revealed .to minimize the risk of falls .appropriate interventions are implemented .the Interdisciplinary Team reviews .and makes additional recommendations . Review of the facility policy Post Fall Analysis Summary & (and) Guidelines for Completion, last reviewed 11/23/15, revealed .after every known resident fall .identify the reason and/or risk factor for the fall .to prepare a plan of care to reduce the potential for future fall . Medical record review revealed Resident #85 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Fall Risk assessment dated [DATE] revealed a falls score of 17, indicating the resident was a high risk for falls. Medical record review of the 14 day Minimum Data Sed ((MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 3, indicating severe cognitive impairment; behaviors including physical, verbal, and rejection of care; and required extensive assist with 2 staff for transfer, hygiene, and toileting. Medical record review of the Progress Notes dated 10/10/17 at 9:41 PM revealed, .resident found sitting in the floor next to the bed. Small skin tear noted to right forearm. no other injury noted . Medical record review of the Progress Notes dated 10/10/17 at 9:49 PM revealed, .while passing hs (nighttime) medications found resident sitting in the floor next to the sink .no injury noted . Medical record review and review of facility falls investigations revealed the facility failed to complete an investigation to determine the cause and to implement interventions to prevent further falls for the falls on 10/10/17. Medical record review of the Progress Notes dated 10/15/17 at 7:47 AM, revealed, .Observed resident lying in floor prone position .skin tear noted on left wrist .Recommendations: Bolster mattress put on bed for intervention . Medical record review and review of facility falls investigations revealed the facility failed to complete an investigation to determine the cause and to implement interventions to prevent further falls for the fall on 10/15/17. Interview with the Director of Nursing (DON) on 11/8/17 at 11:55 AM, in the DON's office, confirmed the facility failed to complete and investigation to for the two falls on 10/10/17 and the fall on 10/15/17. Medical record review revealed Resident #43 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. Review of the significant change MDS dated [DATE] revealed the resident was incontinent of urine, required extensive assist of 2 persons for bed mobility, transfers, toilet use; and extensive assist of 1 person for locomotion on the unit, dressing, and eating. Medical record review the resident's current care plan revealed, .At risk for falls . with the resident's first fall on the care plan dated 9/15/16 and interventions to be utilized to prevent further falls. Review of a falls investigation dated 8/5/17 at 3:15 PM revealed, .Resident observed leaning to the side of her W/C. two nurses assisted to upright position. Resident then observed to quickly lean forward throwing herself out of W/C onto her hands and knees .Immediate action Taken .Tilt drop seat to W/C . Further review revealed the resident had no injuries. Medical record review of the resident's care plan revealed the new intervention for the Tilt drop seat to W/C was not implemented. Review of a falls investigation dated 8/22/17 at 3:15 AM revealed, .Resident observed to be scooting on buttocks in floor in hallway near her room. No obvious injuries noted New intervention: Scheduled toileting Q 2 hours (every 2 hours) day and night (a nursing action that should be done on every incontinent resident) . Review of a falls investigation dated 8/22/17 at 3:49 PM revealed, .Resident was observed lying on left side in floor in the lobby area. W/C cushion had slid down in chair .No injury noted .New Intervention: Anti-skid material in W/C cushion . Medical record review of the resident's care plan revealed the new intervention for the Anti-skid material in W/C was not implemented. Review of a falls investigation dated 8/30/17 at 10:51 PM revealed, .Resident was observed crawling on floor in her room .no injury was noted .New Intervention: Psyc NP (Psychiatric Nurse Practitioner) to review meds (medications) again . Medical record review revealed there was no medication changes and no other interventions to prevent falls was put in place. Interview with the Regional Nurse Consultant and Registered Nurse (RN) #1 on 11/8/17 at 2:42 PM, in the small conference room, confirmed the facility had failed to put new interventions in place for the falls on 8/5/17, 8/22/17, and 8/30/17. Medical record review revealed Resident #104 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed a BIMS score of 3, indicating the resident was severely cognitively impaired. Continued review revealed the resident required extensive assistance with 2 person physical assist for bed mobility and transfers and extensive assistance with 1 person physical assist for all other ADLs. Medical record review of a Progress Note dated 6/1/17 at 11:15 AM, revealed .pt. (patient) found in floor by bed. Upon assessment found large knot to back of head .denies pain with movement of either upper or lower extremities . Medical record review and review of facility falls investigations revealed no investigation was completed to determine the cause of the fall and to implement interventions to prevent further falls. Interview with the Director of Nursing, Administrator, and Regional Consultant Nurse on 11/09/17 at 1:22 PM, in the DON's office, confirmed the facility failed to investigate Resident #104's fall on 6/1/17. Medical record review revealed Resident #93 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed the resident was discharged on [DATE]. Medical record review of Resident #93's care plan initiated 11/23/16 revealed, .at risk for falls .requires ADL (activities of daily living) assist for transfers and mobility . Further review revealed care plan documentation the resident had a fall on 12/15/16. Further review revealed the care plan was revised 5/18/17 with .physical functioning deficit .related to .mobility impairment .extensive assistance of 2 . Medical record review of the Quarterly MDS dated [DATE] revealed a BIMS score of 14, indicating Resident #93 was cognitively intact. Further review revealed the resident required extensive assistance of two person physical assist for bed mobility, dressing, toilet use, and personal hygiene. Continued review revealed the resident was totally dependent with two person physical assist for transfers. Further review revealed Resident #93 was unable to stabilize himself without staff assistance when moving on and off the toilet and was impaired on one side in his lower extremity. Medical record review of a Progress Note dated 6/29/17 at 7:00 PM revealed .discovered laying on the bath room floor in face down position .awake and oriented .answer questions appropriately .laying on stomach . Medical record review of a Fall report dated 6/29/17 revealed .location .bathroom .nursing description .observed laying on bathroom floor .alert and oriented .attempting to stand from toilet to clean self after having a BM (bowel movement) .legs weakened .fell from toilet . Interview with Certified Nursing Assistant (CNA) #1 by telephone on 11/8/17 at 8:01 AM, confirmed she assisted Resident #93 to the restroom the evening of 6/29/17 with assistance from CNA #2. Further interview revealed CNA #1 left the room to obtain supplies and at that time CNA #2 was still in the room. Continued interview revealed upon returning to the room CNA #2 was no longer in the room and Resident #93 was laying in the bathroom floor. Interview with Registered Nurse (RN) #1 on 11/8/17 at 8:35 AM, in the nursing office, confirmed it was the facility's practice if a resident required staff assistance to the restroom, a staff member will stay with them to ensure the resident's safety. Continued interview confirmed it was the facility's practice to never leave a resident alone in the restroom. Interview with the DON on 11/9/17 at 7:55 AM, in the DON's office, confirmed it was her expectation if a resident required assistance to the restroom, staff would stay with the resident to ensure their safety. Interview with the DON on 11/13/17 at 8:15 AM, in the DON's office, confirmed the facility failed to provide supervision for Resident #93 while in the restroom.",2020-09-01
406,"THE WATERS OF CLINTON, LLC",445135,220 LONGMIRE RD,CLINTON,TN,37716,2017-11-13,329,D,0,1,UJ6N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to attempt to taper an antidepressant medication for 1 resident (#59) of 5 residents reviewed for unnecessary medications of 29 residents reviewed. The findings included: Medical record review revealed Resident #59 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the facility Order Recap Report dated 5/1/17 through 11/30/17 revealed .[MEDICATION NAME] (antidepressant medication) .give 20 mg (milligrams) .at bedtimefor depression .start date .8/5/16 .end date .11/13/17 Medical record review of the Consultant Communication to the Physician dated 6/2017 revealed .Gradual Dose Reduction (GDR) for [MEDICAL CONDITION] Agents .[MEDICATION NAME] 20 mg hs (at bedtime) . Continued review revealed no response from the physician. Medical record review revealed Resident #59 remained on the initial dose of [MEDICATION NAME] from 8/5/16 until 11/13/17 without documentation from the facility's physician why a reduction would be contraindicated. Interview with the Director of Nursing (DON) on 11/13/17 at 1:00 PM, in the DON's office, confirmed the facility failed to document a clinical rationale for the continuation of a psychtropic medication by the facility's physician, failed to attempt to taper a [MEDICAL CONDITION] medication, and failed to ensure the resident was free from an unnecessary medication.",2020-09-01
407,"THE WATERS OF CLINTON, LLC",445135,220 LONGMIRE RD,CLINTON,TN,37716,2017-11-13,371,F,0,1,UJ6N11,"Based on the facility policy review, observation, and interview, the facility failed to properly air dry pans and maintain safe operating temperatures in 1 of 1 reach in refrigerators in the dietary department, potentially affecting 85 of 85 residents. The findings included: Review of the facility policy Cleaning Instructions: Food Preparation Appliances dated (YEAR) revealed, .wash and rinse according to manual guidelines for dishwashing .Allow to air dry . Review of the facility policy Refrigerator/Freezer Temperatures dated (YEAR) revealed, .ensure that all cold storage units are at 41 (degrees) or below for refrigeration .If the temperature of the unit is not in the desirable range, a corrective action is taken .management staff is notified . Observation with the Dietary Aide (DA) on 11/6/17 at 6:34 AM, in the kitchen, revealed 6 of 9 - 6.1 quart pans stored wet and available for use. Interview with the DA on 11/6/17 at 6:35 AM, in the kitchen, confirmed 6 of 9 - 6.1 quart pans were stored wet and should have been allowed to dry. Observation with the DA on 11/6/17 at 6:40 AM, in the kitchen revealed 2 internal thermometers located in the reach in refrigerator indicated the temperature of the refrigerator was 50 degrees. Review of the Reach-In Refrigerator/Freezer Temperature Log for the months of (MONTH) through (MONTH) (YEAR) revealed evening refrigerator temperatures were above 41 degrees for 46 of 99 days. Observation with the Dietary Manager (DM) on 11/6/17 at 7:30 AM, in the kitchen, revealed 2 trays with juice, nectar thick liquids and nectar thick milk, and 1 tray of pudding in the reach in refrigerator. Observation revealed temperatures were obtained and there was a temperature of 50 degrees for 1 glass of milk and 1 glass of apple juice. Interview with the DM on 11/6/17 at 7:35 AM, in the kitchen, confirmed the facility failed to maintain the reach in refrigerator at safe operating temperatures and failed to ensure refrigerated liquids were kept at safe temperatures.",2020-09-01
408,"THE WATERS OF CLINTON, LLC",445135,220 LONGMIRE RD,CLINTON,TN,37716,2017-11-13,428,D,0,1,UJ6N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to act on a pharmacy recommendation for an antidepressant gradual dose reduction (GDR) for 1 Resident (#59) of 5 residents reviewed for unnecessary medications of 29 residents reviewed. The findings included: Medical record review revealed Resident #59 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #59's Quarterly Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status score of 3, indicating the resident was severely cognitively impaired. Medical record review of the facility Order Recap Report dated 5/1/17 through 11/30/17 revealed .Celexa (antidepressant) .give 20 mg (milligrams) .at bedtime for depression .start date .08/05/2016 . Medical record review of the pharmacist Consultant Communication to the Physician dated 6/2017 revealed .Gradual Dose Reduction for Psychotropic Agents .Celexa 20 mg hs (at bedtime) . Continued review revealed no physician response to the recommendation from the pharmacist. Interview with the Administrator on 11/7/17 at 2:30 PM, in the conference room, confirmed the facility failed to respond to a recommendation from the pharmacist.",2020-09-01
409,"THE WATERS OF CLINTON, LLC",445135,220 LONGMIRE RD,CLINTON,TN,37716,2017-11-13,520,E,0,1,UJ6N11,"Based on review of Provider History Profile, facility documentation, medical record review, and interview, the facility failed to ensure an effective Quality Assurance (QA) program to recognize and monitor falls and to ensure the QA program was effective in preventing repeat deficiencies at CFR 483.25 (F-323), affecting 4 residents #43, #85, #93, and #104) of 29 residents reviewed. The findings included: Review of the Provider History Profile dated 12/2016 revealed the facility was cited F-323 at the Harm level during the annual Recertification survey on 12/14/16 for failure to ensure a resident was free from accidents resulting in injury. Review of facility documentation Clinical Data Summary dated 3/2017 revealed the facility tracked their falls and benchmarked against the national average. Further review revealed the facility's falls was above the national benchmark in March, May, (MONTH) and (MONTH) (YEAR). Medical record review of 4 residents (#43, #85, #93, and #104) reviewed for falls from 6/1/17 to 11/1/17 revealed the facility failed to develop and implement interventions to prevent falls. Review of the Ad-Hoc QA action plan dated 10/26/17 revealed .100% audit of falls starting on 10/25/17 to ensure interventions in place, care planed (planned), and communicated to staff . Interview with the Administrator on 11/13/17 at 4:00 PM, in his office, confirmed facility falls were above the national average but .a lot are repeat fallers .we started (MONTH) 25 looking at falls .100% of falls have been reviewed with interventions .obviously what they did has not worked .it's not going to happen overnight . Continued review confirmed the QA committee failed to conduct a root cause analysis on facility falls and had not recognized and monitored their system for managing falls.",2020-09-01
410,SIGNATURE HEALTHCARE OF PUTNAM COUNTY,445136,278 DRY VALLEY RD,COOKEVILLE,TN,38506,2017-03-01,223,D,0,1,AQIZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to prevent resident verbal abuse for 1 resident (#193) of 3 residents reviewed for abuse. The findings included: Review of facility policy, Abuse, Neglect and Misappropriation of Property, revealed .It is .policy to prevent the occurrence of abuse .Verbal abuse is use of any oral, written or gestured language that includes any threat, or any frightening, disparaging or derogatory language, to residents .or within their hearing distance, regardless of age, ability to comprehend, or disability . Medical record review revealed Resident #193 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #193 had moderately impaired cognitive skills, had adequate hearing and clear speech, and could make himself understood and understood others. Review of facility documentation dated 12/28/16 at 1:20 PM revealed Licensed Practical Nurse (LPN) #8 was witnessed by Housekeeper #1 and Certified Nurse Aide (CNA) #6 calling Resident #193 inappropriate names. Continued review of the facility documentation revealed LPN #8 stated she was . burned out .I had reached my limit . and she confirmed she called Resident #193 inappropriate names. Review of the Witness Statement by CNA #6 dated 12/28/16 revealed LPN #8 .come up the hall and said He's a dick head as (and} yes I said it out loud . Review of the Witness Statement by Housekeeper #1 dated 12/9/16 revealed Resident #193 .said she (LPN #8) called him a son-of-a-[***] , she (LPN #8) looked back at him and told him God told her to do that . Review of LPN #8's employee record revealed she was hired on 11/29/16, and had passed the abuse registry verification and the background verification. Further review revealed LPN #8 had completed orientation including abuse training. Review of the work schedule for LPN #8 revealed 4 days of working with another LPN on 12/5, 12/6, 12/8, and 12/9/16. LPN #8 worked independently on 12/12, 12/14, 12/17, 12/18, 12/19, 12/22, 12/23 and 12/28/16. LPN #8 was scheduled to work and called out on 12/7, 12/13, 12/25, and 12/26/16. Interview with Resident #193 on 2/27/17 at 2:18 PM in the resident's room, when asked if anyone in the facility had abused him, revealed .a nurse cussing him and she was fired . Telephone interview with Housekeeper #1 on 2/28/17 at 2:26 PM revealed she had overheard Resident #193 and LPN #8 talking in the resident's room doorway and the . LPN was getting mad at him and was rolling her eyes . when the resident stated to the LPN .Yes you did call me a son-of-a-[***] . Further interview revealed the LPN stated .God told her to say it . as she walked away from the resident. Telephone interview with CNA #1 on 2/28/17 at 2:35 PM revealed she had overheard LPN #8 yelled at and cuss at .Resident #193 .said he was a son-of-a-[***] and then said he was a dick head as she (LPN #8) started to walk to the nursing station .she looked back down the hall and said Yes I just said that out loud . Telephone interview with CNA #3 on 2/28/17 at 2:46 PM revealed the CNA overheard a loud exchange between LPN #8 and Resident #193 but could not hear what was said. CNA #3 reported to LPN #2, seated at nursing station, of overhearing a loud exchange. The CNA stated LPN #2 went to LPN #8. Telephone interview with LPN #2 on 2/28/17 at 3:07 PM revealed CNA #3 came to her and told LPN #2 she was needed down the hall .something was said . Further interview revealed LPN #2 went to LPN #8, at the medicine cart in the hallway, and LPN #8 stated Resident #193 had cussed at LPN #8. LPN #2 went to check on Resident #193 who told LPN #2 that LPN #8 had cussed at him. Further interview revealed the resident was monitored by a CNA while LPN #8 was escorted to the ADON/RN #1 office. Interview with ADON/RN#1 on 3/1/17 at 8:40 AM in the chapel revealed LPN #2 reported to the ADON/RN #1 about LPN #8 being heard calling Resident #193 inappropriate names. Further interview revealed LPN #8 was brought to the ADON/RN #1's office and was informed the LPN was overheard calling Resident #193 inappropriate names. Further interview revealed LPN #8 confirmed she had called the resident inappropriate names. Further interview revealed LPN #8 was escorted to the Director of Nursing's (DON's) office where the allegation was discussed and LPN #8 confirmed she had called the resident a name and knew what she had done was not appropriate. Interview with CNA #6 on 3/1/17 at 9:19 AM in the chapel revealed she was in the hallway and had heard LPN #8 .say he's (Resident #193) a dick head and Yes I said that out loud . Further interview revealed the CNA went to the Assistant Director of Nursing (ADON)/Registered Nurse (RN) #1 to report the event when a staff member (unable to recall who) entered the RN's office to report the exchange between LPN #8 and the resident. Interview with the DON on 3/1/17 at 9:31 AM in the DON's office revealed the ADON/RN #1 informed the DON there was a situation involving LPN #8 and the LPN was escorted to the DON's office. Further interview revealed the DON, ADON/RN #1 and LPN #8 discussed what had been overheard and LPN #8 confirmed she had called Resident #193 inappropriate names, she knew it was wrong to do and was embarrassed. Further interview revealed LPN #8 stated she was burned out and wanted to leave . Further interview revealed the LPN was informed her employment was terminated and was escorted off the property.",2020-09-01
411,SIGNATURE HEALTHCARE OF PUTNAM COUNTY,445136,278 DRY VALLEY RD,COOKEVILLE,TN,38506,2017-03-01,371,E,0,1,AQIZ11,"Based on observation and interview, the facility failed to maintain the ice machines in a sanitary manner in 2 of 3 Nourishment Rooms. The findings included: Observation on 2/28/17 at 9:01 AM in the 100/200 hall Nourishment Room revealed an ice machine. Further observation of the interior of the ice machine revealed rusty brown colored debris on the top of the ice slide. Interview with Licensed Practical Nurse (LPN) #6 on 2/28/17 at 9:13 AM in the 100/200 hall Nourishment Room confirmed the top of the ice slide had rusty brown colored debris. Observation on 2/28/17 at 9:04 AM in the 300/400 hall Nourishment Room revealed an ice machine. Further observation of the interior of the ice machine revealed pink colored debris on the bottom of the ice slide where the ice falls into the ice storage bin. Interview with LPN #7 on 2/28/17 at 9:04 AM in the 300/400 hall Nourishment Room confirmed the ice machine interior had pink colored debris on the bottom of the ice slide.",2020-09-01
412,SIGNATURE HEALTHCARE OF PUTNAM COUNTY,445136,278 DRY VALLEY RD,COOKEVILLE,TN,38506,2018-04-25,655,D,0,1,VOWX11,"**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 develop and implement a baseline care plan for the care and maintenance of a peripherally inserted central catheter (PICC) for 1 resident (Resident #250) of 1 residents reviewed for PICC lines of 30 residents reviewed. The findings included: Review of the facility policy Baseline Plan of Care, not dated, revealed .development and implementation of the Baseline plan of care will start at admission and within the first 48 hours .include the minimum healthcare information necessary to properly care for a resident including, but not limited to .goals based on admission orders [REDACTED]. Medical record review revealed Resident #250 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Nursing Admission assessment dated [DATE] revealed Resident #250 was admitted to the facility with a PICC line in the right upper extremity. Medical record review of the Baseline Admission Care Plan dated 4/18/18 revealed no care plan for care and maintenance of the PICC line. Observation of Resident #250 on 04/23/18 at 2:43 PM, in the resident's room, revealed a PICC line in the resident's right upper arm. Interview with the Director of Nursing on 4/24/18 at 5:09 PM, in the conference room, confirmed the facility failed to develop a baseline care plan to address the care and maintenance for Resident #250's PICC line.",2020-09-01
413,SIGNATURE HEALTHCARE OF PUTNAM COUNTY,445136,278 DRY VALLEY RD,COOKEVILLE,TN,38506,2018-08-22,761,D,1,0,JFHZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, observations, and interviews, the facility failed to ensure narcotics were stored under lock and key for one resident (#8) of 8 residents reviewed for medication storage and failed to follow procedures during narcotic reconciliation on 1 of 5 medication carts on 1 of 5 wings of the facility observed for narcotic reconciliation. The findings included: Review of facility policy Controlled Medication and Drug Diversion, last revised 7/24/18, revealed .2. At each shift change or when keys are rendered a physical inventory of all controlled medication is conducted by two staff .this is completed as follows .a. the nurse .surrendering the keys will read from the controlled substance accountability book the name of the resident and the medications to be accounted .oncoming nurse .will locate the medication .count the remaining medication and report .the amount of medication remaining .6. Controlled medications remaining in the facility after the order has been discontinued are retained in the facility in a securely locked area with restricted access until .destroyed by the facility's director of nursing, administrator, and consultant pharmacist . Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident was discharged home 8/1/18. Medical record review of a physician's orders [REDACTED].[MEDICATION NAME] (narcotic) .10 (milligrams) .give one tablet by mouth four times a day as needed .pain . Interview with the Assistant Director of Nursing (ADON) on 8/20/18 at 2:30 PM, in the chapel, revealed on the evening of 8/1/18 she was given Resident #8's [MEDICATION NAME] for destruction by Licensed Practical Nurse (LPN #3), who had removed them from the medication cart after Resident #8 was discharged . Continued interview revealed the ADON did not immediately secure the narcotics in the secure medication storage lock box, but instead placed them in an unlocked desk drawer in her unlocked office and on 8/3/18 when the ADON attempted to retrieve the [MEDICATION NAME], the narcotics were missing from the desk drawer. Interview with the DON on 8/20/18 at 6:00 PM, in the chapel, confirmed the facility failed to secure Resident #8's discontinued narcotics under lock and key in a secure area and failed to follow facility policy. Observation of a narcotic drug reconciliation (narcotic count) with LPN #8 and LPN #9 on 8/21/18 at 12:03 AM, of the D wing medication cart, revealed LPN #8 and LPN #9 completed the narcotic count without naming the resident or the name of each narcotic and did not simultaneously verify the remaining quantity of each narcotic medication compared to the narcotic inventory control card. Interview with the DON on 8/20/18 at 6:00 PM, in the chapel, confirmed the facility failed to ensure narcotics were verified and reconciled during a narcotic count and the facility failed to follow facility policy.",2020-09-01
414,SIGNATURE HEALTHCARE OF PUTNAM COUNTY,445136,278 DRY VALLEY RD,COOKEVILLE,TN,38506,2017-09-27,241,D,1,0,QHMM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, observation, and staff interview, the facility failed to provide dignity covers for catheter bags for 2 (Resident #3 and Resident #10) of 3 sampled residents. This had the potential to affect all 15 residents who had catheters. Failure to provide dignity covers for catheter drainage bags had the potential to demean patients. The findings included: Review of the facility's policy titled, Catherization Care, revised of 9/7/17, indicated, .13. Routinely check to ensure .Drainage bag is covered with a privacy cover unless resident requests otherwise. 1. Resident #3 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/25/17 at 12:00 PM, Resident #3 was observed eating lunch in room [ROOM NUMBER]. The drainage bag for the catheter was attached to the bed. The catheter drainage bag which had approximately 300 cubic centimeters (cc) of urine was visible and did not have a dignity cover on it. 2. On 9/25/17 at 1:30 PM, Resident #10 was observed lying in his bed in room [ROOM NUMBER]. The drainage bag for the catheter which was observed hanging on the bed with approximately 200 cc's of urine was visible without a dignity cover. During an interview on 9/25/17 at 12:30 PM, on the 200 Hallway, Certified Nursing Assistant #1 confirmed the drainage bag for the catheter should have a cover over it. During an interview on 9/25/17 at 2:40 PM, in the conference room, the Director of Nursing (DON) stated all catheter drainage bags should have a dignity cover on them. The DON further stated the facility has ordered new dignity bags for the catheter drainage bags and the facility is currently using pillowcases to cover the catheter drainage bags until the new dignity bags arrive.",2020-09-01
415,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2019-03-26,580,K,0,1,2LOM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on The National Pressure Ulcer Advisory Panel (NPUAP) Prevention and treatment of [REDACTED].#15, #22, and #35) sampled residents with pressure ulcers, failed to notify the physician for moisture related skin breakdown for 1 of 1 (Resident #23) sampled residents, and failed to notify the physician Intravenous (IV) antibiotics had not been administered as ordered for 1 of 1(Resident #41) sampled residents with IV medications. The failure of the facility to notify the physician resulted in Harm to Resident #15 who developed an unstageable pressure ulcer that was assessed as a Stage 3 after debridement, Resident #22 who developed a Stage 2 pressure ulcer, and Resident #35 whose Stage 4 pressure ulcer deteriorated. The failure of the facility to notify the physician regarding wound concerns resulted in Harm to Resident #23 who had Moisture Associated Skin Damage (MASD) that deteriorated to a skin erosion. The facilty's failure to notify the physician about newly identified pressure ulcers and changes in pressure ulcers placed Resident #15, #22, #23 and #35 in Immediate Jeopardy. Immediate Jeopardy (IJ) is 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 Regional Director of Operations, Regional Nurse Consultant, Interim Administrator, Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Business Office Manager, and the Admissions Director were notified of the Immediate Jeopardy on 3/23/19 at 9:00 PM in the Conference Room. The facility was cited at a scope and severity of Immediate Jeopardy for F 580-K. An extended survey was conducted on 3/24/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the jeopardy, was received on 3/25/19 at approximately 5:00 PM. The corrective actions were validated onsite by the surveyors on 3/25/19 and 3/26/19 through review of assessments, auditing tools, in-service training records, policies, Quality Assurance Performance Improvement (QAPI) meeting minutes, observations, and staff interviews. The Immediate Jeopardy was effective 8/11/18 through 3/26/19. The noncompliance continues at F580-E for monitoring of effectiveness of the corrective actions. The findings include: 1. The NPUAP Prevention and treatment of [REDACTED].Comprehensive assessment of the individual and his or her pressure ulcer informs development of the most appropriate management plan and ongoing monitoring of wound healing. Effective assessment and monitoring of wound healing is based on scientific principles, as described in this section of the guideline .1. Complete a comprehensive initial assessment of the individual with a pressure ulcer .Reassess the individual, the pressure ulcer and the plan of care if the ulcer does not show signs of healing .Assess the pressure ulcer initially and re-assess it at least weekly .Document the results of all wound assessments .weekly assessments provide an opportunity for the health professional to assess the ulcer more regularly, detect complications as early as possible, and adjust the treatment plan accordingly .Address signs of deterioration immediately .Assess and document physical characteristics including: location .Stage .size .tissue type .color .periwound condition .wound edges .sinus tracts .undermining .tunneling .exudate .odor .Select a uniform, consistent method for measuring wound length and width or wound area to facilitate meaningful comparisons of wound measurements across time .Select a consistent, uniform method for measuring depth .Stage I: Non blanchable (skin does not lose redness when pressure applied) [DIAGNOSES REDACTED] (redness of skin). Intact skin with non-blanchable redness of a localized area usually over a bony prominence .Stage II: Partial Thickness Skin Loss .presenting as a shallow open ulcer with a red pink wound bed .May also present as an intact or open/ruptured serum-filled blister .Stage III: Full Thickness Skin Loss .subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough (dead tissue) may be present .May include undermining and tunneling .Stage IV: Full Thickness Tissue Loss .with exposed bone, tendon, or muscle. Slough (mass of dead tissue) or eschar (a thick crust) may be present .Unstageable: Depth unknown, Full thickness tissue loss in which the base of the ulcer is covered by a slough (yellow, tan, gray, green, or brown) and or eschar (tan, brown, or black) in the wound bed .Suspected Deep Tissue Injury: Depth unknown. Purple maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure . 2. The facility's PREVENTION AND MANAGEMENT OF WOUNDS policy dated 7/1/13 documented, .Ensure that all nurses are educated on use of the wound care management protocol information sheets .(See attached Treatment Guidelines) .Use the treatment guideline skin/wound management to discuss wound care treatment needs with Physician when obtaining orders for care .Document on the physician order [REDACTED].Submit Treatment Guideline orders to the Wound Care Coordinator or Director of Nursing with the 24 hour report. The Wound Care Coordinator or Director of Nursing will review the treatment guideline for each resident/wound site for appropriateness of care . There were no Treatment Guidelines attached to the facility policy. The facility's undated S.W.[NAME]T. PROGRAM (SKIN AND WEIGHT ASSESSMENT TEAM) policy documented, .Review Date: Date of SWAT meeting .Onset Date: Date of which the open area appeared .Current Size: The measurement of the open area most recently recorded by nursing .Current Stage: The most recent stage determined by nursing or the physician .Odor Present: Putrid smell of the open area on the skin .Drainage Present: Presence of drainage of the open area on the skin .Record on tx (Treatment) sheet: Open area treatments need to be recorded on treatment sheet .Notifications: MD (Medical Doctor), RD (Registered Dietician), MDS (Minimum Data Set Coordinator), Family, Care Plan . The facility's undated Change in Resident's Condition or Status policy documented, .It is the policy of the facility to ensure that the resident's attending physician and Representative are notified of changes in the resident's condition or status .The nurse will notify the resident's attending physician when .There is a significant change in the resident's physical, mental, or psychological status .There is a need to alter the resident's treatment plan . 3. Medical record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 3/8/19 documented, .MD will be called PRN (as necessary) . The nurse's progress notes dated 2/21/19 documented, .Resident found to have open wound/deep tissue injuries noted to buttocks . There was no documentation that a physician was notified about the newly identified wound. The weekly skin review for Resident #15 dated 2/21/19 documented, .Top of right buttock .noted to have black area .that appears to be a deep tissue injury .lower part of buttock has open area noted, purple/black deep tissue injury noted . There was no documentation a physician was notified of the newly identified wound. The General Progress Note for Resident #15 dated 2/28/19 documented, .Skin assessment completed to evaluate wounds on coccyx .coccyx is red throughout and slow to blanch .deep tissue injuries .as well as open areas on his coccyx . There was no documentation that the resident's physician was notified of the wound. The Contract Wound Physician's WOUND EVALUATION & (and) MANAGEMENT SUMMARY dated 3/2/18 documented, (Resident #15) .presents with a wound on their left ischium .stage 3 .wound size (L (length) x (by) W (width) x D (depth)) .3.5 x 4.2 x 0.4 cm (centimeters) .DRESSING TREATMENT PLAN .Santyl apply once daily for 30 days .thick adherent devitalized necrotic tissue .40% (percent) .SURGICAL EXCISIONAL DEBRIDEMENT (removal of dead, damaged, or infected tissue) PR[NAME]EDURE .[MEDICATION NAME] RECOMMENDED ON 3/2/2019 . The wound was staged by the Contract Wound Physician after he debrided the wound. Interview with the ADON on 3/13/19 at 9:57 AM, in the Conference Room, the ADON was asked when the pressure ulcer was identified. The ADON stated, The nurse said there was a wound and I told her (named Consultant Wound Physician) would be here the next day (2/22/19) .(named Consult Wound Physician) and I went (2/22/19) and looked at it (the wound) and we did not see it (the wound) . The ADON was asked if it was over a week after it was identified. The ADON stated, It was. The ADON was asked what stage it was when it was found. The ADON stated, .it was unable to be determined, because it had eschar . The facility did not notify Resident #15's primary physician of the new pressure ulcer or obtain orders for the Contract Wound Physician's recommendation for pressure ulcer treatment. No treatments were ordered for this pressure ulcer. The facility did not obtain an order for [REDACTED]. Interview with the DON on 3/13/19 at 12:36 PM in the Conference Room, the DON was asked if staff should have obtained an order to obtain the [MEDICATION NAME] lab test as recommended by the Contract Wound Physician. The DON stated, Yes. Telephone interview with Registered Nurse (RN) #3 on 3/20/19 at 10:49 AM, RN #3 was asked if she notified the resident's physician of the newly identified pressure ulcer identified on 2/21/19. RN #3 stated, I did not. RN #3 was asked if she thought the pressure ulcer deterioration could have been prevented if Resident #15 had received treatment. RN #3 stated, Yes, absolutely. Interview with Licensed Practical Nurse (LPN) #1 on 3/20/19 at 6:05 PM in the Conference Room, LPN #1 was asked if she knew why the order for the Santyl was not written. LPN #1 stated, I guess the nurse forgot to write the order . LPN #1 was asked who forgot to write the order. LPN #1 stated, Me. The facility's failure to notify Resident #15's physician of the open pressure ulcer, Deep Tissue Injury, unstageable pressure ulcer with eschar that deteriorated to a Stage 3 wound after debridement, and provide timely treatments to the wound resulted in Immediate Jeopardy to Resident #15. 4. Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. The care plan revised on dated 12/19/17 and revised 9/17/18 documented, .MD will be called PRN . A General Nursing Progress note for Resident #22 dated 2/8/19 documented, .she has 2 open wounds on her sacrum/coccyx .One is located in the center at the top of her sacrum and other is on her right buttock . There was no documentation that a physician or nurse practitioner was notified of the 2 new pressure ulcers. A Weekly Skin Review dated 2/12/19 documented, .Area of redness and excoriation to buttocks noted and still under previous treatment of [REDACTED]. Observation in Resident #22's room on 3/20/19 at 9:00 AM, with LPN #1 revealed an unidentified small shallow open crater in the mid-coccyx region with a bright red wound bed and no slough. There was no dressing on the pressure ulcer. Observation and interview with the Contract Wound Nurse Practitioner on 3/21/19 at 10:30 AM, in Resident #22's room revealed Resident #22 had a dressing over the pressure ulcer but the dressing was not intact. The Contract Wound Nurse Practitioner examined the dressing on the coccyx and stated, This is a problem .not adhered (to the skin) . and confirmed the wound should be covered. The Contract Wound Nurse Practitioner assessed the pressure ulcer and stated .Stage 2 .3 by .3 by .1 (.3 (centimeters (cm)) by 0.3 (cm) by 0.1 (cm) . These were the first measurements obtained for this pressure ulcer. A Contract Wound Nurse Practitioner's Consult note dated 3/21/19 documented, .Stage 2 pressure injury to coccyx .use Venelex ointment .Cover with absorbent foam dressing .Cleanse with NS (normal saline) at each dressing change and change daily . The recommendation was ordered on [DATE] by the resident's physician. Interview with the ADON on 3/22/19 at 3:55 PM, in the Conference Room, the ADON was asked if a physician or nurse practitioner had been notified about the new wounds identified on Resident #22 on 2/8/19. The ADON stated, I do not see documentation there. The ADON was asked about Resident #22's Stage 2 sacral wound. The ADON stated, That's new. The facility's failure to assess Resident #22's skin, identify a pressure ulcer and notify the resident's physician of the deterioration of the skin resulted in IJ to Resident #22. 5. Medical record review revealed Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Resident #23's Daily Skilled Nursing Note for Resident #23 dated 2/18/19 documented, .Decubitus Wound . was marked. There was no documentation that the resident's physician or nurse practitioner had been notified of the skin erosion. Review of a nursing wound note dated 2/13/19 revealed a new open area to the buttocks with treatment in place. There was no description of the wound with measurements or documentation the physician was notified. Review of a Daily Skilled Nursing Note dated 2/27/19 revealed moisture related breakdown to buttocks. There was no documentation that a physician or nurse practitioner was notified about the moisture related breakdown to the buttocks. Review of Daily Skilled Nursing Notes, Weekly Skin Review and Skin Assessments between 2/1/19 and 3/20/19 revealed there were no other assessments with measurements for this wound. There was no documentation that a physician or nurse practitioner had been notified about the MASD. Observation in Resident #23's room on 3/20/19 at 8:53 AM, during a surveyor initiated skin sweep, revealed the CNA removed a pink foam dressing from Resident #23's mid buttock area, revealing a shallow open ulcerated area with a red wound bed to the right buttock. Interview with the Contract Wound Nurse Practitioner on 3/22/19 at 11:20 AM, in the Conference Room, the Contract Wound Nurse Practitioner was asked if the facility should have reported the wound to her before the surveyor observed it. The Contract Wound Nurse Practitioner stated, Yes. The Contract Wound Nurse Practitioner confirmed Resident #23 had moisture associated skin damage and stated, .it's an actual wound and it should have wound care .the erosion is a manifestation of a deeper tissue injury .it's (it has) deteriorated . The facility's failure to notify Resident #23's physician that the deteriorating MASD had become worse resulted in IJ to Resident #23 when the MASD deteriorated to an erosion. 6. Medical record review revealed Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed Resident #35 had severely impaired cognition, was dependent on staff for all activities of daily living, was at risk for developing pressure ulcers, and had a Stage 4 pressure ulcer that was not present on admission. The care plan dated 11/14/18 documented, .Any skin integrity issues .the MD will be called PRN . Review of the Wound care Specialist Evaluation dated 6/29/18 revealed Resident #35's sacral pressure ulcer was 1.2 cm long, 0.6 cm wide, and 0.2 cm deep. The Contract Wound Physician recommended Leptospermum honey (honey gathered from the flowers of the manuka bush) be applied once daily. He instructed a nursing staff member of the recommendation, but staff failed to notify the resident's physician about the wound specialist recommendation and an order was not obtained from the resident's physician. Review of the Wound Evaluation and Management Summary revealed a Contract Wound Physician examined Resident #35 on 7/23/18, assessed the wound as 0.2 X 0.2 and recommended Zinc Ointment every shift for the wound treatment, communicated this recommendation to a nursing staff member, but the staff member failed to notify the resident's physician about the recommendations and failed to get an order for [REDACTED].>A Weekly Skin Review dated 7/30/18 documented, .moisture damage to coccyx area .Treatment plan in place . There was no documentation that the moisture damage to the coccyx/sacrum (the area was identified as both by different staff) was reported to a physician or nurse practitioner. The Wound Evaluation and Management Summary dated 8/11/18 documented .0.6 X 0.4 X 0.3 cm .deteriorated . The Contract Wound Physician recommended Leptospermum Honey and Zinc Ointment every shift daily for the wound treatment. This recommendation was communicated to a nursing staff member who failed to notify the resident's physician. There was no order for this recommendation. The facility was unable to provide documentation that any treatments were provided for Resident #35's sacral wound in August. Review of the Weekly Skin Review, Weekly Skin Sheets, and progress notes between 8/11/18 and 9/1/18 revealed no documentation of a description of the wound with measurements by the nursing staff. A weekly Skin Review dated 8/19/18 documented, .Coccyx .Stage III (3) Size of a dime . There was no documentation that the Stage 3 wound was reported to a physician or nurse practitioner. The Wound Evaluation and Management Summary dated 9/1/18 documented .wound sacrum .0.3 X 0.5 X 0.3 (cm) .deteriorated and recommended Leptospermum honey daily and Zinc Ointment around the pressure ulcer every shift. He communicated this change in treatment to a nursing staff member. There was no order for this pressure ulcer treatment recommendation. The Wound Evaluation and Management Summary dated 9/22/18 documented .wound sacrum .2.0 X 1.2 X 0.5 cm .Deteriorated . The Contract Wound Physician recommended Leptospermum honey and Skin Prep around the wound daily for the wound treatment. He communicated this recommendation to a nursing staff member who failed to notify the resident's physician. There was no order for this recommended pressure ulcer treatment. A Contract Wound Nurse Practitioner Wound Consult Note dated 9/28/18 documented, .evaluation of new buttock pressure ulcer .Pt (patient) is known to me from previous treatment few years ago for pressure ulcer in same location .Coccyx area with stage 4 pressure injury .measures 1.3 x 0.4 x 0.3 cm .0.5 (cm) area of fascia (connective tissue) exposed .Moderate serous exudate noted .Use silver alginate cut slim to fit into the wound in 2 layers .Cover with foam dressing .daily .Cleanse with NS (Normal Saline) at each dressing change and use skin protectant wipe on periwound skin prior to applying the foam cover dressing .Selective debridement using a curette necessary to remove biofilm and [MEDICATION NAME] exudate from wound surface . This is the same pressure ulcer that the Contract Wound Physician had been examining. This pressure ulcer deteriorated in size and there was no documentation the primary physician has been notified about the deteriorating pressure ulcer. Observation and interview in Resident #35's room on 3/21/19 at 10:35 AM with the Contract Wound Nurse Practitioner after the Contract Wound Nurse Practitioner removed the foam dressing from the resident's sacrum, the Contract Wound Nurse Practitioner stated, .now it's larger than the last time I saw it . Interview with the Contract Wound Nurse Practitioner on 3/21/19 at 11:01 AM in the Conference Room, the Contract Wound Nurse Practitioner was asked about Resident #35's stage 4 pressure ulcer. The Contract Wound Nurse Practitioner stated, When I saw him on 2/8 (Resident #35's) wound was one oblong wound. It had grown some skin across the middle .converted into small wounds and small always heals faster than large . The Contract Wound Nurse Practitioner was asked if the facility had notified her that the pressure ulcer had gotten worse. The Contract Wound Nurse Practitioner stated, No. The Contract Wound Nurse Practitioner was asked if she wrote treatment orders. The Contract Wound Nurse Practitioner stated, I do not .I tell (named ADON) .they may write them under (named Medical Director) . Review revealed the Contract Wound Nurse Practitioner's treatment recommendations were not consistently communicated to the resident's physician to obtain orders for treatment of [REDACTED]. Interview with the Contract Wound Physician on 3/22/19 at 1:29 PM in the Conference Room, the Contract Wound Physician was asked if the facility had informed him his recommended treatments were not performed between (MONTH) and (MONTH) (YEAR). The Contract Wound Physician stated, Yikes . The Contract Wound Physician confirmed the facility should have assessed the pressure ulcer and notified him of changes. Interview with the DON on 3/22/19 at 5:49 PM in the Conference Room, the DON was asked if the SWAT policy was an effective policy for assessing and treating pressure ulcers. The DON stated, .No Ma'am .it doesn't have parameters as far as staging or changing treatments if they aren't effective . Interview with the DON on 3/22/19 at 5:55 PM in the Conference Room, the DON was asked what wound care issues had been identified since the survey began. The DON stated, .Late skin assessments The DON was asked who was able to access the physician recommendations from the Contract Wound Physician. The DON stated, I looked at it once with guidance .the nurses do not and I do not. I go on through (named ADON's) access . Interview with the DON on 3/22/19 at 7:01 PM in the Conference Room, the DON was asked if nursing staff had documented Resident #35's pressure ulcer description with measurements between 7/1/18-3/11/19. The DON stated, I couldn't find it. The DON was asked if any treatments were administered as recommended and ordered in August. The DON stated, I don't see any. Interview with the Regional Nurse Consultant on 3/23/19 at 12:17 PM in the conference room, the Regional Nurse Consultant was asked if she had identified or addressed any concerns related to pressure ulcers in the facility. The Regional Nurse Consultant stated, In December, I picked up on wound concerns .delays in documentation .lack of documentation . The Regional Nurse Consultant did not notify the resident's physician. The facility's failure to assess Resident #35's skin and identify a declining pressure ulcer, notify the resident's physician of changes in the pressure ulcer, obtain orders for treatment, and transcribe the wound specialist's recommendations placed Resident #35 in Immediate Jeopardy. 7. Medical record review revealed Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Order Summary Report dated 3/1/19 documented, .Meropenem (antibiotic) Solution Reconstituted 500 mg (milligram) Use 500 mg intravenously every 6 hours . Review of the Medication Administration Record [REDACTED]. The Daily Skilled Nursing Note dated 3/11/19 at 2:26 PM, documented, .picc (peripherally inserted central catheter) not working . There was no documentation the physician was notified. Interview with the Family Nurse Practitioner (FNP) on 3/12/19 at 3:10 PM, in the Conference Room, the FNP was asked what she expected the nursing staff to do if a resident didn't received medication as ordered. The FNP stated, . if a resident didn't receive medication, either myself or (Named Physician) to be notified. The FNP was asked if it was acceptable that Resident #41 had missed 6 doses of IV antibiotics. The FNP stated, No it is not. They (staff) should have called us and the notification needs to be documented. Interview with the DON on 3/13/19 at 7:28 AM, in the Conference Room, the DON was asked if it was acceptable for Resident #41 to have missed 6 doses of IV antibiotic. The DON stated, No ma'am. The DON was asked what did she expect her nursing staff to have done. The DON stated, .they should have notified the physician and gotten an order to hold the antibiotic, or send to the ER (emergency room ) to have the PICC line replaced .It's not acceptable at all .it's not my standard .",2020-09-01
416,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2019-03-26,658,K,0,1,2LOM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the The Textbook of Medical-Surgical Nursing, Twelfth Edition, The National Pressure Ulcer Advisory Panel (NPUAP) Prevention and treatment of [REDACTED].#15, #22, #23, #33, #35, and #344) sampled residents reviewed who had wounds. The facility's failure to implement professional standards of practice by not identifying, assessing, reporting, and treating wounds as ordered resulted in an Immediate Jeopardy when Resident #15 developed an unstageable pressure wound that evolved to Stage 3 pressure ulcer, Resident #22 developed a Stage 2 wound, Resident #23 developed a skin erosion after Moisture Associated Skin Damage (MASD), Resident #33's Stage 4 pressure ulcer evolved to a Stage 4 pressure ulcer, Resident #35's Stage 4 pressure wounds deteriorated, and Resident #344 developed 3 Deep Tissue Injuries (DTI). Immediate Jeopardy (IJ) is 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 Regional Director of Operations, Regional Nurse Consultant, Interim Administrator, Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON), Business Office Manager, and the Admissions Director were notified of the Immediate Jeopardy on 3/23/19 at 9:00 PM, in the Conference Room. An extended survey was conducted on 3/24/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the IJ, was received on 3/25/19 at approximately 5:00 PM, and the corrective actions were validated onsite by the surveyors on 3/25/19 and 3/26/19 through review of assessments, auditing tools, in-service training records, policies, Quality Assurance Performance Improvement (QAPI) meeting minutes, observations, and staff interviews. The Immediate Jeopardy was effective 8/11/18 through 3/26/19. The noncompliance continues at F658-E for monitoring of effectiveness of the corrective actions. The findings include: 1. The Textbook of Medical-Surgical Nursing, Twelfth Edition with a Copyright of 2010 documented, .potential problems or complications that are medical in origin .require collaborative interventions with the physician and other members of the health care team .Nurses manage collaborative problems using physician-prescribed and nurse-prescribed interventions to minimize complications .When treating collaborative problems, a primary nursing focus is monitoring patients for the onset of complications or changes in the status of existing complications .The nurse recommends nursing interventions that are appropriate for managing the complications and implements the treatments prescribed by the physician .Ongoing assessment of the surgical site involves inspection for approximation of wound edges .redness, discoloration, warmth, swelling, unusual tenderness, or drainage .the nurse assesses the patient for postoperative complications by assessment of the surgical incision . The NPUAP Prevention and treatment of [REDACTED].Effective assessment and monitoring of wound healing is based on scientific principles, as described in this section of the guideline .1. Complete a comprehensive initial assessment of the individual with a pressure ulcer .Reassess the individual, the pressure ulcer and the plan of care if the ulcer does not show signs of healing .Assess the pressure ulcer initially and re-assess it at least weekly .Document the results of all wound assessments .weekly assessments provide an opportunity for the health professional to assess the ulcer more regularly, detect complications as early as possible, and adjust the treatment plan accordingly .Address signs of deterioration immediately .Assess and document physical characteristics including: location .Stage .size .tissue type .color .periwound condition .wound edges .sinus tracts .undermining .tunneling .exudate .odor .Select a uniform, consistent method for measuring wound length and width or wound area to facilitate meaningful comparisons of wound measurements across time .Select a consistent, uniform method for measuring depth . 2. The facility's PREVENTION AND MANAGEMENT OF WOUNDS policy dated 7/1/13 documented, .Use the treatment guideline skin/wound management to discuss wound care treatment needs with Physician when obtaining orders for care .Document on the physician order [REDACTED].Submit Treatment Guideline orders to the Wound Care Coordinator or Director of Nursing with the 24 hour report. The Wound Care Coordinator or Director of Nursing will review the treatment guideline for each resident/wound site for appropriateness of care . There were no Treatment Guidelines attached to the facility policy. The facility's undated S.W.[NAME]T. PROGRAM (SKIN AND WEIGHT ASSESSMENT TEAM) policy documented, .Current Size: The measurement of the open area most recently recorded by nursing .Current Stage: The most recent stage determined by nursing or the physician .Open area treatments need to be recorded on treatment sheet .Notifications: MD (Medical Doctor), RD (Registered Dietician), MDS (Minimum Data Set Coordinator), Family, .(and) Care Plan . The facility's undated Change in Resident's Condition or Status policy documented, .The nurse will notify the resident's attending physician when .There is a significant change in the resident's physical, mental or psychological status .There is a need to alter the resident's Treatment plan significantly .The nurse will record in the resident's medical record any changes in the resident's medical condition or status . 3. Medical record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review Resident #15's care plan dated 3/8/19 revealed a problem of .increased risk for alteration in skin integrity related to .2-28-19 Unstageable pressure ulcer to buttock .3-8-19 .a Stage 3 .Any skin integrity issues/concerns will be conveyed to the Charge Nurse for further evaluation and/or Treatment changes/new interventions and the MD (Medical Doctor) will be called PRN (as needed) .Monitor Labs and report abnormalities .Administer Wound Care (Treatments) per MD orders . The weekly skin review for Resident #15 dated 2/21/19 documented, .Top of right buttock as noted to have black area noted that appears to be a deep tissue injury .lower part of buttock has open area noted, purple/black deep tissue injury noted . Review of the nursing wound documentation between 2/21/19 and 3/12/19 revealed there were no assessments with measurements in the nursing wound documentation. There was no documentation the resident's primary physician was notified of the newly identified pressure ulcer. The Contract Wound Physician's WOUND EVALUATION & (and) MANAGEMENT SUMMARY dated 3/2/19 documented, .(Resident #15) .presents with a wound on their left ischium .stage 3 .DRESSING TREATMENT PLAN .Santyl apply once daily for 30 days .thick adherent devitalized necrotic tissue .40% (percent) .[MEDICATION NAME] RECOMMENDED ON 3/2/2019 . The facility was unable to provide nursing documentation that a [MEDICATION NAME] level (blood test used to monitor the nutritional status) lab was obtained as recommended by the Contract Wound Physician on 3/2/18 for Resident #15. The nursing staff failed to obtain orders for the Contract Wound Physician's wound treatment recommendations and treatments were not performed until 3/9/19. The recommended order for Santyl was obtained on 3/8/19, and the treatments were started on 3/9/19 for Resident #15's pressure ulcer. Interview with the ADON on 3/13/19 at 9:57 AM, in the Conference Room, the ADON was asked when the pressure ulcer was identified. The ADON stated, .The 21st (2/21/19) The ADON was asked when the first measurements were obtained. The ADON stated, .3/2 .I was waiting on the doctor. We let him do the measurements . Interview with the DON on 3/13/19 at 10:53 AM, at the West Nurses' Station, the DON was asked when she would expect staff to get measurements after discovering a pressure ulcer. The DON stated, Within a few minutes after they identified it. Interview with the DON on 3/13/19 at 12:36 PM, in the Conference Room, the DON was asked if there was an order written [REDACTED]. The DON confirmed the [MEDICATION NAME] level had not been ordered. The DON was asked if the [MEDICATION NAME] level should have been transcribed and performed as ordered. The DON stated, Yes. Telephone interview with Registered Nurse (RN) #3 on 3/20/19 at 10:49 AM, RN #3 was asked what should be done if a newly identified pressure ulcer was found. RN #3 stated, I believe you document what you find, and you treat with something, and notify someone above you to make sure treatments are put into place. RN #3 was asked if she thought the pressure ulcer deterioration could have been prevented if he had gotten treatment. RN #3 stated, Yes, absolutely. Telephone interview with the Contract Wound Physician on 3/20/19 at 1:02 PM, the Contract Wound Physician was asked if the nurses should do a head to toe assessment. The Contract Wound Physician stated, I believe that is their protocol. The Contract Wound Physician was asked if anything was said about Resident #15's deep tissue injury or purple skin. The Contract Wound Physician stated, No, but I don't remember that terminology . The Contract Wound Physician was asked if an order for [REDACTED]. The Contract Wound Physician was asked if he was informed that there was no treatment given until 3/9/19. The Contract Wound Physician stated, I am not aware of any of these things. Interview with Licensed Practical Nurse (LPN) #1 on 3/20/19 at 6:05 PM, in the Conference Room, LPN #1 was asked when she first observed the pressure ulcer on Resident #15. LPN #1 stated, On the 22nd or the 21st (February 21 or 22, 2019) it was like a bruised area . LPN #1 was asked if she failed to look at the pressure ulcer from 2/22/19 to 3/20/19. LPN #1 stated, Yes. The facility failed to ensure the implementation of professional standards of practice for the care of Resident #15's deteriorating pressure ulcer when staff did not complete skin assessments, and nursing staff identified a pressure ulcer on 2/21/19, did not complete wound assessments with measurements, did not report changes in Resident #15's skin condition to a physician or nurse practitioner, did not obtain Physician orders [REDACTED]. The facility's failure to ensure the implementation of professional standards of practice resulted in IJ to Resident #15 when he developed a Stage 3 pressure ulcer. 4. Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The care plan for Resident #22 dated 12/19/17 and revised on 9/17/18 documented, .at increased risk for alteration in skin integrity .Interventions .Any skin integrity issues/concerns will be conveyed to the Charge Nurse for further evaluation and/or Treatment changes/new interventions and the MD will be called PRN .CNA shower/skin observations to be reported to the nurse for any unusual findings/changes in the residents skin integrity . Review of the facility's Skin Monitoring .Comprehensive CNA Shower Review (shower sheets/body audits) between 2/1/19 and 3/15/19 revealed Resident #22 received 2 body audits during the 43 days. There was no documentation that nursing staff were reviewing the shower sheets for new or changing skin problems. A General Progress Note dated 2/8/19 documented, .she has 2 open wounds on her sacrum/coccyx .One is located in the center at the top of her sacrum and other is on her right buttock .[MEDICATION NAME] applied to wounds .placed on left side with (a) pillow behind back . Medical record review revealed no documentation of a description of the pressure ulcer with measurements or that the resident's primary physician or the nurse practitioner was notified about the 2 new areas. A Weekly Skin Review dated 2/12/19 documented, .Area of redness and excoriation to buttocks noted and still under previous treatment of [REDACTED]. Observations in Resident #22's room on 3/20/19 beginning at 9:00 AM, during a surveyor initiated skin sweep, revealed LPN #1 assisted Resident #22 to turn on her side, exposing her sacrum and coccyx area. There was a small shallow open crater in the mid-coccyx region with a bright red wound bed and no slough. There was no dressing on this pressure ulcer. This facility acquired pressure ulcer had not yet been identified by the facility. Observation and interview with the Contract Wound Nurse Practitioner, in Resident #22's room on 3/21/19 at 10:30 AM, revealed Resident #22 was assisted to turn on her side, revealing her sacrum and coccyx area, with a partially adherent dressing over the wound. The Contract Wound Nurse Practitioner examined the dressing on the coccyx and stated, This is a problem .not adhered (to the skin) . The Contract Wound Nurse Practitioner assessed the wound as a Stage 2 .3 by .3 by .1 (0.3 (cm) by 0.3 (cm) by 0.1 (cm) . The Contract Wound Nurse Practitioner was informed this wound was identified on 3/20/19 by the surveyor during the skin sweep and was asked if the wound should have had a dressing on it on 3/20/19. The Contract Wound Nurse Practitioner confirmed the wound should be covered. Interview with the ADON/Treatment Nurse on 3/22/19 at 3:55 PM, in the Conference Room, the ADON was asked if the General Progress Note dated 2/8/19 was an accurate, and complete wound assessment. The ADON stated, No. The ADON was asked if a physician or nurse practitioner had been notified about the new wounds. The ADON stated, I do not see documentation there. The ADON was asked about Resident #22's Stage 2 sacral wound. The ADON stated, That's new. The ADON was asked how she would know when the wound developed. The ADON stated, It's not clear in the documentation. The facility failed to ensure the implementation of professional standards of practice for the care of Resident #22's deteriorating wound when staff did not complete skin assessments, did not identify new wounds, and did not report changes in Resident #22's skin condition to a physician or nurse practitioner. The failure of the facility to ensure the implementation of professional standards of practice resulted in IJ to Resident #22 when she developed a Stage 2 pressure ulcer. 5. Medical record review revealed Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan for Resident #23 dated 5/9/16 and revised 7/7/18 documented, .Focus .Potential risk for Skin breakdown .Moisture associated skin breakdown .Interventions .5/9/16 Conduct weekly skin inspection . Review of Resident #23's Daily Skilled Nursing Notes dated 2/7/19, 2/11/19, and 2/14/19 revealed moisture related breakdown was noted with a treatment in place. There were no completed wound assessments. Review of a Weekly Skin Review dated 2/13/19 revealed a new open area to buttocks with treatment in place. There was no description of the wound with measurements. Review of Resident #23's Daily Skilled Nursing Note dated 2/18/19 documented, .Decubitus Wound . was marked. There was no description of the open area with measurements. Review of a Daily Skilled Nursing Note dated 2/27/19 for Resident #23 revealed moisture related breakdown to buttocks and documented, .Decubitus Wound .buttocks .Resident's pressure ulcer is managed by staff . There was no description of the wound with measurements. There was no documentation that the resident's physician or nurse practitioner was notified of the open area to the buttocks. Review of Resident #23's Daily Skilled Nursing Notes, Weekly Skin Review and Skin Assessments between 2/1/19 and 3/20/19 revealed there were no other assessments with measurements for this wound. There was no documentation that a physician or nurse practitioner had been notified about the worsening MASD. Review of Resident #23's physician's orders [REDACTED]. A Contract Wound Nurse Practitioner Wound Consult Note for Resident #23 dated 3/20/19 at 1:07 PM, documented, .Asked to evaluate patient with buttock wound .Bilateral buttock skin with large area of chronic hyperpigmentation related to moisture. Scattered healed moisture associated skin damage noted on left buttock and the superior sacral area . Interview with the ADON on 3/20/19 at 1:57 PM, in the Conference Room, the ADON was asked if Resident #23's wound had been assessed and measured and if weekly skin assessments were being completed. The ADON stated, No. Apparently not .I'm the one that owned it all .trying to keep our heads above water .it's hard to find good people to come in and want to work . Observation and interview with the Contract Wound Nurse Practitioner on 3/21/19 at 10:55 AM, in Resident #23's room revealed there was no dressing on Resident #23's right buttock wound. The Contract Wound Nurse Practitioner was asked if there should be a dressing over the wound. The Contract Wound Nurse Practitioner stated, I ordered (recommended) for it to be covered and she stated, .This is moisture associated skin damage .this is skin erosion . Interview with the Contract Wound Nurse Practitioner on 3/22/19 at 11:20 AM, in the Conference Room, the Contract Wound Nurse Practitioner was asked if the facility should have reported the wound to her before 3/20/19. The Contract Wound Nurse Practitioner stated, Yes. The facility failed to ensure the implementation of professional standards of practice for the care of Resident #23's deteriorating MASD when staff did not complete skin assessments, did not identify new wounds, and did not report deteriorating changes in Resident #23's MASD to a physician or nurse practitioner. The facility's failure to ensure the implementation of professional standards for care resulted in IJ to Resident #23 when the MASD deteriorated to a skin erosion. 6. Medical record review revealed Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan for Resident #33 dated 2/24/19 documented, .unstageable to left buttock at sacrum and Stage 2 to left buttock distal to sacral ulcer .Weekly measurements and documentation .Administer Wound Care (Treatments) per MD orders . The Admission/Readmission Screener note for Resident #33 dated 2/6/19 documented, .Decubitus on Both Buttocks (unstageable to left buttock at sacrum and Stage 2 to left buttock distal to sacral ulcer) . There was not a complete wound assessment documented for the pressure ulcer. The facility was unable to provide nursing wound assessments with complete wound description and measurements between 2/8/19 and 3/15/19 for Resident #33. The physician's orders [REDACTED].Santyl Ointment 250 UNIT/GM (gram) .Apply to sacrum .every day shift . Review of Resident #33's (MONTH) TAR revealed there was no Santyl Ointment documented as administered for 2/9/19 and 2/26/19 and the Venolex ointment was not applied on 2/26/19. Review of the (MONTH) TAR revealed there was no Santyl documented as administered for 3/7/19, 3/9/19, 3/12/19, 3/13/19, 3/15/19, 3/16/19, 3/18/19, and 3/19/19 and the Venolex ointment was not applied on 3/7/19, 3/9/19, 3/12/19, 3/16/19, and 3/18/19. Interview with Licensed Practical Nurse (LPN) #3 on 3/21/19 at 1:26 PM, in the Conference Room, LPN #3 was asked about Resident #33's pressure ulcer assessments. LPN #3 stated, .Since I've gone to day shift, I've been so busy, I can't remember the last time I did a skin assessment. It's not that I don't do the assessments, I don't fill out the paperwork and the next shift picks it up. Ultimately, I'm still responsible . Interview with the ADON/Treatment Nurse on 3/22/19 at 12:53 PM, in the Conference Room, the ADON confirmed the Santyl treatments were not administered as ordered in (MONTH) and (MONTH) for Resident #33. The ADON was asked if there were any other wound notes. The ADON stated, The only notes in there are from the Nurse Practitioner or (Named Contract Wound Physician) . Interview with the DON on 3/23/19 at 6:20 PM, in the Conference Room, the DON was asked if the care plan interventions should have been implemented. The DON stated, Yes. The DON was asked if weekly wound assessments was on the care plan because this would be considered standard of care. The DON stated, I would say it is a standard of care and I would like to see it done. The facility failed to ensure the implementation of professional standards of practice for the care of Resident #33's pressure ulcer when staff did not complete skin assessments, did not complete wound assessments with measurements, and did not provide wound treatments as ordered. The facility's failure to ensure the implementation of professional standards of practice for care resulted in IJ to Resident #33 when the unstageable pressure ulcer evolved to a Stage 4 pressure ulcer. 7. Medical record review revealed Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan for Resident #35 dated 1/5/17 and revised 11/14/18 documented, .resident is at increased risk for alteration in skin integrity .Any skin integrity issues/concerns will be conveyed to the Charge Nurse for further evaluation and/or treatment changes/new interventions and the MD will be called PRN .Weekly measurements and documentation .Initiate upon .onset of wound all facility wound care protocol .Administer Wound Care (Treatments) per MD orders . A physician's orders [REDACTED].Coccyx .clean with saline, apply Venelex, cover with a foam dsg (dressing) q (every) day shift every 3 day (s) . Review of the (MONTH) (YEAR) TAR revealed this treatment was not provided on 9 of 10 treatment days in July. Medical record review of Resident 35's WOUND CARE SPECIALIST EVALUATION revealed on 6/29/18 the Contract Wound Physician recommended Leptospermum honey to be applied once daily, and he relayed this recommendation to a nursing staff member. Review of the (MONTH) and (MONTH) physician orders [REDACTED]. Review of the (MONTH) (YEAR) TAR revealed Resident #35 received a treatment of [REDACTED]. Medical record review of Resident #35's SPECIALTY PHYSICIAN WOUND EVALUATION MANAGEMENT SUMMARY revealed on 7/23/18 the Contract Wound Physician recommended Zinc Ointment every shift for the wound treatment. Review of the physician orders [REDACTED].#35 revealed there was not an order obtained for treatment from the physician as recommended by the Contract Wound Physician. A Weekly Skin Review for Resident #35 dated 7/30/18 documented, .moisture damage to coccyx area .Treatment plan in place . There was no documentation that the moisture damage was reported to a physician or nurse practitioner. Further review of Nursing Notes, Weekly Skin Reviews and Skin Assessments between 7/28/18 and 8/5/18 revealed no documentation of wound assessments of the sacral/coccyx wound. Medical record review of Resident #35's SPECIALTY PHYSICIAN WOUND EVALUATION MANAGEMENT SUMMARY revealed the Contract Wound Physician examined Resident #35 on 8/11/18 and sacral pressure ulcer was described as enlarging and as deteriorated. The Contract Wound Physician recommended Leptospermum Honey and Zinc Ointment every shift daily for the wound treatment. The facility was unable to provide documentation that the recommended order had been obtained from the physician. Review of Resident #35's Nursing Notes, Weekly Skin Reviews and Skin Assessments between 8/11/18 and 9/1/18 revealed no sacral pressure ulcer assessment. A Weekly Skin Review dated 8/19/18 documented, Coccyx .Stage III (3) .Size of a dime. On 8/29/18 a nurse documented, .tx (treatment) in place .wound doctor visits weekly . Medical record review of Resident #35's SPECIALTY PHYSICIAN WOUND EVALUATION MANAGEMENT SUMMARY revealed on 9/1/18 the Contract Wound Physician recommended Leptospermum honey daily and Zinc Ointment around the pressure ulcer every shift for the wound treatment. There was not an order obtained as recommended by the Contract Wound Physician and Resident #35 did not receive the recommended treatments in September. The physician's orders [REDACTED].Sacrum .clean with saline .apply antimicrobial silver dsg (dressing) .cover with foam dsg qod (every other day) . This order was transcribed on the TAR on 9/19/18. This treatment was provided every day between 9/19/18 and 9/25/18 instead of every other day as ordered. This treatment was not provided on 9/27/18. Review of Nursing Notes, Weekly Skin Reviews and Skin Assessments between 9/1/18 and 9/28/18 revealed no complete wound assessment of Resident #35's sacral/coccyx pressure ulcer by nursing staff. Medical record review revealed on 9/22/18 the Contract Wound Physician recommended Leptospermum honey and Skin Prep around the pressure ulcer daily for the pressure ulcer treatment. Medical record review revealed no order was obtained and Resident #35 did not receive these recommended wound treatments in September. A Contract Wound Nurse Practitioner Wound Consult Note dated 9/28/18 documented, .new buttock pressure ulcer .Coccyx area with stage 4 pressure injury . This was the same pressure ulcer that the Contract Wound Physician had been examining. This pressure ulcer deteriorated in size. Review of Nursing Notes, Weekly Skin Reviews and Skin Assessments between 9/28/18 and 10/12/19 revealed there were no wound assessments of Resident #35's sacral/coccyx pressure ulcer. The (MONTH) (YEAR) TAR documented, .start date 9/19/18 . Review of this TAR revealed the treatment was done every day between 10/1/18 and 10/11/18 and every day between 10/13/18 and 10/18/18, instead of every other day as ordered. Treatments were not documented as performed on 10/20/18 and 10/22/18. A physician's orders [REDACTED].Clean area with NS .Apply Santyl to area and cover with foam dressing daily . The (MONTH) (YEAR) TAR documented, .Start Date 10/24/18 . Review of the (MONTH) TAR revealed the treatments were not documented as performed on 10/24/18, 10/27/18, and 10/31/18. Review of Resident #35's Weekly Skin Review and Weekly Skin Sheets, and Nursing Progress Notes between 10/12/18 and 11/9/18 revealed no documentation of complete wound assessments. A physician's orders [REDACTED].Wound Care to coccyx .Clean area with NS pat dry .Apply collagen dsg to area and cover with foam dressing daily . The (MONTH) (YEAR) TAR for Resident #35 documented, .Start Date 11/01/2018 . Review of this TAR revealed this treatment was not performed on 11/3/18, 11/9/18, and 11/12/18. A physician's orders [REDACTED].Sacrum .clean with saline .fill with silver alginate .cover with foam dsg .change daily . Review of the (MONTH) (YEAR) TAR for Resident #35 documented, .Start date 11/13/2018 . Review revealed the treatment was not documented as performed on 11/16/18, 11/17/18, 11/21/18, 11/23/18, and 11/28/18. Review of the (MONTH) (YEAR) TARS revealed no treatments were documented as performed on 12/6/18, 12/7/18, 12/15/18, 12/23/18, and 12/30/18. Review of the (MONTH) 2019 TARS for Resident #35 revealed no treatments were administered to Resident #35's pressure ulcer on 1/5/19, 1/6/19, 1/9/19, 1/12/19, 1/13/19, 1/18/19, 1/22/19, 1/27/19, and 1/29/19. Review of Nursing Notes, Weekly Skin Reviews, and Skin Assessments between 11/9/18 and 2/5/19 revealed no documentation of a wound assessment. Review of the (MONTH) 2019 TARS revealed no documentation this treatment was provided for Resident #35 on 2/5/19. A physician's orders [REDACTED].Sacrum .clean with saline .apply Venelex oint. (ointment) .cover with foam dsg change daily . The (MONTH) 2019 TAR documented, .Start Date 2/09/2019 . Review of this TAR revealed no documentation this treatment was provided for Resident #35 on 2/9/19, 2/10/19, 2/22/19, and 2/26/19. Review of Resident #35's (MONTH) 2019 TAR revealed no documentation this treatment was provided for Resident #35 on 3/7/19, 3/10/19, and 3/15/19. Review of Nursing Notes, Weekly Skin Reviews, Skin Assessments and Wound notes between 2/5/19 and 3/21/19 revealed no documentation of wound assessments. Observation and interview in Resident #35's room with the Contract Wound Nurse Practitioner on 3/21/19 at 10:35 AM, the Contract Wound Nurse Practitioner stated, . now it's larger than the last time I saw it . Interview with the Contract Wound Nurse Practitioner on 3/21/19 at 11:01 AM, in the Conference Room, the Contract Wound Nurse Practitioner was asked if the facility had notified her that the pressure ulcer had gotten worse. The Contract Wound Nurse Practitioner stated, No. Interview with the Contract Wound Physician on 3/22/19 at 1:29 PM, in the Conference Room, the Contract Wound Physician was asked if he expected his wound recommendations to be followed. The Contract Wound Physician stated, Yes, Ma'am. The Contract Wound Physician was asked if the facility had reported to him that his recommended treatments were not performed between (MONTH) and September. The Contract Wound Physician stated, Yikes . The Contract Wound Physician confirmed the facility should have been assessing the pressure ulcer and notifying him of changes. Interview with the DON on 3/22/19 at 7:01 PM, in the Conference Room, the DON was asked if nursing staff had documented wound assessments of Resident #35's pressure ulcer between 7/1/18-3/11/19. The DON stated, I couldn't find it. The DON was asked if treatments had been administered as either recommended or ordered. The DON stated, I don't see any. The DON confirmed the Contract Wound Physician's recommendations had not been ordered. The DON was asked if it was acceptable to allow pressure ulcers to deteriorate. The DON stated, It is not . The facility failed to ensure implementation of professional standards of practice for Resident #35's pressure ulcer when staff did not monitor, assess, treat and detect deterioration in Residents #35's Stage 4 wound. The failure of the facility to ensure professional standards of practice were implemented resulted in IJ to Re (TRUNCATED)",2020-09-01
417,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2019-03-26,659,K,0,1,2LOM11,"**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 follow resident care plan interventions related to pressure ulcers and non-pressure ulcers for 6 of 23 (Resident #15, #22, #23, #33, #35 and #344) sampled residents reviewed. The facility's failure to follow care plan interventions for wound care resulted in Immediate Jeopardy to Resident #15, #22, #23, #33, #35 and #344. The facility's failure to follow care plan interventions for assessing, identifying, reporting and providing treatments to wounds as ordered resulted in an Immediate Jeopardy when Resident #15 developed an unstageable pressure wound that was assessed as a Stage 3 wound after debridement by the Medical Doctor, Resident #22 developed a Stage 2 wound, Resident #23 developed a skin erosion, Resident #33 and #35's Stage 4 pressure wounds deteriorated, and Resident #344 developed 3 Deep Tissue Injuries (DTI). Immediate Jeopardy (IJ) is 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 Regional Director of Operations, Regional Nurse Consultant, Interim Administrator, Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Business Office Manager, and the Admissions Director were notified of the Immediate Jeopardy on 3/23/19 at 9:00 PM in the Conference Room. An extended survey was conducted on 3/24/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the IJ, was received on 3/25/19 at approximately 5:00 PM, and the corrective actions were validated onsite by the surveyors on 3/25/19 and 3/26/19 through review of assessments, auditing tools, in-service training records, policies, Quality Assurance Performance Improvement (QAPI) meeting minutes, observations, and staff interviews. The Immediate Jeopardy was effective 8/11/18 through 3/26/19. The noncompliance continues at F659-E for monitoring of effectiveness of the corrective actions. The deficient practice is a repeat deficient practice for failure to follow the care plan. The findings include: 1. Review of the facility's Baseline Care Plan Assessment/Comprehensive Care Plan policy documented, .The Comprehensive Care Plan will further expand on the resident's risks, goals and interventions using the Person-Centered Plan of Care approach for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, physical functioning, mental and psychosocial needs. These needs will be defined from observation, interviews, clinical medical record review and through assessments .The facility Interdisciplinary team in conjunction with the resident, resident's family, surrogate or representative as appropriate along with a hands on caregiver, such as a Certified Nursing Assistant will discuss and develop quantifiable objectives along with appropriate interventions in an effort to achieve the highest level of functioning and the greatest degree of comfort/safety/ and overall well-being attainable for the resident . 2. Medical record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 3/8/19 documented, .increased risk for alteration in skin integrity related to .2-28-19 Unstageable pressure ulcer to buttock .3-8-19 .a Stage 3 .Skin will be checked during routine care on a daily basis and during the weekly/biweekly bath or shower schedule .Any skin integrity issues/concerns will be conveyed to the Charge Nurse for further evaluation and/or Treatment changes/new interventions and the MD (Medical Doctor) will be called PRN (as needed) .CNA (Certified Nursing Assistant) shower/skin observations to be reported to the nurse for any unusual findings changes in the residents (resident's) skin integrity .Monitor Labs and report abnormalities .Administer Wound Care (Treatments) per MD orders . Review of the facility's Skin Monitoring .Comprehensive CNA (Certified Nursing Assistant) Shower Review (shower sheets/body audits) between 2/1/19 and 3/15/19 revealed Resident #15 did not receive body audits 39 of the 43 days. Interview with the Staffing Coordinator on 3/20/19 at 6:49 PM, in the Conference Room, the Staffing Coordinator confirmed the body audits were not completed by the CNA for 39 of 43 days. The weekly skin review for Resident #15 dated 2/21/19 documented, .Top of right buttock as noted to have black area noted that appears to be a deep tissue injury .lower part of buttock has open area noted, purple/black deep tissue injury noted . There was no documentation a physician was notified of the newly identified wound. Interview with the Assistant Director of Nursing (ADON) on 3/13/19 at 9:57 AM in the Conference Room, the ADON was asked when the pressure wound was identified. The ADON stated, The nurse said there was a wound . The ADON was asked what stage it was when it was found. The ADON stated, .it was unable to be determined, because it had eschar (a thick crust of dead tissue) . The facility failed to follow the care plan for skin assessments documented on the shower sheet/skin audit sheets, failed to notify the physician of the newly identified wound, failed to obtain an order for [REDACTED]. 3. Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. The care plan dated 12/19/17 and revised on 9/17/18 documented, .at increased risk for alteration in skin integrity .Interventions .Skin will be checked during routine care on a daily basis and during the weekly/bi-weekly bath or shower schedule .Any skin integrity issues/concerns will be conveyed to the Charge Nurse for further evaluation and/or Treatment changes/new interventions and the MD will be called PRN .CNA shower/skin observations to be reported to the nurse for any unusual findings/changes in the residents skin integrity . Review of the facility's Skin Monitoring .Comprehensive CNA Shower Review (shower sheets/body audits) between 2/1/19 and 3/15/19 revealed Resident #22 received body audits 2 of the 43 days. A General Progress Note for Resident #22 dated 2/8/19 documented, .she has 2 open wounds on her sacrum/coccyx . There was no documentation a physician or nurse practitioner was notified of the 2 new wounds and no new orders or wound treatments were obtained for these wounds. Observation in Resident #22's room on 3/20/19 at 9:00 AM, during a surveyor initiated skin sweep with Licensed Practical Nurse (LPN) #1 revealed a small shallow open crater in the mid-coccyx region with a bright red wound bed and no slough. Observation and interview with the Contract Wound Nurse Practitioner in Resident #22's room on 3/21/19 at 10:30 AM, the Contract Wound Nurse Practitioner stated it was a Stage 2 pressure ulcer. Interview with the ADON on 3/22/19 at 3:55 PM, in the Conference Room, the ADON was asked if a physician or nurse practitioner had been notified about the new wounds. The ADON stated, I do not see documentation there. The facility failed to follow the care plan for skin assessments documented on the shower sheet/skin audit sheets, for reporting newly identified pressure wounds, and for wound assessment documentation which resulted in IJ to Resident #22 when she developed a Stage 2 pressure wound. 4. Medical record review revealed Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan for Resident #23 revised 7/7/18 documented, .Focus .Potential risk for Skin breakdown .Moisture associated skin breakdown .Interventions .5/9/16 Conduct weekly skin inspection .Provide thorough skin care after incontinent episodes and apply barrier cream .Skin assessment to be completed . Observation in Resident #23's room on 3/20/19 at 8:53 AM, during a surveyor initiated skin sweep, revealed a shallow open ulcerated area with a red wound bed on the right buttock. Interview with the ADON on 3/20/19 at 1:57 PM, in the Conference Room, the ADON was asked if Resident #23's wound had been assessed. The ADON stated, No. The ADON was asked if the weekly skin assessments were being completed for Resident #23. The ADON stated, Apparently not . The facility failed to follow the care plan for weekly skin assessments and to identify skin breakdown. The failure to identify the moisture associated skin breakdown that deteriorated to a skin erosion resulted in IJ to Resident #23. 5. Medical record review revealed Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 2/24/19 documented, has an alteration in skin integrity and is at risk for additional and/or worsening of skin integrity issues related to .unstageable to left buttock at sacrum and Stage 2 to left buttock distal to sacral ulcer .Skin will be checked during routine care on a daily basis and during the weekly/Bi-weekly bath or shower schedule .Weekly measurements and documentation .Administer Wound Care (Treatments) per MD orders . Review of the Skin Monitoring Comprehensive CNA Shower Review sheets between 2/6/19 and 3/15/19 revealed Resident #33 did not receive body audits 35 days of the 37 days since admission. Review of Resident #33's nurse's progress notes on 2/6/19 revealed there was not a complete admission skin assessment with assessment of the pressure wound. The Nurse's progress notes on 2/7/19, documented, .Decubitus ulcers on Right & (and) Left Buttocks upon admission . The physician progress notes [REDACTED].buttock/sacral deep tissue injury .unstageable pressure ulcer . The facility was unable to provide any wound assessments by the nursing staff between 2/8/19 and 2/22/19, between 2/22/19 and 3/15/19. The physician's orders [REDACTED].Apply to sacrum topically every day shift for pressure ulcer . Review of the (MONTH) Treatment Administration Record (TAR) revealed there was no Santyl Ointment documented as administered on 2/9/19 and 2/26/19. Review of Resident #33's (MONTH) TAR revealed there was no Santyl documented as given on 3/7/19, 3/9/19, 3/12/19, 3/13/19, 3/15/19, 3/16/19, 3/18/19, and 3/19/19. Interview with LPN #3 on 3/21/19 at 1:26 PM in the Conference Room, LPN #3 was asked about Resident #33's pressure ulcer assessment. LPN #3 stated, .I've been so busy I can't remember the last time I did a skin assessment . Interview with the ADON on 3/22/19 at 12:53 PM, in the Conference Room, the ADON was asked if the Santyl treatments were documented daily on the TARs as ordered. The ADON stated, .There are several undocumented holes or spots . The ADON was asked if there was a wound assessment on 2/6/19. The ADON stated, .There should have been . The ADON was asked if thre should be a wound assessment performed by nursing staff. The ADON stated, .Yes, there should be . The facility failed to follow the care plan for wound assessment documentation and providing wound treatments as ordered which resulted in IJ for Resident #33 when the wound deteriorated to a Stage 4 pressure ulcer. 6. Medical record review revealed Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan for Resident #35 dated 1/5/17 and revised 11/14/18 documented, .resident is at increased risk for alteration in skin integrity .Skin will be checked during routine care on a daily basis and during the weekly/Biweekly bath or shower schedule .Any skin integrity issues/concerns will be conveyed to the Charge Nurse for further evaluation and/or treatment changes/new interventions and the MD will be called PRN .Weekly measurements and documentation .Initiate upon .onset of wound all facility wound care protocol .Administer Wound Care (Treatments) per MD orders . A physician's orders [REDACTED].Coccyx .clean with saline, apply Venelex, cover with a foam dsg (dressing) q (every) day shift every 3 day(s) . Review of the (MONTH) (YEAR) TAR for Resident #35 revealed the treatment was not provided on 9 of 10 treatment days in July. Medical record review of a Wound Care Specialist Evaluation for Resident #35 revealed a Contract Wound Physician examined Resident #35 on 6/29/18 and recommended to a nursing staff member the wound treatment of [REDACTED]. Review of the (MONTH) and (MONTH) physician orders [REDACTED]. Review of the (MONTH) (YEAR) TAR revealed Resident #35 received a treatment of [REDACTED]. an order for [REDACTED]. Medical record review of a Specialty Physician Wound Evaluation Management Summary for Resident #35 revealed the Contract Wound Physician recommended to a nursing staff member the treatment of [REDACTED]. Review of physician orders [REDACTED].#35 did not have an order for [REDACTED]. A Weekly Skin Review for Resident #35 dated 7/30/18 documented, .moisture damage to coccyx area . There was no documentation that the moisture damage was reported to a physician or nurse practitioner. Review of Nursing Notes, Weekly Skin Reviews and Skin Assessments between 7/28/18 and 8/5/18 revealed no documentation of a description or measurements of the sacral/coccyx wound. Medical record review of a Specialty Physician Wound Evaluation Management Summary for Resident #35 revealed the Contract Wound Physician examined Resident #35 on 8/11/18. The sacral wound had enlarged and was described as deteriorated. The Contract Wound Physician recommended to a nursing staff member the wound be treated with Leptospermum Honey and Zinc Ointment every shift daily. The facility was unable to provide documentation that any treatments were provided for Resident #35's sacral/coccyx wound in August. Review of Nursing Notes, Weekly Skin Reviews and Skin Assessments between 8/11/18 and 9/1/18 revealed no description of the sacral wound with measurements. Review of Weekly Skin Review notes dated 8/19/18 a nurse documented, .Coccyx .Stage III (3) . Medical record review of a Specialty Physician Wound Evaluation Management Summary revealed the Contract Wound Physician examined Resident #35 on 9/1/18, obtained measurements of the sacral/coccyx wound, recommended to a nursing staff member the treatment of [REDACTED]. Review of the TARS revealed Resident #35 did not receive these recommended treatments in between 9/1/18 and 9/19/18. A facility physician's treatment order for Resident #35 dated 9/18/18 documented, .Sacrum .clean with saline .apply antimicrobial silver dsg (dressing) .cover with foam dsg qod (every other day) .for pressure (pressure) ulcer stage 3 . This was the first treatment order prescribed for Resident #35's sacral/coccyx wound since 6/27/18. Review of Resident #35's (MONTH) (YEAR) TAR revealed the treatment was provided every day between 9/19/18 and 9/25/18 instead of every other day as ordered. This treatment was not provided on 9/27/18. Review of Nursing Notes, Weekly Skin Reviews and Skin Assessments between 9/1/18 and 9/28/18 revealed no description or measurements of Resident #35's sacral/coccyx wound by nursing staff. Medical record review of a Specialty Physician Wound Evaluation Management Summary revealed the Contract Wound Physician examined Resident #35 on 9/22/18, described the wound as deteriorated. The Contract Wound Physician recommended to a nursing staff member the treatment of [REDACTED]. Resident #35 did not receive the recommended treatments in September. A Contract Wound Nurse Practitioner Wound Consult Note dated 9/28/18 documented, .Referred for evaluation of new buttock pressure ulcer .Pt (patient) .Coccyx area with stage 4 pressure injury .Use silver alginate . Cover with foam dressing .daily .Cleanse with NS (Normal Saline) .use skin protectant wipe on periwound skin prior to applying the foam cover dressing . Review of Nursing Notes, Weekly Skin Reviews and Skin Assessments between 9/28/18 and 10/12/19 revealed no description or measurements of Resident #35's sacral/coccyx wound. The (MONTH) (YEAR) TAR documented, .Sacrum .clean with saline .apply antimicrobial silver dsg .cover with foam dsg qod (every other day) for pressure ulcer stage 3 . Review of this TAR revealed the treatment was done every day between 10/1/18 and 10/11/18 and every day between 10/13/18 and 10/18/18, instead of every other day as ordered. Treatments were not documented as performed on 10/20/18 and 10/22/18. A Contract Wound Nurse Practitioner Wound Consult Follow-up note for Resident #35 dated 10/12/18 documented, .Following for treatment of [REDACTED].Coccyx pressure injury .use Santyl ointment in the wound .cover with foam dressing and change daily . A physician's orders [REDACTED].Apply Santyl to area and cover with foam dressing daily . The (MONTH) (YEAR) TAR for Resident #35 documented, .Wound care to coccyx .Clean area with NS (Normal Saline) .Apply Santyl to area .cover with foam dressing daily . Review of the (MONTH) TAR revealed the treatments were not documented as performed on 10/24/18, 10/27/18, and 10/31/18. Review of Weekly Skin Review and Weekly Skin Sheets, and nursing progress notes between 10/12/18 and 11/9/18 revealed no documentation of an assessment of the sacral/coccyx wound with measurements. A physician's orders [REDACTED].Wound Care to coccyx .Clean area with NS pat dry .Apply collagen dsg to area and cover with foam dressing daily . The (MONTH) (YEAR) TAR for Resident #35 documented, 11/1/18 .Wound care to coccyx .Clean area with NS .Apply collagen dsg to area and cover with foam dressing daily . Review of this TAR revealed the treatment was not documented as done on 11/3/18, 11/9/18 and 11/12/18. A Contract Wound Nurse Practitioner Wound Consult Follow-up note for Resident #35 dated 11/9/18 documented, .Sacral pressure ulcer with .bone exposed .Continue to fill area of stage 4 sacral pressure ulcer with silver alginate .Cover with foam dressing . A physician's orders [REDACTED].Sacrum .clean with saline .fill with silver alginate .cover with foam dsg .change daily . The (MONTH) (YEAR) TAR for Resident #35 documented the treatment recommended .Sacrum .clean with saline .fill area with silver alginate .cover with foam dsg .daily .Start date 11/13/2018 . Review of the TARS revealed the treatment was not documented as performed on 11/16/18, 11/17/18, 11/21/18, 11/23/18, and 11/28/18. Review of Nursing Notes, Weekly Skin Reviews, and Skin Assessments between 11/9/18 and 12/7/18 revealed no documentation of an assessment of the sacral/coccyx wound with measurements by the nursing staff. Review of Resident #35's (MONTH) (YEAR) TAR revealed the treatment to the sacral/coccyx wound was not done on 12/6/18, 12/7/18, 12/15/18, 12/23/18, and 12/30/18. Review of Weekly Skin Review and Weekly Skin Sheets, nursing progress notes, and Wound notes between 12/7/18 and 1/26/19 revealed no documentation of an assessment of the sacral/coccyx wound with measurements by nursing staff. Review of the (MONTH) 2019 TAR revealed no treatments were administered as ordered to Resident #35's sacral/coccyx wound on 1/5/19, 1/6/19, 1/9/19, 1/12/19, 1/13/19, 1/18/19, 1/22/19, 1/27/19, and 1/29/19. A Contract Wound Nurse Practitioner Wound Consult Follow-up note for Resident #35 dated 2/8/19 documented, .stage 4 healing .Cluster of x2 (times 2) areas .Hard to get collagen or alginate in small areas .Change and use Venelex ointment in both ulcers of the cluster .Cover with foam dressing . Review of Nursing Notes, Weekly Skin Reviews, Skin Assessments and Wound notes between 1/28/19 and 3/10/19, and between 3/12/19 and 3/21/19 revealed no assessment of the sacral/coccyx wound with measurements nursing staff. Review of Resident #35's (MONTH) 2019 TAR revealed no treatments were administered as ordered to Resident #35's sacral/coccyx wound on 2/5/19. A physician's orders [REDACTED].Sacrum .clean with saline .apply Venelex oint. (ointment) .cover with foam dsg change daily . The (MONTH) 2019 TAR for Resident #35 documented, .Sacrum .clean with saline .apply Venelex oint .cover with foam dsg .change daily Review of the TAR revealed the treatment was not done on 2/9/19, 2/10/19, 2/22/19, and 2/26/19. Review of the (MONTH) 2019 TAR revealed no treatments were administered as ordered to Resident #35's sacral/coccyx wound on 3/7/19, 3/10/19, and 3/15/19. Observation and interview with Contract Wound NP in Resident #35's room on 3/21/19 at 10:35 AM after removal of the foam dressing from the resident's sacrum, the Contract Wound Nurse Practitioner stated, .it was better, now it's larger than the last time I saw it . Interview with the Contract Wound Nurse Practitioner on 3/21/19 at 11:01 AM in the Conference Room, the Contract Wound Nurse Practitioner was asked if the facility had notified her that the wound had gotten worse. The Contract Wound Nurse Practitioner stated, No. Interview with the Contract Wound Physician on 3/22/19 at 1:29 PM, in the Conference Room, the Contract Wound Physician was asked if he expected wound recommendations should be followed. The Contract Wound Physician stated, Yes, Ma'am. The Contract Wound Physician was asked if the facility had reported to him that his recommended treatments were not performed between (MONTH) and September. The Contract Wound Physician stated, Yikes . The Contract Wound Physician confirmed the facility should have been assessing the wound and notifying him of changes. Interview with the DON on 3/22/19 at 7:01 PM in the Conference Room, the DON was asked if nursing staff had documented assessments with measurements of Resident #35's wound between 7/1/18 and 3/11/19. The DON stated, I couldn't find it. The DON was asked if treatments were administered as ordered in August. The DON stated, I don't see any. The facility failed to follow the care plan regarding skin assessments, failed to notify the physician of the deteriorating wound, failed to document the assessment of the wound with measurements, failed to obtain an order for [REDACTED]. 7. Medical record review for Resident #344 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The care plan dated 3/5/19 documented, .an increased risk for alteration in skin integrity related to a Decreased Sensory Perception and [DIAGNOSES REDACTED].DTI (Deep Tissue Injury) to the left heel .with interventions of skin to be checked during routine care on a daily basis, and during the weekly/bi-weekly bath or shower schedule .any skin integrity issues or concerns will be conveyed to the Charge Nurse for further evaluation and/or treatment changes, and new interventions, and the MD will be called PRN .Skin Review Form will be completed on Admission and PRN for any new skin integrity issues .CNA shower/skin observations will be reported to the nurse for any unusual findings/changes in the residents skin integrity .weekly measurements and documentation .Monitor for S/S (Sign and Symptoms) of infection and report to MD as indicated . Medical record review revealed there was no admission skin assessment performed for Resident #344. Review of the Skin Monitoring .Comprehensive CNA Shower Review between 3/1/19 and 3/15/19 revealed no body audits were done during the 15 days since admission. A Skin Assessment for Resident #344 dated 3/4/19 by the ADON dated 3/4/19 documented, .Left heel .Pressure . The Contract Nurse Practitioner's telephone order dated 3/4/19, documented, .Skin Prep (Preparation) Wipes .Apply to bilateral heels topically every day shift for DTI . Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. The Contract Family Nurse Practitioner's telephone order dated 3/8/19, documented, .Left heel .[MEDICATION NAME] daily every shift . Review of Resident #344's (MONTH) 2019 TAR revealed the treatment was not done on 3/9, 3/12, 3/16, 3/18, and 3/19/19. Review of the Weekly Skin Review with an effective date of 3/8/19 and 3/20/19 revealed no wound assessment or measurements of the left heel DTI. Review of the Daily Skilled Nursing Notes For Resident #344 revealed there were no assessments of the left heel DTI on admission 3/1/19, or from 3/3/19 to 3/17/19. Review of the Nurse's Progress Notes dated 3/22/19 revealed Resident #344 left for same day surgery for [REDACTED]. Medical record review revealed there was no re-admission skin assessment of Resident #344 after return to the facility on [DATE]. A Contract Wound Practitioner Wound Consult Note for Resident #344 dated 3/23/19 documented, .Superior sacral area with x2 (times 2) small areas of .deep tissue injury noted . Interview with the DON on 3/24/19 at 12:01 PM, in the Conference Room, the DON was asked when Resident #344's 2 DTI's on her sacrum were identified. The DON stated, yesterday (3/23/19) . The DON was asked if an assessment was done when the resident returned to the facility from the same day surgery. The DON stated, I do not see an assessment . The facility failed to follow the care plan for providing skin assessments on the shower sheet/body audits, completion of the Skin Review Form on admission, wound assessment measurements and documentation, and providing wound treatments as ordered which resulted in IJ to Resident #344 when she developed 3 DTI's.",2020-09-01
418,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2019-03-26,677,D,0,1,2LOM11,"**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 Activities of Daily Living (ADL) assistance was provided related to nail care for 1 of 4 (Resident #38) sampled residents reviewed for ADL care. The findings include: 1. The facility's undated Policy and Procedure Foot Care policy documented, .Purpose .To ensure that residents receive appropriate care and services to maintain health and hygiene of their feet. To ensure that residents feet are inspected on a regular basis . The facility's undated NAIL CARE policy, documented, .It is the policy of the facility to provide personal hygiene needs and to promote health, safety and the prevention of infection. This includes clean, smooth nails at a well-groomed safe length acceptable to the resident . 2. Medical record review revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #38 had a score of 9 on the Brief Interview of Mental Status (BIMS), which indicated moderate cognitive impairment, and required extensive assistance for ADL care. Interview with Resident #38's family member on 3/11/19 at 1:40 PM in Resident #38's room, the family member stated, They aren't trimming his toenails . Observation and interview in Resident #38's room with the Family Nurse Practitioner (FNP) on 3/12/19 at 1:46 PM, revealed Resident #38 had jagged toenails on the toes of his right foot, a long jagged toenail on the left great toe, and long toenails on the remaining toes of his left foot. The FNP inspected Resident #38's toenails on both feet and stated, .couple (on the right foot) need to be filed .(toenail on the left great toe) is jagged and a couple (toenails) need to be cut . Interview with the Director of Nursing (DON) on 3/13/19 at 12:10 PM, in the Conference Room, the DON was asked if it was important for residents in the facility to receive nail care. The DON stated, It's very important. The DON confirmed it was acceptable for CNA's and nurses to assess, trim and file toenails.",2020-09-01
419,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2019-03-26,684,K,0,1,2LOM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on The Textbook of Medical-Surgical Nursing, Twelfth Edition, facility policy review, medical record review, observation, and interview, the facility failed to properly assess, identify, report, and treat wounds for 2 of 2 (Resident #23 and #344) residents reviewed for non-pressure related wounds. The facility's failure to identify, assess, and report Resident #23's worsening Moisture Associated Skin Damage (MASD) resulted in Immediate Jeopardy to Resident #23 when the wound deteriorated to an erosion. The facility's failure to assess timely and accurately a surgical wound or perform skin assessments resulted in Immediate Jeopardy for Resident #344 when the surgical hip wound dehisced (the layers of the surgical wound separated). Immediate Jeopardy (IJ) is 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 Regional Director of Operations, Regional Nurse Consultant, Interim Administrator, Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON), Business Office Manager, and the Admissions Director were notified of the Immediate Jeopardy on 3/23/19 at 9:00 PM, in the Conference Room. The facility was cited F-684-K which is Substandard Quality of Care. An extended survey was completed on 3/24/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the IJ, was received on 3/25/19 at approximately 5:00 PM, and the corrective actions were validated onsite by the surveyors on 3/25/19 and 3/26/19 through review of assessments, auditing tools, in-service training records, policies, Quality Assurance Performance Improvement (QAPI) meeting minutes, observations, and staff interviews. The Immediate Jeopardy was effective 8/11/18 through 3/26/19. The noncompliance continues at F684-E for monitoring of effectiveness of the corrective actions. The findings include: 1. The Textbook of Medical-Surgical Nursing documented, Twelfth Edition, documented, .Ongoing assessment of the surgical site involves inspection for approximation of wound edges, integrity of sutures or staples, redness, discoloration, warmth, swelling, unusual tenderness, or drainage .the nurse assesses the patient for postoperative complications by assessment of the surgical incision . The facility's PREVENTION AND MANAGEMENT OF WOUNDS policy dated 7/1/13 documented, .Document on the physician order [REDACTED]. 2. Medical record review revealed Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #23 required extensive to total assistance of staff, was frequently incontinent of bowel and bladder, and had MASD. The care plan dated 5/9/16 and revised 7/7/18 documented, .Focus .Potential risk for Skin breakdown .Moisture associated skin breakdown .Interventions .5/9/16 Conduct weekly skin inspection .Provide thorough skin care after incontinent episodes and apply barrier cream .Skin assessment to be completed . A physician's orders [REDACTED].#23 documented, .Venelex Ointment .Apply to right buttocks topically two times a day for MASD . Review of the facility's Skin Monitoring Comprehensive CNA (Certified Nursing Assistant) Shower Review (shower sheet/body audits) between 2/1/19 and 3/15/19 revealed Resident #23 did not receive body audits during 40 days of the 43 day period. Review of a physician order [REDACTED]. Review of Resident #23's Daily Skilled Nursing Note dated 2/7/19 revealed moisture related breakdown was noted with a treatment in place. There was no description of the wound with measurements. Review of Daily Skilled Nursing Notes, Weekly Skin Review and Skin Assessments for Resident #23 between 2/1/19 and 3/20/19 revealed there no other assessments with measurements for this wound. There was no documentation that a physician or nurse practitioner had been notified about the worsening MASD. Review of a Daily Skilled Nursing Note dated 2/11/19 revealed treatment in place to buttocks. There was no description of the wound with measurements. Review of Resident #23's Weekly Skin Review dated 2/13/19 revealed an open area to buttocks with treatment in place. There was no description of the wound with measurements. There was no documentation that a physician or nurse practitioner was notified of the open area to the buttocks. Review of a Daily Skilled Nursing Note dated 2/14/19 revealed pink coccyx area. There was no description of the wound with measurements. Review of the Braden Scale (an assessment tool that reflected the likelihood of a resident developing a pressure wound) dated 2/18/19 revealed Resident #23 was at high risk for developing skin wounds. Review of Resident #23's Daily Skilled Nursing Note dated 2/18/19 documented, .Decubitus Wound . was marked. There was no description of the wound with measurements. There was no documentation that a physician or nurse practitioner was notified about a decubitus wound. Review of a Daily Skilled Nursing Note dated 2/27/19 revealed moisture related breakdown to buttocks. There was no description of the wound with measurements. There was no documentation that a physician or nurse practitioner was notified about the breakdown to the buttocks. A Daily Skilled Nursing Note for Resident #23 dated 2/27/19 documented, .Decubitus Wound .buttocks .Resident's pressure ulcer is managed by staff . Review of Resident #23's (MONTH) and (MONTH) 2019 Medication Administration Record [REDACTED]. There were no other treatment orders documented when the MASD worsened. Observations in Resident #23's room on 3/20/19 at 8:53 AM, during a surveyor initiated skin sweep, revealed a CNA giving Resident #23 a bed bath. The CNA removed a pink foam dressing from Resident #23's mid buttock area, revealing a shallow open ulcerated area with a red wound bed to the right buttock. A Contract Wound Nurse Practitioner Wound Consult Note for Resident #23 dated 3/20/19 at 1:07 PM, documented, .Asked to evaluate patient with buttock wound .Bilateral buttock skin with Large area of chronic hyperpigmentation related to moisture. Scattered healed moisture associated skin damage noted on left buttock and the superior sacral area .Right buttock skinnoted (skin noted) to have a 1.2 (length in centimeters (cm)) x (by) 1 (width in cm) x 0.1cm (depth) pink skin erosion . Interview with the ADON on 3/20/19 at 1:57 PM, in the Conference Room, the ADON was asked about the foam dressing on Resident #23's buttock that was found during the surveyor initiated skin sweep. The ADON stated, She doesn't have an order for [REDACTED]. The ADON was asked if Resident #23's wound had been assessed and measured and if weekly skin assessments were being completed. The ADON stated, No. Apparently not .we had an Interim Director of Nursing but I'm the one that owned it all .trying to keep our heads above water .it's hard to find good people to come in and want to work . Observation and interview with the Contract Wound Nurse Practitioner on 3/21/19 at 10:55 AM, in Resident #23's room revealed the Contract Wound Nurse Practitioner positioned Resident #23 on her side to expose the right buttock wound and there was no dressing in place. The Contract Wound Nurse Practitioner was asked if there should be a dressing over the wound. The Contract Wound Nurse Practitioner stated, I ordered for it to be covered and she stated, .this is moisture associated skin damage .this is skin erosion . The Contract Wound Nurse Practitioner measured and confirmed the measurements of the wound with a length of 1.2 cm width of 1.0 cm and depth of 0.1 cm. The Contract Wound Nurse Practitioner was asked when she ordered the foam dressing. The Contract Wound Nurse Practitioner confirmed she did not order the foam dressing until after she was asked to see Resident #23 on 3/20/19, after the surveyor initiated skin sweep. Interview with Licensed Practical Nurse (LPN) #3 on 3/21/19 at 1:26 PM, in the Conference Room, LPN #3 was asked how she identifies skin issues with residents. LPN #3 stated, .the best way I find out is .the CNA .when they do the body audits during the baths or showers or daily care .there's a form they fill out . Interview with the Contract Wound Nurse Practitioner on 3/22/19 at 11:20 AM, in the Conference Room, the Contract Wound Nurse Practitioner was asked if the facility should have reported the wound to her before the surveyor found it. The Contract Wound Nurse Practitioner stated, Yes. The Contract Wound Nurse Practitioner confirmed Resident #23 had moisture associated skin damage and stated, .it's an actual wound and it should have wound care .the erosion is a manifestation of a deeper tissue injury .it's (it has) deteriorated . The facility's failure to identify, assess, and report Resident #23's worsening Moisture Associated Skin Damage (MASD) resulted in Harm to Resident #23 when the wound deteriorated to an erosion. 4. Medical record review revealed Resident #344 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #344 was re-admitted to the facility on [DATE] after the left hip surgical wound was irrigated and debrided at the hospital. The admission MDS dated [DATE] revealed Resident #344 had a surgical wound. The care plan dated 3/5/19 documented, .increased risk for alteration in skin integrity .Interventions .Skin will be checked during routine care on a daily basis and during the weekly/biweekly bath or shower schedule .Skin Review Form will be completed on Admission and .for any new skin integrity issues .CNA shower/skin observations to be reported to the nurse for any unusual findings/changes in the residents skin integrity .Monitor for S/S (Sign and Symptoms) of infection and report to MD (Medical Doctor) as indicated . A hospital's Inpatient Discharge Summary for Resident #344 dated 3/1/19 documented, .Operative Procedures Performed .OPEN REDUCTION HIP, LEFT .REVISION ARTHROPLASTY PARTIAL HIP, LEFT .Keep your incision clean and dry .If the drainage turns yellow/green .incision becomes red and painful .contact the clinic . Medical record review revealed there was no admission assessment of the left hip surgical wound when Resident #344 was admitted on [DATE] to the facility. A Skin assessment dated [DATE] documented, .Right trochanter (hip) Surgical Incision . Review of this skin assessment revealed incomplete wound documentation, and the documentation did not correctly identify that the surgical incision was on the left hip. Review of Resident #344's Nursing Notes revealed there were no completed surgical wound assessments documented from 3/1/19 through 3/4/19. The physician's orders [REDACTED].Left hip incision-paint with [MEDICATION NAME] to the Left hip .cover with dressing daily . The MAR for Resident #344 dated (MONTH) 2019, revealed, Left hip incision-paint with [MEDICATION NAME] cover with dressing daily .Start date .3/9/19 . There was no documentation the treatment was performed on 3/9/19, 3/12/19, 3/16/19, 3/18/19, and 3/19/19. Review of Nursing Notes revealed there were no completed surgical wound assessments documented between 3/6/19 and 3/20/19. Review of Resident #344's facility Skin Monitoring .Comprehensive CNA Shower Review . (shower sheet/body audit) between 3/1/19 and 3/15/19 revealed no body audits were done during the 15 days reviewed and Resident #344's name was not on a daily shower list. Review of Resident #344's Nursing Notes, Weekly Skin Reviews, and Skin Assessments revealed incomplete surgical wound assessments of the left trochanter (hip) surgical wound for 3/6/19, 3/7/19, 3/9/19, 3/10/19, 3/11/19, 3/12/19, 3/14/19, 3/17/19, and 3/18/19. The documentation did not include inspection for approximation of wound edges, redness, discoloration, warmth, swelling, unusual tenderness, or drainage. The nurse's progress notes for Resident #344 dated 3/22/19 at 11:00 AM, documented, .left for same day surgery for [REDACTED]. Medical record review revealed there was no re-admission skin assessment for Resident #344 after she returned to the facility from the same day surgery on 3/22/19. The hospital's Same Day Surgery Discharge Instructions dated 3/22/19 documented, .Notify .Physician .Increased bleeding, drainage, swelling or odor from the surgical site . Interview with the ADON on 3/22/19 at 12:17 PM, in the Conference Room, the ADON was asked if treatments were completed as ordered on [DATE], 3/12/19, 3/16/19, 3/18/19, and 3/19/19. The ADON stated, It wasn't documented, so it wasn't done. Interview with the Director of Nursing (DON) on 3/22/19 at 5:49 PM, in the Conference Room, the DON was asked if wound assessments were completed on admission and readmission for Resident #344's surgical wound. The DON stated, I don't see where the assessments were done. The DON confirmed all residents that enter the building should have a full assessment, including a skin assessment. The DON stated, .all wounds should be monitored and documented . The facility's failure to assess timely and accurately a surgical wound or perform skin assessments resulted in Immediate Jeopardy for Resident #344 when the surgical hip wound dehisced.",2020-09-01
420,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2019-03-26,686,K,0,1,2LOM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on The National Pressure Ulcer Advisory Panel (NPUAP) Prevention and treatment of [REDACTED].#15, #22, #33, #35, and #344) sampled residents with pressure ulcers. The facility's failure to identify, assess, report, and treat wounds as ordered resulted in an Immediate Jeopardy when Resident #15 developed an unstageable pressure wound that evolved to Stage 3 pressure ulcer, Resident #22 developed a Stage 2 wound, Resident #23 developed a skin erosion after Moisture Associated Skin Damage (MASD), Resident #33's Stage 4 pressure ulcer evolved to a Stage 4 pressure ulcer, Resident #35's Stage 4 pressure wounds deteriorated, and Resident #344 developed 3 Deep Tissue Injuries (DTI). Immediate Jeopardy is 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 Regional Director of Operations, Regional Nurse Consultant, Interim Administrator, Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Business Office Manager, and the Admissions Director were notified of the Immediate Jeopardy on 3/23/19 at 9:00 PM in the Conference Room. The facility was cited F 686-K which is Substandard Quality of Care. An extended survey was conducted on 3/24/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the jeopardy, was received on 3/25/19 at approximately 5:00 PM. The corrective actions were validated onsite by the surveyors on 3/25/19 and 3/26/19 through review of assessments, auditing tools, in-service training records, policies, Quality Assurance Performance Improvement (QAPI) meeting minutes, observations, and staff interviews. The Immediate Jeopardy was effective 8/11/18 through 3/26/19. The noncompliance continues at F 686-E for monitoring of effectiveness of the corrective actions. The findings include: 1. The NPUAP Prevention and treatment of [REDACTED].Comprehensive assessment of the individual and his or her pressure ulcer informs development of the most appropriate management plan and ongoing monitoring of wound healing. Effective assessment and monitoring of wound healing is based on scientific principles, as described in this section of the guideline .1. Complete a comprehensive initial assessment of the individual with a pressure ulcer .Reassess the individual, the pressure ulcer and the plan of care if the ulcer does not show signs of healing .Assess the pressure ulcer initially and re-assess it at least weekly .Document the results of all wound assessments .weekly assessments provide an opportunity for the health professional to assess the ulcer more regularly, detect complications as early as possible, and adjust the treatment plan accordingly .Address signs of deterioration immediately .Assess and document physical characteristics including: location .Stage .size .tissue type .color .periwound condition .wound edges .sinus tracts .undermining .tunneling .exudate .odor .Select a uniform, consistent method for measuring wound length and width or wound area to facilitate meaningful comparisons of wound measurements across time .Select a consistent, uniform method for measuring depth .Stage I: Non blanchable (skin does not lose redness when pressure applied) [DIAGNOSES REDACTED] (redness of skin). Intact skin with non-blanchable redness of a localized area usually over a bony prominence .Stage II: Partial Thickness Skin Loss .presenting as a shallow open ulcer with a red pink wound bed .May also present as an intact or open/ruptured serum-filled blister .Stage III: Full Thickness Skin Loss .subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough (dead tissue) may be present .May include undermining and tunneling .Stage IV: Full Thickness Tissue Loss .with exposed bone, tendon, or muscle. Slough or eschar (a thick crust) may be present .Unstageable: Depth unknown, Full thickness tissue loss in which the base of the ulcer is covered by a slough (yellow, tan, gray, green, or brown) and or eschar (tan, brown, or black) in the wound bed .Suspected Deep Tissue Injury: Depth unknown. Purple maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure . The facility's PREVENTION AND MANAGEMENT OF WOUNDS policy dated 7/1/13 documented, .Ensure that all nurses are educated on use of the wound care management protocol information sheets .(See attached Treatment Guidelines) .Use the treatment guideline skin/wound management to discuss wound care treatment needs with Physician when obtaining orders for care .Document on the physician order for [REDACTED].Submit Treatment Guideline orders to the Wound Care Coordinator or Director of Nursing with the 24 hour report. The Wound Care Coordinator or Director of Nursing will review the treatment guideline for each resident/wound site for appropriateness of care . There were no Treatment Guidelines attached to the facility policy. The facility's undated S.W.[NAME]T. PROGRAM (SKIN AND WEIGHT ASSESSMENT TEAM) policy documented, .Review Date: Date of SWAT meeting .Onset Date: Date of which the open area appeared .Current Size: The measurement of the open area most recently recorded by nursing .Current Stage: The most recent stage determined by nursing or the physician .Odor Present: Putrid smell of the open area on the skin .Drainage Present: Presence of drainage of the open area on the skin .Record on tx (Treatment) sheet: Open area treatments need to be recorded on treatment sheet .Notifications: MD (Medical Doctor), RD (Registered Dietician), MDS (Minimum Data Set Coordinator), Family, Care Plan . The facility's Change in Resident's Condition or Status policy documented, .It is the policy of the facility to ensure that the resident's attending physician and Representative are notified of changes in the resident's condition or status .The nurse will notify the resident's attending physician when .There is a significant change in the resident's physical, mental, or psychological status .There is a need to alter the resident's treatment plan . 2. Medical record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum data set ((MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) of 2, indicating severe cognitive impairment. The MDS documented Resident #15 was at risk for developing pressure ulcers/injury. There were no pressure ulcers documented on the 1/23/19 MDS. Review of the care plan for Resident #15 dated 3/8/19 revealed a problem of .increased risk for alteration in skin integrity related to .2-28-19 Unstageable pressure ulcer to buttock .3-8-19 .a Stage 3 .Skin will be checked during routine care on a daily basis and during the weekly/biweekly bath or shower schedule .Any skin integrity issues/concerns will be conveyed to the Charge Nurse for further evaluation and/or Treatment changes/new interventions and the MD will be called PRN (as necessary) .CNA (Certified Nursing Assistant) shower/skin observations to be reported to the nurse for any unusual findings changes in the residents (resident's) skin integrity .Monitor Labs and report abnormalities .Administer Wound Care (Treatments) per MD orders . Review of the Resident #15's Skin Monitoring .Comprehensive CNA Shower Review (shower sheet/body audits) between 2/1/19 and 3/15/19 revealed no documentation Resident #15 received body audits 39 of 43 days. Interview with the Staffing Coordinator on 3/20/19 at 6:49 PM in the Conference Room, the Staffing Coordinator confirmed that the body audits were not completed by the CNA for 39 of 43 days. The nurse's progress notes for Resident #15 dated 2/21/19 documented, .Resident found to have open wound/deep tissue injuries noted to buttocks . There was no assessment of the wound or measurements of the wound documented on 2/21/19. There is no documentation that a physician was notified about the newly identified wound. The nurse's progress notes for Resident #15 dated 2/28/19 documented, .Skin assessment completed to evaluate wounds on coccyx .coccyx is red throughout and slow to blanch .deep tissue injuries .as well as open areas on his coccyx . There was no assessment of the wound with measurements documented on 2/28/19. Interview with the ADON on 3/13/19 at 9:57 AM, in the Conference Room, the ADON was asked when Resident #15's pressure ulcer was identified. The ADON stated, The nurse said there was a wound and I told her (Named Consult Wound Physician) would be here the next day (2/22/19) .(Named Consult Wound Physician and I went and looked at it (2/22/19) and we did not see it . The ADON was asked when the first measurements were done. The ADON stated, .he doesn't chart in our system, that messes me up .he came in on .3/2 and that is when he did the measurements . The ADON was asked why measurements were not done until the Contract Wound Physician came on 3/2/19. The ADON stated, I was waiting on the doctor. We let him do the measurements. The ADON was asked if that was over a week after it was found. The ADON stated, It was. The ADON was asked what stage it was when it was found. The ADON stated, .it was unable to be determined, because it had eschar . The facility was unable to provide documentation of Resident #15's pressure ulcer assessments with measurements until 3/2/19, 9 days after the pressure ulcer was identified. The Contract Wound Physician's WOUND EVALUATION & (and) MANAGEMENT SUMMARY dated 3/2/19 documented, .(Resident #15) .presents with a wound on their left ischium .stage 3 .wound size (L (length) x (by) W (width) x D (depth)) .3.5 x 4.2 x 0.4 cm (centimeters) .DRESSING TREATMENT PLAN .Santyl apply once daily for 30 days .thick adherent devitalized necrotic tissue .40% (percent) .SURGICAL EXCISIONAL DEBRIDEMENT (removal of dead, damaged or infected tissue) PR[NAME]EDURE .[MEDICATION NAME] RECOMMENDED ON 3/2/2019 . The Contract Wound Physician staged the pressure wound a Stage 3 after he debrided the wound. The facility did not notify the primary physician of the newly identified pressure ulcer or obtain orders for the Contract Wound Physician's recommendation for pressure ulcer treatment. No treatments were ordered for this newly identified pressure ulcer. The facility did not obtain an order for [REDACTED].>The (MONTH) 2019 TREATMENT ADMINISTRATION RECORD (TAR) for Resident #15 documented, .Clean wound on left lower buttocks with NS (normal saline). Pat dry. Apply Santyl (an ointment to help break up and remove dead skin and tissue) ointment to area and cover with dressing .daily .Start Date .03/09/2019 . The treatments were administered from 3/9/19 to 3/13/19. The facility was unable to provide a physician order for [REDACTED].>The weekly skin reviews dated 2/21/19 documented top of right buttock is noted to have black area .that appears to be a deep tissue injury .lower part of buttock has open area noted, purple/black deep tissue injury noted . There was no documentation that the doctor was notified or that wound treatment orders were received. The weekly skin review dated 3/5/19 documented, .open area .wound to right buttocks with treatment plan in place . There was no physician order for [REDACTED].>Interview with the DON on 3/13/19 at 10:53 AM at the West Nurse's Station, the DON was asked when staff should obtain measurements after a pressure ulcer was identified. The DON stated, Within a few minutes after they identified it. Interview with the DON on 3/13/19 at 12:36 PM, in the Conference Room, the DON was asked if Resident #15's [MEDICATION NAME] level should have been transcribed and performed as ordered. The DON stated, Yes. Telephone interview with Registered Nurse (RN) #3 on 3/20/19 at 10:49 AM, RN #3 was asked if she notified anyone of the pressure wound that was identified on 2/21/19. RN #3 stated, I texted (named ADON) the next morning to inform her . RN #3 was asked if she notified the physician. RN #3 stated, I did not. RN #3 was asked about the wound when she reassessed it on 2/28/19. RN #3 stated, .it got worse. RN #3 was asked if she thought the pressure ulcer deterioration could have been prevented if Resident #15 had received treatment. RN #3 stated, Yes, absolutely. Telephone interview with Certified Nursing Assistant (CNA) #3 on 3/20/19 at 12:01 PM, CNA #3 described the pressure area that she found on 2/21/19 as a small dime size area, .starting to turn colors, reddish-brown color, like where he would sit on it CNA #3 confirmed she notified RN #3 of the pressure area. Telephone interview with the Contract Wound Physician on 3/20/19 at 1:02 PM, the Contract Wound Physician was asked if he did not see the pressure ulcer on Resident #15's ischium on his first exam (on 2/22/19). The Contract Wound Physician stated, This is correct .we did not see the area she was describing . The Contract Wound Physician confirmed he did not accurately assess the wound until 3/2/19 when it had deteriorated to an unstageable wound with eschar. The Contract Wound Physician recommended Santyl Ointment (an ointment that breaks up and removes dead tissue) as the treatment for [REDACTED]. The orders were not written for treatment changes and the lab test. The Contract Wound Physician was asked about his note on 3/2/19. The Contract Wound Physician stated, .incomplete exam (on 2/22/19) .did not see the area in question. That is why the treatment very much changed . Interview with Licensed Practical Nurse (LPN) #1 on 3/20/19 at 6:05 PM in the Conference Room, LPN #1 was asked if she knew why the order for the Santyl for Resident #15 was not written. LPN #1 stated, I guess the nurse forgot to write the order . LPN #1 was asked who forgot to write the order. LPN #1 stated, Me. Interview with the Contract Wound Physician on 3/22/19 at 1:28 PM in the Conference Room, the Contract Wound Physician was asked about his visit with Resident #15 on 3/2/19. The Contract Wound Physician stated, .the first night I saw him I did not see this one .I missed this area . The Contract Wound Physician was asked if it could have made a difference if it had been identified earlier. The Contract Wound Physician stated, It could have . The facility's failure to assess Resident #15's skin, identify a pressure ulcer before it became an unstageable pressure ulcer with eschar that evolved to a Stage 3 and provide timely treatments to the pressure ulcer placed Resident #15 in Immediate Jeopardy. 3. Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed Resident #22 had significant cognitive impairment, required extensive assistance from staff, was at risk for developing pressure ulcers, and had moisture associated skin damage. The care plan dated 12/19/17 and revised on 9/17/18 documented, .at increased risk for alteration in skin integrity .Interventions .Skin will be checked during routine care on a daily basis and during the weekly/bi-weekly bath or shower schedule .Any skin integrity issues/concerns will be conveyed to the Charge Nurse for further evaluation and/or Treatment changes/new interventions and the MD will be called PRN .CNA shower/skin observations to be reported to the nurse for any unusual findings/changes in the residents skin integrity . Review of the facility's Skin Monitoring .Comprehensive CNA Shower Review between 2/1/19 and 3/15/19 revealed Resident #22 received 2 body audits during the 43 days. A physician's order dated 10/25/18 documented, .Venelex (an ointment to promote wound healing) ointment to bilateral buttocks q (every) shift for wound care to buttocks . Further review revealed no other treatment orders. This order was the only wound treatment order for Resident #22 between 10/25/18 and 3/20/19. A nurses' progress note dated 2/8/19 documented, .she has 2 open wounds on her sacrum/coccyx .One is located in the center at the top of her sacrum and other is on her right buttock .[MEDICATION NAME] (Venelex, an ointment to promote wound healing) applied to wounds . There was no documentation that a physician or nurse practitioner was notified of the 2 new pressure ulcers. The 10/25/18 Venelex order was the only pressure ulcer treatment order documented for Resident #22. A Weekly Skin Review dated 2/12/19 documented, .Area of redness and excoriation to buttocks noted and still under previous treatment of [REDACTED]. Observations in Resident #22's room on 3/20/19 at 9:00 AM with LPN #1 revealed an unidentified small shallow open crater in the mid-coccyx region with a bright red wound bed and no slough. There was no dressing on the pressure ulcer. Observations and interview with the Contract Wound Nurse Practitioner on 3/21/19 at 10:30 AM in Resident #22's room revealed Resident #22 had a dressing over the pressure ulcer but the dressing was not intact. The Contract Wound Nurse Practitioner examined the dressing on the coccyx and stated, This is a problem .not adhered (to the skin) . and confirmed the wound should be covered. The Contract Wound Nurse Practitioner assessed the wound as a Stage 2 .3 by .3 by .1 (0.3 (cm) by 0.3 (cm) by 0.1 (cm) . These were the first measurements obtained for this pressure ulcer. A Contract Nurse Practitioner's Wound Consult note dated 3/21/19 documented, .Stage 2 pressure injury to coccyx .use Venelex ointment .Cover with absorbent foam dressing .Cleanse with NS (Normal Saline) at each dressing change and change daily . The recommendation was ordered on [DATE]. Interview with the ADON/Treatment Nurse on 3/22/19 at 3:55 PM, in the Conference Room, the ADON was asked if a physician or nurse practitioner had been notified about the new wounds identified on Resident #22 on 2/8/19. The ADON stated, I do not see documentation there. The ADON was asked about Resident #22's Stage 2 sacral wound. The ADON stated, That's new. The facility's failure to assess Resident #22's skin, identify a pressure ulcer and provide timely treatment resulted in Harm to Resident #22 and placed Resident #22 in immediate Jeopardy. 4. Medical record review revealed Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS dated [DATE] documented a BIMS of 3 indicating severe cognitive impairment. The resident had 1 stage 2 pressure ulcer and 1 unstageable that was present upon admission. The care plan for Resident #33 dated 2/24/19 documented, has an alteration in skin integrity and is at risk for additional and/or worsening of skin integrity issues related to .unstageable to left buttock at sacrum and Stage 2 to left buttock distal to sacral ulcer .Skin will be checked during routine care on a daily basis and during the weekly/Bi-weekly bath or shower schedule .Weekly measurements and documentation .Administer Wound Care (Treatments) per MD orders . Review of Resident #33's Skin Monitoring Comprehensive CNA Shower Review sheets dated 2/6/19 to 3/15/19 revealed Resident #33 did not receive body audits 35 of 37 days since admission. Review of the nurse's progress notes on 2/6/19 revealed there was not a complete assessment with measurements of the pressure ulcer documented for Resident #33. The Admission Nursing note dated 2/6/19 documented, .Decubitus on Both Buttocks (unstageable pressure ulcer to left buttock at sacrum and Stage 2 pressure ulcer to left buttock distal to sacral ulcer documented on care plan) . The facility was unable to provide a Braden scale (an assessment tool that reflected the likelihood of a resident developing a pressure wound) assessment since Resident #33's admission. The Skin Assessment for Resident #33 dated 2/7/19 documented, .Sacrum .pressure .Length .3 .Width .2 .Depth .0.1 .Unstageable . The physician's orders dated 2/8/19 documented, Santyl Ointment 250 UNIT/GM (gram) .Apply to sacrum topically every day shift for pressure ulcer (Unstageable) .Venolex ointment .apply to left buttock topically every other day shift (Stage 2 pressure ulcer) . A Contract Wound Nurse Practitioner's note for Resident #33 dated 2/8/19 documented, .Wound Consult Note .Referred for evaluation of buttock/sacral deep tissue injury .Left buttock at sacrum has 3 x (by) 2 x 0.1 cm unstageable pressure ulcer with 100% adherent slough .Use Santyl on the sacral ulcer .Cover with foam dressing. Change daily . The facility was unable to provide pressure ulcer assessments from 2/8/19 to 2/22/19. The Contract Wound Physician's INITIAL WOUND EVALUATION & MANAGEMENT SUMMARY for Resident #33 dated 2/22/19 documented, .Stage .Unstageable Necrosis .Size .3.0 x 2.5 x 0.5 cm .Santyl apply once daily . The Contract Wound Physician's .WOUND EVALUATION & MANAGEMENT SUMMARY dated 3/2/19 documented no change in the wound measurements. The physician performed a surgical excisional debridement procedure. The facility was unable to provide any pressure ulcer assessments from 2/22/19 to 3/2/19. The Contract Wound Physician's WOUND EVALUATION & MANAGEMENT SUMMARY dated 3/8/19 documented, .Sacrum .Stage .4 .Size .2.8 x 2.4 x 0.7 cm .SURGICAL EXCISIONAL DEBRIDEMENT PR[NAME]EDURE . The Contract Wound Nurse Practitioner's note dated 3/15/19 documented, .Wound Consult Follow-Up .Stage 3 pressure injury to the coccyx .measures 2.5 (cm) x 1.5 (cm) x 0.3 (cm) . This was the same pressure ulcer the Contract Wound Physician described as a Stage 4 to the sacrum. The facility was unable to provide any pressure ulcer assessments from 3/2/19 to 3/15/19 performed by nursing staff. Review of the (MONTH) and (MONTH) TARs revealed there was no Santyl documented as administered to the sacrum on 2/9/19, 2/26/19, 3/7/19, 3/9/19, 3/12/19, 3/13/19, 3/15/19, 3/16/19, 3/18/19, and 3/19/19 and the Venolex ointment was not applied to the left buttock on 2/26/19, 3/7/19, 3/9/19, 3/12/19, 3/16/19, and 3/18/19. Observation and interview in Resident #33's room with the Contract Nurse Practitioner on 3/21/19 at 9:45 AM, revealed a border gauze (with no date or initials) on the sacral area. The Contract Nurse Practitioner stated, border gauze .6 (cm) x 6 (cm) on sacral area .not labeled (initialed) or dated . The surveyor was unable to determine the date of the last treatment as the dressing was not initialed or dated. Interview with the ADON/Treatment Nurse on 3/20/19 at 5:57 PM in the Conference Room, the ADON was asked if a Braden scale had been completed for Resident #33. The ADON stated, I don't see one for her . Interview with LPN #3 on 3/21/19 at 1:26 PM in the Conference Room, LPN #3 was asked about Resident #33's pressure ulcer assessments. LPN #3 stated, .Since I've gone to day shift, I've been so busy I can't remember the last time I did a skin assessment . Interview with the ADON/Treatment Nurse on 3/22/19 at 12:53 PM in the Conference Room, the ADON was asked if the Santyl treatments were documented daily on the TARs as ordered. The ADON stated, There is a hole on 2/9 (2/9/19) and the 26th (2/26/19) .there are several undocumented holes or spots, 3/7/19, 3/9/19, 3/12/19, 3/13/19, 3/15/19, 3/16/19, 3/18/19 and 3/19/19 . The ADON was asked if there should have been a pressure ulcer assessment between 2/8/19 and 2/22/19. The ADON stated, Yes, there should be. I do not see it . Interview with the DON on 3/23/19 at 6:20 PM in the Conference Room, the DON was asked if the care plan intervention to measure the pressure ulcer weekly should have been implemented. The DON stated, Yes. The facility's failure to assess Resident #33's wound and provide consistent treatments to prevent the pressure ulcer from evolving to a Stage 4 placed Resident #33 in Immediate Jeopardy. 5. Medical record review revealed Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed Resident #35 had severely impaired cognition, was dependent on staff for all activities of daily living, was at risk for developing pressure ulcers, and had a Stage 4 pressure ulcer that was not present on admission. The care plan dated 1/5/17 and revised 11/14/18 documented, .resident is at increased risk for alteration in skin integrity .Skin will be checked during routine care on a daily basis and during the weekly/Biweekly bath or shower schedule .Any skin integrity issues/concerns will be conveyed to the Charge Nurse for further evaluation and/or treatment changes/new interventions and the MD will be called PRN .Weekly measurements and documentation .Initiate upon .onset of wound all facility wound care protocol .Administer Wound Care (Treatments) per MD orders . A physician's order for Resident #35 dated 6/27/18 documented, .Coccyx .clean with saline, apply Venelex, cover with a foam dsg (dressing) q (every) day shift every 3 day(s) . Review of the (MONTH) (YEAR) TAR revealed this treatment was not provided on 9 of 10 treatment days in July. A Change of Condition progress note dated 6/28/18 documented, .Resident has scar tissue in this area and history of two healed ulcers there .Two small areas in the crease of buttock, top measures 0.5 (cm) x0.5 (cm) x0.1 cm, bottom measure 0.8 (cm)x0.5 (cm)x 0.1 cm . Medical record review of the WOUND CARE SPECIALIST EVALUATION form revealed the Contract Wound Physician examined Resident #35 on 6/29/18 and measured the sacral wound. The wound was 1.2 cm long, 0.6 cm wide, and 0.2 cm deep. The Contract Wound Physician recommended Leptospermum honey be applied once daily. He instructed a nursing staff member of the order but the order was not transcribed. Review of the (MONTH) and (MONTH) physician orders revealed no order for the Leptospermum honey. Review of the (MONTH) (YEAR) TAR revealed Resident #35 received a treatment of [REDACTED]. The recommendation from the Contract Wound Physician was not communicated to the physician. Medical record review of Resident #35's SPECIALTY PHYSICIAN WOUND EVALUATION MANAGEMENT SUMMARY revealed the Contract Wound Physician examined Resident #35 on 7/23/18 and recommended Zinc Ointment every shift for the wound treatment, communicated this recommendation to a nursing staff member, but an order was not transcribed and Resident #35 did not receive the Zinc Ointment as recommended. A Weekly Skin Review dated 7/30/18 documented, .moisture damage to coccyx area .Treatment plan in place . There was no documentation that the moisture damage was reported to a physician or nurse practitioner. Review of Nursing Notes, Weekly Skin Reviews and Skin Assessments between 7/28/18 and 8/5/18 revealed no documentation of a description or measurements of the sacral pressure ulcer. Medical record review of Resident #35's SPECIALTY PHYSICIAN WOUND EVALUATION MANAGEMENT SUMMARY revealed the Contract Wound Physician examined Resident #35 on 8/11/18. The sacral wound had enlarged from a length of 0.2 cm, width of 0.2 cm, and no depth to a length of 0.6 cm, width of 0.4 cm and depth of 0.3 cm and was described as deteriorated. The Contract Wound Physician recommended Leptospermum Honey and Zinc Ointment every shift daily for the wound treatment. This recommendation was communicated to a nursing staff member. There was no order for this recommendation. The facility was unable to provide documentation that any treatments were provided for Resident #35's sacral pressure ulcer in August. Review of the Weekly Skin Review, Weekly Skin Sheets, and progress notes between 8/11/18 and 9/1/18 revealed no documentation of a description of the wound with measurements. A Weekly Skin Review dated 8/19/18 documented, .Coccyx .Stage III (3) Size of a dime . There was no documentation that the Stage 3 pressure ulcer was reported to a physician or nurse practitioner. A Weekly Skin Review dated 8/29/18 documented, .tx (treatment) in place for sacrum and wound doctor visits weekly . Review of the Contract Wound physician progress notes [REDACTED].#35 by the Contract Wound Physician between 8/11/18 and 9/1/18. Review of Resident #35's physician's orders and TARs revealed the facility did not provide pressure ulcer treatments for Resident #35 from 7/11/18 until 9/19/18. Medical record review of Resident #35's SPECIALTY PHYSICIAN WOUND EVALUATION MANAGEMENT SUMMARY revealed the Contract Wound Physician examined Resident #35 on 9/1/18 and obtained measurements of the sacral wound with a length of 0.8 cm, width of 0.5 cm, and depth of 0.3 cm. The Contract Wound Physician recommended Leptospermum honey daily and Zinc Ointment around the wound every shift. He communicated this change in treatment to a nursing staff member. There was no order for this pressure ulcer treatment recommendation. A treatment order for Resident #35 dated 9/18/18, signed by the Medical Director, documented, .Sacrum .clean with saline .apply antimicrobial silver dsg (dressing) .cover with foam dsg qod (every other day) .for pressure ulcer stage 3 . This was the first treatment order prescribed for Resident #35's sacral pressure ulcer since identification of the pressure ulcer on 6/27/18. Review of the (MONTH) (YEAR) TAR revealed the order was transcribed on the TAR on 9/19/18. The treatment was administered daily between 9/19/18 and 9/25/18 instead of every other day as ordered. This treatment was not provided on 9/27/18. Review of Resident #35's Nursing Notes, Weekly Skin Reviews and Skin Assessments between 9/1/18 and 9/28/18 revealed no description or measurements of Resident #35's sacral pressure ulcer. Medical record review revealed the Contract Wound Physician examined Resident #35 on 9/22/18 and obtained measurements of the sacral pressure ulcer with a length of 2.0 cm, width of 1.2 cm, depth of 0.5 cm, and described the wound as deteriorated. The Contract Wound Physician recommended Leptospermum honey and Skin Prep around the pressure ulcer daily for the pressure ulcer treatment, and he communicated this recommendation to a nursing staff member. There was no order for this recommended pressure ulcer treatment. A Contract Wound Nurse Practitioner Wound Consult Note for Resident #35 dated 9/28/18 documented, .Referred for evaluation of new buttock pressure ulcer .Pt (patient) is known to me from previous treatment few years ago for pressure ulcer in same location .Coccyx area with stage 4 pressure injury .measures 1.3 (cm) x 0.4 (cm) x0.3 cm .0.5 (cm) area of fascia (connective tissue) exposed .Moderate serous exudate noted .Use silver alginate cut slim to fit into the wound in 2 layers .Cover with foam dressing .daily .Cleanse with NS at each dressing change and use skin protectant wipe on periwound skin prior (TRUNCATED)",2020-09-01
421,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2019-03-26,698,D,0,1,2LOM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, contractual agreement, medical record review, and interview, the facility failed to provide appropriate [MEDICAL TREATMENT] care and services for 1 of 1 (Resident #28) sampled residents reviewed for [MEDICAL TREATMENT]. The findings included: 1. The facility's undated Community [MEDICAL TREATMENT] policy documented, .The facility will obtain orders from the physician for the resident [MEDICAL TREATMENT] days which will be written on the physician order [REDACTED].bleeding from the [MEDICAL TREATMENT] . The facility's undated Assessment of Arterio Venus (Arteriovenous) Shunts, Fistulas & (and) Grafts policy documented, .It is the policy of this facility to evaluate arterio venous shunts, fistulas and grafts by a licensed nurse to facilitate early detection of potential complications which include signs and symptoms of infection, leakage or [MEDICAL CONDITION] .Document Completion of assessment on proper form or TAR (Treatment Administration Record) . 2. The facility's SNF (Skilled Nursing Facility) OUTPATIENT [MEDICAL TREATMENT] SERVICES AGREEMENT dated 1/21/19 documented, .Interchange of Information .The Nursing Facility Shall provide for the interchange of information useful or necessary for the care of the [MEDICAL CONDITION] (End Stage [MEDICAL CONDITION]) Residents, including a Registered Nurse as a contact person at the Nursing Facility whose responsibilities include oversight of provision of Services to the [MEDICAL CONDITION] Residents .Collaboration of Care .Both parties shall ensure that there is documented evidence of collaboration of care and communication between the Nursing Facility and [MEDICAL CONDITION] [MEDICAL TREATMENT] Unit . 3. Medical record review revealed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] and 30 day assessment dated [DATE] documented the resident received [MEDICAL TREATMENT]. The care plan for Resident #28 dated 2/5/19 documented, .The resident is in [MEDICAL CONDITION] & receives [MEDICAL TREATMENT] treatment and management .M (Monday)-W (Wednesday)-F (Friday) at (Named [MEDICAL TREATMENT] Clinic) .interventions .Monitor Access site for abnormal bleeding and/or Signs and Symptoms of Infection. Review of the physician's orders [REDACTED].#28 to receive [MEDICAL TREATMENT] services. Review of the facility's [MEDICAL TREATMENT]/Observation Communication Form for Resident #28 dated 2/15/19, 3/1/19 and 3/11/19 revealed the facility failed to complete the pre-assessment. Review of the facility's [MEDICAL TREATMENT]/Observation Communication Form dated 2/13/19, 2/15/19, 2/18/19, 2/20/19, 2/22/19, 2/25/19, 2/27/19, 3/1/19, and 3/4/19 revealed the facility failed to complete the post assessment. Review of the facility's [MEDICAL TREATMENT]/Observation Communication Form dated 3/1/19 and 3/11/19 revealed 2 documented statements from the [MEDICAL TREATMENT] center asking the facility to complete the communication form. Interview with the Director of Nursing (DON) on 3/13/19 at 11:49 AM, in the Conference Room, the DON confirmed that there were no written physician's orders [REDACTED].",2020-09-01
422,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2019-03-26,812,D,0,1,2LOM11,"Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were followed during dining when 2 of 13 (Certified Nursing Assistant (CNA) #1 and #2) staff members returned a potentially contaminated meal tray to the cart containing clean food trays and failed to distribute and serve food and beverages in a sanitary manner by not following the facility's hand hygiene policy. The findings include: 1. The facility's undated Hand Hygiene policy documented, .Hand hygiene is the single most efficient means of preventing the spread of infection .Hand Washing Procedure .Wet hands with warm water .Apply .soap to hands and rub hands together vigorously .Rinse hands with warm water and dry with a disposable towel .Use towel to turn off faucet . 2. Observations in Resident #27's room on 3/11/19 at 11:29 AM, revealed CNA #1 took a meal tray into the room, removed the cover from the plate and allowed Resident #27 to look at the food. Resident #27 looked at the plate of food and bent over the plate to smell the food. Resident #27 told CNA #1 she did not want it. CNA #1 carried the tray out of the room, and placed it on the meal cart with the clean trays. Interview with the Director of Nursing (DON) on 3/13/19 at 12:17 PM, in the Conference Room, the DON was asked if it was appropriate for a CNA to take a meal tray into a resident's room, remove the cover and allow the resident to smell the food, and then return that tray to the meal cart with the clean trays. The DON stated, No, Ma'am. Observations in Resident #28's room on 3/12/19 at 5:33 PM, revealed CNA #2 performed hand hygiene at the sink after delivering the meal tray to the resident and turned the faucet off with her bare hand. Observations in Resident #24's room on 3/12/19 at 5:38 PM, revealed CNA #2 performed hand hygiene at the sink after delivering the meal tray to the resident and turned the faucet off with her bare hand. Interview with the DON on 3/13/19 at 12:14 PM, in the Conference Room, the DON was asked if it was appropriate to turn off the faucet with a bare hand during hand hygiene. The DON stated, .No it is not .rinse and obtain a towel and turn the water off with the towel .",2020-09-01
423,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2019-03-26,835,K,0,1,2LOM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the Board of Examiners of Nursing Home Administrators (BENHA) form, Administrator's Job Description, Director of Nursing (DON) Job Description, medical record review, observation, and interview, the Administrator failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain and maintain the highest practicable well-being of the residents. Administration failed to review shower sheet completion, and failed to provide oversight and training of contract and permanent staff to prevent the development and deterioration of wounds. The Administration's failure placed Residents #15, #22, #23, , #33, #35, and #344 in Immediate Jeopardy when staff did not assess, report implement, evaluate or treatment for [REDACTED]. An Immediate Jeopardy (IJ) is 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 Regional Director of Operations, Regional Nurse Consultant, Interim Administrator, Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Business Office Manager, and the Admissions Director were notified of the Immediate Jeopardy on 3/23/19 at 9:00 PM in the Conference Room. The facility was cited at scope and severity of Immediate Jeopardy for F684-K and F686-K which is Substandard Quality of Care, F580-K, F658-K, F659-K, F726-K, F835-K, F837-K, F838-K, F841-K, and F865-K. The Immediate Jeopardy was effective 8/11/18 through 3/26/19. An extended survey was conducted on 3/24/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the jeopardy, was received on 3/25/19 at approximately 5:00 PM, and the corrective actions were validated onsite by the surveyors on 3/25/19 and 3/26/19 through review of assessments, auditing tools, in-service training records, policies, Quality Assurance Performance Improvement (QAPI) meeting minutes, observations, and staff interviews. The noncompliance continues at F835-E for monitoring of effectiveness of the corrective actions. The findings include: Review of the facility's BENHA form revealed the facility had employed 4 Administrators since the last annual survey conducted on 5/9/18. The facility's Administrator Job Description undated documented, .leads and directs the overall operation of the facility in accordance with resident needs, federal and state government regulations and company policies/procedures so as to maintain quality care for the residents .Works with the facility management staff and consultants in planning all aspects of facility's operations, including setting priorities and job assignments .Monitors each department's activities, communicates policies, evaluates performance .Conducts regular rounds to ensure resident needs are being addressed, monitors operations of all departments .Ensures consultants and other support resources are appropriately utilized and a high level of inter-departmental teamwork is maintained .Maintains a working knowledge and ensures compliance with all governmental regulations and company Quality Assurance Standards .Promotes practices that maintain staff retention .Manages turnover and ensures adequate staffing through development of recruitment sources, and through appropriate selection, orientation, training, and staff education .Supervises, conducts and participates in department and facility education activities and staff meetings . The facility's undated Director of Nursing Job Description documented, .Under the supervision of the Administrator, has authority, responsibility, and accountability for the functions, activities, and training of the nursing services staff .In the absence of the Administrator, assumes responsibility for the facility. The Director of Nursing (DON) is responsible for the overall management of resident care 24 hours a day, seven (7) days per week .Demonstrated knowledge, skills and techniques necessary to care for residents with the following needs .wound care .active member of the interdisciplinary team .Ensures the residents receive skilled nursing .Assists in the recruitment, interviewing and selection of nursing personnel .Conducts periodic review to ensure all documentation is informative and descriptive of nursing care and of the resident's response to that care .Audits specific resident care issues on a daily basis such as skin .Observes all pressure sores on a weekly basis, evaluating documentation and treatments .Checks for documentation initiation .physician orders, initial assessments, nursing care plan .Care Plans are to match monthly summaries .treatment sheets and physician orders [REDACTED]. Interview with the Administrator on 3/22/19 at 4:04 PM, in the Conference Room, the Administrator was asked what care and services should be in place to prevent pressure wounds and non-pressure wounds from deteriorating. The Administrator stated, I think it starts with the CNAs. They have the most face time with the resident and the shower sheets with the body audits .very important to utilize .the DON has to oversee the nurses to follow each policy that is set up .shower sheets handed to the nurses .the DON .make sure this is being done .a more specific orientation .Agency is a problem .you won't have continuity of care .the biggest problem is not having enough staff .the agency won't show up . The facility was unable to provide evidence shower sheets and body audits were done and treatment changes were implemented. Interview with the Interim Administrator on 3/23/19 at 11:01 AM, the Interim Administrator was asked what concerns had been identified recently in QAPI. The Interim Administrator stated, Staffing, use of agency staffing, call outs by staff, staff coming in late, recruiting to get more staff in the building .documentation and missed documentation .there is always a wound report in every QAPI meeting . The Interim Administrator was asked if the report is reviewed during the QAPI meeting. The Interim Administrator stated, .It depends if the wound nurse (Wound Nurse/ADON) has a problem . The Interim Administrator was asked if any wound problems had been discussed recently in the QAPI meetings. The Interim Administrator stated, .Not that I recall . Interview with the DON on 3/22/19 at 5:49 PM in the Conference Room, the DON was asked what her understanding of the standard of practice for pressure wounds and non-pressure wounds was. The DON stated, You want to assess it once identified, notify the physician .secure treatment, add your order to your TAR (Treatment Administration Record) so it can be done by the nurse. This building has a wound doctor and nurse practitioner but I am not sure how that process works here, if one sees some and one sees the other . The DON was asked about the shower sheet/body audits. The DON stated, They should be completed by the CNA and they should mark any areas that they see. It has to be signed by the charge nurse, the CNA needs to identify if there is a new area. They can always get myself or the ADON if they have trouble identifying it, or if it is MSD (moisture associated skin damage). The DON was asked what wounds should be documented on the wound assessment sheet. The DON stated, All wounds should be documented . The DON was asked if surgical wounds should be documented on the wound assessment sheet. The DON stated, Yes, Ma'am .I don't know if I would identify it as a wound. It could be both ways . The DON was asked how often the wounds should be assessed. The DON stated, They should be looking at the wound measurements weekly . The DON was asked if the wounds were not assessed, would that be a concern. The DON stated, Yes, that would be a problem . Administration failed to provide oversight of staff when they failed to ensure the consistent use of the shower sheet/body audits for each resident. The Administration failed to ensure nurses reviewed the shower sheet/body audits to ensure Certified Nursing Assistants (CNA) had completed them and to note any skin changes. Refer to F659, F684, and F686. Administration failed to ensure services were provided to attain or maintain the highest practical physical, mental, and psychosocial well-being in accordance with the plan of care by not implementing the interventions of the care plan for skin assessments, not performing wound assessments, obtaining physician orders [REDACTED]. The failure to follow the care plan interventions for wounds resulted in IJ for Resident #15, #22, #23, #33, #35, and #344. Refer to F658, F659, F684, and F686. 8. Administration failed to provide oversight and orientation to contract and permanent staff when nurses were allowed to work without completing orientation prior to beginning their shift, when nurses were not provided wound care inservices, and when shifts were staffed with contract nurses and no permanent staff. Refer to F686 and F726.",2020-09-01
424,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2019-03-26,842,D,0,1,2LOM11,"**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 accurate nursing documentation for 2 of 17 (Resident #15 and #38) sampled residents reviewed. The findings include: 1. The facility's undated Admission/Readmission orders [REDACTED].To ensure that all .orders provided to the facility either by the physician or physician extender is accurately documented and transcribed in the resident's medical record . 2. Medical record review revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].[MEDICATION NAME] 1.2 (tube feeding) (symbol for at) 60ML(milliliters)/HR (hour) via PEG (Percutaneous Endoscopic Gastrostomy) TUBE . Review of the facility's Medication Administration Record [REDACTED]. Review of the Nursing Progress Note dated 12/3/18, 12/4/18, 12/6/18, and 12/7/18 revealed [MEDICATION NAME] 1.2 was infusing at 60 ml/hr as ordered. Interview with the Director of Nursing (DON) on 3/13/19 at 9:04 AM, in the DON office, the DON was asked if there was documentation on the (MONTH) (YEAR) MAR for the [MEDICATION NAME] 1.2 tube feeding at 60 ML/hr between 12/3/19 and 12/13/19. The DON stated, I found a few nurses notes that charted he was receiving it, but it's not documented every day. The DON was asked if it was appropriate that nurses were not documenting Resident #38 was receiving the tube feeding as ordered. The DON stated, No, it is not acceptable. 3. Medical record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented, Discharge assessment-return anticipated . Review of Resident #15's nurses notes between 12/26/18 - 12/31/18, revealed there were no nurses notes to explain why Resident #15 was discharged to the hospital. The nurses note dated 1/1/19 documented, .re admitted ,[DATE] (12/29/18) . There were no nurses notes the first 3 days of Resident #15's readmission. Interview with the DON on 3/13/19 at 10:53 AM, at the West Nurse's Station, the DON was asked if she would expect the nurse to chart the resident's condition in the nurses notes. The DON stated, Yes. The DON was asked if there was a nurse's note when he was transferred to the hospital. The DON stated, I don't see a note.",2020-09-01
425,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2019-03-26,880,E,0,1,2LOM11,"**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 ensure practices to prevent the potential spread of infection were maintained for 2 of 2 (Resident #33 and 144) residents reviewed for isolation by not posting signs on the resident's door and when 2 of 3 (Registered Nurse (RN) #2 and Licensed Practical Nurse (LPN) #2) nurses did not perform hand hygiene during medication administration. The findings include: 1. Review of the facility's Initiation/Discontinuation of Isolation Precautions policy revised 6/24/12 documented, .Post an appropriate isolation sign on the door so that all personnel will be aware of isolation precaution and to alert visitor or families that the resident is on isolation precautions. 2. Medical record review revealed Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].Contact Isolation/VRE ([MEDICATION NAME]-Resistant [MEDICATION NAME]) . Observations in the hallway outside Resident #33's room on 3/11/19 at 9:50 AM, 3:10 PM, and on 3/13/19 at 7:35 AM, revealed there was no sign on the door indicating the resident was in isolation. 3. Medical record review revealed Resident #144 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].Isolation precautions for [MEDICAL CONDITIONS] . Observations in the hallway outside Resident #144's room on 3/11/19 at 11:03 AM and 5:53 PM, and on 3/13/19 at 2:53 PM and 5:34 PM, revealed there was no sign on the door indicating the resident was in isolation. Interview with RN #1 on 3/13/19 at 3:04 PM, outside Resident #144's room, RN #1 confirmed there was not a sign on the door and stated, .missing a sign that says to go to the nurses desk before entering. Interview with the Assistant Director of Nursing (ADON) on 3/13/19 at 3:24 PM, in the Conference Room, the ADON was asked if there should be a sign on the residents door who's in isolation. The ADON stated, .there should be a sign on the doors . 4. The facility's undated Hand Hygiene policy documented, .Hand hygiene is the single most efficient means of preventing the spread of infection .Decontaminate hands after removing gloves .Hand Washing Procedure .Wet hands with warm water .Apply .soap to hands and rub hands together vigorously .Rinse hands with warm water and dry with a disposable towel .Use towel to turn off faucet . Observation in Resident #29's room on 3/12/19 beginning at 7:59 AM, revealed RN #2 prepared to administer medications, donned her gloves, administered insulin, removed her gloves and failed to perform hand hygiene. RN #2 donned new clean gloves prior to performing a blood pressure check and administered Resident #29's oral medications. RN #2 did not perform hand hygiene after removing the gloves. RN #2 then donned clean gloves and administered Resident #29's eye drops. Observation in Resident #21's room on 3/13/19 beginning at 9:59 AM, revealed LPN #2 administered medications to Resident #21, performed hand hygiene and turned off the faucet with her bare hand. Interview with the DON on 3/13/19 at 12:14 PM, in the Conference Room, the DON was asked what she expected nurses to do after removing gloves and donning clean gloves. The DON stated, They should wash their hands. The DON was asked if it was appropriate to turn off the faucet with their bare hand when performing hand hygiene. The DON stated, No, it's not.",2020-09-01
426,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2017-05-09,225,D,0,1,TTUW11,"**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 investigate injuries of unknown origin for 1 resident (#4) of 28 residents reviewed. The findings included: Review of facility policy, Abuse Prevention Program, updated 1/19/17 revealed .The nursing staff is responsible for reporting the appearance of bruises .Such reporting will be documented in the Electronic Medical Record (EMR) under the Risk Management section .V.Investigation. All incidents will be documented, whether or not abuse occurred, was alleged or suspected . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 scored 2 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The Resident required extensive assistance of 2 people for transfers and bed mobility, and extensive assistance of 1 person for eating, toileting and personal hygiene. Medical record review of the Incident Note dated 4/18/17 revealed New bruises noted to resident of unknown origin .New bruise approximately 1.5 x (by) 1.5 cm (centimeters) not3 (noted) to left side of chin. Bruise approximately 3 cm x 4 cm noted to right bicep. Bruise approximately 11 cm x 4.5 cm noted to left flank Resident unable to verbalize exactly where bruises came from . Observation on 5/7/17 at 5:26 PM in Resident #2's room revealed the Resident had a bruise to the the left forearm. Interview with Certified Nursing Aide (CNA) #5 on 5/8/17 at 1:40 PM beside the nurses station revealed the CNA was familiar with Resident #2. On or about 4/17/17 the CNA noted a bruise on Resident #2's upper lip. Continued interview revealed the CNA thought it was food however when the CNA attempted to wipe the area it did not wipe off.' Further interview revealed the CNA notifed the charge nurse. Interview with Registered Nurse (RN) #1 on 5/8/17 at 2 PM at the nurses's station revealed RN #1 was familiar with Resident #2. Continued interview revealed RN #1 did not remember the Resident having a fall in the month of April. Further interview revealed RN #1 recalled Resident #2 pulled a dresser over which hit the Resident's head and foot. The Nurse did not remember the date. Interview with the Director of Nursing (DON) on 5/9/17 at 2:36 PM outside the Administrator's office revealed the facility did not have an incident report regarding Resident #2's bruises. Continued interview with the DON confirmed the facility failed to investigate the cause of Resident #2's bruises.",2020-09-01
427,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2017-05-09,241,D,0,1,TTUW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, medical record review, observation and interview, the facility failed to ensure medication was administered to 1 resident (#3) in a private and dignified manner. The findings included: Review of facility policy, 5.1: Drug Administration-General Guidelines, revealed .For residents not in their rooms or otherwise unavailable to receive medication on the pass, the MAR (Medication Administration Record) is 'flagged' per facility protocol. After completing the medication pass, the nurse returns to the missed resident to administer the medication . Medical record review revealed Resident #3 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 5/7/17 at 5:18 PM in the dining room revealed Licensed Practical Nurse (LPN #4) administered Resident #3's medication in a small plastic cup and then left the dining room after the medications were swallowed. Interview with LPN #4 on 5/7/17 at 5:58 PM at the nurse's station confirmed she administered medications to Resident #3 in the dining room. LPN #4 confirmed this was not normal practice and she generally administered medication to residents in their rooms. Interview with Director of Nursing (DON) on 5/9/17 at 4:50 PM outside the conference room confirmed medication was not to be administered in the dining room.",2020-09-01
428,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2017-05-09,242,D,0,1,TTUW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, interview, shower schedule review, and observation, the facility failed to honor the resident's choice for showers for 1 resident (#65) and failed to honor the days for showering for 1 resident (#94) of 28 residents reviewed in the stage 2 sample. The findings included: Review of facility policy, Resident Rights revealed .Self Determination- You may choose your own activities, schedules and health care and any other aspect significant to and affecting your life within the facility . Medical record review revealed Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a 14 day Minimum Data Set ((MDS) dated [DATE] revealed the resident was cognitively intact. Continued review revealed it was very important for the resident to choose between a tub bath, shower, bed bath, or sponge bath. Interview with Resident #65 on 5/7/17 at 7:30 PM in the resident's room revealed when the resident was asked if he was able to choose between a tub bath, bed bath or shower, the resident stated No. Continued review revealed when asked if he was able to choose how many times he took a shower or bath, the resident stated, No, not really. I want a shower so I can get my head wet, but they give me a bed bath most of the time. Review of the Shower Schedule revealed Resident #65 was scheduled to receive a shower on Monday, Wednesday, and Friday each week during day shift (7:00 AM-3:00 PM). Interview with Certified Nurse Aide (CNA) #3 on 5/8/17 at 3:10 PM in the 100 Hall confirmed she was assigned to the resident regularly. Continued interview confirmed the CNA did not assist Resident #65 with a shower as scheduled. Interview with Resident #65 on 5/9/17 at 2:45 PM in the resident's room confirmed he did not receive a shower on Monday 5/8/17. Continued interview revealed the resident stated he asked for a shower 3 different times during the afternoon and evening and was told he would receive a shower that evening, but did not. Interview with the Director of Nursing (DON) on 5/9/17 at 3:30 PM in the Administrator's Office confirmed Resident #65 did not receive a shower per his choice and the shower schedule. The DON confirmed the facility failed to honor the resident's choice for showering. Medical record review revealed Resident #94 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 5-day MDS dated [DATE] revealed Resident #94 scored 9 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. Resident #94 required extensive assistance of 2 persons for bed mobility, and assistance of 1 person for transfers, dressing, eating, toileting, and personal hygiene. Review of a Psychosocial Well-Being assessment dated [DATE] revealed Resident #94's choice was for a shower bath in the mornings on a Tuesday, Thursday, and Saturday schedule. Observation on 5/7/17 at 4:07 PM in Resident #94's room revealed the Resident lying in bed wearing a hospital gown, able to respond to yes-no questions but unable to respond to complex questions such as how was your meal? Phone interview with a family member on 5/8/17 at 9:40 AM revealed the family member visits daily. Further interview revealed Resident #94 was in a state of mental and physical decline when the Resident was admitted to the facility and was unable to communicate choices. However the family member notified the staff the Resident showered daily at 6:00 AM when at home. Continued interview revealed the Resident had a bed bath on Wednesday 5/3/17 and had not received a shower since then. Interview with CNA #5 on 5/8/17 at 1:40 PM at the nurse's station revealed the facility did not have a process for communicating residents' choices for baths to CNAs. Continued interview revealed the CNA was not aware of Resident #94's shower choice. Interview with Resident #94 on 5/9/17 at 1:27 PM in the Resident's room revealed the Resident had a bed bath today, but preferred a shower. Interview with Licensed Practical Nurse (LPN) #1 on 5/9/17 at 1:35 PM at the nurse's station revealed the nurse was unaware of a facility process that ensured Certified Nursing Aides (CNAs) gave residents showers according to the Residents' choices. Interview with CNA #5 on 5/9/17 at 2:48 PM in the hallway in front of the linen closet revealed Resident #94 was on a Monday, Wednesday, and Friday shower schedule. Continued interview revealed Resident #94 received a bed bath instead of a shower. Interview with the DON on 5/9/17 at 2:36 PM at the unused nurse's station revealed the facilty expected residents' choices for Tuesday, Thursday, and Saturday bathing to be honored. Continued interview revealed the facility expected staff to honor residents' choice for showers in place of baths. Further interview revealed the facility expected staff to give residents' baths daily if that was the Residents' choice. The DON confirmed that the facility lacked a process for ensuring CNA's gave the Resident's showers according to the Residents' choice.",2020-09-01
429,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2017-05-09,278,D,0,1,TTUW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to accurately reflect the resident's status for 1 resident (#28) of 28 residents reviewed. The findings included: Medical record review revealed Resident #28 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 no functional impairments for upper extremities or lower extremities. Medical record review of an Occupational Therapy Plan of Care dated 4/14/17 revealed .right forearm supination limited to 20 degrees . and a Physical Therapy Plan of care dated 12/21/16 .bilateral plantarflexion joint contractures . Observation of Resident #28 on 5/8/17 at 8:34 AM in her room revealed the resident had bilateral foot, right elbow and right shoulder limited range of motion. All functional impairments were confirmed by Licensed Practical Nurse (LPN) #4 at that time. Interview with Physical Therapy Assistant (PTA #1) on 5/9/17 at 1:20 PM in the therapy department confirmed Resident #28 has bilateral foot drop. Interview with Registered Nurse (RN #2), MDS Coordinator and Restorative Nursing Program Director on 5/9/17 at 2:34 PM at the east wing nurse's station confirmed the facility failed to accurately assess the resident's functional status for her upper and lower extremities on the Quarterly MDS.",2020-09-01
430,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2017-05-09,281,D,0,1,TTUW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to provide services to meet professional standards for 2 Residents (#28, #80) of 5 residents reviewed for [MEDICAL CONDITION] medications. The findings included: Medical record review revealed Resident #28 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed a physician's orders [REDACTED]. Medical record review dated 12/21/16, revealed Physical Therapy follow up recommendations/approaches: .Patient to perform supine (b) (bilateral) LE (lower extremities) AROM (active range of motion) and PROM (passive range of motion) exercises in bed to tolerance, in all planes, 3 x (times) 10 . This plan was signed by 1 RNP (Restorative Nurse Program) staff and 3 FMP (Functional Maintenance Program) staff. Medical Record review of a Quarterly Minimum Data Set ((MDS) dated [DATE], revealed 0 days of passive or active ROM (range of motion). Further review, revealed 0 days of splint or brace assistance. Medical record review of an Occupational Therpapy Plan of Care dated 4/4/17 revealed, Discharge Plans: .Patient to remain as LTC (long term care) resident at this facility with FMP for recommended set-up/AE (adaptive equipment) during meals and RNP to maintain therapy gains . This document was signed by the resident's Physician. Observation of Resident #28 on 5/8/17 at 8:34 AM in her room revealed the resident had bilateral foot, right elbow and right shoulder limited range of motion. These limitations were confirmed by Licensed Practical Nurse (LPN) #4 at that time. Interview with LPN #1 on 5/9/17 at 8:43 AM at the west hall nurse station reported Resident #28 was not in the RNP program. Interview with Registered Nurse (RN) #2, MDS Coordinator and Restorative Nursing Program Director, on 5/09/17 at 2:34 PM at the east wing nursing station confirmed the facility failed to provide follow up ROM exercises in either of the RNP or the FMP. Resident #80 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physicians Orders dated 5/2017 revealed [MEDICATION NAME] tablet 25 milligram (mg), give 1 tablet by mouth 2 times a day, [MEDICATION NAME] tablet 20mg, 1 tablet by mouth daily, and [MEDICATION NAME] 0.5mg every 8 hours as related to Dementia with behavioral disturbances. Medical record review of the Physicians Orders revealed no order to monitor side effects of [MEDICAL CONDITION] medications for Resident #80. Medical record review of the Medication Administration Records (MAR) dated 12/2017 - 5/2017 revealed no order for monitoring side effects for [MEDICAL CONDITION] medications for Resident #80. Interview with the Director of Nursing on 5/9/17 at 7:37 AM in the Administrator's office confirmed the facility had failed to obtain an order to monitor side effects of [MEDICAL CONDITION] medications for Resident #80.",2020-09-01
431,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2017-05-09,282,D,0,1,TTUW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to monitor and document behaviors for [MEDICAL CONDITION] drug use for 1 Resident (#39) of 5 Residents reviewed for [MEDICAL CONDITION] drug use. The findings included: Review of facility policy, Behavior Management Guideline, revised date of 3/30/16 revealed .The Director of Nursing Service/designee coordinated inservice education to all nursing staff related to behavior management .Documentation requirements . Medical record review revealed Resident #39 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED].with Severe Psychotic Features. Medical record review of the Medication Administration Record (MAR) dated 2/2017 - 5/8/17 revealed the resident recieved the following [MEDICAL CONDITION] medications: [MEDICATION NAME] Sodium (antidepressant), [MEDICATION NAME] (antipsychotic), and [MEDICATION NAME] (antianxiety). Review of the care plan dated 03/20/17 revealed .behaviors which include aggressive behaviors towards others .Interventions .monitor for target behaviors/symptoms of paranoia and delusional thinking and document . Medical record review revealed no documentation of monitoring for behaviors with the use of [MEDICAL CONDITION] medications since 4/2016. Interview with Licenced Practical Nurse (LPN #1) on 5/9/17 at 8:37 AM at the nurses station revealed the monitoring of behaviors was to be documented on the MAR. Continued interview confirmed no monitoring of behaviors had been documented on the MAR from 2/1/2017-5/8/17. Continued interview confirmed an order to discontinue behavior monitoring for antipsychotic and antianxiety medications on 4/14/16. Continued interview revealed LPN #1 was not sure why the order for behavior monitoring was discontinued. When asked if monitoring for behaviors had been completed and documented since 4/14/16, LPN #1 responded I guess not. LPN #1 confirmed the facility failed to monitor and document behaviors for [MEDICAL CONDITION] drug use for Resident #39. Interview with the Director of Nursing on 5/9/17 at 11:57 AM in the conference room revealed licensed staff are expected to document behaviors for residents receiving [MEDICAL CONDITION] medications on the MAR. Continued interview confirmed the facility failed to document behaviors for Resident #39.",2020-09-01
432,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2017-05-09,317,D,0,1,TTUW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to prevent a reduction in range of motion for 1 resident (#28) of 3 residents reviewed for range of motion. The findings included: Medical record review revealed Resident #28 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed a physician's orders [REDACTED]. Medical record review dated 12/21/16 revealed Physical Therapy follow up recommendations/approaches: .Patient to perform supine (b) (bilateral) LE (lower extremities) AROM (active range of motion) and PROM (passive range of motion) exercises in bed to tolerance, in all planes, 3 x (times) 10 . This plan was signed by 1 Restorative Nurse Program (RNP) staff and 3 Functional Maintenance Program (FMP) staff. Medical Record review of a Quarterly Minimum Data Set ((MDS) dated [DATE], revealed 0 days of passive or active ROM (range of motion). Further review revealed 0 days of splint or brace assistance. Medical record review of Occupational Therapy Plan dated 4/4/17 revealed Discharge Plans: .Patient to remain as LTC (long term care) resident at this facility with FMP for recommended set-up/AE (adaptive equipment) during meals and RNP to maintain therapy gains . This document was signed by the resident's Physician. Observation of Resident #28 on 5/8/17 at 8:34 AM, in her room revealed the resident had bilateral foot, right elbow and right shoulder limited range of motion. These limitations were confirmed by Licensed Practical Nurse (LPN) #4 at that time. Interview with LPN #1 on 5/9/17 at 4:40 PM revealed this resident did not have foot drop at the time of admission. Interview with Registered Nurse (RN) #2, MDS Coordinator and Restorative Nursing Program Director on 5/09/17 at 2:34 PM at the east wing nursing station confirmed the facility failed to provide follow up ROM exercises in either of the RNP or the FMP.",2020-09-01
433,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2017-05-09,318,D,0,1,TTUW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to provide appropriate treatment and services to increase range of motion or to prevent further decrease in range of motion for 1 resident (#28) of 3 residents reviewed for range of motion. The findings included: Medical record review revealed Resident #28 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed a physician's orders [REDACTED]. Medical record review dated 12/21/16, revealed Physical Therapy follow up recommendations/approaches: .Patient to perform supine (b) (bilateral) LE (lower extremities) AROM (active range of motion) and PROM (passive range of motion) exercises in bed to tolerance, in all planes, 3 x (times) 10 . This plan was signed by 1 Restorative Nurse Program (RNP) staff and 3 Functional Maintenance Program (FMP) staff. Medical Record review of a Quarterly Minimum Data Set ((MDS) dated [DATE], revealed 0 days of passive or active ROM (range of motion). Further review revealed 0 days of splint or brace assistance. Medical record review of Occupational Therapy Plan dated 4/4/17, revealed Discharge Plans: .Patient to remain as LTC (long term care) resident at this facility with FMP for recommended set-up/AE (adaptive equipment) during meals and RNP to maintain therapy gains . This document was signed by the resident's Physician. Observation of Resident #23 on 5/8/17 at 8:34 AM in her room revealed resident had bilateral foot, right elbow and right shoulder limited range of motion. These limitations were confirmed by Licensed Practical Nurse (LPN) #4 at that time. Interview with LPN #1 on 5/9/17 at 8:43 AM at the west hall nurse's station reported Resident #28 is not in the RNP program. Interview with LPN #1 on 5/9/17 at 4:40 PM revealed this resident did not have foot drop at the time of admission. Interview with Registered Nurse (RN) #2, MDS Coordinator and Restorative Nursing Program Director on 5/9/17 at 2:34 PM at the east wing nurse's station confirmed the facility failed to provide follow up ROM exercises by either the RNP or the FMP.",2020-09-01
434,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2017-05-09,353,E,0,1,TTUW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, shower schedule review, observation, and interview the facility failed to provide sufficient staff for bathing according to the facility shower schedule from 4/24/17- 5/6/17 and the comprehensive care plan for 19 residents (#2, #4, #7, #11, #13, #17, #20, #22, #28, #31, #32, #39, #41, #45, #48, #60, #64, #65, #96) for 28 residents reviewed in the stage 2 sample. The findings included: Medical record review revealed Resident #2 was severely cognitively impaired. Continued review revealed the resident was care planned for showers twice weekly with bed baths as needed (PRN) during the morning. Review of the facility shower schedule revealed the resident was scheduled for showers on Monday, Wednesday, and Friday in the morning. Review of the Shower and Bath Tool used to chart baths and showers by the Certified Nurse Aide (CNA) revealed the resident did not receive a shower on 4/24, 5/1,or 5/3/17 and received a bed bath on 5/5/17 instead of a shower. No PRN (as needed) bed baths were provided. Medical record review revealed Resident #4 was severely cognitively impaired. Continued review revealed the resident was care planned for showers 3 times a week in the evening on Monday, Wednesday, and Friday. Review of the facility shower schedule revealed the resident was scheduled for showers on Tuesday, Thursday, and Saturday in the evening. Review of the Shower and Bath Tool revealed the resident received showers from a Hospice Aide every Tuesday and Thursday. No showers were provided by the facility on Saturday 4/29/17 or 5/6/17. Medical record review revealed Resident #7 was severely cognitively impaired. Continued review revealed the resident was care planned for showers 2-3 times per week and PRN with bed baths in between PRN in the morning. Review of the facility shower schedule revealed the resident was scheduled for showers on Tuesday, Thursday, and Saturday in the evening. Review of the Shower and Bath Tool revealed the resident received no showers during the 2 week period, and received 1 bed bath on 4/25/17 instead of a shower. No PRN bed baths were provided. Medical record review revealed Resident #11 was severely cognitively impaired. Continued review revealed the resident was care planned for showers twice weekly and PRN in the evenings with bed baths in between PRN. Review of the facility shower schedule revealed the resident was scheduled for showers on Tuesday, Thursday, and Saturday in the morning. Review of the Shower and Bath Tool revealed the resident did not receive a shower on 5/4/17 and 5/6/17. Continued review revealed the resident received a bed bath instead of a shower on 4/27, 4/29, or 5/2/17. No PRN bed baths were provided. Medical record review revealed Resident #13 cognitively intact. Interview with Resident #13 revealed the resident was care planned for showers 3 times a week and PRN and the time of the shower did not matter. Review of the facility shower schedule revealed the resident was scheduled for showers on Tuesday, Thursday, and Saturday in the evening. Review of the Shower and Bath Tool revealed the resident did not receive a shower on 4/27, 4/29, 5/2, 5/4, or 5/6/17. No PRN bed baths were provided. Interview with Resident #13 on 5/9/17 at 2:45 PM in the resident's room revealed he routinely received bed baths instead of showers. Medical record review revealed Resident #17 was cognitively intact. Continued review revealed the resident was care planned for showers 3 times weekly with bed baths between as needed in the morning. Review of the facility shower schedule revealed the resident was scheduled for showers on Tuesday, Thursday, and Saturday in the morning. Review of the Shower and Bath Tool revealed the resident did not receive a shower on 5/4 and 5/6/17. Continued review revealed the resident received a bed bath instead of a shower on 4/27 and 5/2/17. The resident did not receive a PRN bed bath on 4/28, 5/1, 5/3, or 5/5/17. Observation on 5/9/17 between 3:30 PM and 4:00 PM in the 200 Hall revealed the resident was overheard asking 2 different staff members on 2 occasions to take a shower. Continued observation revealed the resident was told OK on both occasions but was not observed being taken to the shower. Medical record review revealed Resident #20 had short and long term memory loss and was rarely understood. Continued review revealed the resident was care planned for a shower 3 times weekly and PRN in the morning. Review of the facility shower schedule revealed the resident was scheduled for showers on Monday, Wednesday, and Friday in the morning. Review of the Shower and Bath Tool revealed the resident did not receive a shower on 5/1 or 5/3/17. Continued review revealed the resident received a bed bath instead of a shower on 4/28, and 5/5/17. Medical record review revealed Resident #22 was cognitively intact. Continued review revealed the resident was care planned for bed baths 2 times weekly in the evenings. Review of the facility shower schedule revealed the resident was scheduled for bed baths on Monday and Wednesday in the evening. Review of the Shower and Bath Tool revealed the resident did not receive a bed bath on 4/26, 5/1, or 5/3/17. Medical record review revealed Resident #28 was moderately cognitively impaired. Continued review revealed the resident was care planned for showers 3 times weekly with bed baths in between PRN at night. Review of the facility shower schedule revealed the resident was scheduled for showers on Tuesday, Thursday, and Saturday during the day. Review of the Shower and Bath Tool revealed the resident did not receive a shower on 5/4 or 5/6/17. Continued review revealed the resident received a bed bath instead of a shower on 4/29/17. No PRN bed baths were provided. Interview with Resident #28 on 5/9/17 at 3:50 PM in the resident's room revealed she received a bed bath every other day. Medical record review revealed Resident #31 was cognitively intact. Continued review revealed the resident was care planned for a shower 3 times weekly with bed baths in between PRN in the evening/night. Review of the facility shower schedule revealed the resident was scheduled for showers on Monday, Wednesday, and Friday in the evening. Review of the Shower and Bath Tool revealed the resident did not receive a shower on 4/26, 4/28, 5/1, 5/3, or 5/5/17. Continued review revealed the resident received a bed bath instead of a shower on 4/24/17. No PRN bed baths were provided. Interview with Resident #31 on 5/9/17 at 3:55 PM in the resident's room revealed she received a shower once a week and a bed bath 2-3 times a week. Medical record review revealed Resident #32 was cognitively intact. Continued review revealed the resident was care planned for a shower 3 times weekly, but a bed bath was OK at night. Review of the facility shower schedule revealed the resident was scheduled for a shower on Monday, Wednesday, and Friday in the evening. Review of the Shower and Bath Tool revealed the resident did not receive a shower or a bed bath on 4/26, 4/28, 5/1, 5/3, or 5/5/17. Interview with Resident #32 on 5/9/17 at 4:00 PM in the Day Room revealed the resident wanted a shower 2 times a week but receives a shower 1 time a week. The resident washed herself up at other times after asking for assistance and not receiving any. The resident stated she has to wait 30 minutes or longer for care sometimes because they don't have enough help. Medical record review revealed Resident #39 was severely cognitively impaired. Continued review revealed the resident was care planned for showers twice weekly with bed baths PRN in the evening. Review of the facility shower schedule revealed the resident was scheduled for a shower on Tuesday, Thursday, and Saturday evening. Review of the Shower and Bath Tool revealed the resident did not receive a shower or bed bath on 4/25, 4/27, 4/29, 5/2, 5/4, or 5/6/17. Medical record review revealed Resident #41 had short and long term memory loss and was rarely understood. Continued review revealed the resident was care planned for a shower or bed bath 2-3 times weekly in the morning. Review of the facility shower schedule revealed the resident was scheduled for a shower on Tuesday, Thursday, and Saturday in the evening. Review of the Shower and Bath Tool revealed the resident did not receive a shower or bed bath on 4/27, 4/29, 5/2, 5/4, or 5/6/17. Medical record review revealed Resident #45 was cognitively intact. Continued review revealed the resident was care planned for a bed bath 3 times weekly and a shower on Tuesday, Thursday, Saturday and PRN in the morning. Review of the facility shower schedule revealed the resident was scheduled for a shower on Tuesday, Thursday, and Saturday in the morning. Review of the Shower and Bath Tool revealed the resident did not receive a shower on 4/29, 5/4, or 5/6/17. Continued review revealed the resident received a bed bath instead of a shower on 5/2/17. Interview with Resident #45 on 5/9/17 at 4:05 PM in the resident's room revealed the resident asked the staff for bed baths between showers regularly but does not receive them. Continued interview revealed the resident had to ask staff continuously to receive a shower on his scheduled days to make sure he received one. Medical record review revealed Resident #48 was moderately cognitively impaired. Continued review revealed the resident was care planned for a shower 3 times weekly and PRN with bed baths in between PRN in the evening. Review of the facility shower schedule revealed the resident was scheduled for a shower on Tuesday, Thursday, and Saturday evening. Review of the Shower and Bath Tool revealed the resident received showers from a hospice aide on Tuesday and Thursdays. Continued review revealed the resident did not receive a shower on Saturday 4/29/17 or 5/6/17. No PRN bed baths were provided. Medical record review revealed Resident #60 had short and long term memory loss and was rarely understood. Continued review revealed the resident was care planned for a shower 3 times weekly and bed baths between showers in the morning or late afternoon. Review of the facility shower schedule revealed the resident was scheduled for a shower on Monday, Wednesday, and Friday in the morning. Review of the Shower and Bath Tool revealed the resident did not receive a shower on 5/1 or 5/3/17. Continued review revealed the resident received a bed bath instead of a shower on 5/5/17. No PRN bed baths were provided. Medical record review revealed Resident #64 had short and long term memory loss and was rarely understood. Continued review revealed the resident was care planned for a shower 3 times weekly and PRN with bed baths in between in the evening. Review of the facility shower schedule revealed the resident was scheduled for a shower on Monday, Wednesday, and Friday in the morning. Review of the Shower and Bath Tool revealed the resident did not receive a shower on 4/26, 4/28, 5/1, 5/3, or 5/5/17. Continued review revealed the resident received a bed bath instead of a shower on 4/24/17. No PRN bed baths were provided. Medical record review revealed Resident #65 was cognitively intact. Continued review revealed the resident was care planned to Encourage Choices with Care. Review of the facility shower schedule revealed the resident was scheduled for a shower on Monday, Wednesday, and Friday in the morning. Review of the Shower and Bath Tool revealed the resident did not receive a shower on 4/26, 5/1, or 5/3/17. Continued review revealed the resident received a bed bath instead of a shower on 5/5/17. Interview with Resident #65 on 5/7/17 at 7:30 PM in the resident's room revealed when the resident was asked if he was able to choose how many times he took a shower or bath, the resident stated, No, not really. I want a shower so I can get my head wet, but they give me a bed bath most of the time. Interview with Resident #65 on 5/9/17 at 2:45 PM in the resident's room confirmed he did not receive a shower on Monday 5/8/17. Continued interview revealed the resident stated he asked for a shower 3 different times during the afternoon and evening and was told he would receive a shower that evening, but did not. Medical record review revealed Resident #96 was admitted on [DATE], and was cognitively intact. Continued review revealed the resident was care planned to Encourage Choices with Care. Review of the facility shower schedule revealed the resident was scheduled for a shower on Tuesday, Thursday, and Saturday in the morning. Review of the Shower and Bath Tool revealed the resident did not receive a shower on 4/27, 4/29, 5/2, 5/4, or 5/6/17. Interview with Resident #96 on 5/9/17 at 3:05 PM in the resident's room revealed the resident had not received a shower since she was admitted to the facility on [DATE]. Interview with CNA #3 on 5/8/17 at 1:24 PM in the hall by the Dining Room revealed the CNA stated, .Sometimes we are short staffed and it does take longer to answer the call light . Continued interview revealed the CNA stated she didn't feel like personal care was done between breakfast and lunch because of all the residents that need assistance with feeding. CNA #3 stated, I have to check and change my resident's and give baths and I can't get it all done . Interview with Registered Nurse (RN) #1 on 5/8/17 at 2:55 PM in the 100 hallway confirmed she worked the day shift 7 AM- 3 PM. Continued interview revealed the RN stated she did not have a nurse to replace her at 3 PM 2 times in the last 2 weeks and had to stay until 6 PM one night and 9 PM the next time. Further review revealed the RN stated the past 2-3 months the facility had a large turn over and we just can't keep staff. Interview with CNA #6 on 5/9/17 at 1:00 PM in the Pantry confirmed she came in to work at 11:00 AM to relieve CNA #4 who had worked the night shift (11 PM - 7 AM) and stayed over until 11:00 AM to help shower the residents. Continued interview revealed the CNA stated the day shift was staffed with 3 CNA's and they had a 2 hour window to get all the breakfast trays picked up, and 15 showers to be done before lunch time. The CNA stated, I can't get all the showers done, it's quicker to do a bed bath. Interview with CNA #3 on 5/9/17 at 1:10 PM in the Pantry stated, It's hard for us to take our lunch because we are so busy, and there have been times when I couldn't even do any charting. Interview with CNA #5 on 5/9/17 at 1:15 PM in the Pantry confirmed the CNA's have been working short staffed and, It's much worse on the weekends. Interview with the Director of Nursing (DON) on 5/9/17 at 4:30 PM in the Administrator's office confirmed the facility was short staffed, the facility failed to provide bathing to the resident's to maintain their highest practicable well being, and failed to provide enough staff to care for the residents per their care plans.",2020-09-01
435,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2018-05-09,623,D,0,1,2JD211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to send the Ombudsman a notice of transfer or discharge for 2 of 3 (Resident #20 and 49) sampled residents reviewed for transfer/discharge requirements. The findings included: 1. Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Late Entry For 03/23/2018 .Pt (patient) was ordered to be sent to ER (emergency room ) for eval (evaluation) due to hx (history) of bowel obstruction . Review of the medical record revealed Resident #20 was admitted to the hospital 3/23/18. Interview with the Social Worker on 5/8/18 at 2:50 PM, in the Social Worker's office, the Social Worker was asked if the Ombudsman had been notified of Resident #20's transfer to the hospital. The Social Worker stated, .( I ) started (MONTH) 30th I thought the last Social Worker had notified the Ombudsman . The Social Worker was unable to locate the notification. 2. Medical record review revealed Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Send patient to ER by EMS (Emergency Medical Service) STAT (now) . Review of the medical record revealed Resident #49 was admitted to the hospital 2/6/18. Interview with the Social Worker on 5/9/18 at 5:00 PM, in the Social Worker's office, the Social Worker was asked if the Ombudsman had been notified of Resident #49's transfer to hospital. The Social Worker was unable to provide documentation the Ombudsman was notified of the transfer.",2020-09-01
436,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2018-05-09,690,D,0,1,2JD211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide appropriate care and services for a [MEDICATION NAME] to prevent the potential for urinary tract infections for 1 of 1 (Resident #5) sampled residents reviewed with a [MEDICATION NAME]. The findings included: Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment, required staff assistance with all activities of daily living (ADLs), had an ostomy, and had a [MEDICAL CONDITION] (MDRO). The care plan dated 11/27/17 documented, .Self-Care deficit .requires assistance for ADL function and mobility .has a [DIAGNOSES REDACTED].has a [MEDICATION NAME] and [MEDICAL CONDITION] .requires extensive assistance .to assist with changing .devices .is receiving IV (intravenous) meds (medications) .R/T (related to) .ESBL in urine .Date Initiated .5/07/2018 .on isolation R/T: ESBL in .urine . The physician's orders [REDACTED].Change bsb (bedside bag) to [MEDICATION NAME] q (every) 2 weeks .Start Date .3/22/2018 .Change .[MEDICATION NAME] appliances qod (every other day) .Start Date .2/08/2018 . Review of the Treatment Administration Records (TAR) revealed no documentation the [MEDICATION NAME] bedside bag was changed as ordered on [DATE], or that the [MEDICATION NAME] appliance was changed as ordered on [DATE], 3/12/18, 3/16/18, 3/20/18, 3/22/18, 3/24/18, 3/26/18, 4/1/18, 4/3/18, 4/5/18, 4/7/18, 4/9/18, 4/11/18, 4/15/18, 4/17/18, 4/21/18, 4/23/18, 4/25/18, 4/27/18, or 5/1/18. A hospital history and physical dated 5/4/18 documented, .past medical history significant for .chronic urinary tract infections .[MEDICATION NAME] .ASSESSMENT .Urinary tract infection .has a very strong history of extended-spectrum beta-lactamases . The final discharge orders dated 5/7/18 documented, .Cont (Continue) [MEDICATION NAME] .care . Observations in Resident #5's room on 5/8/18 at 7:50 AM, revealed Resident #5 lying in bed on a bolster-type mattress. The [MEDICATION NAME] drainage tubing was resting on the side of the bolster mattress in an inclined position. Resident #5 complained the mattress was causing difficulty with the urine drainage. Observations in Resident #5's room on 5/9/18 at 2:51 PM, revealed Resident #5 lying in the bed on a low air loss bolster mattress. Licensed Practical Nurse (LPN) #1 was at bedside to change the [MEDICATION NAME] appliance bag. The [MEDICATION NAME] bag to the right side of the abdomen was full of yellow urine. LPN #1 attempted to drain the urine from the [MEDICATION NAME] bag into the drainage tubing, but drainage was impaired by the incline of the side of the bolster mattress. After several attempts to drain the urine by manipulating the tubing, LPN #1 finally pressed down the side of the bolster mattress, which changed the position of the drainage flow downward, and immediately drained 300 milliliters of yellow urine into the drainage bag. Interview with the Director of Nursing (DON) on 5/9/18 at 4:27 PM, in the conference room, the DON was asked if it was appropriate for the [MEDICATION NAME] drainage tubing to be resting on an incline, preventing it from draining. The DON confirmed it was not, and stated, .Positioning is important with her . Observations in Resident #5's room on 5/9/18 at 7:45 AM, revealed Resident #5 lying in bed, covered with bed linens. The [MEDICATION NAME] tubing was connected to the drainage bag, and the drainage bag was lying on the floor. Interview with the DON on 5/9/18 at 4:27 PM, in the conference room, the DON was asked if it was appropriate for the drainage bag to be on the floor. The DON stated, No. Interview with the DON on 5/9/18 at 4:48 PM, in the conference room, the DON was asked about the missing documentation for changing the [MEDICATION NAME] appliance and bedside bag on the TARs. The DON stated, .They failed to document . The DON was asked if that was acceptable. The DON stated, They should be charting it .",2020-09-01
437,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2018-05-09,880,D,0,1,2JD211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to prevent the potential spread of infections when 1 of 1 (Assistant Director of Nursing (ADON)) staff member failed to perform appropriate hand hygiene during wound care. The findings included: The facility's Handwashing/Hand Hygiene policy documented, .All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .Employees must wash their hands .Before and after direct resident contact .Before and after performing any invasive procedure .Before and after changing a dressing .After contact with a residents mucous membranes and body fluids .After handling soiled or used linens, dressing . Medical record review revealed Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations of wound care in Resident #45's room on 5/8/18 at 4:21 PM, revealed the ADON gathered supplies, entered Resident 45's room, and donned gloves without performing hand hygiene. The ADON cleaned an open wound to Resident #45's right foot with sterile saline and gauze, and then applied Santyl to the wound using gauze with the same gloved hands. The ADON did not change gloves or wash hands between the dirty and clean procedure. The ADON moved to the surgical incision to the right ankle, and swabbed it with a [MEDICATION NAME] swabstick. Next, the ADON moved to a large dark purplish-black discolored wound to the right heel and sprayed it with skin prep, and then applied clean foam dressings to the wounds with the same gloved hands. The ADON did not perform hand hygiene between the ankle wound and the heel wound, and did not perform hand hygiene between cleaning the wounds and applying clean dressings. Interview with the ADON on 5/8/18 at 4:38 PM, outside of Resident #45's room, the ADON was asked if she should have washed her hands before providing wound care. The ADON stated, Yes, I didn't did I . The ADON was asked if she should have washed her hands between glove changes. The ADON stated,Yes. The ADON confirmed she should have performed hand hygiene between each wound. Interview with the Director of Nursing (DON) on 5/9/18 at 4:27 PM, in the conference room, the DON was asked when she expected staff to wash hands. The DON stated, Every time they are ready to do something with a resident . The DON was asked if she expected them to wash hands between glove changes. The DON stated, Yes. The DON was asked if she expected staff to perform hand hygiene between wounds during wound care. The DON stated, Yes.",2020-09-01
438,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2019-11-27,725,D,1,0,Y85H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of the facility staffing schedules, review of the time detail reports, observation, and interview, it was determined the facility failed to provide sufficient staffing to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 6 of 27 (11/3/19, 11/11/19, 11/13/19, 11/15/19, 11/23/19, and 11/24/19) days in Novenber. The facility had a census of 55 residents. The findings include: 1. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had a BIMS score of 14, which indicated no cognitive impairment. Interview with Resident #1 on 11/26/19 at 12:50 PM, in Resident #1's room, Resident #1 was asked if there was enough staff at the facility to give her the care she needed. Resident #1 stated, I'm blind so I have a hard time getting to the bathroom at night .I believe they need more help. Observation on 11/26/19 at 11:25 AM and 12:50 PM in Resident #1's room, revealed Resident #1 with hair that appeared oily and there was a urine odor in her room. 2. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Interview with Resident #2 on 11/26/19 at 5:20 PM, in Resident #2's room, Resident #2 was asked if there was enough staff to give her the care she needed. Resident #2 stated, There is not enough staff here and they don't answer the call lights timely on days or nights . 3. Observations on 11/26/19 at 12:03 PM at the East Nurses Station, revealed a family member of Resident #4 complaining to the staff member at the desk that his sheets were dirty and the room smelled of urine. Observations of Resident #4's room revealed the sheets had yellowish stains visible and the room did have an odor of urine. Interview with Resident #4 and 2 of his family members on 11/26/19 at 12:09 PM, in Resident #4's room, the family member stated, .came to take (Resident #4) out for Thanksgiving dinner and he (Resident #4) was upset because his sheets are dirty and the room smells of urine. 4. Review of the Certified Nursing Aide (CNA) schedule for 11/3/19 revealed that CNA #7 and #8 were scheduled for the night shift (11:00 PM - 7:00 AM) on 11/3/19. The actual time detail revealed only 1 CNA (CNA #8) worked on the night shift. The facility had a census of 59 residents. Review of the CNA schedule for 11/11/19 revealed that CNA #5, #12, and #13 were scheduled for 3:00 PM - 11:00 PM shift. Review of the actual time detail revealed 2 CNAs (CNA #5 and #12) worked the 3:00 PM - 11:00 PM shift on 11/11/19. The facility had a census of 53 residents. Review of the actual time detail revealed one CNA (CNA #12) worked on 11/13/19 on the 3:00 PM - 11:00 PM shift. The facility had a census of 52. Review of the CNA schedule for 11/15/19 revealed that CNA #10 and #11 were scheduled for 11:00 PM - 7:00 AM. Review of the actual time detail revealed only 1 CNA (CNA #11) worked on 11/15/19 for the 11:00 PM - 7:00 AM shift. The facility had a census of 52. Review of the CNA schedule for 11/23/19 revealed that CNA #9, #10, and #11 were scheduled on the night shift. Review of the actual time detail revealed only 1 CNA (CNA #11) worked the night shift on 11/23/19. The facility had a census of 56. Review of the CNA schedule for 11/24/19 revealed CNA # 8, #9, and #11 were scheduled on the night shift. Review of the actual time detail revealed only 1 CNA (CNA #11) worked the night shift on 11/24/19. The facility had a census of 55. 5. Interview with CNA #1 on 11/26/19 at 1:12 PM, in the Conference Room, CNA #1 was asked if there was enough staff for the residents to receive the care they needed. CNA #1 stated, .no not always enough time to complete everything .not enough staff for all the residents to get showers, just bed baths. They don't get the care they need. CNA #1 was asked how many residents she was assigned today. CNA #1 stated, today 12 .responsible for 18 sometimes .Laundry is only here 8 hours and we often run out of sheets, washcloths, and towels. The first weekend of November, I worked 25 hour shift due to no one showing up for third shift . Interview with CNA #2 on 11/26/19 at 1:42 PM, in the Conference Room, CNA #2 was asked if there was enough staff for the residents to receive the care they needed. CNA #2 stated, No need more CNAs . CNA #2 was asked how many residents she was assigned today. CNA #2 stated, .I have 13 .I stay over until 7:00 PM, if they have a call in. We do run out of clean sheets and washcloths due to laundry only doing one shift . Interview with CNA #3 on 11/26/19 at 2:05 PM, in the Conference Room, CNA #3 was asked if there was enough staff for the residents to receive the care they needed. CNA #3 stated, No, no residents on 700 hall had showers today, they got bed baths. CNA #3 was asked how many residents she was assigned today. CNA #3 stated, Today 12 .I have worked West (hall) by myself with 22 residents Interview with CNA #4 on 11/26/19 at 2:27 PM, in the Conference Room, CNA #4 was asked if there was enough staff for the residents to receive the care they needed. CNA #4 stated, Not enough staff to give care needed .last week 3 days I was by myself on second shift on West (hall) with 22 residents . CNA #4 was asked how many residents she was assigned today. CNA #4 stated, 12 today. Interview with CNA #5 on 11/26/19 at 2:53 PM, in the Conference Room, CNA #5 was asked if there was enough staff for the residents to receive the care they needed. CNA #5 stated, Absolutely short staffed to give the care these residents need .I have stayed over when only one CNA on third shift . Interview with the Administrator on 11/26/19 at 3:40 PM, in the Conference Room, the Administrator was asked about the working schedule. The Administrator stated, I had to take over the scheduling in mid-November. The person that had been doing the schedule had been doing it since (MONTH) and had been doing really good. But then she was making a hot mess of it, she didn't have them accurate. She was leaving people off the assignments sheets and schedule . Interview with Licensed Practical Nurse (LPN) #1 on 11/26/19 at 3:50 PM, in the Conference Room, LPN #1 was asked if there was enough staff for the residents to receive the care they needed. LPN #1 stated, No I don't. LPN #1 was asked if the residents appeared clean when she arrived or if she noticed any odors. LPN #1 stated, .I have noted oily hair on residents and odors occasionally. Interview with CNA #6 on 11/26/19 at 5:04 PM, on the 300 Hall, CNA #6 was asked if there was enough staff for the residents to receive the care they needed. CNA #6 stated, .I was on East (hall) with 30 residents by myself .worked 2 nights by myself. Interview with CNA #7 on 11/27/19 at 6:00 AM, in the Conference Room, CNA #7 was asked if there was enough staff for the residents to receive the care they needed. CNA #7 stated, No there is not enough staff .we run out of linens regularly most nights lately . CNA #7 was asked how many residents she was assigned. CNA #7 stated, 22. Interview with CNA #8 on 11/27/19 at 6:20 AM, at the East Nurses Station, CNA #8 was asked if there was enough staff for the residents to receive the care they needed. CNA #8 stated, No not enough for the residents to get care needed .often one CNA for the whole building .",2020-09-01
439,"THE WATERS OF UNION CITY , LLC",445138,1105 SUNSWEPT DR,UNION CITY,TN,38261,2019-09-25,638,D,0,1,7V2811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to complete a quarterly assessment, using the Centers for Medicare & Medicaid Services-specific RAI process within the regulatory time frames for 2 of 19 (Resident #2 and #5) sampled residents reviewed. The findings include: 1. The MDS 3.0 RAI Manual v (version) 1.16 (MONTH) 1, (YEAR) page 2-33 documented, .The Quarterly assessment must be completed at least every 92 days following the previous OBRA (Omnibus Budget Reconciliation Act) assessment of any type .The ARD (Assessment Reference Date) (A2300) must be not more than 92 days after the ARD of the most recent OBRA assessment of any type .The MDS completion date (Item Z0500B) must be no later than 14 days after the ARD (ARD + 14 calendar days) . 2. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD date of 7/3/19 revealed Item Z0500B was not completed. The MDS should have been completed by 7/17/19. Telephone interview with the Regional MDS Coordinator on 9/24/19 at 1:16 PM, the Regional MDS Coordinator was asked if the 7/3/19 MDS for Resident #2 was completed. The Regional MDS Coordinator stated, It is not. The Regional MDS Coordinator was asked if it should have been completed. The Regional MDS Coordinator stated, If it is from July, then yes. 3. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD date of 8/2/19 revealed Item Z0500B was not completed. The MDS should have been completed by 8/16/19. Telephone interview with the Regional MDS Coordinator on 9/24/19 at 1:16 PM, the Regional MDS Coordinator was asked if the 8/2/19 MDS for Resident #5 was completed. The Regional MDS Coordinator stated, It is not. The Regional MDS Coordinator was asked if it should have been completed. The Regional MDS Coordinator stated, If that was the ARD date, then, yes it should have.",2020-09-01
440,"THE WATERS OF UNION CITY , LLC",445138,1105 SUNSWEPT DR,UNION CITY,TN,38261,2019-09-25,759,D,0,1,7V2811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the GERIATRIC MEDICATION HANDBOOK, 11TH Edition provided by the American Society of Consultant Pharmacists, medical record review, observation, and interview, the facility failed to ensure 1 of 3 (Registered Nurse (RN) #1) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 3 errors were observed out of 29 opportunities, resulting in an error rate of 10XXX 759% The findings include: 1. The GERIATRIC MEDICATION HANDBOOK, 11TH edition provided by the American Society of Consultant Pharmacists documented, .DIABETES: INJECTABLE MEDICATIONS . [MEDICATION NAME] .Insulin . [MEDICATION NAME] . Rapid-Acting Insulin .ONSET .15 min . ADMINISTRATION/COMMENTS .5-10 minutes prior to meals . 2. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].= 5 (units) .300-349 = 10 (units) .subcutaneously before meals . Observations in Resident's #18's room on 9/23/19 at 11:33 AM, revealed Registered Nurse (RN) #1 administered [MEDICATION NAME] 10 units subcutaneously to Resident #18 for a blood glucose level of 337. A meal or substantial snack was not offered to Resident #18 until a meal tray was delivered at 12:30 PM, which was 57 minutes later. The failure of the nurse to provide a meal or substantial snack within 5-10 minutes of administration of the [MEDICATION NAME] resulted in medication administration error #1. Observations in Resident #18's room on 9/23/19 at 5:10 PM, revealed RN #1 administered [MEDICATION NAME] 5 units subcutaneously to Resident #18 for a blood glucose level of 213. A meal or substantial snack was not offered to Resident #18 until the RN provided Resident #18 with a supplement at 5:53 PM, which was 43 minutes later. The failure of the nurse to provide a meal or substantial snack within 5-10 minutes of administration of the [MEDICATION NAME] resulted in medication administration error #2. 3. Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Observations in Resident #24's room on 9/23/19 at 4:53 PM, revealed RN #1 administered [MEDICATION NAME] 5 units subcutaneously to Resident #24. A meal or substantial snack was not offered to Resident #24 until a meal tray was delivered at 5:21 PM, which was 28 minutes later. The failure of the nurse to provide a meal or substantial snack within 5-10 minutes of administration of the Novolg resulted in medication administration error #3. Interview with the Director of Nursing (DON) on 9/23/19 at 5:24 PM, in the DON Office, The DON was asked when should a resident receive a substantial snack or meal after receiving [MEDICATION NAME] insulin. The DON confirmed the resident should have received a meal or snack within 5-10 minutes of insulin administration.",2020-09-01
441,"THE WATERS OF UNION CITY , LLC",445138,1105 SUNSWEPT DR,UNION CITY,TN,38261,2019-09-25,760,D,0,1,7V2811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the GERIATRIC MEDICATION HANDBOOK, 11TH edition provided by the American Society of Consultant Pharmacists, medical record review, observation, and interview, the facility failed to ensure 1 of 3 (Registered Nurse (RN) #1) nurses administered medications free of significant medication errors. The findings include: 1. The GERIATRIC MEDICATION HANDBOOK, 11TH edition provided by the American Society of Consultant Pharmacists documented, .DIABETES: INJECTABLE MEDICATIONS . [MEDICATION NAME] .Insulin .[MEDICATION NAME] .Rapid-Acting Insulin .ONSET .15 min .ADMINISTRATION/COMMENTS .5-10 minutes prior to meals . 2. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].=5 (units) .300-349 =10 (units) .subcutaneously before meals . Observations in Resident's #18's room on 9/23/19 at 11:33 AM, revealed Registered Nurse (RN) #1 administered [MEDICATION NAME] 10 units subcutaneously to Resident #18 for a blood glucose level of 337. A meal or substantial snack was not offered until a meal tray was delivered to Resident #18 at 12:30 PM, which was 57 minutes later. The failure of the nurse to provide a meal or substantial snack within 5-10 minutes of administration of the [MEDICATION NAME] resulted in a significant medication error. Observations in Resident #18's room on 9/23/19 at 5:10 PM, revealed RN #1 administered [MEDICATION NAME] 5 units subcutaneously to Resident #18 for a blood glucose level of 213. A meal or substantial snack was not offered until the RN provided Resident #18 with a supplement at 5:53 PM, which was 43 minutes later. The failure of the nurse to provide a meal or substantial snack within 5-10 minutes of administration of the [MEDICATION NAME] resulted in a significant medication error. 3. Medical record review revealed Resident # 24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Observations in Resident #24's room on 9/23/19 at 4:53 PM, revealed RN #1 administered [MEDICATION NAME] 5 units subcutaneously to Resident #24. A meal or substantial snack was not offered until a meal tray was delivered to Resident #24 at 5:21 PM, which was 28 minutes later. The failure of the nurse to provide a meal or substantial snack within 5-10 minutes of administration of the Novolg resulted in a significant medication error. Interview with the Director of Nursing (DON) on 9/23/19 at 5:24 PM, in the DON Office, The DON was asked when should a resident receive a substantial snack or meal after receiving [MEDICATION NAME] insulin. The DON confirmed the resident should have received a meal or snack within 5-10 minutes of insulin administration.",2020-09-01
442,"THE WATERS OF UNION CITY , LLC",445138,1105 SUNSWEPT DR,UNION CITY,TN,38261,2019-09-25,880,D,0,1,7V2811,"**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 maintained for 1 of 2 (Resident #48) sampled residents observed during a dressing change. The findings include: 1. The Lippincott Manual of Nursing Practice, 10th EDITION documented, .Keep the drainage bag in a dependent position, below the level of the bladder . 2. Medical record review revealed Resident #48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 3. A physician's orders [REDACTED].Cleanse wound to sacral area with Dakins, pat dry, Apply Calcium Alginate and Collogen dressing to wound bed, cover with ABD (abdominal) pad, secure with border dressing daily every day shift . A physician's orders [REDACTED].May change indwelling silicone silver tip catheter number 18 Fr (french) 30 cc (cubic centimeters) bulb as needed for [MEDICAL CONDITION] . 4. Observations in Resident #48's room on 9/24/19 at 2:20 PM, revealed Registered Nurse (RN) #1 performed dressing changes with the assistance of Certified Nursing Assistant (CNA) #1 and CNA #2. CNA #1 placed Resident #48's indwelling urinary catheter tubing and bag on the foot of the bed during the dressing change. CNA #1 and #2 changed a blue pad saturated with bloody drainage from the resident's sacral wound by rolling the resident, and placed a clean, dry blue pad under the resident on top of a bed sheet that was saturated with wound drainage. After the dressing change, Resident #48 was positioned in the bed and the bedside drainage bag was positioned back under the bed at 3:03 PM, 35 minutes later. Interview with CNA #1 on 9/24/19 at 3:05 PM, in Resident #48's room, CNA #1 was asked if it was appropriate to leave the catheter bag on the bed during the dressing change. CNA #1 stated, no . Interview with CNA #2 on 9/24/19 at 3:07 PM, in Resident #48's room, CNA #2 was asked if it was appropriate to cover the saturated bed linen with a clean blue pad. CNA #2 stated, .no .we did not have the supplies in the room . Interview with the Director of Nursing (DON) on 9/25/19 at 11:25 AM, in the DON Office, the DON was asked if it was appropriate to place a bedside drainage bag in the bed with a resident during a dressing change. The DON stated, .no ma'am . The DON was asked it was appropriate to replace blue pads over bed linen that was saturated with drainage from a wound. The DON stated, .all of the linens should have been changed .",2020-09-01
443,MIDTOWN CENTER FOR HEALTH AND REHABILITATION,445139,141 N MCLEAN BLVD,MEMPHIS,TN,38104,2018-08-03,686,D,1,0,Q36011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview the facility failed to notify the physician of a new area of skin breakdown for 1 of 3 sampled residents (Resident #11) reviewed for pressure ulcer/injury to the skin. The findings include: The facility's Pressure Ulcer/Injury Risk Assessment policy revised (MONTH) (YEAR) documented, .Notify attending MD (medical doctor) if new skin alteration noted . The facility's Pressure Ulcers/Skin Breakdown - Clinical Protocol policy revised (MONTH) 2014 documented, .The physician will authorize pertinent orders related to wound treatments .and application of topical agents if indicated for type of skin alteration . The facility's Pressure Ulcers/Injuries Overview policy revised (MONTH) (YEAR) documented, .Shearing occurs when layers of skin rub against each other or when the skin remains stationary and the underlying tissue moves and stretches and angulates or tears the underlying capillaries and blood vessels causing tissue damage . Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed the resident was sometimes understood with a cognitive score of 3 of 15 indicating severe cognitive impairment and the presence of disorganized thinking; required extensive assistance of 2 staff for bed mobility; was dependent for toileting;and was always incontinent of bowel and bladder. Review of the comprehensive plan of care initiated following the admission MDS assessment dated [DATE] and updated 7/24/18 revealed appropriate care plan interventions were implemented for assessed problems and needs which included risk for skin impairment related to incontinence, immobility, combativeness, resistance and refusal of care during personal care. Review of the C.N.[NAME] (Certified Nursing Assistant (CNA)) SKIN CARE ALERT dated 7/19/18 revealed a new red area was identified on Resident #11's right upper buttocks during bathing. Following the CNA notifying Licensed Practical Nurse (LPN) #2, the LPN documented her assessment findings in a SKIN OBSERVATION TOOL - (Licensed Nurse) dated 7/19/18. Review of her skin assessment revealed the resident's right and left buttocks had excoriated areas and documented, .two small areas of open areas smaller than a penny . There was no documentation in the nursing progress notes or physician telephone orders of the physician being notified of the change in the condition of the resident's skin or receipt of any orders for treatment of [REDACTED]. Review of a nursing progress note dated 7/23/18 revealed LPN #1, the wound care nurse, was notified of Resident #11's change in skin condition, assessed the skin, notified the Wound Physician and received new treatment orders. The Wound Physician would follow up to evaluate the resident's wound on 7/25/18. Review of a physican order dated 7/23/18 revealed orders for daily and as needed wound cleansing, treatment and dressing change. Review of a wound assessment follow up note by LPN #1 dated 7/29/18 revealed the resident's buttocks wounds and surrounding area of skin appeared to be caused by shearing and additional appropriate care plan interventions were put into place. Interview with the 4th floor Unit Manager (UM) and LPN #1 on 7/23/18 at 3:25 PM in the 4th floor UM office, the UM was asked about Resident #11's skin breakdown identified by the CNA on 7/19/18. The UM revealed, LPN #1 and the Wound Physician had evaluated Resident #11's skin on 7/18/18 and he had no wounds present at that time. The UM and LPN #1 were not notified of the resident's skin breakdown until 7/23/18. The UM revealed, according to her review of documentation and interview with staff on duty on 7/19/18, the CNA had documented and notified the nurse on duty of the appearance of Resident #11's skin and nursing documentation revealed open areas on his buttocks. The UM stated, .The nurse didn't reach out or document . LPN #1 was asked if Resident #11 was turned and repositioned. LPN #1 revealed the resident resisted turning and repositioning and braced his hands on the upper side rails, pushing against staff who were trying to reposition him. Interview with LPN #1 on 7/26/18 at 12:25 PM in the Chapel, when asked about Resident #11's change in skin condition identified on 7/19/18, LPN #1 confirmed the resident's prior buttock wound had healed on 6/13/18, and on 7/19/18 new areas on his buttocks were identified. LPN #1 stated the preventive barrier cream in use prior to the new skin breakdown was not an appropriate treatment for [REDACTED].#2 should have notified her or the physician of the change in condition. LPN #1 stated when she was made aware of Resident #11's skin condition on 7/23/18, she had assessed the resident's skin and contacted the Wound Physician for appropriate treatment orders. Interview with the Director of Nursing (DON) on 8/1/18 at 12:15 PM in the DON's office, when asked about the facility's protocol for notification of changes in residents' skin, the DON stated, .for open areas, the nurse should notify her (LPN #1) immediately or the physician .",2020-09-01
444,MIDTOWN CENTER FOR HEALTH AND REHABILITATION,445139,141 N MCLEAN BLVD,MEMPHIS,TN,38104,2019-09-17,641,D,0,1,VPVC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure assessments were completed accurately to reflect the resident's status for transfers and Range of Motion (ROM) for 2 of 31 (Resident #37 and 80) sampled residents reviewed. The findings include: 1. Medical record review revealed Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #37 required limited assistance with transfers during the 7 day look back period. Review of the Documentation Survey Report dated (MONTH) 2019, revealed Resident #37 received extensive assistance with transfers on 4/4/19, 4/5/19, 4/7/19, 4/8/19, and 4/10/19. Interview with MDS Coordinator #1 on 9/17/19 at 3:00 PM, in the Chapel, MDS Coordinator #1 was asked if the quarterly assessment dated [DATE] was coded accurately to reflect the residents ability to transfer. MDS Coordinator #1 stated, No, that's not the way I would have coded it . Medical record review revealed Resident #80 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual MDS dated [DATE] revealed Resident #80 had no impairment to the upper extremities or lower extremities. The annual MDS was not coded to reflect Resident #80's left sided ROM impairments. The comprehensive care plan revised 8/7/19 documented, .ADL (Activities of Daily Living) self-care performance deficit r/t (related/to) [MEDICAL CONDITION] .Limited Mobility, Stroke .Contractures of the L (left) arm .L side Paralysis . Observations in Resident #80's room on 9/15/19 at 3:14 PM and 9/16/19 at 1:37 PM, revealed Resident #80's mouth drooped on the left side and her left hand appeared to be contracted. Resident #80 was unable to straighten her arm or hand. Interview with MDS Coordinator #1 on 9/17/19 at 3:16 PM, in the Chapel, MDS Coordinator #1 was asked if the annual MDS dated [DATE] was coded correctly for range of motion limitation. MDS Coordinator #1 stated, No. MDS Coordinator #1 was asked how it should have been coded. MDS Coordinator #1 stated, Limitation on 1 side, the left side. Interview with the Occupational Therapist (OT) on 9/17/19 at 5:11 PM, in the Chapel, the OT confirmed Resident #80 had left-sided range of motion impairment.",2020-09-01
445,MIDTOWN CENTER FOR HEALTH AND REHABILITATION,445139,141 N MCLEAN BLVD,MEMPHIS,TN,38104,2019-09-17,761,D,0,1,VPVC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure medications were stored properly and securely when 1 of 11 (Respiratory Medication Cart) medication storage areas was left unlocked and unattended and 1 of 8 (Respiratory Therapist (RT) #1) staff members left medications out of sight and unattended. The findings include: 1. The facility's Storage of Medications policy with a revision date of (MONTH) 2007, documented, .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others . 2. Observations in the 3rd Floor West Hall in front of room [ROOM NUMBER] on 9/17/19 at 8:50 AM, revealed the Respiratory Medication Cart was unlocked and unattended. Observations during medication administration in Resident #84's room on 9/17/19 at 8:55 AM and 9:02 AM, revealed RT #1 entered Resident #84's room to administer an inhalation medication. RT #1 placed an inhaler on the over bed table, and entered the bathroom to wash his hands, leaving the medication out of sight and unattended. RT #1 returned to bedside to administer the inhaler, but then left the room to get an alcohol pad, leaving the medication out of sight and unattended. 3. Interview with the Director of Nursing (DON) on 9/17/19 at 2:24 PM, in the DON office, the DON was asked if the medication cart should be left unlocked and unattended, and if medications should be left at the bedside unattended. The DON stated, No.",2020-09-01
446,MIDTOWN CENTER FOR HEALTH AND REHABILITATION,445139,141 N MCLEAN BLVD,MEMPHIS,TN,38104,2018-11-15,550,E,0,1,W4ME11,"Based on policy review, observation, and interview, the facility failed to ensure that residents were treated with dignity and respect as evidenced by 4 of 12 (Resident #7, 86, 91, and 75) residents did not receive their meal tray timely with the other residents seated at their table in the 400 Hall dining room, 1 of 23 (Certified Nursing Assistant (CNA) #1) staff members referred to a resident as a feeder, and an indwelling Foley catheter drainage bag was uncovered for 1 of 3 (Resident #44) sampled residents reviewed with indwelling catheters. The findings include: 1. The facility's Quality of Life-Dignity policy dated (MONTH) 2009 documented, .Each resident shall cared for in a manner that promotes and enhances quality of life, dignity, respect .7 .speak respectfully to residents at all times .addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her .care needs .a. helping the resident to keep urinary catheter bags covered . 2. Observations in the 400 dining room on 11/13/18 beginning at 11:45 AM, revealed the following: Resident #95 and Resident #7 were seated at the same table. Resident # 95 received their meal tray at 11:48 AM. Resident #7 received their meal tray at 12:24 PM. This was 36 minutes after the first meal tray was served to the table. Resident #28, Resident #12, Resident #86, Resident #91, and Resident #75 were seated at the same table. Resident #28 and Resident #12 received their meal tray at 11:55 AM. Resident #86 received their meal tray at 12:14 PM, 19 minutes after the first tray was served. Resident #91 and Resident #75 received their meal at 12:24 PM, 34 minutes after the other residents at their table were served. Observations outside the 400 dining room on 11/13/18 at 11:57 AM revealed CNA #1 stated, .she's a feeder . referring to Resident #46. Interview with the Director of Nursing (DON) on 11/15/18 at 2:14 PM in the Lobby, the DON confirmed that residents should not be referred to as feeders and all residents seated at the same table should receive their trays at the same time. 3. Observations in Resident #44's room on 11/13/18 at 10:28 AM and 3:32 PM revealed Resident #44 was in a wheelchair in his room, wheeling himself from the room towards the hall. An indwelling urinary catheter was hanging from the wheelchair, uncovered and not in a dignity bag with visible urine in the bag. Observations in the 400 hall dining room on 11/13/18 at 12:15 PM revealed Resident #44 was seated in a wheelchair, an indwelling urinary catheter was hanging from the wheelchair, not covered or in a dignity bag, with visible urine in the bag. Interview with the DON on 11/15/18 at 10:47 AM in the Chapel, the DON was asked if a catheter bag should be covered or in a dignity bag. The DON stated, Yes.",2020-09-01
447,MIDTOWN CENTER FOR HEALTH AND REHABILITATION,445139,141 N MCLEAN BLVD,MEMPHIS,TN,38104,2018-11-15,623,D,0,1,W4ME11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to notify the Ombudsman of emergency transfers for 2 of 5 (Resident #68 and 147) sampled residents reviewed for hospitalization . The findings include: 1. The facility's Transfer or Discharge Notice policy dated (MONTH) (YEAR) documented, .4. A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman . 2. Medical record review revealed Resident #68 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Progress Notes dated 9/15/18 documented, .resident transferred to (Named Hospital) for Mental Status Change, doctor and family notified .resident returned at 6:45 PM from (Named Hospital) . Review of the Emergency Transfers from Facility form for (MONTH) (YEAR) revealed Resident #68's name was not on this list. The facility was unable to provide documentation the Ombudsman had been notified when Resident #68 had been transferred to the hospital. Interview with the Director of Nursing (DON) on 11/14/18 at 5:45 PM in the Chapel, the DON confirmed this resident was not on the list and stated, I didn't think we notified if they leave and come right back . 3. Medical record review revealed Resident #147 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Progress Notes dated 7/28/18 documented, .CNA (Certified Nursing Assistant) alerted the writer that resident was non-responsive .T.O. (telephone order) given to send resident to ER .5:55 AM Transportation arrived to transport resident . Review of the Emergency Transfers from Facility form for (MONTH) (YEAR) revealed Resident #147's name was not on this list. The facility was unable to provide documentation the Ombudsman had been notified when Resident #147 had been transferred to the hospital. Interview with the Social Services Director on 11/15/18 at 2:26 PM in the Chapel, the Social Services Director was asked if the Ombudsman was notified when residents are discharged or transferred from the facility. The Social Services Director stated, Yes, ma'am. The Social Services Director was then asked how it was determined which residents to put on the log for notification of transfer or discharge. The Social Services Director stated, The way I was told is that if they do not stay past midnight then we do not count them and if they weren't long term care then I didn't count them . The Social Services Director was asked if a resident goes to the hospital and doesn't stay past midnight are they placed on the log and if they are not long term care residents they are not put on the log. The Social Services Director stated, Yes, ma'am . The Social Services Director was then asked if Resident #147 should have been on the (MONTH) (YEAR) log. The Social Services Director stated, .he was short term so no he was not on the list .",2020-09-01
448,MIDTOWN CENTER FOR HEALTH AND REHABILITATION,445139,141 N MCLEAN BLVD,MEMPHIS,TN,38104,2018-11-15,641,E,0,1,W4ME11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to accurately assess residents for urinary catheters, Percutaneous Endoscopic Gastrostomy (PEG) tube, fall, and discharge disposition for 5 of 31 (Resident #44, 73, 117, 142, and 145) sampled residents reviewed. The findings include: 1. Medical record review revealed Resident #44 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. The Care Plan dated 3/12/18 and revised 9/19/18 documented, .(Named Resident #44) has an Indwelling Catheter r/t (related to) [MEDICAL CONDITION] . The Medication Review Report documented, .Order Summary .FOLEY CATHETER CARE EVERY SHIFT AND D[NAME]UMENT OUTPUT every shift for URINARY OBSTRUCTION .Start Date 09/06/2018 . The Progress Notes dated 9/6/18, 9/8/18, 9/9/18, and 9/12/18 documented Resident #44 had an indwelling urinary catheter present. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed no indwelling urinary catheter, and urinary incontinence was not rated. Observations in Resident #44's room on 11/13/18 at 10:28 AM and 3:32 PM revealed Resident #44 was in a wheelchair in his room and an indwelling urinary catheter was hanging from the wheelchair. Observations in the 400 hall dining room on 11/13/18 at 12:15 PM, revealed Resident #44 was seated in a wheelchair and an indwelling urinary catheter was hanging from the wheelchair. Interview with MDS Coordinator #1 on 11/15/18 at 12:10 PM in the Chapel, MDS Coordinator #1 was asked if the MDS for Resident #44 should have been coded as having an indwelling urinary catheter. MDS Coordinator #1 confirmed the MDS was inaccurate and stated, You are right. 2. Medical record review revealed Resident #73 was admitted to the facility with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].ENTERAL FEED [MEDICATION NAME] 1.5 AT 72 ML (milliliters) HR (hour) X (times) 20 HOURS . Review of the quarterly MDS assessment dated [DATE] revealed no PEG tube feeding. Observations in Resident #73's room on 11/15/18 at 8:28 AM revealed a PEG feeding of [MEDICATION NAME] 1.5 calorie at 72 milliliters per hour (ml/hr) with 45 ml/hr water flush infusing per pump. Interview with MDS Coordinator #1 on 11/15/18 at 12:10 PM in the Chapel, MDS Coordinator #1 was asked if the MDS for Resident #73 should be coded as having a PEG tube feeding. MDS Coordinator #1 stated, Yes and confirmed the MDS was not coded correctly. 3. Medical record review revealed Resident #117 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The fall investigation dated 10/22/18 documented, .resident sitting on buttock in front of wheelchair .no apparent injuries . Review of the 30 day MDS assessment dated [DATE] revealed no falls. Interview with MDS Coordinator #1 on 11/15/18 at 11:03 AM in the MDS office, MDS Coordinator #1 was asked if Resident #117 was coded for a fall on the MDS. MDS Coordinator #1 stated, No, he is not and confirmed the MDS was not accurately coded. 4. Medical record review revealed Resident #142 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].CHANGE FOLEY 16FR (French) AS NEEDED .D[NAME]UMENT OUTPUT AND FOLEY CARE DAILY EVERY SHIFT . Review of the 5 day MDS assessment dated [DATE] revealed no indwelling urinary catheter. Observations in Resident #142's room on 11/14/18 at 8:08 AM and 11/15/18 at 9:55 AM revealed Resident #142 resting in bed with an indwelling catheter bag hanging on the right side of the bed rail. Interview with MDS Coordinator #1 on 11/15/18 at 11:47 AM in the MDS office, MDS Coordinator #1 was asked if the MDS was coded correctly for an indwelling catheter. MDS Coordinator #1 stated, .does not say he has a cath (catheter) .no. 5. Medical record review revealed Resident #145 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Discharge home with family . The Discharge Summary dated 8/24/18 documented, .1. Discharge to .Home . Review of the discharge MDS assessment dated [DATE] revealed Resident #145's discharge disposition was coded for discharge to an acute hospital. Interview with MDS Coordinator #2 on 11/15/18 at 2:21 PM in the MDS office, MDS Coordinator #2 was asked if Resident #145 was discharged home. MDS Coordinator #2 stated, Yes and confirmed Resident #145 was not coded accurately for discharge disposition.",2020-09-01
449,MIDTOWN CENTER FOR HEALTH AND REHABILITATION,445139,141 N MCLEAN BLVD,MEMPHIS,TN,38104,2018-11-15,812,D,0,1,W4ME11,"Based on policy review, observation, and interview, 2 of 23 (Certified Nursing Assistant (CNA) #2 and 1) staff members failed to serve food under sanitary conditions during dining observations and the facility failed to ensure enteral feedings were stored under sanitary conditions as evidenced by 9 enteral feedings were stored past the use by date in 1 of 3 (3rd Floor) nourishment rooms. The findings include: 1. The facility's Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices policy dated (MONTH) 2008 documented, .1. All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness .6. Employees must wash their hands: .h. After engaging in other activities that contaminate the hands . 2. Observations in the West 400 hall on 11/13/18 beginning at 12:03 PM revealed CNA #2 entered Resident #96's room and delivered a meal tray to the resident. CNA #2 assisted the resident up in the bed with the assistance of another CNA, and CNA #2 continued to set up the resident's meal tray without performing hand hygiene. CNA #2 then entered Resident #116's room and delivered a meal tray to the resident without performing hand hygiene, set up the meal tray, adding salt and pepper to the food, and sugar to the tea. CNA #2 then delivered a meal tray to Resident #110's room and set up the meal tray without performing hand hygiene. Observations in the North 400 hall on 11/13/18 beginning at 12:27 PM revealed CNA #1 entered Resident #103's room, delivered and set up a meal tray to the resident without performing hand hygiene. CNA #1 then entered Resident #79's room, delivered and set up the meal tray without performing hand hygiene. Observations in the 400 Hall dining room on 11/15/18 at 8:11 AM revealed CNA #1 warmed Resident #91's meal tray and then began to feed the resident. As CNA #1 was feeding the resident, CNA #1 blew on the food, prior to giving the resident a bite to cool the food. This was done 5 times as he fed the eggs to the resident. Interview with the Director of Nursing (DON) on 11/15/18 at 10:47 AM in the Chapel, the DON was asked what should staff do after assisting residents, touching things in the rooms, and prior to setting up meal trays or delivering meal trays. The DON stated, Should use hand gel or wash hands. The DON was asked if staff should blow on food to cool it prior to giving the food to a resident. The DON stated, No. 3. Observations in the 3rd Floor nourishment room on 11/14/18 at 8:45 AM, revealed 9 bottles of Glucerna 1.2 (an enteral feeding) with a use by date of (MONTH) (YEAR). Interview with Licensed Practical Nurse #1 (LPN) on 11/14/18 at 8:47 AM, in the 3rd Floor nourishment room, LPN #1 was asked should these 9 bottles of enteral feedings past the use by date be stored here. LPN #1 stated, .No, it shouldn't . Interview with the DON on 11/15/18 at 9:16 AM, in the chapel, the DON was asked should any enteral feedings with a use by date of (MONTH) (YEAR) be stored in the nourishment room. The DON stated, No, it should not .",2020-09-01
450,MIDTOWN CENTER FOR HEALTH AND REHABILITATION,445139,141 N MCLEAN BLVD,MEMPHIS,TN,38104,2017-12-07,637,D,0,1,IIYT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual v1.15 (MONTH) 1, (YEAR), medical record review, and interview, the facility failed to ensure a significant change in status assessment was completed related to hospice services on 1 of 33 (Resident #34) sampled residents reviewed. The findings included: The MDS 3.0 RAI Manual v 1.15 (MONTH) 1, (YEAR) page 46 documented, .A SCSA (Significant Change in Status Assessment) is required to be performed when a terminally ill resident enrolls in a hospice program Medical record review revealed Resident #34 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 6/27/17 documented, .HOSPICE/Terminal illness .Resident is diagnosed with [REDACTED]. The physician's orders [REDACTED].>No significant change MDS assessment was completed when Resident #34 was admitted to hospice services. Interview with MDS Coordinator #1 on 12/7/17 at 8:18 AM, in the MDS office, MDS Coordinator #1 was asked if a significant change assessment should have been completed when Resident #34 was admitted to Hospice. MDS Coordinator #1 stated, Yes .",2020-09-01
451,MIDTOWN CENTER FOR HEALTH AND REHABILITATION,445139,141 N MCLEAN BLVD,MEMPHIS,TN,38104,2017-12-07,640,E,0,1,IIYT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual v 1.15 (MONTH) 1, (YEAR), medical record review and interview the facility failed to complete and transmit MDS assessments timely for 5 of 33 (Resident #1, 2, 4, 16, and 19) sampled residents reviewed. The findings included: 1. The MDS 3.0 RAI Manual v 1.15 (MONTH) 1, (YEAR) page 633 documented, .In accordance with the requirements .long-term care facilities participating in the Medicare and Medicaid programs must meet the following conditions: .Completion Timing: - For all non-Admission .assessments, the MDS Completion Date must be no later than 14 days after the Assessment Reference Date (ARD) . and page 634 documented, .Assessment Transmission: .MDS assessments must be submitted within 14 days of the MDS Completion Date . 2. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 had a quarterly MDS with an ARD of 10/18/17 and a completed date of 11/30/17. 3. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 had a quarterly MDS with an ARD of 10/6/17 and a completed date of 11/30/17. 4. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #4 had a significant change MDS with an ARD of 10/18/17 and a completed date of 12/1/17. Interview with MDS Coordinator #2 on 12/5/17 at 5:40 PM, in the Chapel, MDS Coordinator #2 was asked when were the quarterly MDS dated [DATE] for Resident #1, the significant change MDS dated [DATE] for Resident #4, and quarterly MDS dated [DATE] for Resident #2 transmitted to the state. She stated, 12-5-17. She was asked when they should have been transmitted. She stated, Not exactly sure, I think about 7 days. She was asked if they should have been transmitted prior to 12/5/17. She stated, Yes. 5. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #16 had a quarterly MDS with an ARD of 11/14/17 and a completed date of 12/6/17. Interview with MDS Coordinator #2 on 12/7/17 at 11:03 am, in the MDS office, MDS Coordinator #2 was asked to review MDS dated [DATE] for Resident #16 and was asked what date the MDS was completed. MDS Coordinator #2 stated, It should have been completed 11/28/17. MDS Coordinator #2 was asked if it was acceptable for the MDS to not be completed timely. MDS Coordinator #2 stated, No it is not acceptable. 6. Medical record review revealed Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS for Resident #19 with an ARD of 11/15/17 was not signed by the Registered Nurse. The assessment was not completed or transmitted to the state. Interview with MDS Coordinator #3 on 12/7/17 at 10:25 AM, in the MDS office, MDS Coordinator #3 was asked about the MDS assessment dated [DATE] for Resident #19 that was not completed or transmitted. As she looked into the computer at the MDS, she stated, Holy Cow, it is not completed. She was asked when should it have been completed and transmitted. She stated, A long time ago.",2020-09-01
452,MIDTOWN CENTER FOR HEALTH AND REHABILITATION,445139,141 N MCLEAN BLVD,MEMPHIS,TN,38104,2017-12-07,641,D,0,1,IIYT11,"**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 falls and [MEDICAL CONDITION] care for 2 of 33 (Resident #55 and 62) sampled residents reviewed. The findings included: 1. Medical record review revealed resident #55 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Nursing Assessment for Resident #55 revealed falls with no injury on 7/9/17, 8/31/17, and 9/4/17. The quarterly Minimal Data Set ((MDS) dated [DATE] documented no falls since the last MDS assessment. Interview with MDS Coordinator #1 on 12/7/17 at 8:20 AM, in the MDS office, MDS Coordinator #1 was asked if the 9/6/17 MDS should have been coded to reflect falls. MDS Coordinator #1 stated, Yes, 2 or more . 2. Medical record review revealed Resident #62 was admitted [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Medication Administration Record [REDACTED]. Review of the quarterly MDS dated [DATE] revealed [MEDICAL CONDITION] care was not marked as being performed. Interview with MDS Coordinator #1 on 12/7/17 at 8:20 AM, in the MDS office, MDS Coordinator #1 was asked if the 9/8/17 MDS should have been coded to reflect [MEDICAL CONDITION] care. MDS Coordinator #1 stated, Yes.",2020-09-01
453,MIDTOWN CENTER FOR HEALTH AND REHABILITATION,445139,141 N MCLEAN BLVD,MEMPHIS,TN,38104,2017-12-07,689,D,0,1,IIYT11,"**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 fall intervention measures were in place for 1 of 3 (Resident #55) sampled residents reviewed for falls. The findings included: 1. The facility's Falls policy documented, It is the intent of this facility to provide residents with assistance and supervision in an effort to minimize the risk of falls and fall related injury. 2. Medical record review revealed resident #55 was admitted on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 4/18/17 revealed .risk for fall .7/9/17 mats at bedside . Review of the (Named Facility) Nursing Assessment for (Resident #55) revealed falls with no injury on 7/9/17, 8/31/17, 9/4/17, 9/26/17, 10/13/17, and 11/23/17. The Certified Nursing Assistant (CNA) care guide (not dated) documented, RESIDENT CARDEX INFO (Information) .OVERALL EVALUATION .LOW BED WITH MATS . The Nursing Assessment for Resident #55 dated 9/4/17 documented, .Fall specific information .RESIDENT SLID OUT OF BED LYING ON HER RIGHT SIDE NEXT TO AIR CONDITION UNIT .Area of fall and position patient was found: LYING ON RT (right) SIDE . The Nursing Assessment for Resident #55 dated 9/26/17 documented, .Fall specific information .pt (patient) on the floor in a sitting position with back against the bed .Area of fall and position patient was found: .floor to pt's (patient's) right side of bed . The Nursing Assessment for Resident #55 dated 10/13/17 documented, .Fall specific information .Resident noted to be on floor beside bed on mat .Area of fall and position patient was found: .Noted on left side of bed on mat, lying on right side . Observations in Resident #55's room on 12/5/17 at 7:59 AM, revealed Resident #55 lying in bed on her right side, eyes closed, without mats on the floor at bedside. Interview with Unit Manager #1 on 12/5/17 at 4:56 PM, at the 300 hall nurses station, Unit manager #1 was asked what fall interventions Resident #55 should have in place. Unit Manager #1 stated, Mats at bedside when in bed . Interview with Unit Manager #1 on 12/5/17 at 5:42 PM, in Resident #55's room, Unit Manager #1 confirmed no mats were in the room or bathroom to be placed at the bedside. Observations in Resident #55's room on 12/6/17 at 8:03 AM, revealed Resident #55 in bed with a mat on the floor on the Resident's left side of the bed, another mat was in the room, stored between the wall and the side of the closet. Interview with Unit Manager #1 on 12/6/17 at 8:31 AM, at the 300 hall way nurses station, Unit Manager #1 was asked which side of the bed the mats in Resident #55's room should be placed on. Unit Manager #1 stated, We put it on the side where she actually gets out of bed, where she fell . In Resident #55's room, Unit Manager #1 confirmed that Resident #55 should have a fall mat on the right side of the bed. Interview with the Director of Nursing (DON) on 12/7/17 at 10:01 AM, in the DON office, the DON was asked if she would expect to see Resident #55 in bed without fall mats in place. The DON stated, No, she should have them when she is in bed .",2020-09-01
454,MIDTOWN CENTER FOR HEALTH AND REHABILITATION,445139,141 N MCLEAN BLVD,MEMPHIS,TN,38104,2017-12-07,761,D,0,1,IIYT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, 1 of 9 (Licensed Practical Nurse (LPN) #1) nurses failed to ensure medications and biologicals were stored safely when medications were left unattended in a resident's room during medication administration. The findings included: 1. The facility's STORAGE OF MEDICATION policy documented, .Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration .The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medication . Observations in Resident #28's room on 12/5/17 at 9:10 AM, revealed LPN #1 entered the room, placed a [MEDICATION NAME] injection on the resident's overbed table at the bedside. LPN #1 went into the resident's restroom before administering the medications, leaving the medications unattended and out of sight. Interview with the Director of Nursing (DON) on 12/5/17 at 9:36 AM, in the 200 hall dining room, the DON was asked if it was acceptable to leave medication in the resident's rooms unattended. The DON stated, No .it is not acceptable.",2020-09-01
455,SIGNATURE HEALTHCARE OF PRIMACY,445140,6025 PRIMACY PARKWAY,MEMPHIS,TN,38119,2018-02-13,550,D,0,1,EIX211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Federal Resident / Patient Rights, observation, and interview, the facility failed to maintain or enhance resident dignity and respect when 3 of 15 (Certified Nurse Assistant (CNA) #2 and 3, and Dietary Cook #1) staff members failed to knock before entering a room. The findings included: 1. The Federal Resident/Patient Rights documented, Every facility resident has a right to a dignified existence . Observations on the west hall on 2/11/18 at 11:53 AM, revealed CNA #2 delivered meal trays to rooms 107, 110 and 115. CNA #2 failed to knock on the door or announce herself prior to entering the rooms. Observations on the west hall on 2/11/18 at 12:31 PM, revealed Dietary Cook #1 delivered a sandwich to room [ROOM NUMBER] and failed to knock on the door or announce herself prior to entering the room. Observations on the west hall on 2/12/18 at 5:06 PM, revealed CNA #2 delivered a meal tray to room [ROOM NUMBER], placed the tray on the over bed table and exited the room and then returned. CNA #2 failed to knock or announce herself prior to entering the room. Observations on the west hall on 2/12/18 at 5:06 PM, revealed CNA #3 delivered meal trays to room [ROOM NUMBER] and 117. CNA #3 failed to knock or announce herself prior to entering the rooms. Interview with the Director of Nursing (DON) on 2/13/18 at 2:57 PM, in the human resource conference room, the DON was asked what should staff to do before entering a room. The DON stated, I expect them to knock and announce themselves . The DON was then asked what should staff to do when their arms are full. The DON stated, If they have their hands full I still expect them to announce themselves.",2020-09-01
456,SIGNATURE HEALTHCARE OF PRIMACY,445140,6025 PRIMACY PARKWAY,MEMPHIS,TN,38119,2018-02-13,693,D,0,1,EIX211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to follow physician's orders for a tube feeding for 1 of 2 (Resident #230) sampled residents reviewed with a tube feeding. The findings included: Medical record review revealed Resident #230 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 1/29/18 revealed Resident #230 was at nutrition and/or hydration risk with approaches to provide Percutaneous Endoscopic Gastrostomy (PEG) feeding as ordered. The physician's orders dated 2/2/18 documented, .[MEDICATION NAME] 1.5 cal (calorie) per peg tube at 50 cc (cubic centimeters)/hr (hour) for 22 hours, on at 8am, off at 6am . Observations in Resident #230's room on 2/11/18 at 2:44 PM and 4:57 PM, revealed Resident #230 was in the bed, [MEDICATION NAME] 1.5 was infusing at 55 ml/hr. Interview with Registered Nurse (RN) #1 on 2/12/18 at 2:20 PM, at the 200 hall medication cart, RN #1 was asked what Resident #230's feeding rate should be. RN #1 stated, 55 .oh no .50 . RN #1 confirmed Resident #230's feeding rate was infusing at 55 cc/hr. Interview with the Director of Nursing (DON) on 2/13/18 at 10:26 AM, in the Admissions office, the DON was asked if she expected her staff to follow the physician's orders. The DON stated, Yes. The DON was asked if an order for [REDACTED].",2020-09-01
457,SIGNATURE HEALTHCARE OF PRIMACY,445140,6025 PRIMACY PARKWAY,MEMPHIS,TN,38119,2018-02-13,695,D,0,1,EIX211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to provide appropriate oxygen therapy for 1 of 6 (Resident #74) sampled residents reviewed for oxygen therapy. The findings included: The facility's Departmental (Respiratory Therapy) - Prevention of Infection policy documented, .The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment .Infection Control Considerations Related to Oxygen Administration .7. Change the oxygen cannulae (cannula) and tubing every seven (7) days, or as needed . Medical record review revealed Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. O2 (oxygen) @ (at) 2L (liters) BNC (binasal cannula) . The care plan dated 2/7/18 documented, .Problem .Resident has [MEDICAL CONDITION] condition/Dx (diagnosis) of [MEDICAL CONDITIONS] exacerbation, resp (respiratory)failure .Approach .Change O2 tubing once a week . Observations in Resident #74's room on 2/11/18 at 10:06 AM, 2:57 PM, 5:00 PM, and on 2/12/18 at 7:41 AM, and 2:03 PM revealed the oxygen tubing was dated, but the date was illegible, and the filter on the concentrator was dirty. Interview with Registered Nurse (RN) #1 on 2/13/18 at 10:20 AM, in Resident #74's room, she was asked when this O2 tubing was changed. RN #1 confirmed the date could not be read and stated, I will change it, can not tell when was changed. RN #1 confirmed the filter was dirty and stated, will need to change. RN #1 was asked if they document when the tubing or the filter would be changed. RN #1 stated, No, just date the tubing. Interview with the Director of Nursing (DON) on 2/13/18 at 10:33 AM, in the Admission office, the DON was asked how often O2 tubing and the filter should be changed. The DON stated, every week",2020-09-01
458,SIGNATURE HEALTHCARE OF PRIMACY,445140,6025 PRIMACY PARKWAY,MEMPHIS,TN,38119,2018-02-13,801,F,0,1,EIX211,"Based on policy review, observation, and interview, the facility failed to ensure the Registered Dietician (RD) provided oversight of the kitchen when food was not prepared and served under sanitary conditions as evidenced by inappropriate tray line serving temperatures. The facility had a census of 82, with 78 of those residents receiving a meal tray from the kitchen. The findings included: The facility's Dietician policy documented, .Specific Responsibilities .7. Through observation and evaluation, promote food production and service procedures that conserve nutritive value, flavor, appearance, and quality, and are attractively served at the proper temperature .9. Develop and conduct person-centered Inservice training for dietary personnel and, as needed, for other healthcare community personnel . Observations in the kitchen on 2/12/18 at 5:00 PM, revealed Dietary Cook #1 took temperatures on the serving line. The pork loins temperature was 137 degrees Fahrenheit (F) and the corned beef temperature was of 89 degrees F. The first cart with 16 meals trays had left the kitchen to be served. Observations in the kitchen on 2/12/18 at 5:10 PM, revealed Dietary Cook #1 continued to serve the dinner trays and a plate of pork loin was requested and served. Interview with the Registered Dietician (RD) on 2/12/18 at 5:12 PM, in the Kitchen Manager office, the RD was asked should meat that didn't reach the appropriate temperature be served. The RD stated, .it should have been reheated . The RD was asked what the reheated temperature of the meat should be. The RD stated, 165. Interview with the Kitchen Manager on 2/12/18 at 5:15 PM, in the Kitchen Manager office, the Kitchen Manager was asked if she was going to let her dietary staff serve meat that didn't reach a safe temperature. The Kitchen Manager stated, No! and hurriedly stopped the cook from serving any more meals. The Kitchen Manager was asked what the reheated meat temperature should be. The Kitchen Manager stated, .Hold on a second .I'm not sure . Interview with the RD on 2/12/18 at 5:18 PM, in the Kitchen Manager office, the RD was asked what the reheated meat temperature should be. The RD stated, .It should get back up to 165. The RD was asked whose responsibility it was for the kitchen staff to know what the food temperatures should be. The RD stated, .The Kitchen Manager and if she doesn't know, she can ask her assistant. Interview with the Administrator on 2/13/18 at 9:05 AM, in the dining room, the Administrator stated, .Yes .her (the RD) lack of leadership was my concern .not taking ownership of the situation with the food temperatures yesterday .",2020-09-01
459,SIGNATURE HEALTHCARE OF PRIMACY,445140,6025 PRIMACY PARKWAY,MEMPHIS,TN,38119,2018-02-13,812,F,0,1,EIX211,"Based on policy review, observation, and interview, 1 of 15 (Certified Nursing Assistant (CNA) #1) staff members failed to distribute and serve food and beverages in a sanitary manner during dining and the facility failed to ensure food was prepared and served under sanitary conditions as evidenced by inappropriate tray line serving temperatures. The facility had a census of 82, with 78 of those residents receiving a meal tray from the kitchen. The findings included: 1. The facility's Handwashing/Hand Hygiene policy documented, .Policy Statement .The facility considers hand hygiene the primary means to prevent the spread of infections .Policy Interpretation and Implementation .7. Use an alcohol-based hand rub containing at least 62% (percent) alcohol, or, alternatively, soap .and water for the following situations .b. Before and after direct contact with residents .o. Before and after handling food . Observations in the 200 hall on 2/11/18 beginning at 12:16 PM, revealed CNA #1 assisted to position Resident #35 in bed, touched the resident and the bed. CNA #1 did not perform hand hygiene, continued to set up the resident's meal tray and touched the bread on his tray. CNA #1 repositioned Resident #56 in the bed and adjusted his bed, then continued to set up his meal tray, and touched the bread, without performing hand hygiene. CNA #1 asked the resident if he wanted butter on the bread, he stated no, and CNA #1 placed the bread back into the packet, and touched the bread again. CNA #1 adjusted Resident #59's bed, moved a wheelchair, and continued to set up the resident's meal tray, without performing hand hygiene. Observations in Resident #129's room on 2/11/18 at 12:45 PM, revealed CNA #1 repositioned the resident in bed with gloves on, then continued to set up the resident's meal tray with gloves on and did not perform hand hygiene. Interview with the Director of Nursing (DON) on 2/13/18 at 3:23 PM, in front of the Admission office, the DON was asked what should be done after assisting residents, touching objects and prior to setting up a meal tray or touching food. The DON stated, wash hands . 2. The facility's Dietician policy documented, .Specific Responsibilities .7. Through observation and evaluation, promote food production and service procedures that conserve nutritive value, flavor, appearance, and quality, and are attractively served at the proper temperature .9. Develop and conduct person-centered Inservice training for dietary personnel and, as needed, for other healthcare community personnel . Observations in the kitchen on 2/12/18 at 5:00 PM, revealed Dietary Cook #1 took temperatures on the serving line. The pork loins temperature was 137 degrees Fahrenheit (F) and the corned beef temperature was of 89 degrees F. The first cart with 16 meals trays had left the kitchen to be served. Observations in the kitchen on 2/12/18 at 5:10 PM, revealed Dietary Cook #1 continued to serve the dinner trays and a plate of pork loin was requested and served. Interview with the Registered Dietician (RD) on 2/12/18 at 5:12 PM, in the Kitchen Manager office, the RD was asked should meat that didn't reach the appropriate temperature be served. The RD stated, .it should have been reheated . The RD was asked what the reheated temperature of the meat should be. The RD stated, 165. Interview with the Kitchen Manager on 2/12/18 at 5:15 PM, in the Kitchen Manager office, the Kitchen Manager was asked if she was going to let her dietary staff serve meat that didn't reach a safe temperature. The Kitchen Manager stated, No! and hurriedly stopped the cook from serving any more meals. The Kitchen Manager was asked what the reheated meat temperature should be. The Kitchen Manager stated, .Hold on a second .I'm not sure . Interview with the RD on 2/12/18 at 5:18 PM, in the Kitchen Manager office, the RD was asked what the reheated meat temperature should be. The RD stated, .It should get back up to 165. The RD was asked whose responsibility it was for the kitchen staff to know what the food temperatures should be. The RD stated, .The Kitchen Manager and if she doesn't know, she can ask her assistant.",2020-09-01
460,SIGNATURE HEALTHCARE OF PRIMACY,445140,6025 PRIMACY PARKWAY,MEMPHIS,TN,38119,2018-05-21,658,D,1,0,K56Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, resident rights review, job description review, medical record review, and interview, the facility failed to ensure that licensed nurses did not borrow medications prescribed to one resident and administer those medications to another resident for 1 of 3 (Resident #1) sampled residents reviewed for medication administration. The findings included: 1. The facility's Medication Administration . policy documented, .Medications supplied for one resident are never administered to another resident . 2. The JOB DESCRIPTION .Charge Nurse (LPN or RN) (Licensed Practical Nurse or Registered Nurse) documented, .Essential Duties & Responsibilities .Prepare and administer medication as ordered by the physician .Verify that prescribed medication for one resident is not administered to another . 3. Medical record review revealed Resident #1 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1 did not have a comprehensive assessment completed because he was only in the facility for approximately 31 hours before leaving against medical advice. The physician admission orders [REDACTED]. The pharmacy's Shipping Manifest Pharmaceuticals dated 4/21/18 at 12:36 PM, revealed [MEDICATION NAME], and Duloxetine were delivered to the facility for Resident #1. The pharmacy's Shipping Manifest Pharmaceuticals dated 4/21/18 at 5:17 PM, revealed [MEDICATION NAME] was delivered to the facility for Resident #1. The (MONTH) Medication Administration Record [REDACTED]. No [MEDICATION NAME] was delivered from the pharmacy due to no written prescription was available and sent to the pharmacy. Interview with the Director of Nursing (DON) on 5/9/18 beginning at 9:35 AM, in the conference room, the DON provided a narcotic sign out sheet for a random resident that revealed 1 [MEDICATION NAME] was signed out on 4/21/18 at 12:00 AM. The DON reviewed the MAR for the same resident and revealed documentation that 1 [MEDICATION NAME] was administered to that resident. Review of Resident #1's MAR indicated [REDACTED]. The DON was asked about Resident #1's MAR indicated [REDACTED]. The DON stated that even though other resident medications should not be borrowed, she confirmed the nurses did borrow medications from other residents and documented they were administered on Resident #1's MAR. The DON stated that the nurses should not borrow medications. The (MONTH) MAR indicated [REDACTED]. Telephone interview with LPN #1 on 5/9/18 at 10:00 AM, in the conference room, LPN #1 confirmed that she signed the [MEDICATION NAME] as given on the random resident's MAR indicated [REDACTED]. LPN #1 confirmed she administered the borrowed [MEDICATION NAME] it to Resident #1. Telephone interview with LPN #1 on 5/17/18 at 8:04 AM, LPN #1 was asked if she administered [MEDICATION NAME] to Resident #1. LPN #1 stated that she did give him a [MEDICATION NAME] sometime during that first night and she confirmed that he did take the medication. LPN #1 confirmed that she did borrow medications from other residents.",2020-09-01
461,SIGNATURE HEALTHCARE OF PRIMACY,445140,6025 PRIMACY PARKWAY,MEMPHIS,TN,38119,2018-05-21,697,D,1,0,K56Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, resident rights review, medical record review, and interview, the facility failed to manage or prevent pain to help residents attain or maintain the highest practicable level of well-being for 1 of 3 (Resident #1) sampled residents reviewed for pain. The findings included: 1. The facility's Pain Management policy documented, .The purpose of this policy is to outline guidelines that will promote effective pain management, including .timely response to complaints of pain .Our facility is committed to help each resident attain or maintain their highest reasonable level of well-being and to prevent or manage pain to the extent possible. Our pain management policy includes recognizing when the resident experiences pain .and management or prevention of pain consistent with professional standards of care and in accordance with the plan of care .MANAGEMENT .When treating pain, start with drugs appropriate to the resident's current level of pain and progress by increasing the dose of that drug until maximum benefit is obtained . 2. The Residents Rights documented, .Nursing home residents have the right .to reside and receive services with reasonable accommodation .to voice grievances about care or treatment they do or do not receive .and to receive prompt response from the facility . 3. Medical record review revealed Resident #1 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1 did not have a comprehensive assessment completed because he was only in the facility for approximately 32 hours. The Baseline Admission Care Plan documented, .Problem .Resident has pain .Related to .Diabetic [MEDICAL CONDITION] .Approach .Administer pain medications per physicians orders . The hospital physician admission orders [REDACTED]. The original handwritten prescriptions signed by the physician for these medications were not found when Resident #1 arrived to the facility via ambulance. Medical record review revealed Resident #1 did not receive [MEDICATION NAME] for pain, [MEDICATION NAME] for anxiety, or [MEDICATION NAME] for [MEDICAL CONDITION] during his stay at the facility. Review of the hospital medication reconciliation discharge paperwork dated 4/20/18 revealed Resident #1 had last received [MEDICATION NAME] on 4/15/18 at 3:14 AM, [MEDICATION NAME] on 4/19/18 at 9:50 PM, [MEDICATION NAME] on 4/20/18 at 11:22 AM, and [MEDICATION NAME] on 1/16/18 at 12:00 AM, while a patient in the hospital. The nurse's notes dated 4/21/18 at 2:57 AM, Licensed Practical Nurse (LPN) #1 documented, .CONCERNED WITH MEDS (Medications) NOT BEING HERE .RESIDENT NOT PLEASED .ASKING TO GO BACK TO HOSPITAL .NOW AT DESK REQUESTING PAIN PILL. MEDS STILL NOT AVAILABLE FROM PHARMACY .4:12 AM .AT DESK AT THIS TIME TALKING AGGRESSIVELY TO NURSE ABOUT HIS MEDS. WILL NOT ALLOW NURSE TO EXPLAIN MED SITUATION TO HIM. KEEPS OVERTALKING NURSE AND YELLING ABOUT THIS IS NOT RIGHT. REQUESTING THAT I CALL AMBULANCE FOR HIM TO GO BACK TO HOSPITAL. ADVISED THAT HE (Resident #1) MAY DO SO BUT IT WOULD NOT BE AN EMERGENCY TRANSFER FROM FACILITY .(RESIDENT #1) STATING .NURSE TOLD HIM THAT MEDS WERE ON THE WAY .I CANNOT GIVE HIM MEDS THAT I DO NOT HAVE . The (MONTH) MAR indicated [REDACTED]. Resident #1 was not administered any [MEDICATION NAME] from 4/20/18 at 11:22 AM (at the hospital) until 4/21/18 at 4:33 AM (at the nursing home facility). Resident #1 did not have any pain medication for a total of 17 hours and 11 minutes. Resident #1 did not receive any additional pain medication for an additional 21 hours and 17 minutes during his stay at this facility and he left against medical advice on 4/22/18 at 1:50 AM. On 4/21/18 at 5:43 AM, LPN #2 documented, .Writer then Called NP (Nurse Practitioner) on call .and explained the issue, she was given his dx (diagnosis) with chronic pain she ordered to give Tylenol 650mg every 4 hours as needed for pain. he refused to receive it saying it upsets his stomach. DON (Director of Nursing) then notified about issue. (Named Medical Director) was called but could not be reached at the time .DON was notified of unresolved issue, she ordered to transfer resident to hospital for uncontrolled pain .he refused and stated that [MEDICATION NAME] would be fine at the moment . The nurse's note dated 4/22/18 at 4:02 AM, documented, REPORTED PER VS (VITAL SIGNS) THAT BP (BLOOD PRESSURE) IS 176/99. PRN (AS NEEDED) [MEDICATION NAME] OFFERED WITH TYLENOL FOR C/O (COMPLAINT OF) PAIN. DECLINED TYLENOL. STATED IT CAUSES GI (GASTROINTESTINAL) UPSET. RESIDENT OBSERVED PACKING BELONGINGS AND STATED THAT HE WILL BE LEAVING TONIGHT .SAID HE WOULD CALL 911 OR AMBULANCE SERVICE. ADVISED TO ALLOW NURSE TO GIVEN HIM PRN FOR BP. STATED THAT HE COULD NOT TAKE IF HE DIDN'T HAVE HIS PAIN MED (MEDICATION) ALSO. INFORMED THAT NO PAIN MED AT THIS TIME EXCEPT TYLENOL AVAILABLE. (RESIDENT #1) REMAINED DETERMINED TO LEAVE. FINISHED PACKING ALL BELONGINGS AND AT DESK ASKING WHAT PAPER TO SIGN TO GET OUT OF HERE. PRESENTED WITH AMA (AGAINST MEDICAL ADVICE) PAPERS. READ OVER PAPERS AND SIGNED .OBSEVRED EXTING (OBSERVED EXITING) UNIT WITH PERSONAL BELONGS TOWARD FRONT DOOR OF FACILITY. ALARM SOUNDED OF EXIT AT 0150 AM .6:23 AM FACILITY ADMINISTRATOR AND DON MADE AWARE OF AMA OF RESIDENT. The pharmacy's Shipping Manifest Pharmaceuticals dated 4/21/18 at 12:36 PM, revealed the following medications were delivered to the facility for Resident #1. [MEDICATION NAME] 30 tablets, Atorvastatin 30 tablets, [MEDICATION NAME] 30 tablets and Duloxetine 60 tablets. The pharmacy's Shipping Manifest Pharmaceuticals dated 4/21/18 at 5:17 PM, revealed the following medications were delivered to the facility for Resident #1. Losartan 60 tablets, [MEDICATION NAME] 30 tablets, [MEDICATION NAME] 30 tablets and [MEDICATION NAME] 7 tablets. The DON provided a narcotic sign out sheet for a random resident that revealed 1 [MEDICATION NAME] was signed out on 4/21/18 at 12:00 AM. Review of Resident #1's (MONTH) MAR indicated [REDACTED]. Interview with Resident #1 on 5/8/18 beginning at 2:14 PM, in the conference room, he was asked about his stay at this facility in April. Resident #1 confirmed he was admitted to the facility at approximately 5:50 PM on 4/20/18 and the hospital sent written prescriptions with him in an envelope. He stated they lost the prescriptions and he did not get any pain medicine when he was there. He stated that he had [MEDICAL CONDITION] pain and anxiety. Interview with the DON on 5/9/18 beginning at 9:35 AM, in the conference room, she was asked about the facility's process if narcotic prescriptions are lost when residents are admitted to the facility. The DON stated that they cannot get narcotics if there is no written prescription. The DON stated that the facility was looking into the incident and would be doing a process improvement plan. The DON confirmed that Resident #1 should not have gone so long without pain medication. The DON was asked about Resident #1's continued requests for medication. The DON confirmed that Resident #1 was hard to manage and he was not truthful. She stated that they offered to send him to the ER but he refused. Telephone interview with Resident #1 on 5/9/18 at 2:10 PM, revealed he was upset with how he was treated. He stated that he felt they didn't care about him and he told them if he couldn't get his medicine and he was hurting that he was going to leave. He stated that he asked the supervisor to call an ambulance so he could go to the hospital and that she told him you have a phone, you can call and get over there yourself and it wasn't an emergency. He stated that they didn't want to do anything to help him. He continued to say he did not get his medications especially his pain medication. During a telephone interview with the Nurse Practitioner on 5/9/18 at 2:40 PM, the Nurse Practitioner was asked about Resident #1 and did she receive a call from the nursing staff that he needed pain medication. The Nurse Practitioner stated, I don't have my computer up and I don't have my notes but they called me about a patient and it was a while back, but when they call about a patient, the hospital is supposed to send their scripts (handwritten prescriptions) with them, with the amount of issues with controlled substances of that nature, we don't write narcotics until you actually see that patient, so if they call and say we don't have the script, then the patient typically gets Tylenol until either I will tell them to call the hospital and ask them where's the script at, find the script so you guys can go pick it up and do it that way, but in the meantime there is a Tylenol ordered to give them a chance to maintain them until then. Telephone interview with LPN #1 on 5/17/18 at 8:04 AM, LPN #1 was asked if she administered (Named Narcotic) to Resident #1. LPN #1 stated that she did give him a [MEDICATION NAME] sometime during that first night, because he was acting out. She was asked if she administered any other medications to him during his stay. She stated that she gave him one other medicine that morning at about 6:00 AM. LPN #1 was asked if she administered any other medications to Resident #1. She stated that she did not give him anything else because his medications had not come from the pharmacy yet. LPN #1 confirmed that she did borrow those 2 medications from other residents.",2020-09-01
462,SIGNATURE HEALTHCARE OF PRIMACY,445140,6025 PRIMACY PARKWAY,MEMPHIS,TN,38119,2018-12-19,658,D,0,1,C6P811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, 2 of 5 (Licensed Practical Nurse (LPN) #1 and Registered Nurse (RN) #1) nurses failed to follow the facility policy for administration of medications through an enteral tube and administration of eye drops. The findings included: 1. The facility's Medication Administration Enteral Tubes policy documented, .The powder from each medication is mixed with water before administration. The souffle cup is rinsed with water to get all of the medication contained within the cup to facilitate the ordered dose .Enteral tubes are flushed with at least 15 ml (milliliters) of water before administering any medications and after all medications have been administered .PR[NAME]EDURES .Crush each immediate-release tablets, one at a time, into a fine powder, and dissolve in water .Dilute each liquid medication with water .Administer liquid medications first .Clean feeding syringe and return to bedside stand . Medical record review revealed Resident #18 was admitted to the facillity on 7/31/18 with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Give 1 Tablet .1 time Daily .[MEDICATION NAME] 10 MG . GIVE 1 TABLET .ONCE DAILY .[MEDICATION NAME] .150 MG .TWICE DAILY .[MEDICATION NAME] ([MEDICATION NAME]) 5MG/ML .5 ML .EVERY 12 HOURS .FLUSH TUBE WITH 30ML H2O (water) BEFORE AND AFTER MEDICATION . Observations in Resident #18's room on 12/18/18 at 9:10 AM, revealed LPN #1 administered an unmeasured amount of water, then poured in dry crushed [MEDICATION NAME], poured in an unmeasured amount of water, added dry crushed aspirin, added an unmeasured amount of water, added [MEDICATION NAME] solution without diluting, added an unmeasured amount of water, then added [MEDICATION NAME] liquid without diluting and followed with an unmeasured amount of water. LPN #1 did not measure the water and only poured a small amount of water following each medication. LPN #1 did not mix these medications with water prior to administering them through the enteral tube. Interview with the Director of Nursing (DON) on 12/19/18 at 12:00 PM, outside the Chapel, the DON was asked should enteral medications be diluted prior to administering in the enteral tube. The DON stated, Yes, they should . 2. The facility's Medication Administration Eye Drops policy documented, .With a gloved finger, gently pull down lower eyelid to form a pouch, while instructing resident to look up .Hold inverted medication bottle between the thumb and index finger, and press gently to instill prescribed number of drops into pouch near outer corner of eye . Medical record review revealed Resident #73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].REFRESH TEARS 0.5% (percent) EYE DROPS .Give 1 Each in both eyes. As Needed .DRY EYES . Observations in Resident #73's room on 12/18/18 at 9:40 AM, revealed RN #1 administered eye drops without forming a pouch and held the bottle of medications above the eye and administered one drop over the center of the eye. Interview with the DON on 12/19/18 at 11:07 AM, at the East Nurses' Station, the DON was asked how should eye drops be administered. The DON stated, .form a pouch .",2020-09-01
463,SIGNATURE HEALTHCARE OF PRIMACY,445140,6025 PRIMACY PARKWAY,MEMPHIS,TN,38119,2018-12-19,686,D,0,1,C6P811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to follow physician orders [REDACTED].#47) sampled residents reviewed with pressure ulcers. The findings included: Medical record review revealed Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The significant change Minimum Data Set ((MDS) dated [DATE] revealed a stage 2 pressure ulcer, stage 3 pressure ulcer and 1 suspected deep tissue injury (sDTI). The physician's orders [REDACTED].Order Date .9/11/2018 .BILATERAL HEEL BOOTS (Prevalon heel boots for prevention and treatment of [REDACTED]. The Pressure Ulcer Record dated 12/6/18 documented, .Date of Origin 09/10/2018 .Left heel stage 2 ruptured blister .Facility acquired .Length .0.3 .Width .0.3 .Depth .0.0 . SPECIALTY INTERVENTIONS .bilateral heel boots . The Pressure Ulcer Record dated 12/6/18 documented, .Date of Origin 09/10/2018 .Right heel sDTI .Facility acquired .Length .0.0 .Width .0.0 .Depth .0.0 . SPECIALTY INTERVENTIONS .bilateral heel boots .Sdtl .right heel has resolved .Prevalon boot remains in place for protection . Observations at the West Nurses' Station on 12/17/18 at 4:10 PM, revealed Resident #47 was sitting in a wheelchair only wearing one heel boot on her left foot. Wound care observations in Resident #47's room on 12/18/18 at 10:20 AM, revealed Resident #47 was in the bed lying on a special air mattress. Licensed Practical Nurse (LPN) #2 removed a non-skid sock from Resident #47's left foot. The wound area had a small scab with no drainage. A heel boot was on the resident's right foot, the wound area was dry and intact. Observations on 12/19/18 at 8:33 AM, revealed Resident #47 was dressed, sitting in her wheelchair by the bed, only wearing non-skid socks on both feet. Resident #47 was not wearing bilateral heel boots. Interview with LPN #4 on 12/19/18 at 9:38 AM, in Resident #47's room, LPN #4 was asked what Resident #47 was wearing on her feet. LPN #4 stated, Non-skid socks . LPN #4 was shown Resident #47's physician order [REDACTED].#4 then placed the heel boot on the resident's left foot and was unable to find the heel boot for Resident #47's right foot. Interview with the Director of Nursing (DON) on 12/19/18 at 9:00 AM, in the DON office, the DON was asked if staff should follow physician orders [REDACTED]. The DON stated, Absolutely .",2020-09-01
464,SIGNATURE HEALTHCARE OF PRIMACY,445140,6025 PRIMACY PARKWAY,MEMPHIS,TN,38119,2018-12-19,759,E,0,1,C6P811,"**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 2 of 5 (Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #3) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 3 errors were observed out of 26 opportunities, resulting in an error rate of 11.538%. The findings included: 1. The facility's Medication Administration General Guidelines policy dated 05/2016 documented .Medications are administered as prescribed .Prior to administration, review and confirm MEDICATION ORDERS FOR [REDACTED].Verify medication is correct three (3) times before administering the medication. a. When pulling medication package from med cart b. When dose is prepared c. Before dose is administered . 2. Medical record review revealed Resident #73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].ASPIRIN 81 MG (milligrams) .Give 1 Tablet by mouth 1 time(s) Daily .[MEDICATION NAME] 10 MG TABLET ([MEDICATION NAME] oxalate) Give 1 Tablet by mouth 1 times(s) Daily .[MEDICATION NAME] 10 MG TABLET ([MEDICATION NAME]) Give 0.5 Tablet by mouth 1 time(s) Daily .[MEDICATION NAME] 5 MG TABLET .Give 1 Tablet by mouth 1 time(s) Daily .[MEDICATION NAME] 20 MG TABLET (toresemide) GIVE 2 TABLETS (40 MG) BY MOUTH EVERY OTHER DAY .[MEDICATION NAME] SOD (Sodium) 100 MG SOFTGEL ([MEDICATION NAME] sodium) Give 1 Caplet by mouth 2 time(s) Daily .[MEDICATION NAME] 5 MG TAB (Tablet) ([MEDICATION NAME]) Give 1 Tablet by mouth 2 time(s) Daily . Observations on 12/18/18 beginning at 9:30 AM, at the medication cart at the East Nurses' Station, RN #1 prepared the following medications for Resident #73: [MEDICATION NAME] Sodium 100 MG 1 tablet [MEDICATION NAME] 5 MG 1 tablet Aspirin 81 MG 1 tablet Toresemide 20 MG 1 tablet [MEDICATION NAME] 10 MG 1/2 tablet [MEDICATION NAME] 5 MG 1 tablet [MEDICATION NAME] 10 MG 1 tablet Interview with RN #1 on 12/18/18 at 9:35 AM, at the medication cart at the East Nurses' Station, RN #1 confirmed there were 6 and a half pills in the souffle cup to administer to this resident. There should have been 7 1/2 pills, there was only one toresemide 20 MG tablet in the souffle cup instead of 2. Observations in Resident #73's room on 12/18/18 at 9:45 AM, revealed RN #1 administered these 6 1/2 pills to this resident by mouth. The administration of the toresemide 20 MG instead of 40 MG resulted in medication error #1. 3. Medical record review revealed Resident #197 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's telephone orders dated 12/10/18 documented .(symbol for decrease) Losartan 25 mg po (by mouth) day (daily) . The physician's telephone orders dated 12/16/18 documented, .[MEDICATION NAME] 2 squirts each nostril Q (every) Day . The Medication Administration Record [REDACTED].LOSARTAN POTASSIUM 25 MG .Give 1 Tablet by mouth 1 time(s) Daily . Observations in Resident #197's room on 12/19/18 at 8:05 AM, revealed LPN #3 administered losartan potassium 100 mg to Resident #197 and 1 spray of [MEDICATION NAME] to each nostril. Failure of the nurse to administer the correct dose of losartan potassium and [MEDICATION NAME] resulted in medication error #2 and 3. Interview with LPN #3 on 12/19/18 at 9:45 AM, at the East Nurses' Station, LPN #3 confirmed the medication card contained Losartan Potassium 100 mg and 7 of the 30 tablets were missing from the card. LPN #3 stated, It was discontinued on 12/11/18 and I gave too much. Interview with LPN #3 on 12/19/18 at 10:35 AM, at the East Nurses' Station, LPN #3 confirmed she only gave this resident 1 spray of [MEDICATION NAME] to each nostril. Interview with the Director of Nursing (DON) on 12/19/18 at 11:12 AM, at the East Nurses' Station, the DON was asked how should nurses administer the correct drug and amount. The DON stated, . check Medication Administration Record, [REDACTED].",2020-09-01
465,SIGNATURE HEALTHCARE OF PRIMACY,445140,6025 PRIMACY PARKWAY,MEMPHIS,TN,38119,2018-12-19,760,D,0,1,C6P811,"**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 residents were free of significant medication errors when 1 of 5 (Licensed Practical Nurse (LPN) #3) nurses did not administer significant medications at the correct dosage. The findings include: 1. The facility's Medication Administration General Guidelines policy dated 5/2016 documented .Medications are administered as prescribed .Prior to administration, review and confirm MEDICATION ORDERS FOR [REDACTED].Verify medication is correct three (3) times before administering the medication. a. When pulling medication package from med cart b. When dose is prepared c. Before dose is administered . 2. Medical record review revealed Resident #197 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].(symbol for decrease) Losartan (a blood pressure medication) 25 mg (milligrams) po (by mouth) day (daily) . The Medication Administration Record [REDACTED].LOSARTAN POTASSIUM 25 MG .Give 1 Tablet by mouth 1 time (s) Daily . Observations in Resident #197's room on 12/19/18 at 8:05 AM, revealed LPN #3 administered losartan potassium 100 mg to Resident #197. The failure of the nurse to administer the correct dose of losartan potassium resulted in a significant medication error. Interview with LPN #3 on 12/19/18 at 9:45 AM, at the East Nurses' Station, LPN #3 confirmed the medication card contained Losartan Potassium 100 MG and 7 of the 30 tablets were missing from the card. LPN #3 stated, It was discontinued on 12/11/18 and I gave too much. Interview with the Director of Nursing (DON) on 12/19/18 at 11:12 AM, at the East Nurses' Station, the DON was asked how should nurses administer the correct drug and amount. The DON stated, .check Medication Administration Record, [REDACTED].",2020-09-01
466,SIGNATURE HEALTHCARE OF PRIMACY,445140,6025 PRIMACY PARKWAY,MEMPHIS,TN,38119,2018-12-19,761,E,0,1,C6P811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observations, and interview, the facility failed to ensure medications were properly and securely stored when medications were unattended in 1 of 62 (room [ROOM NUMBER]B) resident rooms, 1 of 5 (Licensed Practical Nurse (LPN) #2) nurses left medications unattended and out of their sight, and medications were not dated when opened in 2 of 8 (West 2 Medication Cart and West 1 Medication Cart) medication storage areas. The findings included: The facility's BEDSIDE MEDICATION STORAGE policy dated 5/2016 policy documented, .PR[NAME]EDURES .4. Bedside medication .Lockable drawers or cabinets are required . The facility's STORAGE OF MEDICATION policy dated 11/2017 documented, .POLICY Medications and biologicals are stored properly .to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .PR[NAME]EDURES .3. In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications .are allowed to access medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended any persons with authorized access .12. Insulin products should be stored in the refrigerator until opened. Note the date on the label for insulin vials and pens when first used . The MEDICATIONS WITH SHORTENED EXPIRATION DATES provided by the American Society of Consultant Pharmacists documented, .[MEDICATION NAME] .Discard when the counter reaches zero or three months after removal from the protective foil package .[MEDICATION NAME] .Vials/Cartridges/[MEDICATION NAME] expire 28 days after or removing from the refrigerator, whichever comes first .[MEDICATION NAME] R (Regular) .Vial: Expires 42 days after opening or removing from refrigerator, whichever comes first . Observations in room [ROOM NUMBER]B on 12/17/18 at 9:30 AM, 12:10 PM, 5:05 PM, and on 12/18/18 at 8:10 AM, revealed a bottle of Dakins solution (1/2 strength sodium hypochlorite 25 percent, a medicated wound irrigation) sitting on top of the nightstand beside the resident's bed. Interview with the Director of Nursing (DON) on 12/18/18 at 8:50 AM, at the West Nurses' Station, the DON was asked if a wound treatment medication should be left at the bedside. The DON stated, No. Observations in Resident #197's room on 12/18/18 at 5:06 PM, revealed LPN #2 placed the resident's medication cups with medications on the over-bed table and went to the bathroom to wash her hands, leaving the medications out of her view. She then left the room to get a syringe, leaving the medications on the over-bed table and out of her view. Interview with the DON on 12/19/18 at 11:10 AM, at the East Nurses' Station, the DON was asked, should medications be left unattended. The DON stated, No. Observations in the West 2 Medication Cart on 12/19/18 at 10:45 AM, revealed 1 open vial of [MEDICATION NAME] R with no open date, 1 open [MEDICATION NAME] Pen with no open date, and 2 open [MEDICATION NAME] inhalers with no open date. Interview with LPN #1 on 12/19/18 at 10:47 AM, at the West 2 Medication Cart, LPN #1 confirmed these medications were not dated when they were opened. Observations in the West 1 Medication Cart on 12/19/18 at 10:55 AM, revealed 1 [MEDICATION NAME] with no open date. Interview with the Director of Nursing (DON) on 12/19/18 at 11:35 AM, in the DON Office, the DON was asked if medications with shortened expiration dates should be dated when opened. The DON stated, Yes.",2020-09-01
467,SIGNATURE HEALTHCARE OF PRIMACY,445140,6025 PRIMACY PARKWAY,MEMPHIS,TN,38119,2018-12-19,880,E,0,1,C6P811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were followed when 2 of 5 (Licensed Practical Nurse (LPN) #1 and 3) nurses failed to perform hand hygiene appropriately, use barriers, and clean reusable equipment during medication administration. The findings included: The facility's Handwashing/Hand Hygiene policy documented, Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel. Discard towels into trash . The facility's Cleaning and Disinfecting Non-Critical Resident-Care Items policy documented, Reusable items are cleaned and disinfected or sterilized between residents ( .stethoscopes, durable medical equipment) . The facility's Clean Glucometer/PT ([MEDICATION NAME]) -INR (International Normalized Ratio) Competency policy documented, .If no visible organic material is present disinfect the exterior surfaces after each use using .facility approved disinfectant with either an EPA (Evironmental Protection Agency) registered detergent/germicide with a turberculocidal or HBV (Hepatis B Virus)/[MEDICAL CONDITION](Human Immunodeficiency Virus) label claim, or a dilute bleach solution of 1:10 to1:100 concentration . Observations in Resident #18's room on 12/18/18 at 9:05 AM, revealed LPN #1 went to the bathroom and placed the medication cups on the sink without a barrier. LPN #1 washed her hands, took the paper towels and dried her hands, then placed the towels on the sink behind the faucet. LPN #1 placed the syringe on the table without a barrier and without cleaning the table. LPN #1 placed the stethoscope on the resident's abdomen, and then put the stethoscope around her neck. LPN #1 did not clean the stethoscope prior to touching the resident's abdomen. After administering the medications, LPN #1 carried the trash and insulin syringe to the bathroom, washed her hands, and then proceeded gather up the trash and took it back to the room, put the syringe in a sharps box and trash in the wastebasket. LPN #1 did not perform hand hygiene after this. Interview with the Director of Nursing (DON) on 12/19/18 at 11:20 AM, at the East Nurses' Station, the DON was asked should the stethoscope be cleaned between residents. The DON stated, Yes, stethoscopes should be wiped down. The DON was asked should a barrier be used. The DON stated, Yes . Observations in Resident #18's room on 12/18/18 at 9:10 AM, revealed LPN #1 did not clean the over bed table before placing items on the table without a barrier. Observations in Resident #445's room on 12/19/18 at 7:30 AM, revealed LPN #3 carried glucometer, a bottle of test strips, lancets, and alcohol pads to the room, placed all the items in her pocket, washed her hands, then took out the items from her pocket. LPN #3 cleaned the glucometer with an alcohol pad. Observations at the East Nurses' Station on 12/19/18 at 8:05 AM, revealed LPN #3 left Resident 197's room after completing his accucheck. LPN #3 then proceeded to clean the glucometer with an alcohol pad and placed the glucometer on the top of the cart without a barrier. Interview with the DON on 12/19/18 at 11:12 AM, at the East Nurses' Station, the DON was asked how should glucometers to be disinfected. The DON stated, .We don't use alcohol wipes, we use germicidal wipes .",2020-09-01
468,BRADLEY HEALTH CARE & REHAB,445141,2910 PEERLESS RD,CLEVELAND,TN,37312,2017-08-08,226,D,1,0,IIH211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, and interview, the facility failed to follow facility policy during an investigation of an allegation of abuse for 1 resident (#1) of 3 residents review for abuse. The findings included: Review of the facility's Policy and Procedure for Resident Abuse, last revised 11/6/11, revealed .any employee suspected of resident abuse .will be promptly removed of duty until the supervisor and/or administrator and abuse coordinator completes an investigation .nursing staff will thoroughly examine the resident for any signs of injury or abuse . Medical record review revealed Resident #1 was admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. Medical record review of a Nurse's Progress Notes dated 7/18/17 at 4:00 AM revealed .At 0300 (3:00 AM) CNA's (Certified Nurse Assistants) .entered room to change resident after small BM (bowel movement) .CNAs were administering peri-care when resident states 'they are hurting me' . (Licensed Practical Nurse (LPN) #4) and CNA entered the room to check on resident and resident stated 'I want my door closed because my private area has just been abused' .Notified abuse coordinator and investigation process stated (started) . Review of CNA #1 and CNA #2's time card report dated 7/18/17 revealed CNA #1 and CNA #2 left the facility at 6:23 AM (3 hours and 23 minutes after the allegation was made). Interview with the Director of Nursing (DON) on 8/7/17 at 3:20 PM, in the conference room, revealed she was not sure when the CNAs exited the facility. Telephone interview with LPN #4 on 8/7/17 at 3:44 PM confirmed CNA #1 and CNA #2 remained on the unit and continued to provide care to other residents during the investigation. Interview with the Administrator on 8/7/17 at 6:01 PM, in the conference room, revealed .talked to (Registered Nurse (RN) #1) .was told the CNAs were removed .CNAs not to do care .felt it (allegation of abuse) was not valid .if it were a situation where we immediately felt like resident were abused they'd be sent home immediately .I know they were not to perform care . Continued interview confirmed CNA #1 and CNA #2 were not removed from resident care during an investigation of an allegation of abuse and the facility failed to follow facility policy.",2020-09-01
469,BRADLEY HEALTH CARE & REHAB,445141,2910 PEERLESS RD,CLEVELAND,TN,37312,2017-10-18,372,F,1,1,8EWI11,"> Based on facility policy review, observation and interview, the facility failed to dispose of garbage and refuge in a sanitary manner in 3 of 3 dumpsters observed. The findings included: Review of a facility policy Garbage and Rubbish Disposal dated 4/2004 revealed .Garbage and rubbish containing food waste shall be stored so as to be inaccessible to vermin .Outside dumpsters .must be kept .free of litter around the dumpster area . Observation with the Certified Dietary Manager (CDM) on 10/16/17 at 10:10 AM, outside at dumpster area, revealed the following items on the grounds surrounding the dumpsters: a). Two cardboard boxes b). Disposable Plastic ware c). Various pieces of paper, partial plastic aprons, and strips of packaging tape Continued observation with the CDM behind the dumpsters revealed a thick wet greasy type substance under, and behind the dumpsters appearing to come from 2 of 3 dumpsters observed. Interview with the CDM on 10/16/17 at 10:15 AM, outside of the kitchen confirmed the facility failed to dispose of garbage and refuge properly, and failed to maintain the dumpster area in a sanitary manner.",2020-09-01
470,BRADLEY HEALTH CARE & REHAB,445141,2910 PEERLESS RD,CLEVELAND,TN,37312,2018-10-31,571,D,1,1,0MUL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the facility admission packet, medical record review, review of trust transaction history, observation, and interview, the facility charged the personal fund account for incontinence care items for 1 resident (#72) of 34 incontinent residents reviewed of 44 sampled residents. The findings include: Review of the facility admission packet and resident rights revealed the facility would provide incontinence care supplies for the residents. Medical record review revealed Resident #72 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #72's Admission Record revealed the resident's primary payer source was Medicaid ICF (Intermediate Care Facility). Medical record review of a quarterly Minimum Data Set assessment dated [DATE] revealed Resident #72's Brief Interview for Mental Status score was 15, indicating the resident was cognitively intact. Further review revealed the resident required supervision for all activities of daily living, was always continent of bladder, and occasionally incontinent of bowel. Medical record review of a social services note dated 8/23/18 revealed .Daughter and son have been requesting that a prescription be signed regarding (Resident #72's) briefs that she has been receiving from (medical supply company). I (social services) have spoken with (medical supply company), BCBS (insurance company), and her Choices CC (Medicaid Care Coordinator) and because she is in a long term care nursing facility, she can no longer receive the (disposable) briefs and her insurance be charged . Further review revealed the Medicaid insurance company told the facility they would not pay for the briefs because the resident was in a long term care nursing facility and .that is part of her care that we supply the briefs .if we send BCBS a bill for them to pay for her briefs, not only will they not pay for them but that is considered Medicaid fraud and we (facility) could face fraud charges for billing her insurance for something that we provide .(physician) will not sign the paper for this very reason and because the address is the sons address and she does not live with the son in the community. The son has been bringing the (disposable) briefs to (Resident #72) in the facility. The only reason why her insurance has been paying for the briefs is because the address is a community address and not the facilities . Continued review revealed the residents' daughter and son had been notified the resident's insurance would not pay for the briefs because the resident was in a long term care nursing facility. Review of Resident #72's Trust-Transaction History from 6/1/18-9/30/18 revealed $33.33 was withdrawn by the facility from the resident's trust fund on 9/14/18 for the cost of disposable briefs. Observation and interview with Resident #72 on 10/29/18 at 12:42 PM, in the resident's room, revealed the resident was wearing a disposable brief. Interview with the resident revealed the resident did not like the cloth briefs offered by the facility, and preferred disposable briefs. Interview with the Business Office Manager on 10/30/18 at 4:20 PM, in the Business Manager's office, confirmed Medicaid residents were charged for disposable briefs, or the facility would provide cloth briefs at no cost to residents who did not want to pay for disposable briefs. Continued interview confirmed the facility supplied disposable briefs for Medicare residents because the briefs were considered medical supplies for those residents.",2020-09-01
471,BRADLEY HEALTH CARE & REHAB,445141,2910 PEERLESS RD,CLEVELAND,TN,37312,2018-10-31,580,D,0,1,0MUL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to obtain consent and notify the resident representative of changes to the psychiatric drug regimen of 1 resident (#82) of 5 residents reviewed for unnecessary medications of 44 residents sampled. The findings include: Medical record review revealed Resident #82 was admitted to the facility 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 10, indicating Resident #82 was moderately cognitively impaired. Medical record review of the Order Listing Report, dated 10/31/18, revealed .[MEDICATION NAME] (antianxiety and antidepressant medication) 5 MG (milligrams) Give 1 tablet by mouth one time a day .Last Order Date .01/26/18 . Medical record review of the Psychiatric Progress Note, dated 1/26/18, revealed .Treatment Plan .1.) Start [MEDICATION NAME] 5 mg PO (by mouth) QDAY (daily) . Medical record review of the Psychiatric Progress Note dated 5/17/18, revealed .family wants patient taken off of [MEDICATION NAME] .upset that they never gave consent for it to be started 1/2018 . Medical record review of Resident #82's signed consents revealed no documentation of a signed consent, or verbal notification to the family, prior to the addition of [MEDICATION NAME] to the drug regimen on 1/26/18. Interview with the Director of Nursing (DON) on 10/31/18 at 3:55 PM, in the DON's office, confirmed there was no signed consent or documentation of notification to the resident representative of changes to the psychiatric drug regimen for Resident #82.",2020-09-01
472,BRADLEY HEALTH CARE & REHAB,445141,2910 PEERLESS RD,CLEVELAND,TN,37312,2018-10-31,644,D,0,1,0MUL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to refer to the state-designated authority for a Level II PASARR (Preadmission Screening and Resident Review), after the resident was identified with a possible serious mental disorder, for 1 resident (#112) of 7 residents reviewed for PASARR. The findings include: Review of facility policy Admission Criteria, revised (MONTH) (YEAR), revealed .Any new psychiatric [DIAGNOSES REDACTED]. Medical record review revealed Resident #112 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the PASARR form dated 7/26/17 revealed Resident #112's [DIAGNOSES REDACTED]. Further review revealed the resident was negative for the level one screening, and if the nursing facility determined any inaccuracies in diagnoses, a Status Change review would be required. Medical record review of the [DIAGNOSES REDACTED]. Medical record review of a psychotherapy progress note dated 7/25/18 revealed the resident was sad, intermittently tearful, and expressed feelings of loneliness, hopelessness, and emotional isolation. Medical record review of the [DIAGNOSES REDACTED]. Interview with Minimum Data Set (MDS) nurse #1, responsible for completing PASARR's at the facility, on 10/30/18 at 8:36 AM, in the MDS office, revealed the most recent PASARR completed was on 7/26/17, prior to the addition of 2 mental health diagnoses. MDS nurse #1 stated another PASARR was completed for Resident #112 on 8/19/18 but .was canceled . MDS nurse #1 confirmed PASARRs had not been completed after the new mental health [DIAGNOSES REDACTED].",2020-09-01
473,BRADLEY HEALTH CARE & REHAB,445141,2910 PEERLESS RD,CLEVELAND,TN,37312,2018-10-31,812,F,0,1,0MUL11,"Based on facility policy review, observation, and interview the facility failed to maintain a sanitary kitchen free from undated, unlabeled foods, or opened to air food items in 2 coolers; and free from dirt and debris in 1 ice cream freezer, 1 walk in cooler, 1 of 3 steam tables, and on 1 dish in the kitchen, potentially affecting 149 of 151 residents. The findings include: Review of facility policy, Dietary Food Storage Policy with an implementation date of 10/29/18 revealed .It is the policy of this facility to avoid inappropriate storage of food products for the safety and well-being of the residents .Improper food storage may include, but not be limited to .Foods uncovered and/or exposed to air .Foods undated .Foods unlabeled .Broken seals, leakage . Review of the facility policy, Refrigerators and Freezers, dated 10/31/18, revealed .Supervisors will inspect refrigerators and freezers .for .ice buildup .Refrigerators and freezers will be kept clean, free of debris, and mopped .on a scheduled basis and more often as necessary . Review of the facility policy, Dietary Equipment Serviceability Policy with an implementation date of 10/29/18 revealed .Staff members of the Dietary Department must recognize that they have a responsibility to insure the safe and sanitary working condition of all equipment used in the preparation and delivery of food to the residents of our facility .Employees are required to inspect equipment for corrosion, rust, and general cleanliness .In the event that any of the above items are discovered, correction action must take place and the CDM (Certified Dietary Manager) must be notified . Review of the facility policy, Dishwashing Machine Use, dated 10/31/18 revealed .Dishes and utensils are inspected for any debris or unsanitary contact prior to use .Immediate action will be taken and dishes or utensils will be unused until properly cleaned and sanitized . Observation and interview with the Dietary Manager (DM) on 10/29/18 at 9:36 AM, in the kitchen, of the tray line cooler, revealed: A) Nine 4 ounce plastic glasses containing purple liquid undated, unlabeled, and available for resident use. B) Seven 4 ounce plastic glasses with a light tan liquid undated, unlabeled, and available for resident use. Interview with the DM confirmed the liquid drinks were grape juice and apple juice. Continued interview confirmed the drinks were undated and unlabeled and available for resident use. Observation and interview with the DM on 10/29/18 at 9:42 AM, in the kitchen, of the ice cream freezer, revealed: A) 6 loose cardboard pieces 6 to 7 inches long by 2-3 inches wide scattered throughout the bottom of the freezer. B) Seven loose wooden ice cream spoons lying on the bottom of the ice cream freezer. C) 1 piece of red loose tape lying on the bottom of the ice cream freezer. D) Large solid pieces of ice on the bottom of the ice cream freezer. Interview with the DM confirmed the facility failed to inspect the freezer for ice buildup and there was debris scattered throughout the ice cream freezer. Observation and interview with the DM on 10/29/18 at 9:52 AM, in the kitchen, of the walk in cooler, revealed: A) One 5 pound plastic container of shredded white chicken salad open to air, with a broken plastic seal, chicken salad leaking down the sides of the container, available for resident use. B) 3 large onion peels on the floor in the walk in cooler. Interview with the DM confirmed there was open to air food items and debris on the floor of the walk in cooler. Continued interview confirmed the facility failed to inspect the walk in cooler. Observation and interview with the DM on 10/29/18 at 10:59 AM, in the kitchen, of the stand-alone cooler, near the dry storage room, revealed: A) 56 slices of yellow pasteurized American cheese in a 2 gallon plastic bag open to air and available for resident use. Interview with the DM confirmed there was open to air food items in the stand alone cooler. Observation and interview with the DM on 10/29/18 at 11:16 AM, in the kitchen, at the 3 compartment portable steam table, next to the ice cream freezer, revealed: A) Dark brown hardened and rust colored loose debris scattered throughout the 3 compartments of the steam table. Interview with the DM confirmed the facility failed to inspect the steam table for corrosion, rust, and general cleanliness. Continued interview confirmed the facility failed to maintain a sanitary 3 compartment steam table which was used for resident food preparation. Observation and interview with the DM on 10/29/18 at 11:27 AM, in the kitchen, at the 3 bay steam table, with the prepared hot lunch foods revealed: A) One 9 inch 3 divider plate under the front shelf of the steam table, covered in brown and yellow debris and available for resident use. Interview with the DM confirmed the facility failed to inspect dishes for debris.",2020-09-01
474,BRADLEY HEALTH CARE & REHAB,445141,2910 PEERLESS RD,CLEVELAND,TN,37312,2018-10-31,908,F,0,1,0MUL11,"Based on facility policy review, observation, and interview the facility failed to maintain 1 of 3 three compartment steam tables in safe operating condition in 1 of 1 kitchens potentially affecting 149 of 151 residents. The findings include: Review of the facility policy, Dietary Equipment Serviceability Policy, with an implementation date of 10/29/18, revealed .It is the policy of this facility to maintain proper working equipment .free from .disrepair .Staff members of the Dietary Department must recognize that they have responsibility to insure (ensure) the safe and sanitary working condition of all equipment used in the preparation and delivery of food to the residents of our facility . Observation and interview with the Dietary Manager (DM) on 10/29/18 at 11:16 AM, in the kitchen, of the 3 compartment portable steam table, next to the ice cream freezer, revealed 1 of 3 missing control knobs in 1 of 3 bays. Interview with the DM confirmed the facility used the portable steam table in preparation and delivery of food to the residents in the facility. Continued interview confirmed the control knob button on the compartment steam table should have been replaced, was not in safe working order, and was in disrepair.",2020-09-01
475,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2020-02-19,600,D,1,0,XNV111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of a facility investigation, medical record review, and interview, the facility failed to prevent abuse for 1 resident (Resident #3) of 6 residents reviewed for abuse, resulting in Resident #3 being hit by another resident. The findings include: Review of the facility's policy titled, Abuse, Neglect, and Misappropriation of Property, dated 5/8/2019, showed .It is the organization's intention to prevent the occurrence of abuse . Review of a facility investigation dated 2/5/2020 showed .(Resident #1) in (Resident #3's) room standing over him and (Resident #1) was observed hitting the resident (Resident #3) in the forehead with his fist . No injuries were noted. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Care Plan for Resident #3 dated 8/30/2019 and reviewed on 11/13/2019 revealed the resident had an intermittent [MEDICAL CONDITION] and would cuss at staff and make threats toward roommates. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] showed Resident #3 scored an 8 (moderate cognitive impairment) on the Brief Interview for Mental Status. The resident had no behaviors during the look back period. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of an admission Care Plan dated 1/24/2020 showed Resident #1 was assessed for behaviors including verbal aggression toward others, including yelling and threatening others, and physical aggression toward others. Review of an admission MDS dated [DATE] showed the Resident #1 had short and long term memory problems and had exhibited verbal behaviors towards others 1-3 days during the look back period. During an interview on 2/19/2020 at 2:02 PM, Certified Nursing Assistant (CNA) #1 stated .(Resident #3) was upset .(Resident #1) was punching (Resident #3) on his head . During an interview on 2/19/2020 at 2:55 PM, CNA #2 stated .heard (Resident #3) hollering .went to check on him .(Resident #1) was hitting (Resident #3) .told him we can't hit other people . During an interview on 2/19/2020 at 3:00 PM, the Administrator confirmed the facility failed to prevent abuse to Resident #3.",2020-09-01
476,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2020-02-19,609,D,1,0,XNV111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of a facility investigation, medical record review, and interview, the facility failed to report an allegation of abuse to the State Survey Agency within 2 hours for 1 resident (Resident #3) of 6 residents reviewed for abuse. The findings include: Review of the facility's policy Abuse, Neglect and Misappropriation of Property, dated 5/8/2019, revealed .all alleged violations involving abuse .are reported immediately, but no later than 2 hours after the allegation is made . Review of a facility investigation dated 2/5/2020 showed .(Resident #1) in (Resident #3's) room standing over him and (Resident #1) was observed hitting the resident (Resident #3) in the forehead with his fist . The incident was reported to the State Survey Agency on 2/6/2020 at 4:14 PM (the next day). Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During an interview on 2/19/2020 at 3:00 PM, the Administrator confirmed the facility failed to report the incident to the State Survey Agency within 2 hours after the incident occurred. Refer to F-600",2020-09-01
477,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2018-06-12,600,D,1,0,TEPY11,"**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 interviews the facility failed to prevent abuse for 2 (#1 and #2) of 5 residents reviewed for abuse. The findings included: Review of the undated facility policy Abuse, Neglect and Misappropriation or Property, revealed .It is (facility's) policy to prevent the occurrence of abuse .willful means non-accidental .the individual must have acted deliberately, not that the individual must have intended to cause harm .If a Stakeholder observes a resident exhibiting any form of abuse toward another resident, the Stakeholder will intervene immediately to interrupt the incident and remove and/or separate the residents involved . Medical record review revealed Resident #1 was admitted to the facility on [DATE], readmitted on [DATE], and discharged on [DATE], with the [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Medical record review revealed Resident #2 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Review of an Annual MDS dated [DATE], revealed a BIMS score of 7, indicating severe cognitive impairment. Interview with Licensed Practical Nurse (LPN) #1 on 6/11/18 at 11:18 AM, via telephone, revealed I was in the East Wing Nurses Station across from the two residents; I was only about ten feet away from them. (Resident #2) came up to (Resident #1), and (Resident #1) asked (Resident #2) how he was doing. (Resident #2) replied he was coming to see what he was doing. I think he (Resident #1) said fine how are you? (Resident #2) replied he had come to look at the ladies, asses because he knew that was what (Resident #1) was doing. That upset (Resident #1), and (Resident #1) called (Resident #2) a Son of a [***] , at that point I stood up and said something like, now (Resident #1) don't talk like that, and he said I don't give a damn, I watched them for a minute, and then I started out from the nurses' station. I'm not sure who swung first, but they both began to swing at, and hit each other. Further interview confirmed based on what she had witnessed the two residents had intentionally hit each other. Interview with the Assistant Director of Nursing (ADON) on 6/11/18 at 3:32 PM, in the conference room, confirmed she had conducted the facility investigation, and based on interviews, and witness statements Resident #1 and Resident #2 had willingly and deliberately exchanged punches to each other, and the facility failed to prevent abuse of two residents.",2020-09-01
478,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2017-08-16,312,D,0,1,QGF311,"**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 provide assistance with oral care for 1 dependent resident (#63) of 3 residents reviewed for Activities of Daily Living (ADLs), of 21 residents sampled. The findings included: Review of the facility policy Oral Care, revised 6/1/15, revealed .A resident who appears to be able to care for self may be forgetting to care for teeth or dentures .Make sure resident removes dentures to clean .Make sure resident is brushing teeth and tongue . Medical record review revealed Resident #63 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 scored 15 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. Continued review revealed the resident required extensive assistance with personal hygiene and oral care. Medical record review of Resident #63's Care Plan dated 7/20/15 revealed the resident was at risk for complications related to self care deficit. Medical record review of Certified Nursing Assistant (CNA) documentation of ADLs dated 4/1/17 to 8/16/17 revealed oral care had not been provided daily for Resident #63. Interview with Resident #63's family member on 8/14/17 at 11:28 AM, in the resident's room, confirmed the family member was providing oral care. I have to take care of .teeth, and I only come once or twice a week . Observation of Resident #63's mouth on 8/15/17 at 2:45 PM, in the resident's room, revealed the upper dentures were covered with debris in between the teeth. Interview with Licensed Practical Nurse (LPN) #1 on 8/15/17 at 2:45 PM, in the resident's room, confirmed .Yeah, they look like they (dentures) need to be cleaned . Interview with Resident #63 on 8/16/17 at 10:12 AM, in the resident's room, confirmed staff had not assisted her with oral care on 8/16/17. Interview with Resident #63 and the family member on 8/16/17 at 1:16 PM, on the facility's porch, confirmed oral care had not been provided. Interview with the Director of Nursing (DON) on 8/16/17 at 2:01 PM, in the resident's room, confirmed oral care was not performed for Resident #63. Yes, it should be done everday and I expect them to do it . Continued interview confirmed the facility failed to provide oral care for Resident #63.",2020-09-01
479,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2017-08-16,441,D,0,1,QGF311,"Based on observation and interview, the facility failed to ensure handwashing was maintained for 1 of 4 Certified Nursing Assistants (CNAs) observed, during 1 lunch meal observed. The findings included: Observation of the main dining room on 8/14/17 from 12:00-12:12 PM, in the main dining room, revealed CNA #1 placed trash in the covered trash can, proceeded to a female resident at a table in the middle of the dining room, touched the resident and resident's eating utensil, then touched and greeted the other resident at the table, The CNA proceeded to a resident at the next table, touched her and her utensils, then sat down and assisted the resident by cueing and feeding bites of food to her. Interview with CNA #1 on 8/14/17 at 12:15 PM, in the main dining area, confirmed the CNA had not washed hands between contact with the 3 residents observed. Interview with the Director of Nurses (DON) on 8/14/17 at 2:40 PM, in the conference room, confirmed handwashing was required between contact with residents. Interview with the DON on 8/15/17 at 3:30 PM, in the conference room, confirmed the facility did not have a formal method for auditing handwashing compliance and the DON had made casual observations only.",2020-09-01
480,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2018-09-13,600,E,1,0,9GQL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, observation, review of the facility's investigation, and interviews the facility failed to protect residents from abuse for 4 residents (#3, #6, #7, and #8) of 14 residents reviewed for abuse. The findings include: Review of the undated facility policy, Abuse, Neglect and Misappropriation or Property, revealed .It is (facility's) policy to prevent the occurrence of abuse .Abuse includes physical abuse, mental abuse, verbal abuse .willful means non-accidental .Verbal abuse is use of any oral, written or gestured language that includes any threat, or any frightening, disparaging or derogatory language, to residents .regardless of .ability to comprehend . Medical record review revealed Resident #3 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 had short and long term memory deficits and moderately impaired cognitive skills for daily decision making . Observation and interview with Resident #3 on 9/10/18 at 1:40 PM, in Resident #3's room, revealed the resident was awake, alert, and lying in bed. Continued observation revealed the resident did not appear fearful or anxious at this time. Interview with Resident #3 revealed no recollection of the incident. Interview with the Speech Pathologist (SLP) on 9/12/18 at 9:25 AM, in the conference room, revealed they were bringing in the meal trays. (Identified resident) was walking around. (Resident #3) had just been served, and (Identified resident) came up behind her and reached around and picked up her milk. (Resident #3) had a verbal outburst .HEY and flailed her arm up; that action and her verbal outburst appeared to be what provoked (Identified resident) to hit her on her left upper arm. (Identified resident) did intentionally hit her; it wasn't an accident. She intended to strike her. Medical record review revealed Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed a Brief Interview for Mental Status score of 6, indicating severe cognitive impairment. Continued review revealed Resident #6 required extensive assistance with bed mobility, transfers, mobility, personal hygiene, and toilet use. Review of a facility investigation dated 8/19/18, revealed an identified resident directed harsh, foul language at Resident #6during a random encounter. Continued review revealed the identified resident had a history of [REDACTED]. Observation and interview on 9/10/18 at 2:20 PM with Resident #6 in her room revealed the resident seated in a wheelchair, well-groomed, and without fearfulness or anxiety. Interview at this time revealed Resident #6 could not recall anything happening, but stated I think one of them talked bad to me. Interview with Certified Nursing Assistant (CNA) #2 on 9/11/18 at 5:55 PM, in the conference room revealed, (Resident #6) was coming out of her room in her Wheel chair (w/c) she stood up, about that time the identified resident came out of his room. I was coming out of a Room on B hall, and the CNA (Certified Nurse Aide) from A hall said (Resident #6) is standing up, so I took off towards her. Her roommate was yelling, and she had come to the hall to get help. (Identified resident} was yelling at her you stupid [***] sit down in that f---ing (used entire word) chair. I've told you not to be standing and to not come out of your room. I (referring to CNA #2) am going towards them, telling him I've got this, but he keeps on coming towards us and cursing her. I sat her down in her chair, and am trying to calm her, and he keeps cursing. I took her out of the room, and rolled her up the hall to the nurse. He followed us and said I own these people, and own the halls. He was speaking in a threatening tone, and it frightened (Resident #6). He was directly speaking to (Resident #6). Medical record review revealed Resident #7 was admitted to the facility on [DATE], and readmitted on [DATE] with the [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. Continued review revealed physical behavioral symptoms directed towards others occurring 1 to 3 days during the assessment period. Review of a Care Plan dated 3/14/16, for Resident #7 revealed .8/16/18 Res (resident) to Res altercation .Separate Residents .15 minute checks . Medical record review revealed Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE], with the [DIAGNOSES REDACTED]. Review of a Quarterly MDS dated [DATE], revealed a BIMS score of 8 indicating moderate cognitive impairment. Review of a Care Plan dated 6/21/18 for Resident #8 revealed 8/16/18 Res to Res altercation .Staff education .8/21/18 DC 15 minute checks . Review of the facility's investigation dated 8/24/18, revealed (Resident #7) .stated both residents entered the dining room doorway at the same time. (Resident #8) .called .(Resident #7) a [***] , and (Resident #7) .slapped .( Resident #8) across the face. (Resident #8) . reported she then slapped .(Resident #7) across the face. When (Resident #8) .was interviewed she stated she was going out to smoke .someone got in front of her, she told them to stop pushing, the other resident had slapped her in the face and she returned the slap. Continued review revealed the facility has two separate smoking times for both residents to eliminate the possibility of these two residents interacting. Observation/interview with Resident #7 on 9/10/18 at 1:50 PM, in the smoke shack, revealed the resident seated in a chair. Continued observation revealed no aggressive behavior observed. Interview with Resident #7 at this time revealed the resident stated, I just hit her; I don't know why. Observation/interview with Resident #8 on 9/10/18 at 2:00 PM, in the smoke shack revealed the resident was unable to recall the incident, and stated she hadn't had any problems with anybody. Interview with the Environmental Services Staff member on 9/10/18 at 3:00 PM, in the conference room, revealed she had witnessed at least part of the altercation between Resident #7 and Resident #8. I was coming out of laundry, and overheard (Resident #8) calling (Resident #7) a [***] . I took off running up there to see what was going on. I saw (Resident #8) had her hand on (Resident #7)'s side and (Resident #7) had her hand on (Resident #8)'s face. I don't know who hit who first, I saw them hitting at the same time. They were both willfully swinging at each other with open hands. Interview with the Administrator on 9/13/18 at 4:40 PM, in the conference room, confirmed the facility had failed to follow their abuse policy, and had failed to protect residents (#3, #6, #7, and #8) from abuse.",2020-09-01
481,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2018-09-13,677,D,1,0,9GQL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, facility documentation review, and interview, the facility failed to provide assistance with bathing to maintain personal hygiene for 1 resident (#1) of 3 residents reviewed. The findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] and discharged on [DATE], with [DIAGNOSES REDACTED]. Review of an Admission Minimum (MDS) data set [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Continued review revealed the resident required extensive assistance with toileting, and personal hygiene. Review of a facility document, Bathing Report, dated 7/20/18 through 8/6/18, revealed no documentation Resident #1 received scheduled showers on 7/19/18, 7/23/18, 7/28/18, or 8/4/18. Interview with the Director of Nursing on 9/11/18 at 4:21 PM, in the conference room confirmed the facility failed to provide assistance with bathing for 4 of 7 scheduled showers.",2020-09-01
482,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2018-09-13,684,D,1,0,9GQL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility documentation, and interviews, the facility failed to provide 1 antipsychotic medication and 1 antianxiety medication as ordered for 1 resident (#9) of 3 residents reviewed. The findings include: Review of the facility policy, Medication Administration Guidelines, dated 5/16 revealed .Medications are administered in accordance with written orders of the prescriber .Medications are administered within 60 minutes of scheduled time . Medical record review revealed Resident #9 was admitted to the facility on [DATE], and discharged on [DATE], with the [DIAGNOSES REDACTED]. Review of the Physician Order Sheet dated 9/7/18, revealed .[MEDICATION NAME] .5 mg Tablet by mouth three times a day .Ziprasidone HCL 80 mg twice daily . Review of the Medication Administration Record [REDACTED].Ziprasidone HCL 80 mg (milligram) give one cap (capsule) by mouth twice a day with food .16:00 (4:00 PM) and AM . with no documentation the medication was administered at 4:00 PM on 9/7/18. Continued review revealed .[MEDICATION NAME] .5 mg Tablet Give one tab (tablet) by mouth three times a day 6:00 (AM), 14:00 (2:00 PM), 20:00 (8:00 PM) with no documentation the medication was administered at 2:00 PM or 8:00 PM on 9/7/18. Interview with Licensed Practical Nurse (LPN) #6 on 9/12/18 at 12:00 PM, in the conference room, confirmed she had not given Resident #9 his 8:00 PM, dose of .5 mg of [MEDICATION NAME] (antianxiety medication). I figured his medication would be here soon and I would give it then. I didn't think a .5 mg of [MEDICATION NAME] would make much difference. I did not attempt to obtain the medication from the E-box (emergency box) or contact the pharmacy. Interview with LPN #3 on 9/12/18 at 12:40 PM, in the conference room, confirmed Resident #9's [MEDICATION NAME] and Ziprasidone HCL (antipsychotic medication) had not been delivered to the facility by the pharmacy at the time they were scheduled to be administered. Continued interview confirmed she did not administer Resident #9 a scheduled 2:00 PM dose of .5 mg [MEDICATION NAME] or his 4:00 PM scheduled dose of 80 mg Ziprasidone HCL. Continued interview confirmed LPN #3 did not attempt to obtain the 2:00 PM, dose of .5 mg [MEDICATION NAME] from the E-box. Interview with the Director of Nursing on 9/12/18 at 4:10 PM, in the conference room, confirmed Resident #9 did not receive his 4:00 PM scheduled dose of Ziprasidone 80 mg, and did not receive his 2:00 PM and 8:00 PM dose of .5 mg [MEDICATION NAME]. Continued interview revealed it was her expectation if a medication was unavailable for a resident the Physician was to be notified for a new order. Continued interview confirmed they had access to a local pharmacy, and [MEDICATION NAME] was available in the E-box, but had not been utilized. Further interview confirmed the facility failed to provide Resident #9 his medications as ordered.",2020-09-01
483,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2018-09-13,692,D,1,0,9GQL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of facility documentation, and interview, the facility failed to follow a recommendation from the Registered Dietitian for an oral Nutritional Supplement for weight loss for 1 resident (#1) of 3 residents reviewed for weight loss. The findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] and discharged on [DATE], with [DIAGNOSES REDACTED]. Review of an Admission Minimum (MDS) data set [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Review of a facility document, Weights, revealed Resident #1's weight on 7/23/18 was 220.4 pounds, and on 7/31/18 was 211.8 pounds, indicating a weight loss of 8.6 pounds or 3.9% in 8 days. Review of a Nutrition Note dated 8/1/18, revealed .Res (resident) obese/[MEDICAL CONDITION] and wt. (weight) Review of the Medication Administration Record [REDACTED] Review of Physician Telephone Orders dated 8/1/18 through 8/6/18, revealed no order for Med pass 90 ml TID. Interview with the Director of Nursing on 9/11/18 at 4:21 PM, in the conference room, confirmed Resident #1 did have weight loss during admission. Continued interview confirmed the Registered Dietitian's recommendation on 8/1/18 for Med Pass 90 ml 3 times daily was not followed and facility failed to provide the recommended oral supplement for weight loss.",2020-09-01
484,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2018-09-19,638,D,0,1,W7N711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to complete an annual Minimum Data Set (MDS) for 1 resident (#1) of 25 residents reviewed. The findings include: Medical record review revealed Resident #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MDS history, revealed Resident #1 had an entry MDS assessment completed on 3/26/18, a quarterly assessment was completed on 4/13/18, and no further assessments were noted in the system. Telephone interview with the Clinical Reimbursement Consultant on 9/19/18 at 5:10 PM, confirmed an annual MDS with an assessment reference date of 7/14/18, was initiated and not completed, and no further assessments have been completed for Resident #1.",2020-09-01
485,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2018-09-19,656,D,0,1,W7N711,"**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 revise the Comprehensive Care Plan to address post fall interventions for 1 resident (#22) of 25 residents reviewed. The findings include: Review of the facility's Falls Policy Statement, undated, revealed .If a fall occurs the following actions will be taken: Update care plan . Medical record review revealed Resident #22 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 maximum to total assistance with all activities of daily living, and had previously fallen. Medical record review of the Nursing Assessment for description of falls and the post fall interventions initiated dated: on 4/12/18 revealed the resident fell out of bed, and the post fall intervention was to assess the resident's normal routines; 4/30/18 the resident fell from the wheel chair, and the post fall intervention was to offer to assist the resident to bed after the evening meal; 5/14/18 the resident fell from the bed, and the post fall intervention was to monitor pain, place fall mats next to bed; 5/18/18 the resident fell from the bed, and the post fall intervention was to place fall mats to both sides of the bed; 6/12/18 the resident fell from the wheel chair, and the post fall intervention was to remove the wheel chair foot rests; 6/29/18 the resident fell from the bed, and the post fall intervention was to place fall mats next to the bed; 7/31/18 the resident fell from the bed, and the post fall intervention was to keep the resident close to the nurse's station; and on 8/5/18 the resident fell from the wheel chair, and the post fall intervention was to keep the resident close to the nurse's station and to assess the resident's routines. Medical record review of the Comprehensive Care Plan dated 4/17/18 revealed .At risk for fall related injury .assist resident with transfers as needed .anticipate resident needs .monitor for pain . with no further interventions to prevent further falls. Observation of Resident #22 on 9/17/18 to 9/19/18 at various times from 8:00 AM to 5:00 PM, revealed the resident was in the bed with a curved mattress, was very restless, but made no attempts to climb out of the bed. Interview with the Interim Director of Nursing on 9/19/18 at 7:25 PM, in the conference room, confirmed Resident #22's Comprehensive Care Plan had not been revised to address the post fall interventions.",2020-09-01
486,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2018-09-19,758,D,0,1,W7N711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to attempt a Gradual Dose Reduction (GDR) of [MEDICAL CONDITION] medications for 1 resident (#38) of 5 residents reviewed for unnecessary medications of 25 residents sampled. The findings include: Medical record review revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum (MDS) data set [DATE] revealed Resident #38 was easily annoyed and rummages through items, received antipsychotic, antidepressant, and antianxiety medications 7 days each week, and no GDR had been attempted. Medical record review of the physician's orders [REDACTED]. Continued review revealed a physician's orders [REDACTED]. Medical record review of the monthly pharmacist reviews, revealed the pharmacist initialed each month the resident's medications were reviewed, with no recommendations for GDR of [MEDICAL CONDITION] medications. Observation on 9/19/18 at 2:30 PM, on the secure unit revealed Resident #38 was seated at the table in the day area with a busy cloth (promotes self-directed activity). Continued observation revealed the resident was calm and observed the activity taking place. Interview with the Corporate Regional Nurse on 9/19/18 at 5:30 PM, in the conference room confirmed no GDRs of Resident #38's [MEDICATION NAME], and [MEDICATION NAME] had been attempted since the resident's admission to the facility on [DATE].",2020-09-01
487,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2018-09-19,812,F,0,1,W7N711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, and interview the facility failed to maintain a sanitary kitchen with undated, unlabeled foods, expired foods, opened to air food items, and dirt and/or debris in 1 of 3 food storage bins, and improper cleaning of 1 of 3 food storage bins in the kitchen. The facility failed to maintain sanitary resident nourishment refrigerators with undated, unlabeled foods and expired foods, in 3 of 3 food nourishment refrigerators affecting 75 of 76 residents. The findings include: Review of facility policy Food Storage with a revised date of [DATE] revealed . Food items should be stored .with good sanitary practice .Any expired or outdated food products should be discarded .Use use-by-dates on all food stored in refrigerators .Remember to cover, label, and date .Dry storage .Clean and sanitize outside of food bins daily . Review of the facility policy Foods Brought by Family/Visitors with a review date of [DATE], revealed, .Perishable foods will be stored in re-sealable containers with tight fitting lids in the refrigerator .Containers will be labeled with the resident's name .Staff will discard perishable foods on or before the use by date . Observation and interview with the Dietary Manager (DM) on [DATE] at 9:,[DATE]:55 AM, in the kitchen, of the 2nd milk cooler, revealed: Seven 6 fluid ounce cartons of apple cranberry nutritional juice drinks, undated and available for resident use. Nine 6 fluid ounce cartons of orange nutritional juice drinks, undated, and available for resident use. Interview at this time with the DM confirmed the nutritional drinks were not dated, and the DM was unsure how long the nutritional drinks had been in the milk cooler, and was unaware of how to read the code (expiration date) on the nutritional drinks. Further interview confirmed the nutritional drinks were expired. Observation and interview with the DM on [DATE] at 9:42 AM, in the kitchen, revealed dark black and brown debris around the top of the sugar, flour, and cornmeal storage bins. Continued observation revealed dark brown and black debris in the cornmeal storage bin. Interview confirmed the facility failed to maintain the sugar, flour, and cornmeal storage bins in a sanitary manner. Observation and interview with the DM on [DATE] from 9:,[DATE]:02 AM, at the walk-in refrigerator, in the kitchen revealed: 3 pound bag of shredded cheddar cheese undated, open to air, and available for resident use. 1 half pound bag of shredded mozzarella cheese open to air, undated and available for resident use. 1 pound of sliced provolone cheese open to air, undated, and available for resident use. 8 pancakes in a plastic bag open to air, undated, and available for resident use. Interview with the DM at this time confirmed all items identified in the refrigerator were undated and open to air. Observation and interview with the DM, on [DATE] from 10:,[DATE]:06 AM, in the kitchen, revealed 2 slices of bread in a partially closed plastic bag open to air and available for resident use on the bread rack. Interview confirmed the facility failed to secure the open bread. Observation and interview with the DM on [DATE] at 9:,[DATE]:58 AM, of the secure unit nourishment refrigerator in the nursing station, revealed: Three, 4 ounce, low fat strawberry/banana yogurt cups with an expiration date of [DATE] and available for resident use. Interview with the DM at this time confirmed the yogurt cups were expired and available for resident use. Observation and interview with the DM on [DATE] at 10:,[DATE]:08 AM, of the 200 hall, nursing station, nourishment refrigerator revealed: Half a gallon carton of whole cultured buttermilk approximately ,[DATE]th full labeled with a resident's name and expired date of [DATE] available for resident use. Two opened, 24-ounce favored yellow sodas, ,[DATE] full, unlabeled without the resident's name, undated when opened, and available for resident use. Interview with the DM at this time confirmed the cultured milk had expired and the facility failed to discard the expired milk. Further interview confirmed the facility failed to label, and date sodas available for resident use. Observation and interview with the DM on [DATE] at 10:,[DATE]:16 AM, of the 300 hall, resident nourishment refrigerator, revealed: One, 20 ounce bottle of fruit punch electrolyte replacement drink, approximately ,[DATE] full, undated and unlabeled with a resident's name. Interview with the DM at this time confirmed the facility failed to label and date the fruit punch electrolyte replacement drink.",2020-09-01
488,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2018-09-19,880,D,0,1,W7N711,"Based on review of facility policy, observation, and interview, the facility failed to distribute and serve food under sanitary conditions for 1 unit of 3 units observed for dining, and failed to perform proper hand hygiene after providing peri-care for 1 resident of 2 residents observed for peri-care. The findings include: Review of the facility policy, Handwashing/Hand Hygiene, revised 8/2015 revealed .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .Use an alcohol-based hand rub .or, alternatively, soap .and water for the following situations .Before and after assisting a resident with meals .After contact with objects (e.g., (for example) medical equipment} in the immediate vicinity of the resident .After removing gloves . Observation on 9/17/18 from 1:00 PM-1:07 PM, on the Harriman Unit revealed Certified Nursing Assistant (CNA) #2 delivered a lunch tray to Resident #29 in the resident's room, moved the resident's bedside table and exited the room without performing hand hygiene; CNA #2 then delivered a lunch tray to Resident #62, moved the resident's bedside table, touched the resident's bed and the privacy curtain, and exited the room without performing hand hygiene; CNA #2 proceeded to deliver a lunch tray and pour coffee for Resident #42, and exited the room without performing hand hygiene. Further observation revealed CNA #2 delivered a lunch tray to Resident #58, moved a soiled shirt from the bedside table, touched the linen on the resident's bed, moved the resident's bedside table, touched the call light which was laying on the bedside commode, placed the soiled clothes in a plastic bag, and carried the soiled clothes to the soiled utility room. Continued observation revealed CNA #2 did not perform hand hygiene and proceeded to the cart to retrieve another tray. Interview with CNA #2 on 9/17/18 at 1:07 PM, on the Harriman hallway, confirmed CNA #2 had failed to perform hand hygiene between residents and after contact with objects in the resident's rooms during the lunch meal tray pass. Interview with the Interim Director of Nursing (DON) on 9/17/18 at 3:00 PM, in the hall outside of the DON's office, confirmed staff was expected to perform hand hygiene between residents during the meal tray pass and after touching objects in the resident's room. Observation on 9/19/18 at 3:48 PM, in a resident's room of Certified Nursing Assistant (CNA) #1 providing peri-care for a resident revealed after CNA #1 completed the peri-care, the CNA touched the resident's blanket to place the blanket over the resident, repositioned the call light, and washed the bedpan, and then removed the contaminated gloves. Continued observation revealed CNA #1 did not perform hand hygiene after she removed the contaminated gloves, donned one new glove, and adjusted the resident's head of the bed. Interview with CNA #1 on 9/19/18 at 3:55 PM, on the Harriman hallway, confirmed she had not removed the contaminated gloves and performed hand hygiene after providing resident care prior to donning one new glove. Interview with the Interim Director of Nursing on 9/19/18 at 5:10 PM, in the conference room confirmed the facility failed to follow their facility policy regarding hand hygiene after resident care and before donning new gloves",2020-09-01
489,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2019-10-16,656,D,0,1,RL5D11,"**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 revise the care plan to include the use of the back and collar brace for 1 resident (#35) of 25 residents reviewed for care plans. The findings include: Review of the facility policy, Comprehensive Care Plans, revised 7/19/18, revealed .Each resident's Comprehensive Care Plan is designed to .incorporate identified problem areas; incorporate risk factors associated with identified problems . Medical record review revealed Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #35's Current Comprehensive Care Plan, dated 6/28/19, revealed no documentation of the back and collar brace. Medical record review of the Admission Minimum (MDS) data set [DATE] revealed Resident #35 had a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment, and was unable to complete the interview. Medical record review of Physician Order Report revealed .7/11/19 .Back and collar brace .Special Instructions: Resident needs to wear her back and collar brace . Observation of Resident #35 on 10/14/19 at 2:46 PM, in the main dining room revealed Resident #35 was smiling and engaged in a group bingo activity. Interview with the Unit Manager (UM) #1 on 10/15/19 at 2:42 PM, confirmed she was unaware of the brace. Further interview confirmed it was UM #1's responsibility to apply the brace. Interview with Corporate Nurse #1 on 10/16/19 at 9:13 AM, in the conference room, confirmed it was her expectation that the brace intervention be care planned. Further interview confirmed the brace was not included on Resident #35's Current Comprehensive Care Plan .it's not on there .",2020-09-01
490,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2019-10-16,689,D,0,1,RL5D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, review of the facility's falls documentation, observation, and interview, the facility failed to implement appropriate interventions to prevent falls, failed to complete a fall risk assessment, and failed to complete a fall investigation for 1 resident (#70) of 3 residents reviewed for accidents. The findings include: Review of the facility Falls Policy, dated 7/16/19, revealed .All residents will have a comprehensive fall risk assessment on admission/readmission, quarterly, annually and with significant change of condition .Appropriate care plan interventions will be implemented and evaluated as indicated by assessment .If a fall occurs the following actions will be taken .Evaluate resident .Document the evaluation, pertinent facts and incident . Medical record review revealed Resident #70 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #70's Admission Minimum Data Set ((MDS) dated [DATE], revealed the resident had severe cognitive impairment. Continued review revealed the resident required extensive assist of 1 staff member for bed, transfer, and dressing. Medical record review of Resident #70's Fall Risk Assessment, dated 3/21/19, revealed a score of 24, a score of 10 or greater, indicated the resident was at high risk for falls. Review of the facility Falls Investigation, dated 4/18/19, revealed Resident #70 had a fall without injury. Review of a facility Falls Investigation, dated 6/20/19, revealed .Fall without injury . Continued review revealed the fall investigation had not been completed. Medical record review of Resident #70's Fall Risk Assessment, dated 7/18/19, revealed a score of 18, a score of 10 or greater, indicated the resident was at high risk for falls. Review of a facility Falls Investigation, dated 8/20/19, revealed the resident had an unwitnessed fall without injury. Medical record review of the Comprehensive Care Plan dated 9/19/19, revealed a new fall intervention had not been implemented after the falls on 6/20/19 and 8/20/19. Medical record review of the Fall Risk Assessment revealed a quarterly falls risk assessment had not been completed for 9/24/19. Observation of Resident #70 on 10/15/19 at 7:40 AM, in the residents room, sleeping in bed. Interview with the Interim Director of Nursing on 10/16/19 at 12:05 PM, in the conference room, confirmed the facility failed to follow their falls policy, failed to complete a falls investigation, failed to complete falls risk assessments and failed to implement appropriate falls interventions to prevent falls for Resident #70.",2020-09-01
491,"THE WATERS OF WINCHESTER, LLC",445145,1360 BYPASS ROAD,WINCHESTER,TN,37398,2018-02-14,600,D,1,0,CEZ811,"**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 prevent abuse for 1 (Resident #2) of 4 residents reviewed for abuse. The findings included: Review of the facility policy Abuse Prevention Program Updated 1/19/17 revealed .It is the policy of this facility to prevent resident abuse . Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Minimum Data Set ((MDS) dated [DATE] for Resident #9 revealed a Brief Interview for Mental Status (BIMS) score of 4 indicating severe cognitive impairment. Continued review revealed the resident exhibited no behaviors during the review period. Resident #2 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of an MDS dated [DATE] for Resident #2 revealed the resident was rarely/never understood. Continued review revealed no behaviors were exhibited during the review period. Observation on 2/12/18 at 10:25 AM, of Resident #2, in her room on the secure unit revealed the resident seated on the side of her bed. Continued observation revealed the resident was awake and alert, however did not answer questions appropriately. Review of the facility investigation dated 1/19/18 revealed .At 12:53 PM (Resident #2) was struck four times on the left shoulder by (Resident #9) after she wondered into his room .Upon attempting to enter (resident #9's) room, she (Resident #2) backed out; he followed her out, and then struck her four times on the left shoulder with an open hand . Review of a Progress Note dated 1/19/18 at 3:06 PM, for (Resident #3) revealed .Resident opened door to (Resident #9's) room attempting to enter. Resident began backing out of room at which time (Resident #9) struck 3-4 times making contact to left shoulder . Interview on 2/14/18 at 12:00 PM, with[NAME]Lowhorn DON, in the conference room confirmed Resident #9, did willfully hit Resident #2 in attempt to remove her from his room, and the facility failed to prevent abuse for one resident #2.",2020-09-01
492,"THE WATERS OF WINCHESTER, LLC",445145,1360 BYPASS ROAD,WINCHESTER,TN,37398,2018-02-14,812,F,1,0,CEZ811,"> Based on facility policy review, observation, and interview, the facility failed to maintain the dish machine to ensure dishes were sanitized; failed to properly sanitize dishes in the 3 compartment sink; failed to maintain kitchen equipment and floors in a clean and sanitary manner; and failed to properly store and label dry foods and refrigerated food items, affecting 84 of 87 residents on census. The findings included Review of the facility policy Dishwashing: Machine dated (YEAR) revealed .The Dining Services staff shall maintain the operation of the dish machine according to established procedure and manufacturer guidelines .to ensure effective cleaning and sanitizing .if the dish machine cannot be repaired in a timely manner, the facility will utilize manual dishwashing procedure . Review of the facility policy Sanitation Solution dated (YEAR) revealed .Bleach may be used as a sanitizer when prepared according to the following guidelines .1 Tablespoon bleach + l gallon of water . Review of the facility policy Cleaning Rotation dated (YEAR) revealed .Equipment and utensils will be cleaned .Items cleaned after each use: .Can opener .Work tables and counters .Items cleaned daily: Stove top .Microwave oven .Kitchen and dining room floors .Items cleaned monthly .Ice machines . Review of the facility policy Storing Utensils, Tableware, and Equipment dated (YEAR) revealed .Cleaned and sanitized equipment and utensils should be handled in a way that protects them from contamination . Review of the facility policy Food Storage dated (YEAR) revealed .Label all food items. The label must include the name of the food and the date by which it should be sold, consumed, or discarded .Dry storage guidelines to be followed .store dry food on shelves .six inches off the floor . Review of the facility policy Labeling and Dating of Foods dated (YEAR) .All foods stored will be properly labeled and dated .all ready to eat foods .will be re-dated with the date the item was opened and a use by date . Review of the facility policy Dishwashing: Manual dated (YEAR) revealed .QAC (Quaternary Ammonium) typically 200-400 PPM .The concentration of chemical or hot water will be tested before cleaning .and recorded on the three compartment sink log sheet .The pots and pans will be drained and air-dried . Observation on 2/12/18 at 9:00 AM, with the Certified Dietary Manager (CDM), in the kitchen revealed the following [NAME] The steamer with dried debris on the interior sides and bottom, and on the outside handle. B. 3 of 3 work tables with dried and flaky debris on the top work area, and the bottom storage areas. C. Juice Machine with dried sticky debris on the base of the machine, and around dispensing spouts. D. Deep Fryer with thick debris on the interior sides, and splash guard, also food particles from the day prior in a fryer basket. E. Stove top and burners with various types of thick dried and burnt debris. F. Ice Machine with dark pink slimy debris on the spill guard and inside of the door. [NAME] Microwave with dried debris on the interior top, sides, carousel, and bottom. H. Can Opener with dried debris on the blade and base I. Cutlery Rack with dried, and sticky debris on the top and knife storage slots. [NAME] Kitchen floor had multiple areas of dried food/beverage debris, and small particles paper. Continued observation with the CDM, in the dish room revealed a low temperature dish machine. Further Observation revealed the machine was not dispensing sanitizer into the sanitizing cycle in 3 of 3 cycles observed. Interview on 2/12/18 at 9:15 AM, with the CDM revealed the dishes would be washed and sanitized in the 3 compartment sink, and no dishware had been returned to the kitchen for usage. Observation on 2/12/18 at 9:17 AM, with the CDM, in the kitchen revealed the following items available for resident consumption: [NAME] 5# bag of oats approximately 3/4 full, open to air, and no label with an open date or use by date. B. 1# bag of dry gravy mix approximately 1/2 full, open to air, and no label with an open date or use by date. C. 10# box of Elf Graham crackers approximately 1/2 full open and on the floor. Further observation with the CDM, of a reach in cooler revealed the following beverages available for resident consumption [NAME] 12 four ounce bowls with canned pears with no label or use by date. B. 10 eight ounce glasses with various beverages with no label or use by date. C. 6 one quart decanters filled with no label or use by date. Further observation of the kitchen with the CDM revealed [NAME] 2 of 12 two inch quarter steam table pans stored wet, and with dried food debris. B. 2 of 5 4 inch quarter steam table pans stored wet, and with dried food debris. Interview on 2/12/18 at 9:40 AM, with the CDM, confirmed the facility failed to maintain the dish machine to ensure proper sanitation of dishes, and failed to maintain clean and sanitary kitchen equipment, utensils, and floors. Further interview confirmed the facility failed to properly store and label foods in the dry storage area and in 2 of 2 reach in coolers. Observation on 2/12/18 at 10:05 AM, with the CDM in the kitchen revealed 2 dietary employees washing dishes in the 3 compartment sink. Further observation revealed no sanitizer testing strips were available to use. Interview on 2/12/18 at 10:08 AM, with the Cook confirmed she had not tested the sanitizer solution in the three compartment sink prior to washing dishes.",2020-09-01
493,"THE WATERS OF WINCHESTER, LLC",445145,1360 BYPASS ROAD,WINCHESTER,TN,37398,2019-06-11,609,D,1,0,MC9611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of a facility policy, medical record review, and interviews, the facility failed to report an injury of unknown injury involving bodily injury for 1 resident (#1) of 3 residents reviewed for injuries of unknown origin. The findings include: Review of facility policy Abuse Prevention Policy Updated 1/19/17 revealed .All personnel must promptly report any incident of resident abuse, mistreatment or neglect, including injuries of unknown origin .when the source of the injury was not observed or known by any person . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a 14 day Minimum (MDS) data set [DATE] revealed Resident #1 scored a 4 (severe cognitive impairment) on the Brief Interview for Mental Status. Medical record review of a nursing progress note dated 5/27/19 at 3:16 PM revealed .c/o (complains of) increased pain to right hip .(named physician) informed .received a new order to obtain right hip x-ray . Medical record review of a Mobile Radiology Report dated 5/27/19 revealed .There is a right hip hemiarthroplasty in normal position. A moderately displaced [MEDICAL CONDITION] trochanter is present. Surgical staples are present in the proximal right thigh laterally. No other fracture dislocation or other abnormalities of the right hip are present .Conclusion .Displaced [MEDICAL CONDITION] trochanter, new . Interview with Licensed Practical Nurse (LPN) #2 on 6/10/19 at 4:20 PM, in the conference room, revealed .on 5/27/19 she (Resident #1) started having some hip pain even with her PRN (as needed) medication .she had started to complain of pain in her hip, her medication was not as effective as it had been. I called the doctor and told him and he ordered a right hip x-ray .I am not aware of anything out of the ordinary occurring, the only thing different was an increased complaint of pain. No one reported anything from any shift (increased pain or injury) . Telephone interview with LPN #2 on 6/11/19 at 9:40 AM revealed .when I came in on the 27th around 6:30 PM .(LPN #1) reported .(Resident #1) had complained of increased pain and the x-ray technician was here .I picked up the x-ray results off the fax early on the 28th and passed them to the day shift nurse .during the night she never complained of pain .and there weren't any non-verbal signs of pain or any discomfort .I am not aware of anything happening, any incidents or a fall that would have attributed to the fracture. I know now I should have checked the fax machine and reported the results immediately . Interview with the Director of Nursing (DON) on 6/11/19 at 11:25 AM, in the conference room, revealed .on Tuesday morning about 10:30 AM, I was notified of the x-ray results of a lesser trochanter fracture on (Resident #1's) right side. I immediately started an investigation .during the interviews with staff no one was aware of any incidents or occurrences that would have attributed to a fracture. I was not able to identify anything indicating abuse/neglect or concerns related to quality of care . Continued interview confirmed the x-ray was obtained at approximately 6:30 PM on 5/27/19 and the x-ray report was faxed to the facility on [DATE] at approximately 7:00 AM. Further interview revealed the DON was notified of the results at approximately 10:30 AM and .I should have been notified immediately when the results were reviewed by the nurse at 7:00 AM . Continued interview confirmed the facility failed to report an injury of unknown origin timely to the State survey agency and the facility failed to follow facility policy.",2020-09-01
494,"THE WATERS OF WINCHESTER, LLC",445145,1360 BYPASS ROAD,WINCHESTER,TN,37398,2017-06-21,159,D,0,1,0D6Y11,"Based on review of facility policy, review of the trial balance for resident trust funds, and interview, the facility failed to make trust funds available on the week-end for 1 resident (#78) of 15 residents interviewed. The findings included: Review of the facility policy titled, Resident Trust issued: 10/20/15, included under the section: Procedure, numbered 1 through 12. Review of procedure 6. Banking Times will be posted and access to resident funds will be available on Saturday and Sunday during banking hours. Those residents wishing to withdraw or deposit money may do so at these times. Observation on entrance revealed there was no posting of banking hours on 6/19/17 or on 6/20/17. Interview of Resident #78, on 6/19/17 at 4:19 PM, revealed he does have a personal funds account with the facility. Resident #78 stated he is not able to withdraw funds from his account on the week-ends. You can only get money when the business office is open and she works Monday thru Friday. A sign posted on 6/21/17 outside the door of the business office included the following information: Resident Trust Banking Hours Monday through Friday from 9am to 5pm Interview of Business Office Manager (BOM), at 7:45 a.m. on 6/21/17, verified the residents had no access to funds on Week-ends. We have nothing in writing or posted in regards to time to access funds from personal accounts. The BOM stated she was aware that residents should have access to funds on the week-ends but she just hadn't implemented a program.",2020-09-01
495,"THE WATERS OF WINCHESTER, LLC",445145,1360 BYPASS ROAD,WINCHESTER,TN,37398,2017-06-21,241,G,0,1,0D6Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations and interviews, the facility failed to honor 1 resident's (#62) preferences for grooming services, identified through 1 of 3 family interviews conducted, of 35 residents sampled. This failure resulted in Harm to Resident #62. The findings included: Medical record review of Resident #62's History and Physical dated 12/28/15 revealed Resident #62 was a [AGE] year-old male with a past medical history of [REDACTED]. The history further revealed the resident was immobile, with [DIAGNOSES REDACTED]. A review of Resident #62's Physician's Progress Note dated 4/13/17 indicated the resident's judgement/insight was appropriate. The note indicated the resident communicated by pointing and shaking his head yes or no. Review of the most recent Minimum Data Set (MDS) Quarterly assessment dated [DATE], indicated the resident required extensive assistance and was dependent on 1-2 staff for bed mobility, transfers, toilet use, dressing, and personal hygiene. Under the section titled E0800: Rejection of Care - Presence & Frequency Resident #62 was coded as .behavior not exhibited. Continued review revealed a staff assessment for mental status was conducted, and the resident had no problems with short or long term memory, was able to recall the current season, location of his room, names and faces of staff members and that he is in a nursing home. Observations on 6/19/17 at 11:42 AM, 6/19/17 at 2:51 PM, 6/19/17 at 4:53 PM, and 6/20/17 at 8:13 AM, revealed Resident #62 in his room lying in bed. Resident #62 had facial hair (whiskers) noted on his face and his hair was unkempt and had not been combed. Continued observation revealed the resident was wearing a gown with brown stains around the front chest area in 3 of the observations. A family interview on 6/20/17 at 9:35 AM with Family Member #1, revealed the family member was very concerned about Resident #62 not receiving his showers as scheduled. The family member said the issue seemed to be affecting Resident #62. Family Member #1 indicated Resident #62 was sad and unhappy about his (unkempt) appearance. Family Member #1 also stated Resident #62 had gone 10 days without having a shower, and it bothered the resident greatly. The family member reported this (no baths and unkempt appearance) had happened several times with the resident going for long stretches of not being showered for 7 days or more. According to the family member, prior to his [MEDICAL CONDITION], Resident #62 always took pride in his appearance and his daily grooming or lack thereof as a major concern. Family Member #1 stated the nurses had been told about it but the problem continued to occur. Observation on 6/20/2017 at 12:45:PM Resident #62 observed awake, sitting up in bed watching TV, unshaven with long facial whiskers, hair unkempt with multiple white flakes, eyes with crusty substance in corners, and gown had tan stains on front chest area. Resident was non-verbal. Easily understands others and is easily understood, as resident is able to nod head to respond Yes or No. When asked if he had a shower on Saturday, 3 - 4 days ago, resident responded, No by nodding his head. Asked resident has it been 10 days or more since he last had a shower? Resident nodded his head to respond, Yes. Asked resident if he had refused to shower in the last 10 days, resident adamantly shook his head, No. Asked resident how does it make you feel when you haven't had a shower in 10 days? Resident responded with sad facial expression with watery substance welling in eyes. Asked resident if it was his preference to receive his showers at minimum twice a week on Wednesdays and Saturdays as scheduled? Resident smiled and nodded, Yes. An interview was conducted with CNA #2 (Shower Tech) on 6/20/17 at 1:06 PM. CNA #2 stated Resident #62 loved his showers and rarely refused them. CNA #2 said Resident #62 may miss a shower if he was out on a family visit. She said he has refused nailcare once or twice Review of P[NAME] (plan of care) Response History Report dated from 5/25/17 - 6/20/17 indicated the resident last received a shower on 6/10/17, approximately 10 consecutive days. Continued review revealed from 5/25/17 - 6/2/17 Resident #62 did not receive a shower for 9 consecutive days. Interview with the Assistant Director of Nursing on 6/20/17 at 4:02 PM, revealed the resident was scheduled to receive a shower on Wednesdays and Saturdays. She reviewed the CNA's activities of daily living (ADL) documentation for baths and showers for the past 30 days and confirmed the resident's last shower was on 6/10/17. Continued interview confirmed each resident is scheduled to have at least 2 showers per week, with bed baths to supplement in between during AM (morning) care and it is not acceptable for a resident to go 10 days without a shower.",2020-09-01
496,"THE WATERS OF WINCHESTER, LLC",445145,1360 BYPASS ROAD,WINCHESTER,TN,37398,2017-06-21,309,D,0,1,0D6Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to follow physician's orders for 1 resident (#80) of 4 residents reviewed for weight loss, of 34 residents reviewed. The findings included: Medical record review revealed Resident #80 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a hospital History and Physical dated 6/1/17 revealed XXX[AGE] year-old .female, who comes to the hospital because of severe swelling all over, shortness of breath (SOB) .She was known to have jugular venous distention, bilateral [MEDICAL CONDITION] .She had been recently admitted 9 days prior from .a fall where she had rib fracture and the effusion in her chest has apparently worsened .Exertion makes her shortness of breath worse, rest and oxygen makes it better .Impression: 1. [MEDICAL CONDITION] . Medical record review of a physician's order dated 6/2/17 revealed Daily weights for [MEDICAL CONDITIONS] in the morning . Medical record review of the Weights and Vitals Summary revealed the following: on 6/6/17 weight recorded as 223 lbs. (pounds) via wheelchair; on 6/7/17 weight recorded as 220.4 lbs. via mechanical lift; on 6/8/17 weight recorded as 220.4 lbs. via wheelchair; on 6/10/17 weight recorded as 212.4 lbs. via mechanical lift; on 6/11/17 weight recorded as 207 lbs. via mechanical lift; on 6/12/17 weight recorded as 203.6 lbs. standing; on 6/13/17 weight recorded as 198.6 lbs. via mechanical lift; on 6/14/17 weight recorded as 197 lbs. via mechanical lift; on 6/17/17 weight recorded as 197 via bedscale; and on 6/20/17 weight recorded as 165.4 lbs. via mechanical lift. Medical record review of a nursing note dated 6/8/17 revealed Assessment: Resident cont (continues) to have +3 [MEDICAL CONDITION] to BLE (bilateral lower extremities), crackles to lower ls (?lungs), Dr .notified, new order for [MEDICATION NAME] 80mg bid (twice a day), Potassium 20 meq bid, Resident alert with confusion at times, able to make needs known .Resp (respirations) even non labored, SOB noted when laying flat .HOB (head of bed) elevated .poor appetite noted this shift . Observation on 6/20/17 at 12:40 PM revealed the resident lying on the bed with the HOB elevated with the spouse at bedside. Interview with the Director of Nursing (DON) on 6/20/17 at 4:20 PM, in the DON's office revealed 1 of the weights obtained on 6/17/17 or 6/20/17 was not accurate and the weight on 6/17/17 was documented as being obtained via a bedscale was not accurate because the facility did not have a bedscale. Continued interview revealed the Restorative Aide did all the weights in the facility when she was working. Further interview revealed the same type of scale needed to be used consistently, and if a different scale needed to be used for individual residents a reason for the change in the type of scale used needed to be documented. Further interview confirmed daily weights were not obtained for Resident #80 on the following dates: 6/3/17, 6/4/17, 6/5/17, 6/9/17, 6/15/17, 6/16/17, 6/18/17, and 6/19/17 (8 of 18 opportunities from 6/3/17-6/20/17).",2020-09-01
497,"THE WATERS OF WINCHESTER, LLC",445145,1360 BYPASS ROAD,WINCHESTER,TN,37398,2017-06-21,312,G,0,1,0D6Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations and interviews, the facility failed to provide the necessary assistance to maintain personal hygiene and grooming preferences for 1 resident (#62) of 34 residents reviewed. This failure resulted in Harm for Resident #62. The findings included: Medical record review of Resident #62's History and Physical, dated 12/28/15 revealed Resident #62 was a [AGE] year-old male with a past medical history of [REDACTED]. The history further revealed the resident was immobile, with [DIAGNOSES REDACTED]. Review of Resident #62's Physician's Progress Note dated 4/13/17, indicated the resident's judgement/insight was appropriate. The note indicated the resident communicated by pointing and shaking his head yes or no. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE], indicated the resident required extensive assistance and was dependent on 1-2 staff for bed mobility, transfers, toilet use, dressing, and personal hygiene. Under the section titled E0800: Rejection of Care - Presence & Frequency Resident #62 was coded as .behavior not exhibited. Continued review revealed a staff assessment for mental status was conducted, showing the resident had no problems with short or long term memory, was able to recall the current season, location of his room, names and faces of staff members and that he is in a nursing home. Observations on 6/19/17 at 11:42 AM, 6/19/17 at 2:51 PM, 6/19/17 at 4:53 PM, and 6/20/17 at 8:13 AM, revealed Resident #62 in his room lying in bed. Resident #62 had facial hair (whiskers) noted on his face and during each observation his hair was unkempt and had not been combed. Continued observation revealed the gown he was wearing, for the 3 observations, contained small brown stains around the front chest area. A family interview was conducted on 6/20/17 at 9:35 AM with Family Member #1, who stated, he/she was very concerned about Resident #62 not receiving his showers as scheduled. Continued interview revealed Resident #62 had gone 10 days without having a shower. The family member reported this (no baths and unkempt appearance) had happened several times that the resident gone for long stretches of not being showered for 7 days or more. Observation on 6/20/2017 at 12:45 PM resident observed awake, sitting up in bed watching TV, unshaven with long facial whiskers, hair unkempt with multiple white flakes, eyes with crusty substance in corners, and gown has tan stains on front chest area. Resident is non-verbal. Easily understands others and is easily understood, as resident is able to nod head to respond Yes or No. When asked if he had a shower on Saturday, 3 - 4 days ago, resident responded, No by nodding his head. Asked resident has it been 10 days or more since he last had a shower? Resident nodded his head to respond, Yes. Asked resident if he had refused to shower in the last 10 days, resident adamantly shook his head, No. An interview was conducted with CNA #2 (Shower Tech) on 6/20/17 at 1:06 PM. CNA #2 stated, she worked day shift and performed all the scheduled showers during the day. She said she shampooed the hair, shaved them, and cut residents' fingernails. She said she does not chart or keep a log of who received a shower and what care was given. According to CNA #2, . the assigned floor (nurse aides) CNAs do that. She further stated, Resident #62 loved his showers and rarely refused them. CNA #2 said Resident #62 may miss a shower if he was out on a family visit. She said he has refused nailcare once or twice Review of P[NAME] (plan of care) Response History Report dated from 5/25/17 - 6/20/17 indicated the resident last received a shower on 6/10/17, approximately 10 consecutive days. From 5/25/17 - 6/2/17 Resident #62 did not receive a shower for 9 consecutive days. Interview with the Assisstant Director of Nursing on 6/20/17 at 4:02 PM, revealed the resident was scheduled to receive a shower on Wednesdays and Saturdays. She reviewed the CNA activities of daily living (ADL) documentation for baths and showers for the past 30 days and confirmed the resident's last shower was on 6/10/17.",2020-09-01
498,"THE WATERS OF WINCHESTER, LLC",445145,1360 BYPASS ROAD,WINCHESTER,TN,37398,2017-06-21,371,F,0,1,0D6Y11,"Based on facility policy review, observation, and interview the facility failed to: 1) Maintain the dish machine's wash and rinse cycle temperatures, and the sanitizing chemical parts per million (PPM) levels at the manufacturer's recommended specifications potentially affecting 86 residents who receive plated meals, and 2) Failed to maintain food temperatures on the main dining room steam table in accordance with food service guidelines affecting 6 residents confirmed to have received meals from the steam table. The findings included: Review of the facility's policy, Dish Machine Use and Care not dated, revealed, The Maintenance department should check and record the internal dish machine temperatures at least once per week with a non-mercury thermometer or test strips. Review of facility's policy, Dishwashing Machine, dated (YEAR) revealed the following: Check the machine each morning before any dishes are washed, and again after each meal before dishes are washed. If the dishwasher has not been used for several hours, it is recommended to (sic) allow the machine to run for a cycle or two to allow the dishwasher to reach proper function. Check to ensure that the wash and rinse cycles are achieving proper temperature per manufacture (sic) guidelines. If a chemical sanitizer is used, check the concentration using the correct test strip. Record wash/rinse temperatures and sanitizer concentration if used on the dish machine log before any dishes are washed. Refer to the guidelines on the dish machine log for acceptable temperatures and sanitizer concentrations for high and low temperature dish machines. If not at the correct hot water temperature, or the proper sanitizing concentration, do not proceed to wash dishes. Corrective action must be taken. Review of facility's policy attachment, Dishwasher Temperature Log dated (YEAR) revealed, Low Temperature Dish Machine must be at least 120 degrees F (Fahrenheit) Wash, 50-100 PPM Hypochlorite (sanitizing solution). 1. During observations on 6/19/2017 at 8:46 AM, in the kitchen, Dishwasher #1 was observed rinsing dirty dishes (plates, glasses, and trays) and preparing additional trays for washing in the Low Temperature (Temp) Hobart (AM Select) Dishwasher. During the observation two trays of wet dishes (plates) were sitting on the completed rack. Dishwasher #1 was asked, how and when the dish machine temperature checks were performed and recorded. Dishwasher #1 stated he/she checks the dish machine's temperature each morning by running a few cycles first; then he/she records the last test cycle's wash and rinse temperatures. Dishwasher #1 was requested to run a test cycle to check the dish machine's current wash and rinse temperatures and to demonstrate how he/she performs PPMs to check the amount of sanitizing chemical in the rinse water each day. Dishwasher #1 stated, He/she has been working at the facility for one month and was not aware of when or how to test for proper PPM levels of chemical. Review of manufacturer's information panel on the side of the dish machine revealed: Chemical water specifications: WASH = 120 degrees / Chemical water RINSE = 120 degrees Review of facility posted Dish Machine Temperature Log dated (MONTH) (YEAR) revealed no wash or final rinse temperatures were recorded for 6/19/17, of the observed dishwashing process. The PPM for 6/19/17 was logged as 100 and signed with initials by Dishwasher #1. Dishwasher #1 stated the 6/19/17 temperatures were done and both wash and rinse cycles were above 120. The (MONTH) (YEAR) log also showed ten separate entries signed by Dishwasher #1 for recorded wash temperatures, final rinse temperatures, and PPM readings on 6/04/17, 6/05/17, 6/06/17, 6/11/17, 6/12/17, 6/13/17, 6/16/17 (twice), 6/18/17, and 6/19/17. Dishwasher #1 confirmed the signed initials for the dates as listed and further stated, He/she was not aware of when or how to test for proper PPM levels of chemical. Observation on 6/19/17 at 9:04 AM revealed Dishwasher #1 ran a test cycle revealing the wash cycle temperature was 120 degrees and the rinse cycle temperature was 84. A second test cycle was run at 9:07 AM revealing the wash cycle temperature was 118 degrees and the rinse cycle was 113. At 9:10 AM the Dietary Manager (DM) came into the wash room and ran a test cycle revealing the wash cycle temperature was 120 degrees and the rinse cycle was 87. An interview was conducted with the DM on 6/19/2017 at 9:12 AM. The DM stated she was going to call the Maintenance Director to have him check the water temperatures. She further stated she would prepare to serve lunch on paper items until the water temperatures for the dishwasher and PPM readings could be resolved. The DM stated Dishwasher #1 was hired about one month ago and has been trained, like all staff hired for dishwashing, to check daily dish machine temperatures, chemical sanitizer PPM testing, and how to record findings on the dishwasher temperature logs. DM reviewed Dishwasher #1's training file and was unable to locate documentation of Dishwasher #1's training on the dish machine chemical sanitizer testing. Observation on 6/19/2017 at 10:10 AM with DM and Cook #1 revealed both present to retest the dishwasher temperatures and PPMs as follows: At 10:12 AM a test cycle was run revealing the wash cycle temperature was 128 degrees Fahrenheit (F) and the rinse cycle was 116 F. At 10:20 AM a test cycle was run revealing the wash cycle temperature was 127 F, and the rinse cycle was 113 F. The PPM was tested 8 - 10 times with Ecolab Precision and Chlorine Strips revealing 0 PPM level with each final rinse test. The chemical tubing was inspected during the wash and rinse cycles by the DM, who acknowledged she was unable to see chemicals flowing through tubing. At 10:45 AM, the DM stated she called the food service contractor who performed monthly maintenance checks and asked him to come and check out the machine. An interview was conducted with the DM on 6/19/2017 at 2:30 PM, who revealed the subcontractor for the dishwasher maintenance came to the facility at 1:40 PM. She said he tested the dishwasher PPM levels with his own chlorine test strips four times, and the PPM showed zero. He then primed the chemical tubes and retested it and the PPM was at 100. Continued interview confirmed the rinse cycle repeatedly showed readings at 118 or below. The Maintenance Director was present and left to go turn the water heater up. After waiting a few minutes, the subcontractor repeated the wash and rinse temperatures and they were 124 (wash) and 121 (rinse). The DM said the subcontractor provided the appropriate strips, to use on the facility's machine. Interview conducted with Maintenance Director on 6/21/2017 at 11:52 AM who stated he could not find his weekly temperature logs for the facility. He stated he would check the water faucet temperatures in the kitchen on a weekly basis as this was included in his entire facility weekly temperature checks. He provided a handwritten copy of quarterly dish machine temperature checks performed by maintenance. He confirmed he was not performing weekly internal dish machine temperature checks as stated in policy. He stated the dish machine has a designated water heater and it was turned up from 130 to 150 degrees on Monday, 6/19/17. 2. Observation on 6/19/2017 at 11:40 AM revealed the steam table temperatures were completed in the kitchen prior to meal distribution by Cook #2 as follows: Carrots - 157, Barbecue (BBQ) pork -167, ground BBQ Pork 175, Tater Tots 181, green bean 182, Pureed green beans 193. During observations on 6/19/2017 at 12:12 PM, the steam table temperatures were measured in the main dining room by Cook #2 as follows: Carrots - 186, Mashed Potatoes - 143, Pureed green beans - 141, (Barbeque) BBQ pork (Ground) -121, BBQ pork (Pureed) -135. Observation at 12:17 PM revealed Cook #1 left the steam table to report findings to the Dietary Manager. Continued observation revealed the food remained covered on the steam table awaiting reheat and the Dietary Manager's notification. Interview at 12:22 PM with the DM in the kitchen regarding Cook #1 leaving the steam table to notify the DM of reported low temperatures for BBQ pork, revealed the DM was not aware and she would tell Cook #1 to pull the BBQ off the steam table and reheat it. Observation in the main dining room at 12:27 revealed Cook #1 had plated and served the pureed and ground BBQ pork to 6 residents who required assistance with feeding from staff. All 6 residents had consumed more than one to three table spoons of the BBQ pork. The 6 residents' identities were given to the DM. Interview conducted with Cook #1 on 6/19/2017 at 2:25 PM confirmed she was aware the steam table temperature for the BBQ pork (Pureed and Ground) was below the acceptable range temperatures. She stated she immediately left to tell the dietary manager of her findings and was stopped by a staff member to ask to do something else and she forgot. Cook #1 further stated upon return to the steam table she commenced to prepare the plates with the BBQ pork without reheating. During an interview with the DM, she stated the cook should have informed her immediately, pulled the BBQ pork immediately, and reheated it until it was at an acceptable level. She said she liked a 165 (degrees Fahrenheit) or above for all her meats.",2020-09-01
499,"THE WATERS OF WINCHESTER, LLC",445145,1360 BYPASS ROAD,WINCHESTER,TN,37398,2017-06-21,441,D,0,1,0D6Y11,"Based on facility policy review, observation and interview, the facility failed to follow infection control procedure per policy in the decontamination of a blood glucose monitor devise between the use on 2 residents (#61 and #99) out of 5 residents on the D unit of the facility, of 34 residents reviewed. The findings included: Review of the facility policy titled Blood Glucose Monitor Decontamination with an effective date 05/05/2016 revealed A wipe that is an EPA (environmental protection agency) registered as tuberculocidal; effective against HIV (humane immunosuppressant virus), HBV (Hepatitis B virus) and broad spectrum of bacteria will be utilized to clean the monitor. It is 0.525% sodium hypochlorite which is equivalent to a 1:10 bleach dilution solution, and meets recommendation for use on equipment from Clostridium difficile rooms (such as Clorox germicidal wipes). If a product wipe is not available a 1:10 bleach solution may be substituted. Policy: The blood glucose monitor will be cleaned and disinfected with wipes following use on each resident (when monitors are shared by multiple residents) or at the times designated on Individual Blood Glucose Monitor Decontamination Policy (for residents with assigned monitor). Procedure: 1. After performing the glucose testing, the nurse, wearing gloves, will use a disposable wipe to clean all external parts of the monitor. 2. Leave monitor damp for maximal kill time indicated on product label. If the monitor begins to dry before maximal kill time, use another wipe for the total dampness kill time indicated on product label. 3. Place clean monitor on a clean surface. 4. If a dried salty residue remains once dry, simply wipe with a clean cloth to remove. 5. Remove gloves and perform hand hygiene. 6. Return monitor to cart or other clean storage area. 7. Please be sure to keep the wipe away from the meter strip portal. Observation of medication administration on 6/20/17 at 11:29 AM, for Resident #99, revealed Licensed Practical Nurse (LPN) #1 to remove the glucose monitor device out of her uniform pocket and placed the glucose monitor on top of the resident table. LPN #1 used a disposable lancet devise to obtain a blood sample. The blood sample was placed on the test strip which was inserted into the end of the glucose monitor. The nurse disposed of the lancet device and strip to the sharps container. LPN #1 returned to the medication cart and placed the dirty glucose monitor on top of medication cart. No barrier was used to protect the top of the medication cart from the contaminated glucose monitor. LPN #1 opened an alcohol wipe and wiped off the meter and placed it back on top of medication cart. At 11:47 AM LPN #1 picked up the same glucose monitor used on Resident #99 and went into the room of Resident #61. LPN #1 placed the glucose monitor on the resident's bedside table without a barrier. LPN #1 obtained the blood sample from Resident #61 using a disposable lancet devise. The blood sample was placed on the test strip and inserted in the end of the glucose monitor devise. The test strip and lancet devise were disposed of in the sharps container. LPN #1 returned to the medication cart and wiped the glucose monitor with an alcohol wipe and placed the glucose monitor back in the medication cart drawer. No barrier was used to protect supplies in the mediation cart drawer from contamination from the glucose monitor that was not cleaned properly. Interview with LPN #1, on 6/20/17 at 11:55 AM revealed I use alcohol wipes between residents to clean the glucose monitor and at the end of my shift I would clean with a bleach wipe. Continued interview confirmed confirmed the glucose monitor was cleaned with alcohol and no barrier was used in resident rooms or on top of medication cart or in the drawer of the medication cart to prevent cross-contamination by the glucose monitor.",2020-09-01
500,"THE WATERS OF WINCHESTER, LLC",445145,1360 BYPASS ROAD,WINCHESTER,TN,37398,2017-06-21,520,D,0,1,0D6Y11,"Based on review of facility policy, review of the Quality Assurance and Performance Improvement (QAPI) committee attendance records, and interview the facility failed to hold a formalized meeting quarterly. The findings included: Review of the facility's policy QAPI, undated, revealed .The QAPI Committee shall look for opportunities for improvement on a continuous basis, and promote an environment of CQI-Continuous Quality Improvement environment analyze data monthly to identify opportunities for improvement .The Committee will make recommendations, and hold a formalized meeting at a minimum of quarterly . Review of the facility's QAPI committee attendance records revealed a quarterly QAPI meeting was conducted on 12/9/16 and the next QAPI meeting was not conducted until 4/28/17. Interview with the Administrator on 6/21/17 at 11:00 AM in the Administrator's office confirmed the facility had a QA meeting on 12/9/16 and 4/28/17. Further interview confirmed the facility did not hold a formalized meeting quarterly between 12/9/16 and 4/28/17.",2020-09-01
501,"THE WATERS OF WINCHESTER, LLC",445145,1360 BYPASS ROAD,WINCHESTER,TN,37398,2018-09-06,689,D,0,1,R2J911,"**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 a new falls intervention was implemented after a fall for 1 resident (#28) of 3 residents reviewed for accidents of 30 sampled residents. The findings include: Review of the facility policy, Incidents/Accidents/Falls, undated revealed .The facility will ensure that incidents and accidents that occur involving residents are identified, reported, investigated and resolved .All falls will have a site investigation by appropriate staff .Each fall needs a new intervention rolled out . Medical record review revealed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Significant Change Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident was cognitively intact. Continued review revealed the resident required extensive assistance for bed mobility, dressing, tranfers and toileting. Medical record review of facility documentation dated 2/9/18, revealed .Pt (patient) hit the emergency light in bathroom; had ambulated w/o (without) calling for assistace .pt was on her knees on the floor .negative for any new injuries . Medical record review of the care plan revealed .2/8/18 fall in room. No injuries . Continued review revealed no new intervention was implemented after the fall on 2/8/18. Interview with the Assistant Director of Nursing on 9/6/18 at 9:00 AM, in the conference room, confirmed the facility failed to follow their policy and failed to implement a new intervention to prevent further falls for Resident #28.",2020-09-01
502,"THE WATERS OF WINCHESTER, LLC",445145,1360 BYPASS ROAD,WINCHESTER,TN,37398,2018-09-06,692,D,0,1,R2J911,"**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 a resident was reevaluated by a Registered Dietician (RD) after a significant change for 1 resident (#28) reviewed for nutrition of 30 sampled residents. The findings include: Review of the facility policy,Screening and Initial Evaluation, undated revealed . A nutritional assessment is completed at least annually .New admits, Annuals and those Resident's with significant changes will be placed on the list for the RD (Registered Dietician) to see on their next visit. The Registered Dietician will review the assessment completed by the DM (Dietary Manager), and complete an in depth nutritional assessment upon admission or significant change would warrant an in depth assessment sooner. Any other resident who is deemed high risk such as those with .[MEDICAL TREATMENT] .will be placed on the list for the RD to review at their next visit .A quarterly note will be entered into the health record by the Dining Services Manager (Dietary Manager) .no less that quarterly .The care plan will be updated as changes are made in nutritional interventions as they occur . Medical record review revealed Resident #28 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact, had a weight loss of 5% or more and was receiving [MEDICAL TREATMENT]. Medical record review of the Quarterly MDS dated [DATE] revealed a BIMS score of 12 indicating the resident had moderate cognitive impairment. Medical record review of the resident's weight dated 11/3/17 (previous admission) revealed a weight of 122 pounds (lbs). Continued review revealed a readmission weight on 12/23/17 was 92.2 lbs (a decrease of 29.8 lbs) Medical record review of a Registered Dietician assessment dated [DATE] revealed .Screening Factors from MDS .Below desired weight range .Poor intake/Potential Medical record review of a RD progress noted dated 12/28/17 revealed .New Re-Admit .with [MEDICAL CONDITION] (End Stage [MEDICAL CONDITION]), dysphagia .anorexia, dehydration, N/V (nausea/vomiting) .CBW (current body weight) 92.2 # (pounds) .BMI .16.9 (suboptimal for age/clinical status) .Ideal body wt (weight) .115# . Medical record review of a Physicians order dated 1/8/18 revealed an order to admit for Resident #28 for hospice services. Medical record review of a Hospice note dated 2/9/18 revealed discontinue weights per hospice for comfort. Interview with the Director of Food Services (Dietary Manager) on 9/6/18 at 10:00 AM, outside the kitchen, confirmed he was not aware until recently that he was responsible for documenting quarterly notes on residents. Continued interview confirmed he did not complete any quarterly notes on Resident #28. Interview with the Director of Nursing on 9/6/18 at 1:30 PM, in the conference room confirmed the facility failed to follow their policy and failed to ensure Resident #28 was re-evaluated quarterly by the RD and Director of Food Services.",2020-09-01
503,"THE WATERS OF WINCHESTER, LLC",445145,1360 BYPASS ROAD,WINCHESTER,TN,37398,2018-09-06,761,D,0,1,R2J911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure expired blood collection tubes were properly disposed of in 1 of 1 storage rooms. The findings include: Observation of the A hall storage room, with Registered Nurse (RN) #1, on [DATE], at 12:05 PM, revealed the following: 97 expired blue top blood collection tubes expired [DATE]. Interview with RN #1, on [DATE], at 12:06 PM, in the A hall storage room confirmed the blood collection tubes were expired and available for resident use.",2020-09-01
504,GRACE HEALTHCARE OF FRANKLIN,445146,1287 WEST MAIN,FRANKLIN,TN,37064,2020-01-09,554,D,0,1,PNLU11,"**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 1 of 4 nurses (Licensed Practical Nurse (LPN) #1) remained with a resident during an inhalation treatment for 1 of 10 sampled residents (Resident #32) observed during medication administration. The findings include: The facility policy titled, Administering Medications through a Small Volume (Handheld) Nebulizer, dated 10/2010 documented, .Remain with the resident for the treatment . Review of the medical record, showed Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Physician order [REDACTED].[MEDICATION NAME] SUL (Sulfate) 1.25 MG (milligram)/ (per) 3ML (milliliters) SOL. (solution) GIVE ONE PER NEBULIZER EVERY 4 HOURS . Observation in the resident's room on 1/7/20 at 8:06 AM, showed LPN #1 administered the [MEDICATION NAME] nebulizer treatment to Resident #32. LPN #1 left the room and was absent during the entire treatment. The facility was unable to provide a self-administration assessment for nebulizer treatments for Resident #32. During an interview conducted on 1/8/20 at 4:07 PM, the Director of Nursing confirmed the nurse should stay with the resident during the breathing treatment unless the resident has had a self-administration assessment.",2020-09-01
505,GRACE HEALTHCARE OF FRANKLIN,445146,1287 WEST MAIN,FRANKLIN,TN,37064,2020-01-09,637,D,0,1,PNLU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to complete a Significant Change Minimum Data Set (MDS) assessment for 1 of 18 sampled residents (Resident #56) reviewed. The findings include: Review of the medical record, showed Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Physician order [REDACTED].Order Date 10/10/19 .Start Date 10/10/19 .ADMIT TO HOSPICE SERVICES WITH (Named Hospice Company) . Review of the medical record, showed there was no Significant Change MDS assessment completed when Resident #56 was referred to hospice services. During an interview conducted on 1/6/20 at 2:15 PM, the MDS Coordinator confirmed Resident #56 should have had a significant change MDS assessment done when hospice services were ordered.",2020-09-01
506,GRACE HEALTHCARE OF FRANKLIN,445146,1287 WEST MAIN,FRANKLIN,TN,37064,2020-01-09,812,F,0,1,PNLU11,"Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by a burner stove with thick black carbon build up on the stove eyes, carbon build up in an oven, and 1 of 2 dietary staff (Cook #1) failed to perform hand hygiene with glove use and had facial hair exposed. The facility had a census of 57 residents with 57 of those residents receiving a tray from the kitchen. The findings include: 1. The facility policy titled, Oven .Convection .Gas, dated 12/11/19 documented, .Remove spills, spillovers, and burned food deposits .wash oven interior . The facility policy titled, Stove Top, dated 2/19/15 documented, Wipe off burner grids using clean cloth and detergent .Remove stovetop sections .Take to pot and pan sink and scrub or send through dishmachine . The facility policy titled, PERSONAL HYGIENE/SAFETY/FOOD HANDLING, dated 3/5/19 documnted, .Beards or any body hair that may be exposed .must be covered . The facility policy titled, Handwashing/Hand Hygiene, dated 8/2019 documented, .Use an alcohol-based hand rub containing at least 62% (percent) alcohol .alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations .After removing gloves . 2. Observation in the Kitchen on 1/6/20 at 10:48 AM, 1/7/20 at 8:50 AM, and on 1/8/20 at 2:02 PM, showed a stove top with 6 burners with thick black carbon build up and an oven with brown debris and carbon build up. During an interview conducted on 1/8/20 at 2:05 PM, the Dietary Manager was asked if the 6 burner stove was clean. The Dietary Manager stated, Build up. She confirmed carbon build up on the 6 burner stove. The Dietary Manager was asked about the oven. She stated, Does not appear to be clean. 3. Observation in the Kitchen on 1/6/20 at 10:49 AM, showed Cook #1's beard and mustache was not completely covered. Observation in the 200 Hall on 1/6/20 at 12:05 PM, showed Cook #1's beard and mustache was not completely covered as he served lunch plates. Observation in the 300 Hall on 1/6/20 at 12:14 PM, showed Cook #1 checked the food temperatures, removed his gloves, and donned new gloves without performing hand hygiene. Observation in the Kitchen on 1/7/20 at 8:50 AM, showed Cook #1's beard and mustache was not completely covered. During an interview conducted on 1/8/20 at 2:15 PM, the Dietary Manager was asked about facial hair in the kitchen. The Dietary Manager stated, I would expect all of the hair should be covered. During an interview conducted on 1/9/20 at 8:50 AM, the Registered Dietician (RD) was asked what she expected staff to do between removing and donning gloves. The RD stated, Wash their hands.",2020-09-01
507,GRACE HEALTHCARE OF FRANKLIN,445146,1287 WEST MAIN,FRANKLIN,TN,37064,2019-02-22,656,D,0,1,U7IF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to prevent accidents related to falls for 1 of 12 (Resident #30) residents when fall interventions were not implemented. The findings include: The facility's Falls and Fall Risk, Managing policy revised on 3/2018 documented, .the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling . Medical record review revealed Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Plan dated 6/1/17 documented, .9/24/18 Rojo (pressure relieving) cushion to wheelchair .12/26/18-Educate R/T (related to) proper cushion and placement in w/c (wheelchair) .1/14/19 Fall-Ensure dysem is in w/c (wheelchair) staff education . Review of the facility's Resident Incident Report dated 12/26/18 documented, .leaning forward and slid out .wc (wheelchair) .cushion eval (evaluated) improper cushion in place .new Rojo (pressure relieving cushion) being ordered .a fall without injury . Review of the facility's Resident Incident Report dated 1/14/19 documented, .found lying on floor in front of wheelchair .care planned to have dycem to wc (wheelchair) .was not present .no injury . Interview with the Director of Nursing (DON) on 2/21/19 at 3:58 PM, in the Family Room, the DON was asked if the interventions were in place for Resident #30's falls on 12/26/18 and 1/14/19. The DON stated, No, they were not in place.",2020-09-01
508,GRACE HEALTHCARE OF FRANKLIN,445146,1287 WEST MAIN,FRANKLIN,TN,37064,2019-02-22,689,D,0,1,U7IF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to ensure 1 of 12 (Resident #30) residents were free from accident hazards by not implementing the interventions for falls. The findings include: 1. The facility's Falls and Fall Risk, Managing policy revised on 3/2018 documented, .the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling . 2. Medical record review revealed Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Plan dated 6/1/17 documented, .9/24/18 Rojo (pressure relieving) cushion to wheelchair .12/26/18-Educate R/T (related to) proper cushion and placement in w/c (wheelchair) .1/14/19 Fall-Ensure dysem is in w/c (wheelchair) staff education . The Significant Change and Quarterly Minimum Data Set ((MDS) dated [DATE] and 12/28/18 documented 2 falls with no injury. Review of the facility's Resident Incident Report dated 12/26/18 documented, .leaning forward and slid out .wc (wheelchair) cushion eval (evaluated) improper cushion in place .new Rojo (pressure relieving cushion) being ordered .a fall without injury . Review of the facility's Resident Incident Report dated 1/14/19 documented, .found lying on floor in front of wheelchair .care planned to have dycem to wc (wheelchair) .was not present .no injury . Interview with the Director of Nursing (DON) on 2/21/19 at 3:58 PM, in the Family Room, the DON was asked if the Rojo cushion was in place for the fall on 12/26/18 and if the dycem cushion was in place for the fall on 1/14/19. The DON stated, No, they were not in place.",2020-09-01
509,GRACE HEALTHCARE OF FRANKLIN,445146,1287 WEST MAIN,FRANKLIN,TN,37064,2019-02-22,693,D,0,1,U7IF11,"Based on policy review, observation, and interview the facility failed to ensure correct placement for the Percutaneous Endoscopic Gastrostomy (PEG) before administering medication when 1 of 6 (Licensed Practical Nurse (LPN)#1) failed to check placement. The findings include: The facility's Administering Medications through an Enteral Tube policy revised (MONTH) (YEAR) documented, .check placement . Observation in Resident # 16's room on 2/19/19 beginning at 2:40 PM, LPN #1 did not check placement of the PEG tube before administering medications. Interview with the Director of Nursing (DON) on 2/21/19 at 11:05 AM, in the lobby, the DON was asked do you expect placement to be checked before administering medication through a PEG tube, the DON stated, .yes .",2020-09-01
510,GRACE HEALTHCARE OF FRANKLIN,445146,1287 WEST MAIN,FRANKLIN,TN,37064,2019-02-22,760,D,0,1,U7IF11,"**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 that residents were free from significant medication error when 1 of 6 (Licensed Practical Nurse (LPN)#1) nurses failed to administer the correct dose of Tegretal, an anticonvulsant medication. The findings include: 1. The facility's Administering Medications through an Enteral Tube Administration policy revised (MONTH) (YEAR) documented, .correct dose of medication .confirm placement of feeding tube .Administer medication . 2. Medical record review revealed Resident #16 was admitted [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].[MEDICATION NAME] 200 MG (milligram). GIVE ONE TABLET BY PEG (Percutaneous Enteral Gastrostomy) TUBE THREE TIMES DAILY . 3. Observations during medication administration on 2/19/19 beginning at 2:40 PM, in Resident #16's room. LPN #1 had crushed the [MEDICATION NAME] and diluted the medication with water. LPN #1 did not check placement of the PEG tube. LPN #1 flushed the PEG tube with 30 milliters of water by pushing the plunger of a syringe attached to the end of the PEG tube. The force of pushing the plunger on the syringe blew the side port of the PEG tube open. LPN #1 poured the diluted medication into the enteral syringe. An undetermined amount of medication leaked from the tube, resulting in Resident #16 not receiving the complete dose of medication. Interview with Director of Nursing (DON) on 2/21/19 at 11:05 AM, in the lobby, the DON was asked if PEG tube placement should be checked before medication was administered. The DON stated, .yes . The DON confirmed that medication should be administered as ordered.",2020-09-01
511,GRACE HEALTHCARE OF FRANKLIN,445146,1287 WEST MAIN,FRANKLIN,TN,37064,2019-02-22,761,D,0,1,U7IF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored when 1 of 6 (Licensed Practical Nurse (LPN) #1) nurses left medication unattended during medication administration. The findings include: 1. The facility's Storage of Medications policy revised (MONTH) 2007 documented, .store all drugs and biologicals in a safe, secure .manner . 2. Observations on 2/19/19 beginning at 2:38 PM, in the 300 hall, LPN #1 placed a [MEDICATION NAME] 200 milligram (mg) tablet in a cup on the medication cart. LPN #1 entered room [ROOM NUMBER] to wash her hands, leaving the medication on the cart unattended and out of sight. 3. Observations on 2/19/19 beginning at 3:26 PM, in Resident #47's room, LPN #1 placed a vial of [MEDICATION NAME] medication on Resident #47's table. LPN #1 left the room leaving the medication unattended and out of sight. Interview with the Director of Nursing (DON) on 2/21/19 at 11:05 AM, in the lobby, the DON was asked should medication be left unattended. The DON stated, .No .",2020-09-01
512,GRACE HEALTHCARE OF FRANKLIN,445146,1287 WEST MAIN,FRANKLIN,TN,37064,2018-04-04,759,D,0,1,GCV311,"**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 1 of 4 (Registered Nurse (RN) #1) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 9 medication errors were observed out of 29 opportunities for error, resulting in a medication error rate of 31.03%. The findings included: The facility's Medications via Gastrostomy Tube policy documented, .Purpose .To administer medications through a gastrostomy tube in an accurate, safe, timely, and sanitary manner .Remove plug at the end of the tube and attach syringe .Clamp tube once correct placement is noted .Remove piston from syringe .pour up to 30 ml (milliliters) of water into syringe .Tilt the tube to allow air to escape as the fluid flows downward .Just before the syringe empties of water, add medication in accordance with physician order [REDACTED]. Medical record review revealed Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].[MEDICATION NAME] 0.5 mg (milligrams) .BID (twice a day) . The physician's orders [REDACTED]. 1.DAILY-VIT (Multivitamin) TAB (tablet) GIVE ONE PER PEG (Percutaneous Endoscopic Gastrostomy) TUBE ONCE DAILY . 2.[MEDICATION NAME] (Atorvastatin) 10 MG (milligram) TABLET ONE TAB PER PEG TUBE DAILY . 3.MAGNESIUM OXIDE 400 MG TABLET GIVE ONE TAB PER PEG TUBE ONCE DAILY . 4.OS-CAL (Oyster Shell Calcium) 500 (MG) TABLET GIVE ONE PER PEG BID (twice daily) . 5.[MEDICATION NAME] POWDER (Polyethylene [MEDICATION NAME]) 17 GRAMS VIA PEG TUBE .DAILY . 6.[MEDICATION NAME] (LEVETIRACETAM) 100 MG/ML .GIVE 5ML BY MOUTH TWICE A DAY . 7.[MEDICATION NAME] ([MEDICATION NAME]) 15 MG TABLET GIVE ONE TAB PER PEG DAILY . 8.[MEDICATION NAME] .37.5 MG TABLET .ONE TABLET VIA (PEG) TUBE TWICE A DAY . Observations in Resident #21's room, on 4/3/18 beginning at 10:52 AM, revealed the following: 1. RN #1 donned gloves, exposed Resident #21's PEG tube, and placed a washcloth covered with 2 brown paper napkins under the peg tube. RN #1 obtained a 60 ml piston syringe and used the syringe to draw up the dissolved [MEDICATION NAME], connected the syringe to the PEG tube and administered the medication. RN #1 removed the syringe and an undetermined amount of liquid leaked out of the PEG tube onto the napkins which resulted in medication error #1. 2. RN #1 flushed the tube with 10 mls of water, disconnected the syringe, drew up the dissolved Multivitamin, connected the syringe to the PEG tube and administered the medication. RN #1 removed the syringe and an undetermined amount of liquid leaked out of the PEG tube onto the napkins, which resulted in medication error #2. 3. RN #1 flushed the peg tube with 10 mls of water, disconnected the syringe, drew up the dissolved Atorvastatin and administered the medication. RN #1 disconnected the syringe and an undetermined amount of fluid leaked out of the PEG tube onto the napkins which resulted in medication error #3. 4. RN #1 flushed the PEG tube with 10 mls of water, disconnected the syringe, drew up the dissolved Magnesium Oxide and administered the medication. RN #1 disconnected the syringe and an undetermined amount of fluid leaked out of the PEG tube onto the napkins which resulted in medication error #4. 5. RN #1 then flushed the PEG tube with 10 mls of water, drew up the dissolved Oyster Shell Calcium, reconnected the syringe to the PEG tube and administered the medication. RN #1 removed the syringe and an undetermined amount of liquid leaked out of the PEG tube onto the napkins, which resulted in medication error #5. 6. RN #1 flushed the tube with 10 mls of water, disconnected the syringe, used the syringe to draw up the dissolved Polyethylene [MEDICATION NAME], reconnected the syringe to the PEG tube and administered the medication. RN #1 removed the syringe and an undetermined amount of liquid leaked out of the PEG tube onto the napkins which resulted in medication error #6. 7. RN #1 flushed the tube with 10 mls of water, disconnected the syringe, used the syringe to draw up the dissolved Levetiracetam, reconnected the syringe to the PEG tube and administered the medication. RN #1 removed the syringe and an undetermined amount of liquid leaked out of the PEG tube onto the napkins which resulted in medication error #7. 8. RN #1 flushed the tube with 10 mls of water, disconnected the syringe, used the syringe to draw up the dissolved [MEDICATION NAME], reconnected the syringe to the PEG tube and administered the medication. RN #1 removed the syringe and an undetermined amount of liquid leaked out of the PEG tube onto the napkins which resulted in medication error #8. 9. RN #1 flushed the tube with 10 mls of water, disconnected the syringe, used the syringe to draw up the dissolved [MEDICATION NAME], reconnected the syringe to the PEG tube and administered the medication. RN #1 removed the syringe and an undetermined amount of liquid leaked out of the PEG tube onto the napkins which resulted in medication error #9. After all of the medications had been administered through the PEG tube, the napkins under the PEG tube were saturated with liquid and multicolored particles. RN #1's failure to properly clamp the PEG tube after each medication was administered resulted in Resident #1 not receiving the full dose of each medication as ordered, with a medication error rate of 31.03%. Interview with RN #1 on 4/3/18 at 11:15 AM in Resident #21's room, RN #1 confirmed that the 2 napkins she had placed under the PEG tube were completely saturated with liquid and had some particles on them. Interview with the Director of Nursing (DON) on 4/4/18 at 2:08 PM in the Family Room, The DON confirmed that there would be no way to know if Resident #21 received all the medication if fluid was flowing out of the PEG tube after each time a medication was administered.",2020-09-01
513,GRACE HEALTHCARE OF FRANKLIN,445146,1287 WEST MAIN,FRANKLIN,TN,37064,2018-04-04,880,D,0,1,GCV311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, document review, and interview, the facility failed to ensure employees were free of communicable disease for 1 of 8 (Certified Nursing Assistant (CNA) #1) newly hired employees reviewed. The findings included: The facility's (Named Facility) CLINICAL SUPPORT POLICY documented, .Each newly hired employee will be screened for TB ([MEDICAL CONDITION]) infection and disease after an employment offer has been made but prior to the employee's duty assignment . The facility was unable to provide documentation that CNA #1 was free of communicable disease. Review of facility documents revealed that CNA #1 actually worked 25 scheduled shifts from 2/12/18 to 3/31/18. Interview with the Administrator on 4/4/18 at 3:47 PM in the Family Room, the Administrator was asked if the facility had no medical proof that CNA #1 was free of communicable disease. The Administrator stated, Correct.",2020-09-01
514,GRACE HEALTHCARE OF FRANKLIN,445146,1287 WEST MAIN,FRANKLIN,TN,37064,2019-04-24,600,J,1,0,G6YR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, review of a facility investigation, medical record review, observation, and interview, the facility failed to prevent neglect for 1 of 6 (Resident #1) residents reviewed, which resulted in Resident #1 exiting the facility, was found sitting in a creek containing water and sustained hypothermia (dangerously low body temperature) and a hematoma (swelling and bruising)around her right eye. The facility's failure to prevent neglect placed Resident #1 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). F-600 was cited at a scope and severity of J and is Substandard Quality of Care. The Nursing Home Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 4/23/19 at 12:00 PM, in the Family Room. The IJ was effective from 3/18/19 through 3/19/19. The IJ was removed on 3/19/19 when the facility implemented a corrective action plan. Corrective actions were validated by the surveyor on 4/22/19 - 4/24/19. The IJ was cited as past noncompliance and the facility is not required to submit a plan of correction for those tags. The findings include: The Wandering, Unsafe Resident policy, revised (MONTH) 2014 documented, .The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement .The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 5 day Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was moderately cognitively impaired, had poor decision making skills, required cues and supervision, was ambulatory with an unsteady gait and used a walker, and wandering occurred 1-3 days of the assessment period. Medical record review of Resident #1's Baseline Care Plan, dated 3/12/19, revealed the resident was at risk for elopement as evidenced by wandering and the intervention was ensure staff is aware of resident's wander risk, and exit alarms. Review of the facility's list of residents at risk for elopement revealed Resident #1 was not included on the list from 3/12/19 - 3/18/19. Medical record review of Resident #1's nurses' note dated 3/17/19 at 3:13 PM documented, .Wandering into resident's room and pushing on exit door handles . Review of the facility investigation dated 3/18/19 revealed, on 3/18/19 at approximately 2:00 AM, the facility staff were unable to locate Resident #1 and initiated the protocol for elopement of a resident. Continued review revealed the facility staff searched all rooms in the facility and the outside grounds and notified the Administrator and local police department of the missing resident. Emergency Management Agency and Search and Rescue Dog (K9) responded. At approximately 4:45 AM, Resident #1 was found sitting in a creek embankment containing water by Emergency Management Services and was transported to the hospital. Based on the United States Weather Service records, the recorded low temperature for the facility area on 3/18/19 was 37 degrees Fahrenheit. Medical record review of an acute care hospital Hospitalist Progress Note dated 3/18/19 at 9:40 AM documented, .Assessment Plan: 1.[MEDICAL CONDITION], 2. UTI (urinary tract infection), 3. Hypothermia secondary to prolonged exposure outside in the cold. Initial temperature 92.2 (Fahrenheit) (normal body temperature 98.6) on arrival resolved with bear (Bair) hugger (warming device) .[MEDICAL CONDITION] (elevated potassium level) . Review of the (Named Hospital) history and physical dated 3/18/19 documented, The ER patient (Resident #1) was found to have [MEDICAL CONDITION](elevated heart rate) hypertension (elevated blood pressure) as well as hypothermia patient started on Bair hugger (warming device) .Vital Sign Ranges Last 24 Hours 92.2 F (Fahrenheit) -98.2 F (normal body temperature 98.6 F) .patient has hematoma around the right eye . The (Named) Police Department (PD) report number documented, .3/18/19 at approximately 0304 (3:04 AM) hours dispatched to a missing person endangered .Nursing staff and officers searched the facility and immediate areas .0331 (3:31 AM) hrs (hours) EMA (Emergency Management Agency) K9 (Search and Rescue dog) notified .0411 (4:11 AM) K9 began track .As we were tracking (Resident #1's) scent, we were notified that (Resident #1) was seen lying in the embankment. Once verified that it was (Resident #1), she was transported by EMS (Emergency Management Services) to (named hospital) . Observations on 3/21/19 and 4/22/19 revealed the facility had 7 entrance/exit doors with keypads that required a code to open or enter/exit: 1 Front Main entrance/exit doorway; 1 Dining Room exit doorway; 1 100 hall end of hall exit doorway; 1 patio entrance/exit doorway; 1 200 hall end of hall exit doorway; 1 300 hall vending machine entrance/exit doorway visible from the nurse's station; 1 300 hall end of hall exit doorway. Observations on 3/21/19 at 2:00 PM behind the facility, revealed the enbankment to be a steep enbankment, with undergrowth of grass and weeds, there was a creek with water in the creek bed. Observations on 4/23/19 at 2:10 PM behind the facility, revealed the enbankment to be a steep enbankment, with undergrowth of grass and weeds, there was a creek with water in the creek bed. There had been a recent rain and the creek was slightly deeper than the observation on 3/21/19. Interview with the DON on 3/21/19 at 3:37 PM, in the Family room, the DON stated, She (Resident #1) was found sitting in the creek, water was to her waist while sitting in the creek. Legs were wet. Top was dry. She was disoriented. The Search and Rescue dog with the policeman found her with help of the fire department. Interview with Certified Nursing Assistant (CNA) #4 on 4/22/19 at 1:34 AM, in the 300 hallway, CNA #4 was asked if she sat in the hallway most nights. CNA #4 stated, Yeah, we all do when we finish rounds . CNA #4 was asked if she heard any door alarms sounding on the shift 7:00 PM - 7:00 AM beginning 3/17/19. CNA #4 stated, No. I didn't. Interview with the Maintenance Director on 4/22/19 at 4:20 PM in the Family Room, the Maintenance Director confirmed the Front Main entrance door code had been posted on the code box beside the door both at the entrance and exit code box .on that day (3/18/19) I immediately came in around 5:30 (AM) and checked all exit doors to verify working properly .I pulled open every code box at the exit doors and checked the wiring to make sure working properly .All batteries were working properly, however I went ahead and ordered all new batteries and .replaced all batteries in every code box .I then went into the ceiling above 200 hall exit door and opened the junction box and made sure all wiring was correct and tight, the wiring was working but it was discolored so I replaced it over the 200 hall exit door .I inserviced all day and night shift staff of the elopement policy and procedure and we did .drill (elopement scenario) for each shift . Interview with Licensed Practical Nurse (LPN) #1 on 4/22/19 at 4:52 PM, in the Family Room, LPN #1 was asked if she heard any door alarms sounding on the shift 7:00 PM - 7:00 AM beginning on 3/17/19. LPN #1 stated, I don't recall any alarms going off. LPN #1 stated, No, I was at the desk. LPN #1 was asked if Resident #1 had been observed walking to or past the nurses' station. LPN #1 stated, No. Interview with Registered Nurse (RN) #1 on 4/22/19 at 5:55 PM, in the Family Room, RN #1 was asked if she heard any door alarms sounding. RN #1 stated, Not that I recall. RN #1 was asked if she watched the 200 hall while CNA #1 was helping on the other hall. RN #1 stated, I watched for call lights. RN #1 was asked if she could see down the hall. RN #1 stated, No, I was at the desk. RN #1 was asked if Resident #1 had been observed walking to or past the nurses' station. RN #1 stated, No. RN #1 confirmed her witness statement. RN #1 stated, .That night (named Resident #1) had been up and down the (200) hallway .At 2:00 AM I peeked in her (Resident #1) room to check on her and she was not in her room .I asked (named CNA #1) did you see her leave her room and she said no .I then told all staff to begin searching in all rooms, bathrooms, closets everywhere as well as outside . Interview with CNA #2 on 4/22/19 at 6:47 PM, in the Family Room, CNA #2 stated, I saw (Named Resident #1) going down the hall, 200 hall .directed her back into her room about 12:15 (AM). I went back to my hall on 300. CNA #2 was asked if she heard any door alarms sounding that night. She stated, No. CNA #2 was asked if Resident #1 had been observed walking to or past the nurses' station. CNA #2 stated, No. Interview with CNA #3 on 4/22/19 at 7:05 PM, in the Family room, CNA #3 stated, I asked (Named CNA #1) to help me with a resident on 100 hall around 1:30 (AM). She came to room [ROOM NUMBER] .She left the room after 15 to 20 minutes . CNA #3 was asked if she heard any door alarms sounding that night. She stated, No. CNA #3 was asked if Resident #1 had been observed walking to or past the nurses' station. CNA #3 stated, No. Telephone interview with CNA #1 on 4/22/19 at 7:20 PM, CNA #1 stated, .I ate my meal between 12 (AM) and 1(AM). Meal was in the breakroom. I heated it up in the breakroom across from the nurses' station. Nobody was particularly watching the room (Resident #1's room). Others were watching for lights (resident call lights) or listening for the lights. I left to help (Named a CNA) for about 10 minutes. I did rounds. She (Resident #1) was by her door. I directed her back in her room. I finished my round, probably 4 people, and 2 rooms. Then went and heated my meal. I had a light going off. I went and answered the lights. Went to the bathroom a couple of times. Her door was shut. CNA #1 was asked who was monitoring the hall, particularly Resident #1's room, while she was off the hall. CNA #1 stated, Not sure. I was in/out rooms. CNA #1 was asked if she heard any door alarms sounding that night. CNA #1 stated, No .CNA #1 was asked if Resident #1 had been observed walking to or past the nurses' station. CNA #1 stated, No .saw her (Resident #1) wander out of her room and down the hall toward the nurses' station or walk in her room . A second telephone interview with CNA #1 on 4/22/19 at 7:30 PM, CNA #1 confirmed her witness statement. She stated, .The last time I saw (named Resident #1) was approximately 12:15 AM. I redirected her back to her room. She said she was going to bed and closed the door .At approximately 2:00 AM the nurse (RN #1) said (named Resident #1) was not in her room, did I know where she was .that is when we started searching the facility and the grounds . Interview with the Administrator on 4/23/19 at 9:25 AM, in the Family Room, the Administrator stated, I could see how going into other people's rooms could lead to exiting. Interview with the DON on 4/23/19 at 10:15 AM, in the Family Room, the DON stated, I looked back at the nurses' notes for the day before (day prior to the elopement) During that day, based on the nurses' notes, she was wandering that day and went to an exit door and exhibited those behaviors .Going to exit doors . The DON was asked what her expectations were for monitoring a resident with behaviors of wandering/at risk for elopement. The DON stated, .I would not expect them to be left alone. Be kept in sight. I would expect a visual . Record review of maintenance records of the Resident Monitoring Systems: Check operation of door monitors and patient wandering system dated 3/6/19 - 4/17/19 revealed, the logs were completed weekly and passed inspection. Review of the Emergency Power Generators logbook dated 3/8/19 - 4/16/19 were completed weekly and passed inspection. The facility's failure to monitor and supervise a cognitively impaired resident resulted in Resident #1 wandering away from the facility during the night and suffering from hypothermia and a hematoma around her right eye. The facility's corrective action plan included the following: On 3/18/19 the facility did the following: [NAME] A Certified Nursing Assistant (CNA) was stationed by the 200 hall door until all emergency doors and wiring of emergency doors were inspected for proper functioning. B. The Maintenance Director checked the functionality of all 7 exit doors, door code boxes and the alarm systems of the doors. 1. Opened every code box at every exit door and checked the wiring to ensure working properly. 2. Checked every code box battery to ensure they were working properly. Ordered all new batteries as a preventive measure. On 3/19/19 replaced all batteries in the code boxes on all exit doors. C. In the ceiling above the 200 hall exit door, opened the junction box to ensure all wiring was correct, tight, and replaced the discolored wiring. D. The security code to the 200 hall entrance/exit door was changed by the Maintenance Director. E. The Maintenance Director changed the wiring from the 200 hall exit door to the generator due to discoloration of the wires. F. The DON and designee re-assessed all residents in the building to determine any resident at risk for elopement. Results were no new residents identified as an elopement risk or added to the list. [NAME] Conducted in-services with 100% of all staff on wandering residents, elopement, abuse and systemic changes that were implemented to promote resident safety. Staff was required to have the in-service education prior to working their next shift. Changes included: 1. If staff observed changes in a resident's behavior that included wandering and/or exit seeking, the nurse must complete an elopement risk assessment. After completing the risk assessment, if the resident is determined to be at risk of elopement, the resident is to be added to alert charting to be completed by nursing. 2. The CNA is to communicate to nurses any observed changes in a resident's behavior that involved wandering and/or exit seeking. 3. The Elopement Binder was updated to include a current facesheet and picture of each resident at risk of elopement. An Elopement Binder will be kept at the receptionist desk and one at the nurses' station. 4. If any entrance/exit door alarm sounds, a staff member is to go to the door and check outside. Don't assume it was a visitor. H. The Care Plan for Resident #1 was updated to include new interventions for the risk for elopement. I. Completed an elopement scenario drill for each shift. [NAME] DON and designee conducted in-services with nursing staff on procedure process for risk of elopement: 1. If resident is observed with elopement behaviors the following must be done: a. Ensure safety of resident/residents b. Complete Elopement risk assessment c. Notify MD (Doctor of Medicine) and family d. Notify DON and Administrator e. Medical records to update Elopement Binder f. Begin Alert charting. K. The Nursing Home Administrator, DON, Assistant Director of Nursing (ADON), Director of Social Services, Maintenance Director, Regional Director Operational Support and Regional Director Clinical Services Support conducted an ad hoc Quality Assurance Meeting to review the circumstances of the incident and implement an immediate action plan for the investigation of the incident. The surveyors verified the facility's corrective action plan on 4/22/19 - 4/24/19 as follows: [NAME] Review of the Quality Assurance Performance Improvement meeting, attendance, agenda sheets and minutes confirmed the facility conducted an ad hoc Quality Assurance meeting on 3/18/19, and began review monthly on 4/19/19 to ensure sustainability of the plan of correction. B. Medical record reviews revealed 100% of residents were re-assessed on 3/18/19 using the Nursing Risk Assessment for Elopement Risk with 100% completion. C. Observation of the Resident Monitoring System log and interview with the Maintenance Director on 4/22/19 at 10:50 AM, in the Family Room, confirmed the 7 exit door alarms were checked weekly for functioning alarm sounding. Continued interview confirmed the battery function of the security code boxes was checked monthly. D. Review of the list of residents at risk of elopement confirmed the list was updated and the Elopement Binders were updated to include all residents currently at risk of elopement. E. On 4/23/19 at 2:05 PM, the surveyor attempted to exit through the doorway located at the end of the 200 hall by pushing on the door, setting off the alarm. The facility staff responded immediately. F. Comparison of facility in-service records and sign in/out sheets, for policy reviews and changes beginning 3/18/19 were validated. Interview with the DON on 4/23/19 at 10:15 AM, in the Family Room, confirmed staff education was 100% complete. Continued interview revealed the facility had conducted elopement scenarios with facility staff on 3/18/19 and 3/19/19 and will continue at random. [NAME] Multiple observations and interviews were conducted by the surveyor with residents and employees on both shifts throughout the complaint survey conducted on 3/21/19 - 4/24/19, which confirmed full implementation of the systemic changes to enhance resident/staff safety and the reporting. H. Review of the facility's self-reported incidents to the State Agency and review of the Concern/Comment Log revealed the facility had no other incidents of allegations of neglect and/or elopement since the implementation of the corrective action plan.",2020-09-01
515,GRACE HEALTHCARE OF FRANKLIN,445146,1287 WEST MAIN,FRANKLIN,TN,37064,2019-04-24,609,J,1,0,G6YR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, review of a facility investigation, medical record review, and interviews, the facility failed to report an allegation of neglect to the State Survey Agency timely for 1 of 6 (Resident #1) residents reviewed for neglect. Resident #1 eloped and the incident was not reported to the State Survey Agency within 2 hours. The facility's failure to report neglect timely placed Resident #1 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). F-609 was cited at a scope and severity of J and is Substandard Quality of Care. The Nursing Home Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 4/23/19 at 12:00 PM, in the Family Room. The IJ was effective from 3/18/19 through 3/19/19. The IJ was removed on 3/19/19 when the facility implemented a corrective action plan. Corrective actions were validated by the surveyor on 4/22/19 - 4/24/19. The IJ was cited as past noncompliance and the facility is not required to submit a plan of correction for those tags. The findings include: The facility's Abuse Prevention Policy & Procedure, revised 2/26/18 documented, .All allegations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately to the state survey agency, adult protective services and to all other agencies as required, per state and federal guidelines .Immediately means as soon as possible, but not later than 2 hours after the allegation is made . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 5 day Minimum Data Set ((MDS) dated [DATE] revealed, Resident #1 was moderately cognitively impaired, had poor decision making skills, required cues and supervision, wandering occurred 1-3 days of the assessment period, had an unsteady gait and used a walker when ambulating. Medical record review of Resident #1's Baseline Care Plan, dated 3/12/19, revealed the resident was at risk for elopement as evidenced by wandering and the intervention was ensure staff is aware of resident's wander risk, and exit alarms. Medical record review of Resident #1's nurses' note dated 3/17/19 at 3:13 PM revealed, .Wandering into resident's room and pushing on exit door handles . Review of the facility investigation dated 3/18/19 revealed, on 3/18/19 at approximately 2:00 AM, the facility staff were unable to locate Resident #1 and initiated the protocol for elopement of a resident. Continued review revealed the facility staff searched all rooms in the facility and the outside grounds and notified the Administrator and local police department of the missing resident. At approximately 4:45 AM, Resident #1 was found lying in a creek embankment containing water and transported to the hospital. Based on the United States Weather Service records, the recorded low temperature for the facility area on 3/18/19 was 37 degrees Fahrenheit. Medical record review of an acute care hospital Hospitalist Progress Note dated 3/18/19 at 9:40 AM documented, .Assessment Plan: 1.[MEDICAL CONDITION], 2. UTI (urinary tract infection), 3. Hypothermia secondary to prolonged exposure outside in the cold. Initial temperature 92.2 (Fahrenheit) (normal body temperature 98.6) on arrival resolved with bear (Bair) hugger (warming device) .[MEDICAL CONDITION] (elevated potassium level) .Hematoma (bruising and swelling) around the right eye . Interview with the DON on 3/21/19 at 2:55 PM in the Family Room, the DON stated, .The Administrator reported (the incident to the State) that morning after she (Resident #1) was taken to the ER (emergency room ) . Interview with the Administrator on 4/22/19 at 2:00 AM in the Family Room, the Administrator stated, .I was notified 3:13 (AM) by phone from the night shift RN (Registered Nurse) a resident had eloped .I called the DON to inform her of the elopement . Review of the facility self-report revealed the incident was reported to the state survey agency on the morning of 3/18/19 (at 7:13 AM approximately 5 hrs and 13 minutes after the incident). The facility's corrective action plan included the following: On 3/18/19 the facility did the following: [NAME] A Certified Nursing Assistant (CNA) was stationed by the 200 hall door until all emergency doors and wiring of emergency doors were inspected for proper functioning. B. The Maintenance Director checked the functionality of all 7 exit doors, door code boxes and the alarm systems of the doors. 1. Opened every code box at every exit door and checked the wiring to ensure working properly. 2. Checked every code box battery to ensure they were working properly. Ordered all new batteries as a preventive measure. On 3/19/19 replaced all batteries in the code boxes on all exit doors. C. In the ceiling above the 200 hall exit door, opened the junction box to ensure all wiring was correct, tight, and replaced the discolored wiring. D. The security code to the 200 hall entrance/exit door was changed by the Maintenance Director. E. The Maintenance Director changed the wiring from the 200 hall exit door to the generator due to discoloration of the wires. F. The DON and designee re-assessed all residents in the building to determine any resident at risk for elopement. Results were no new residents identified as an elopement risk or added to the list. [NAME] Conducted in-services with 100% of all staff on wandering residents, elopement, abuse and systemic changes that were implemented to promote resident safety. Staff was required to have the in-service education prior to working their next shift. Changes included: 1. If staff observed changes in a resident's behavior that included wandering and/or exit seeking, the nurse must complete an elopement risk assessment. After completing the risk assessment, if the resident is determined to be at risk of elopement, the resident is to be added to alert charting to be completed by nursing. 2. The CNA is to communicate to nurses any observed changes in a resident's behavior that involved wandering and/or exit seeking. 3. The Elopement Binder was updated to include a current facesheet and picture of each resident at risk of elopement. An Elopement Binder will be kept at the receptionist desk and one at the nurses' station. 4. If any entrance/exit door alarm sounds, a staff member is to go to the door and check outside. Don't assume it was a visitor. H. The Care Plan for Resident #1 was updated to include new interventions for the risk for elopement. I. Completed an elopement scenario drill for each shift. [NAME] DON and designee conducted in-services with nursing staff on procedure process for risk of elopement: 1. If resident is observed with elopement behaviors the following must be done: a. Ensure safety of resident/residents b. Complete Elopement risk assessment c. Notify MD (Doctor of Medicine) and family d. Notify DON and Administrator e. Medical records to update Elopement Binder f. Begin Alert charting. K. The Nursing Home Administrator, DON, Assistant Director of Nursing (ADON), Director of Social Services, Maintenance Director, Regional Director Operational Support and Regional Director Clinical Services Support conducted an ad hoc Quality Assurance Meeting to review the circumstances of the incident and implement an immediate action plan for the investigation of the incident. The surveyors verified the facility's corrective action plan on 4/22/19-4/24/19 as follows: [NAME] Review of the Quality Assurance Performance Improvement meeting, attendance, agenda sheets and minutes confirmed the facility conducted an ad hoc Quality Assurance meeting on 3/18/19, and began review monthly on 4/19/19 to ensure sustainability of the plan of correction. B. Medical record reviews revealed 100% of residents were re-assessed on 3/18/19 using the Nursing Risk Assessment for Elopement Risk with 100% completion. C. Observation of the Resident Monitoring System log and interview with the Maintenance Director on 4/22/19 at 10:50 AM, in the Family Room, confirmed the 7 exit door alarms were checked weekly for functioning alarm sounding. Continued interview confirmed the battery function of the security code boxes was checked monthly. D. Review of the list of residents at risk of elopement confirmed the list was updated and the Elopement Binders were updated to include all residents currently at risk of elopement. E. On 4/23/19 at 2:05 PM, the surveyor attempted to exit through the doorway located at the end of the 200 hall by pushing on the door, setting off the alarm. The facility staff responded immediately. F. Comparison of facility in-service records and sign in/out sheets, for policy reviews and changes beginning 3/18/19 were validated. Interview with the DON on 4/23/19 at 10:15 AM, in the Family Room, confirmed staff education was 100% complete. Continued interview revealed the facility had conducted elopement scenarios with facility staff on 3/18/19 and 3/19/19 and will continue at random. [NAME] Multiple observations and interviews were conducted by the surveyor with residents and employees on both shifts throughout the complaint survey conducted on 3/21/19 - 4/24/19, which confirmed full implementation of the systemic changes to enhance resident/staff safety and the reporting. H. Review of the facility's self-reported incidents to the State Agency and review of the Concern/Comment Log revealed the facility had no other incidents of allegations of neglect and/or elopement since the implementation of the corrective action plan.",2020-09-01
516,GRACE HEALTHCARE OF FRANKLIN,445146,1287 WEST MAIN,FRANKLIN,TN,37064,2019-04-24,689,J,1,0,G6YR11,"**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 a safe environment that provided adequate supervision to prevent elopement for 1 of 6 (Resident #1) cognitively impaired, vulnerable sampled residents reviewed who had elopement behaviors/risk. Immediate Jeopardy (IJ) is 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 facility failed to ensure a safe environment and placed Resident #1 in Immediate Jeopardy (IJ) by failing to adequately supervise Resident #1, a cognitively impaired resident with known wandering behavior, who was missing for approximately 2 hours from the facility before the staff realized she had eloped from the facility. Resident #1 had eloped from the facility and was not located until approximately 4.5 hours later when she was found lying in a creek embankment containing water and suffered from hypothermia (dangerously low body temperature) and hematoma (swelling and bruising) around her right eye. This resulted in an IJ for Resident #1. The facility identified 9 cognitively impaired residents who were independently mobile via ambulation or wheelchair with wandering behaviors. The facility reported a total census of 57 residents. F-689 was cited at a scope and severity of J and is Substandard Quality of Care. The Nursing Home Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 4/23/19 at 12:00 PM in the Family Room. The IJ was effective from 3/18/19 through 3/19/19. The IJ was removed on 3/19/19 when the facility implemented a corrective action plan. Corrective actions were validated by the surveyor on 4/22/19 - 4/24/19. The IJ was cited as past noncompliance and the facility is not required to submit a plan of correction for those tags. The findings include: The facility's Wandering, Unsafe Resident policy, undated documented, .The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement .The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) .The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as detailed monitoring plan will be included . Medical record review revealed Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The 5 day Minimum Data Set ((MDS) dated [DATE] revealed, Resident #1 was moderately cognitively impaired, had poor decision making skills, required cues and supervision, wandering occurred 1-3 days of the assessment period, had an unsteady gait and used a walker with ambulation. The Baseline Care Plan dated 3/12/19 documented, .PROBLEM Date: 3/12/19 I am at risk for elopement as evidenced by .Wandering .Other encephalitis (symbol for increased) agitation (symbol for increased) confusion Ambulatory .3-18-19 - Elopement - Resident Sent to ER (emergency room ) c (with) minor injuries . Review of the facility's list of residents at risk for elopement revealed Resident #1 was not included on the list from 3/12/19 - 3/18/19. Medical record review included the following notes that documented Resident #1 displayed impaired cognitive status. A Nurse's Note dated 3/14/19 3:36 AM documented, .Some confusion . A Nurse's Note dated 3/14/19 4:40 PM documented, .Some confusion noted . A Nurse's Note dated 3/14/19 11:53 PM documented, Resident up in room rearranging belongings. Stated she got OOB (out of bed) at 6:00 pm thinking her son was coming to take her to get her mail but he did not come .Up in the hall requesting toilet paper, but some was found to be already in place in her room . A Nurse's Note dated 3/17/19 3:13 PM documented, .increased confusion. When helping resident get dressed this morning resident kept attempting to put her shirt on as her pants. Walked out of her room several times asking for the bathroom .Wandering into residents room and pushing on exit door handles . A Nurse's Note dated 3/18/19 6:10 AM (late entry) documented, Pt (patient) not in her (Resident #1's) room all rooms searched completely .Police notified and given information of incident . A Police Department incident report dated 3/18/19 at 3:01 AM to 4:45 AM documented, (Named Nurse and Certified Nursing Assistant (CNA)) informed officers that (Resident #1) left the facility between 0000-0030 (12:00 AM-12:30 AM) hours .last seen wearing a pink sweatshirt, blue pants, possibly wearing slippers, and suffers from dementia .stated (Resident #1) had been wandering around all-night in the hallway .0331 (3:31 AM) hours EMA (Emergency Management Agency) K9 (Search and Rescue dog) notified .0411 (4:11 AM) hours - K9 began track Based on the United States Weather Service records, the recorded low temperature for the facility area on 3/18/19 was 37 degrees Fahrenheit. Review of the (Named Hospital) history and physical dated 3/18/19 documented, The ER patient (Resident #1) was found to have [MEDICAL CONDITION](elevated heart rate) hypertension (elevated blood pressure) as well as hypothermia patient started on Bair hugger (warming device) .Vital Sign Ranges Last 24 Hours 92.2 F (Fahrenheit) -98.2 F (normal body temperature 98.6 F) .patient has hematoma around the right eye . Observations on 3/21/19 at 2:00 PM behind the facility, revealed the enbankment to be a steep enbankment, with undergrowth of grass and weeds, there was a creek with water in the creek bed. Observations on 4/23/19 at 2:10 PM behind the facility, revealed the enbankment to be a steep enbankment, with undergrowth of grass and weeds, there was a creek with water in the creek bed. There had been a recent rain and the creek was slightly deeper than the observation on 3/21/19. A telephone interview with Certified Nursing Assistant (CNA) #1 on 3/21/19 at 1:30 PM, CNA #1 was asked when was the last time she saw Resident #1. CNA #1 stated, I saw her about 12:15 (AM). Took her to her room, put her to bed and closed the door . Interview with the DON on 3/21/19 at 3:37 PM, in the Family room, the DON stated, She (Resident #1) was found sitting in the creek, water was to her waist while sitting in the creek. Legs were wet. Top was dry. She was disoriented. The Search and Rescue dog with the policeman found her with help of the fire department. Interview with Registered Nurse (RN #1) on 4/22/19 at 5:55 PM, in the Family Room, RN #1 was asked when was the last time she saw Resident #1. RN #1 stated, Can't recall exact time I last saw her. She was going in other rooms and coming in/out hallway .Just thought I'd check in on her. It was 2:00 AM. Checked the room. Asked (named CNA) if she had seen her leave . Interview with CNA #2 on 4/22/19 at 6:47 PM, in the Family Room, CNA #2 was asked when was the last time she saw Resident #1. CNA #2 stated, I saw her going down the hall .about 12:15 AM. I went back to my hall on 300 . CNA #2 was asked if she heard any door alarms sounding that night. CNA #1 stated, No . A telephone interview with CNA #1 on 4/22/19 at 7:20 PM, CNA #1 stated, .I heated up my meal in the breakroom across from the nurses' station. Nobody was particularly watching the room. I went about 1:30 (AM) and helped (named CNA). I had a light going off I went and answered the lights. Went to the bathroom a couple of times. CNA #1 was asked who was monitoring the hall. CNA #1 stated, Not sure. I was in/out rooms. CNA #1 was asked if she heard any door alarms sounding that night. CNA #1 stated, No Interview with the Administrator on 4/23/19 at 9:25 AM, in the Family Room, the Administrator stated, I could see how going into other people's rooms could lead to exiting. Interview with the DON on 4/23/19 at 10:15 AM, in the Family Room, the DON stated, I looked back at the nurses' notes for the day before (day prior to the elopement) During that day, based on the nurses' notes, she was wandering that day and went to an exit door and exhibited those behaviors .Going to exit doors . The DON was asked what her expectations were for monitoring a resident with behaviors of wandering/at risk for elopement. The DON stated, .I would not expect them to be left alone. Be kept in sight. I would expect a visual . The facility failed to ensure a safe environment for Resident #1 when they had no knowledge of her location for approximately 4.5 hours. Resident #1 had been assessed and documented as cognitively impaired with risk for elopement as evidenced by wandering behaviors and eloped from the facility on 3/18/19. She was found 4.5 hours later on 3/18/19 lying in a creek embankment containing water. The facility's corrective action plan included the following: On 3/18/19 the facility did the following: [NAME] A Certified Nursing Assistant (CNA) was stationed by the 200 hall door until all emergency doors and wiring of emergency doors were inspected for proper functioning. B. The Maintenance Director checked the functionality of all 7 exit doors, door code boxes and the alarm systems of the doors. 1. Opened every code box at every exit door and checked the wiring to ensure working properly. 2. Checked every code box battery to ensure they were working properly. Ordered all new batteries as a preventive measure. On 3/19/19 replaced all batteries in the code boxes on all exit doors. C. In the ceiling above the 200 hall exit door, opened the junction box to ensure all wiring was correct, tight, and replaced the discolored wiring. D. The security code to the 200 hall entrance/exit door was changed by the Maintenance Director. E. The Maintenance Director changed the wiring from the 200 hall exit door to the generator due to discoloration of the wires. F. The DON and designee re-assessed all residents in the building to determine any resident at risk for elopement. Results were no new residents identified as an elopement risk or added to the list. [NAME] Conducted in-services with 100% of all staff on wandering residents, elopement, abuse and systemic changes that were implemented to promote resident safety. Staff was required to have the in-service education prior to working their next shift. Changes included: 1. If staff observed changes in a resident's behavior that included wandering and/or exit seeking, the nurse must complete an elopement risk assessment. After completing the risk assessment, if the resident is determined to be at risk of elopement, the resident is to be added to alert charting to be completed by nursing. 2. The CNA is to communicate to nurses any observed changes in a resident's behavior that involved wandering and/or exit seeking. 3. The Elopement Binder was updated to include a current facesheet and picture of each resident at risk of elopement. An Elopement Binder will be kept at the receptionist desk and one at the nurses' station. 4. If any entrance/exit door alarm sounds, a staff member is to go to the door and check outside. Don't assume it was a visitor. H. The Care Plan for Resident #1 was updated to include new interventions for the risk for elopement. I. Completed an elopement scenario drill for each shift. [NAME] DON and designee conducted in-services with nursing staff on procedure process for risk of elopement: 1. If resident is observed with elopement behaviors the following must be done: a. Ensure safety of resident/residents b. Complete Elopement risk assessment c. Notify MD (Doctor of Medicine) and family d. Notify DON and Administrator e. Medical records to update Elopement Binder f. Begin Alert charting. K. The Nursing Home Administrator, DON, Assistant Director of Nursing (ADON), Director of Social Services, Maintenance Director, Regional Director Operational Support and Regional Director Clinical Services Support conducted an ad hoc Quality Assurance Meeting to review the circumstances of the incident and implement an immediate action plan for the investigation of the incident. The surveyors verified the facility's corrective action plan on 4/22/19-4/24/19 as follows: [NAME] Review of the Quality Assurance Performance Improvement meeting, attendance, agenda sheets and minutes confirmed the facility conducted an ad hoc Quality Assurance meeting on 3/18/19, and began review monthly on 4/19/19 to ensure sustainability of the plan of correction. B. Medical record reviews revealed 100% of residents were re-assessed on 3/18/19 using the Nursing Risk Assessment for Elopement Risk with 100% completion. C. Observation of the Resident Monitoring System log and interview with the Maintenance Director on 4/22/19 at 10:50 AM, in the Family Room, confirmed the 7 exit door alarms were checked weekly for functioning alarm sounding. Continued interview confirmed the battery function of the security code boxes was checked monthly. D. Review of the list of residents at risk of elopement confirmed the list was updated and the Elopement Binders were updated to include all residents currently at risk of elopement. E. On 4/23/19 at 2:05 PM, the surveyor attempted to exit through the doorway located at the end of the 200 hall by pushing on the door, setting off the alarm. The facility staff responded immediately. F. Comparison of facility in-service records and sign in/out sheets, for policy reviews and changes beginning 3/18/19 were validated. Interview with the DON on 4/23/19 at 10:15 AM, in the Family Room, confirmed staff education was 100% complete. Continued interview revealed the facility had conducted elopement scenarios with facility staff on 3/18/19 and 3/19/19 and will continue at random. [NAME] Multiple observations and interviews were conducted by the surveyor with residents and employees on both shifts throughout the complaint survey conducted on 3/21/19 - 4/24/19, which confirmed full implementation of the systemic changes to enhance resident/staff safety and the reporting. H. Review of the facility's self-reported incidents to the State Agency and review of the Concern/Comment Log revealed the facility had no other incidents of allegations of neglect and/or elopement since the implementation of the corrective action plan.",2020-09-01
517,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2019-07-18,641,D,0,1,DRI311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to complete a quarterly Minimum Data Set (MDS) for 1 of 35 (Resident #128) sampled residents reviewed. The findings include: 1. The facility's MDS Assessment policy revised 3/2019 documented, .All MDS assessments (e.g.,admission, annual, significant change, quarterly review, etc.) and discharge and reentry records will be completed and electronically encoded .in accordance with current OBRA (Omnibus Budget Reconciliation Act) regulations governing the transmission of MDS data .Quarterly (Non-Comprehensive) . 2. Medical record review revealed Resident #128 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's medical record revealed Resident #128 had an admission MDS assessment on 3/21/19. A quarterly MDS assessment would have been due on 6/21/19. The facility failed to complete a quarterly assessment until 7/18/19. Interview with MDS Coordinator #1 on 7/18/19 at 10:56 AM, in the Conference Room, MDS Coordinator #1 was asked if Resident #128's quarterly assessment due 6/21/19 had been completed. MDS Coordinator #1 stated, .no it hasn't been done .it hasn't been started . Interview with the Administrator on 7/18/19 at 1:22 PM, in the Conference Room, the Administrator was asked if the quarterly assessment due 6/21/19 for Resident #128 should have been completed timely. The Administrator stated, Yes, it should have.",2020-09-01
518,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2019-07-18,656,D,0,1,DRI311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to develop a comprehensive care plan for 1 of 31 (Resident #126) sampled residents reviewed. The findings include: 1. The facility's undated Care Planning Interdisciplinary Team policy documented, .A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS) (Minimum Data Set) . 2. Medical record review revealed Resident #126 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed the admission MDS was completed 6/21/19. The comprehensive care plan should have been completed by 6/28/19. The facility was unable to provide a comprehensive care plan for Resident #126. 3. Interview with MDS Coordinator #2 on 7/18/19 at 6:06 PM, in the Conference Room, MDS Coordinator #2 was asked what overdue meant in the Point Click Care system )the facility's electronic medical record system). MDS Coordinator #2 stated, It (care plan) hasn't been completed. MDS Coordinator #2 was asked when the comprehensive care plan was due. MDS Coordinator #2 stated, .21 days after admission . MDS Coordinator #2 was asked whose responsibility it was to complete the comprehensive care plan. MDS Coordinator #2 stated, .the person who completed the assessment .",2020-09-01
519,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2019-07-18,689,D,0,1,DRI311,"Based on observation and interview, the facility failed to ensure the environment was free of accident hazards when unsecured chemicals were observed in 1 of 4 (100 Hall) shower rooms. The findings include: Observations in the 100 Hall shower room on 7/15/19 at 5:23 AM, 7:46 AM, 8:01 AM, and 8:14 AM, revealed (2) 1 gallon plastic containers of hair and body cleanser and (1) opened, unlabeled and unsealed plastic container, containing a clear yellowish liquid with a strong chemical odor. Interview with Certified Nursing Assistant (CNA) #1 on 7/15/19 at 9:14 AM, in the 100 Hall shower room, CNA #1 was asked if the hair and body cleanser should be left out when not in use. CNA #1 stated, .no. CNA #1 was asked what is this clear yellowish liquid in the unlabeled, unsealed and opened gallon container. CNA #1 stated, .it is bleach . CNA #1 was then asked if these items should be stored unsecured, unsealed and unlabeled in the shower room. CNA #1 stated, No, they should be locked up. Interview with the Administrator on 7/18/19 at 6:19 PM, in the Administrator Office, the Administrator was asked how should chemicals such as bleach be stored. The Administrator stated, .not accessible to residents . The Administrator was asked how should hair and body cleanser be stored in the shower room when not in use. The Administrator stated, .in a locked cabinet .",2020-09-01
520,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2019-07-18,698,D,0,1,DRI311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to provide appropriate care and services for 1 of 1 (Resident #130) residents reviewed for [MEDICAL TREATMENT]. The findings include: 1. The facility's undated [MEDICAL TREATMENT] Policy and Procedure documented, .When resident is sent to [MEDICAL TREATMENT] unit .copy of the Facility [MEDICAL TREATMENT] Communication Record to accompany the resident .When the resident returns from [MEDICAL TREATMENT] unit .Review all test reports and the [MEDICAL TREATMENT] Communication Record returned with the resident . 2. Medical record review revealed Resident #130 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 30 day admission Minimum Data Set ((MDS) dated [DATE] documented Resident #130 received [MEDICAL TREATMENT]. Review of the [MEDICAL TREATMENT] communication record revealed the following forms were not completed prior to [MEDICAL TREATMENT] on 6/12/19, 6/21/19, 6/24/19, 6/26/19, 6/28/19, 7/8/19, 7/12/19, and 7/15/19. Interview with the Director of Nursing (DON) on 7/18/19 at 10:38 AM, in the Conference Room, the DON was asked when should the [MEDICAL TREATMENT] communication records be completed. The DON stated, Before the resident leave the facility for [MEDICAL TREATMENT]. The DON was asked should the resident have their communication records completed for each [MEDICAL TREATMENT] visit. The DON stated, Yes.",2020-09-01
521,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2019-07-18,759,E,0,1,DRI311,"**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 4 of 10 (Licensed Practical Nurse (LPN) #2, #3, #8, and Registered Nurse (RN) #1) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 4 errors were observed out of 36 opportunities, resulting in an error rate of 11.11%. The findings include: 1. The facility's undated MEDICATION ADMINISTRATION-GENERAL GUIDELINES policy documented, .Prior to administration, the medication and dosage schedule on the resident's Medication Administration Record [REDACTED].Medications are administered in accordance with written orders of the attending physician .Medications are administered within 60 minutes of scheduled time . 2. Medical record review revealed Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Physician order [REDACTED].[MEDICATION NAME] Aerosol 80-4.5 MCG (microgram) .2 puff inhale orally two times a day . Observations in Resident #19's room on 7/16/19 at 8:06 AM, revealed LPN #2 administered one puff of [MEDICATION NAME] inhaler to Resident #19. The administration of 1 puff of [MEDICATION NAME] resulted in medication error #1. Interview with LPN #2 on 7/16/19 at 8:10 AM, at the 300 Hall Nurses' Station, LPN #2 was asked how many puffs should the resident receive during medication administration. LPN#2 stated, 2 puffs. 3. Medical record review revealed Resident #105 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Physician order [REDACTED].[MEDICATION NAME] Solution intramuscularly 100 mg (milligrams) every 12 hours . Observations in Resident #105's room on 7/16/19 at 9:30 AM, revealed LPN #3 administered 80 mg of [MEDICATION NAME] intramuscular in the right arm to Resident #105. The administration of 80 mg of [MEDICATION NAME] resulted in medication error #2. Interview with LPN #3 on 7/16/19 at 10:10 AM, at the100 Hall Nurses' Station, LPN #3 was asked what is the correct dose of [MEDICATION NAME] for Resident #19. LPN #3 stated, 100 milligrams. LPN #3 was asked did the resident get the correct dose of [MEDICATION NAME] during the medication administration. LPN #3 stated, No. 4. Medical record review revealed Resident #48 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Physician order [REDACTED].[MEDICATION NAME] Tablet 20 MG Give 1 tablet by mouth at bedtime . Observations in Resident #48's room on 7/16/19 at 4:59 PM, revealed LPN #8 administered [MEDICATION NAME] 40 mg to Resident #48. The administration of the 40 mg of [MEDICATION NAME] and at 4:59 PM resulted in medication error #3. Interview with LPN #8 on 7/16/19 at 5:04 PM, at the 100 Hall Nurses' Station, LPN #8 was asked what time are the bedtime medications given. LPN #8 stated, At 8 pm. 5. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Physician order [REDACTED].Aspirin Tablet 325 MG Give 1 tablet .PEG (Percutaneous endoscopic gastrostomy)-Tube one time a day . Observations in Resident #13's room on 7/17/19 at 10:04 AM, revealed RN #1 administered Aspirin 81 mg via (by way of) peg tube to Resident #13. The administration of Aspirin 81 mg resulted in medication error #4. Interview with RN #1 on 7/17/19 at 11:32 AM, at the 300 Hall Nurses' Station, RN #1 was asked should 325 mg of Aspirin have been administered. RN #1 stated, Yes .I gave her 81 mg . Interview with the Director of Nursing (DON) on 7/16/19 at 5:18 PM, in the Conference Room, the DON was asked should the residents receive the correct dosage during the medication administration. The DON stated, Absolutely. The DON was asked what time are the bedtime medications administered. The DON stated, 9 PM.",2020-09-01
522,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2019-07-18,761,E,0,1,DRI311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure medications and chemicals were not stored in the same compartment, medications were dated when opened, not expired, and medications were secured and attended for 9 of 14 (Patriot and Tulip Split Hall Medication Cart, Sunflower Hall Medication Cart, Tulip Medication Room, Daisy Hall Medication Cart, Daisy Medication Room, Rose Hall Medication Cart, Rose Medication Room, Sunflower Medication Room, and Tulip Hall Medication Cart) medication storage areas. The findings include: 1. The facility's Undated STORAGE OF MEDICATIONS policy documented, .Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access .Orally administered medications are separated from externally used medications .Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock . 2. Observations on the Patriot Hall and Tulip Split Medication Cart on 7/15/19 at 5:42 AM, revealed one carton of Med Pass (nutritional supplement) and 1 bucket of Micro Kill disinfectant wipes stored in the same compartment. Observations in the Sunflower Hall Medication Cart on 7/15/19 at 5:50 AM, revealed 1 vial of [MEDICATION NAME]dated 4/13/19, 1 tub of Micro Kill disinfectant wipes, and 1 quart of Promod (nutritional supplement) stored in the same compartment. Observations in the Tulip Hall Medication Room on 7/15/19 at 6:39 AM, revealed (1) 100 ml (milliliter) bag of [MEDICATION NAME] with an expiration date of 5/13/19. Observations in the Daisy Medication Cart on 7/15/19 at 7:28 AM, revealed 1 [MEDICATION NAME] Flex Pen opened and undated. Observations in the Daisy Hall Medication Room on 7/15/19 at 7:33 AM, revealed 2 vials of [MEDICATION NAME] vaccine opened and undated. Observations in the Rose Hall Medication Cart on 7/15/19 at 7:39 AM, revealed the following: a. 1 opened [MEDICATION NAME] inhaler with an open date of 6/13/19 b. 1 Sprivia inhaler with an open date of 6/14/19 c. 1 opened and undated vial of [MEDICATION NAME] 1 percent (%) Observations in the Rose Hall Medication Room refrigerator on 7/15/19 at 7:59 AM, revealed: a. 2 open and undated vials of [MEDICATION NAME] vaccine b. (1) 100 milliliter (ml) bag of [MEDICATION NAME] with an expiration date of 7/13/19 c. (3) bags of D5W ([MEDICATION NAME] 5% in water) and 1/2 NS (Normal Saline) 1000 ml with an expiration date of (MONTH) 2019 Observations in the Sunflower Medication Room refrigerator on 7/15/19 at 8:26 AM, revealed: a. 3 open and undated vials of [MEDICATION NAME] vaccine Observations on the Tulip Hall Medication Cart on 7/16/19 at 8:10 AM, revealed the following: a. 1 open bottle of Humalog with an open date of 6/11/19 b. 1 [MEDICATION NAME] inhaler with an open date of 6/4/19 c. 1 box of alcohol prep pads stored with 1 box of [MEDICATION NAME] and [MEDICATION NAME] in the same compartment Observations at the Sunflower Hall on 7/16/19 at 8:31 AM, revealed the Sunflower Medication Cart was open and unattended. 3. Interview with the Licensed Practical Nurse (LPN) #6 on 7/16/19 at 8:31 AM, at the Sunflower Medication Cart, LPN #6 was asked should you leave your medication cart unlocked and unattended. LPN #6 stated, Never. Interview with the Director of Nursing (DON) on 7/16/19 at 10:50 AM, in the Conference Room, the DON was asked should the medication storage areas have expired medications, and open and undated medications. The DON stated, No. The DON was asked should internal and external medications and chemicals be stored together in the same drawer on the medication cart. The DON stated, No. The DON was asked should nursing staff leave their medication carts open and unattended. The DON stated, No.",2020-09-01
523,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2019-07-18,812,F,0,1,DRI311,"Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by a dirty ice machine and milk cooler, rusted tables and shelves, loose food particles in the freezer, dusty storage shelves, boxes stored on the floor, open and undated items in the cooler, pots and pans with carbon build-up and a greasy brown substance, and dirty floors and doors. The facility had a census of 139 residents with 125 of those residents receiving a tray from the kitchen. The findings include: 1. The facility's undated CLEANING . policy documented, .Food and Nutrition Services staff shall maintain the sanitation of the Food and Nutrition Services Department . The facility's undated HOW TO CLEAN AND SANITIZE POTS, PANS . policy documented, .Participants will learn proper method of cleaning and sanitizing pots and pans . The facility's undated ICE MACHINE CLEANING . policy documented, .Participants will understand how to wash and sanitize an ice machine .ice chest should be washed and sanitized daily . The facility's undated LABELING AND DATING FOR SAFE FOOD STORAGE policy documented, .Use Use-by-dates on all food once opened and stored under refrigeration . The facility's undated FOOD STORAGE policy documented, .Improper storage of food is the main reason for foodborne illness . 2. Observations in the kitchen beginning on 7/15/19 at 5:41 AM, revealed the following: a. a rusty colored substance covered the bowl of the hand washing sink b. a black, slimy substance on the lip and inside edge of the ice machine c. a black, slimy substance on the rubber seal inside the milk cooler d. torn and dirty foil partially covered the bottom shelf of the coffee and tea service table, the portions of the bottom shelf visible appeared rusted e. mixed vegetables scattered over the bottom of reach-in freezer #2 f. a dry storage shelf appeared rusted g. 5 dry storage shelves covered with a thick layer of dust h. 2 boxes of plastic lids, 1 box of straws, 1 box of plastic bowls, 1 box of cups, and 1 box of oranges stored on the floor i. 1 open gallon of Italian dressing with a use by date of 5/7/19 in the Reach-in refrigerator #2 j. 1 open and undated 30 ounce (oz) jar of sandwich spread in Reach-in refrigerator #2 k. 3 frying pans with a greasy, brown substance and carbon build-up on the outside l. 1 small pot with carbon build-up on the outside m. 2 deep pans with carbon build-up and a greasy, brown substance on the outside n. 8-1/2 (inch) deep pans with carbon build-up and a greasy, brown substance on the outside o. 15-1/4 (inch) deep pans with carbon build-up and a greasy, brown substance on the outside p. 9 large baking sheet pans with carbon build-up q. 3 small baking sheets with a greasy, brown substance on the outside r. dirty floor covered with black and brown build-up s. double doors to the dining room with blacks streaks and brown build-up covering the lower half of the doors Interview with the Registered Dietitian (RD) on 7/15/19 at 8:54 AM, in the 100 Hall, the RD was asked how long the facility had been without a Dietary Manager. The RD stated, .about 3 months. The RD was asked who was responsible for the kitchen sanitation. The RD stated, .I am, since we don't have a CDM (Certified Dietary Manager) . Interview with the RD on 7/18/19 at 11:18 AM, in the Conference Room, the RD was asked should the surfaces, rubber seals or anything inside of the ice machine and milk cooler have a black, slimy substance on them. The RD stated, No. The RD was asked should boxes containing food and plastic dinner ware items be stored on the floor. The RD stated, .not on the floor. The RD was asked should tables and shelves in the kitchen be covered in rust and dust. The RD shook her head no. The RD was asked should open and undated items be stored in the refrigerator. The RD stated, No . The RD was asked should the freezer floor be covered with food particles. The RD stated, No . The RD was asked should the kitchen floors be dirty with black and brown build-up. The RD stated, It should be clean . The RD confirmed the facility had been without a CDM since (MONTH) 24th. Interview with the Administrator on 7/18/19 at 5:24 PM, in the Administrator Office, the Administrator confirmed the kitchen should not be dirty or unsanitary. The Administrator was asked should pots and pans have carbon build-up and a greasy, brown substance on them. The Administrator stated, No. The Administrator was asked whose responsibility it was to ensure the kitchen was maintained in a clean and sanitary manner for the residents. The Administrator stated, .both the CDM and the Administrator. The Administrator confirmed the facility did not have a CDM at this time.",2020-09-01
524,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2019-07-18,842,D,0,1,DRI311,"**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 weights were accurately obtained and recorded for 1of 4 (Resident #10) sampled residents reviewed for nutritional risk. The findings include: 1. The facility's undated Weight Monitoring policy documented, Monthly weights will be done by the C.N.A (Certified Nursing Assistant) .All weights will be documented in the weight record .Any resident with a weight of five-pound discrepancy will be reweighed by the charge nurse immediately .The charge nurse will be reweighing any discrepancy . 2. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's Weights and Vitals Summary record dated 7/17/19 revealed no recorded weights for (MONTH) 2019 and (MONTH) 2019. Review of the facility's Weights and Vitals Summary record revealed a weight discrepancy of 27.2 pounds from 4/24/19 (259.2 pounds) to 7/3/19 (232 pounds) and a weight discrepancy of 24.5 pounds from 7/3/19 (232 pounds) to 7/17/19 (256.5 pounds) with no recorded reweights. Observations at the end of the 200 Hall on 7/17/19 at 2:10 PM, revealed the weight of the wheelchair was obtained by the Assistant Director of Nursing (ADON) and resulted in a 39.1 pound weight. Certified Nursing Assistant (CNA) #1 and CNA #2 assisted Resident #10 onto the digital wheelchair scales while in his wheelchair and obtained the weight for Resident #10 with the result of 256.5 pounds without the deduction of the wheelchair weight. The weight entered into the electronic medical record for 7/17/19 was 256.5 and the wheelchair weight was not deducted from this weight. Interview with the Director of Nursing (DON) on 7/17/19 at 6:14 PM, in the Conference Room, the DON was asked if the weight of 256.5 pounds that was recorded in the computer for Resident #10 on 7/17/19 reflected the deduction of the wheelchair weight of 39.1 pounds. The DON stated, No, it was not .from admission until now the restorative aids have failed to subtract the wheelchair weight. The DON was asked who was responsible for ensuring that the weights are correct, and if there were any discrepancies that reweights were obtained. The DON stated, The ADON. Interview with the ADON on 7/18/19 at 4:28 PM, in the Conference Room, the ADON confirmed that it was his responsibility to put all weights into the computer system for review, all residents with weight discrepancies should be reweighed, and that the restorative staff failed to deduct the wheelchair weight for Resident #10.",2020-09-01
525,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2019-07-18,880,D,0,1,DRI311,"**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 1 of 1 (Resident #126) residents reviewed in transmission based precautions did not have isolation signage on the resident's door and 1 of 1 (Licensed Practical Nurse (LPN) #8) nurses failed to perform proper hand hygiene during Percutaneous Endoscopic Gastrostomy (PEG) tube care. The findings include: 1. The facility's undated Handwashing Technique policy documented, .To prevent and control transmission of infections, employees hands will be washed . 2. Medical record review revealed Resident #126 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].contact isolation d/t (due to)[MEDICAL CONDITION] ([MEDICAL CONDITION]-Resistant Staphylococcus Aureus) (a bacterium with antibiotic resistance) in sputum . Observations on the 100 Hall outside of Resident #126's room on 7/15/19 at 5:25 AM, 6:43 AM, and 8:32 AM, revealed no sign on the door alerting staff or visitors to see the nurse prior to entering the room. Interview with LPN #9 on 7/15/19 at 8:32 AM, on the 100 Hall, LPN #9 was asked if Resident #126 was in isolation. LPN #9 stated, Yes . Interview with the Director of Nursing (DON) on 7/18/19 at 5:50 PM, in the Conference Room, the DON was asked how staff, visitors, and residents were notified that someone was in isolation. The DON stated, .sign on the door that says please see nurse before entering. 3. Medical record review revealed Resident #303 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].Clean peg site with soap and water, pat dry .apply TAO (triple antibiotic ointment) .apply gauze to peg site Q (every) shift . Observations in Resident #303's room on 7/18/19 at 8:53 AM, revealed LPN #8 washed her hands, donned gloves, prepared soapy water in an emesis basin, removed the old dressing from the enteral feeding site, cleansed around the enteral feeding site with soap and water, removed her gloves, and donned clean gloves without performing hand hygiene. LPN #8 dried the area around the enteral feeding site, removed her right glove, donned a glove on her right hand, without performing hand hygiene, applied a topical antibiotic ointment to the enteral feeding site and applied a split gauze sponge around the enteral feeding site. Interview with the DON on 7/18/19 at 9:18 AM, in the Conference Room, the DON was asked what she expected her staff to do between glove changes. The DON stated, Wash their hands.",2020-09-01
526,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2018-07-19,684,D,1,0,0VM311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation and interview, the facility failed to follow physician's treatment orders for 1 of 3 (Resident #3) sampled residents reviewed for wound care and treatment. The findings included: Medical record review revealed Resident#3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED].Cleanse lt (left) lower leg with wound cleaner, pat dry, apply dry 4x4's . and wrap with [MEDICATION NAME] qd (every day)/prn (as needed) one time a day for arterial/venous ulcers (.) (MONTH) reapply if dressing becomes soiled or dislodged as needed . Review of physician's orders [REDACTED].Cleanse rt (right) lower leg with wound cleaner, pat dry, apply dry 4x4's . and wrap with [MEDICATION NAME] qd/prn. one time a day for venous/arterial ulcers (.) (MONTH) reapply if dressing becomes soiled or dislodged as needed . Observation in Resident #3's room on 7/16/18 at 3:00 PM revealed the dressings on Resident #3's bilateral lower extremities were dated 7/13/18. The dressings were not changed and treatments were not provided on 7/14/18 or 7/15/18 as ordered by the physician. Interview with Licensed Practical Nurse (LPN) #1 on 7/16/18 at 3:30 PM in Resident #3's room, LPN #1 confirmed Resident #3's bilateral lower extremities dressings were dated 7/13/18. The facility failed to ensure wound treatments were changed according to physician's orders [REDACTED].",2020-09-01
527,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2018-07-19,773,D,1,0,0VM311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation and interview, the facility failed to obtain laboratory (lab) tests as ordered and failed to promptly notify the physician of a critical laboratory result for 1 of 3 (Resident #9) sampled residents reviewed for laboratory services. The findings included: Review of the undated (Named Facility) Lab Protocol documented, .Lab results are pulled from (Named Lab Company) system daily Monday-Friday by designated personnel and reviewed by DON (Director of Nursing) and ADON (Assistant Director of Nursing) .All critical labs are to be called to facility per (Named Lab Company) Monday-Friday. Nurses are to accept critical lab reports and call MD (Medical Doctor) with results. Monday-Friday if labs are called after hours then 3-11 supervisor/charge nurses are to take critical lab results and report to MD/DNP (Doctorate Nurse Practitioner) . Medical record review for Resident #9 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #9 was assessed with [REDACTED].#9 was severely cognitively impaired. Review of a physician order [REDACTED].[MEDICATION NAME] Suspension (generic [MEDICATION NAME]) 125 mg/5ml (125 milligrams in 5 milliliters) give 8 ml by mouth every 12 hours for anticonvulsant . Review of a physician order [REDACTED].[MEDICATION NAME] level every 3 months starting on 5/1/18 . The [MEDICATION NAME] level result dated 5/1/18 was low at 7.0 ug/ml (units per gram/milliliter) with a reference range of 10.0-20.0 ug/ml. The physician ordered a one time dose of [MEDICATION NAME] suspension 500 mg (milligram) to be given on 5/2/18. Review of a physician order [REDACTED].Repeat [MEDICATION NAME] level one time . There was no documentation this repeat [MEDICATION NAME] level was obtained as ordered. Review of a physician order [REDACTED]. This [MEDICATION NAME] level result was at a critical level high of 25.4 ug/ml. The physician was notified and gave an order to hold the [MEDICATION NAME] Suspension until 5/25/18 and to repeat the [MEDICATION NAME] level on 5/24/18. There was no documentation this repeat [MEDICATION NAME] level was performed. Review of a physician order [REDACTED].Repeat [MEDICATION NAME] level on 5/24/18 . There was no documentation that this repeat level was obtained. The physician visited the resident on 5/25/18 and ordered a STAT( immediate) [MEDICATION NAME] level to be drawn. This STAT [MEDICATION NAME] level result was high at 23.5 ug/ml. The physician decreased the [MEDICATION NAME] suspension dosage to 7 ml two times a day and ordered a repeat [MEDICATION NAME] level to be drawn in one week. There was no documentation this repeat [MEDICATION NAME] level was performed as ordered. A Nurses note dated 5/31/18 revealed the physician was notified again of the high [MEDICATION NAME] level result dated 5/25/18 with an order obtained to further decrease the [MEDICATION NAME] Suspension dose to 6 ml twice a day and to repeat a [MEDICATION NAME] level on 6/7/18. The 6/7/18 [MEDICATION NAME] level result was a critical high level of greater than 34. The laboratory result form documented the critical high level was called to (Named Licensed Practical Nurse) on 6/8/18 at 7:49 AM. There was no documentation the physician was notified of this critical high result until 6/9/18. The physician discontinued the [MEDICATION NAME] dose until 6/12/18 and ordered a recheck of the [MEDICATION NAME] level to be drawn on 6/11/18. The 6/11/18 level result was within normal limits of 12.7 ug/ml. The physician restarted the [MEDICATION NAME] suspension dosage at 5 ml two times a day on 6/12/18. Observations of Resident #9 on 7/18/18 at 10:30 AM revealed him to be alert, up in a geri chair at bedside watching television and voiced no complaints. Interview with the Unit Manager on 7/18/18 at 7:50 AM, in the Conference room, the Unit Manager was asked about the missed labs and delay in physician notification of the critical lab result and the Unit Manager stated, I am not sure what happened about the 5/2/18 lab order, I do know the 5/24/18 lab order was canceled by the laboratory and was not sure why was not aware of the redraw order for the first of (MONTH) .I saw that critical lab (on 6/9/18) for 6/7/18 and had the LPN handle that on 6/9/18. Not sure why the nurse did not inform the physician of that critical lab. The resident never displayed any symptoms of toxicity. Interview with the Nurse Practitioner on 7/18/18 at 10:00 AM, in the Conference room, the Nurse Practitioner (NP) involved in Resident #9's care was asked about the missed labs and delay in notification of the critical high [MEDICATION NAME] level and the NP stated, I was not aware the levels were not drawn on the first of June, (Named Resident #9) had no signs/symptoms during that time, I decreased his [MEDICATION NAME] slowly .I do expect to be notified of critical lab results. The facility failed to ensure that laboratory tests were obtained as ordered and failed to ensure prompt notification of a critical [MEDICATION NAME] level on Resident #9.",2020-09-01
528,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2018-07-19,806,D,1,0,0VM311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on menu review, tray card review, medical record review, observations and interviews, the facility failed to ensure nourishing, palatable meals, honoring resident preferences were served to 1 of 3 (Resident #1) sampled residents reviewed for nutrition. The findings included: Medical record review for Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The record revealed Resident #1 with an order dated 6/15/18 for a Mechanical Soft Diet. Resident #1 was assessed on the 1/26/18 Annual and the 4/25/18 Quarterly Minimum Data Set (MDS) with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated Resident #1 was independent with decision making skills and required extensive assistance with Activities of Daily Living (ADLs). Further medical record review revealed the only Dietary Progress note to date in (YEAR) was dated 6/14/18 and documented Resident #1 had a 3% (percent) weight loss that month and a recommendation to liberalize her diet was noted. A Nurse's note dated 6/19/18 documented, Patient complaint of meal not being what she wants .she wants to talk to dietary supervisor . There was no documentation in the medical record the Dietary Manager or the Registered Dietician had conducted a follow up visit to address the 6/19/18 request made by the resident. There were no dietary notes in the medical record documenting the frequent trips to the grocery or attempts to accommodate Resident #1's food preferences. The Care Plan did not address Resident #1's food complaints/preferences/attempts to accommodate. Review of the Noon meal Menu for 7/15/18 revealed Roast Beef, Mashed Potatoes, Capri Mix Vegetables, Banana Cream Pie, and Dinner Roll to be served. The Noon meal Menu for 7/16/18 revealed Baked Chicken, Greens, Cornbread, and Strawberries with topping to be served. Observations on 7/15/18 at 12:20 PM of the noon meal revealed Resident #1 served Roast Beef, Vegetable Medley, and a Baked Sweet Potato. The Roast Beef and Sweet Potato were listed on the tray card as dislikes. The resident was observed to be eating the Sweet Potato and stated, .had one last night, get them frequently, have to eat something . Observations on 7/16/18 at 12:50 PM of the noon meal revealed Resident #1 served Baked Chicken, Greens, and a Baked Sweet Potato. The Sweet Potato was listed on the tray card as a dislike. The resident was observed to be eating the Sweet Potato and stated, .3 days in a row for Sweet Potatoes . Review of the tray card used in dietary to plate each meal for Resident #1 revealed the following foods listed as dislikes: No milk, juice, bread, chicken and dumplings, yams, roast beef, gravy or pork. Interview with the Dietary Manager on 7/11/18 at 10:30 AM, in the Conference room, the Dietary Manager stated, .(Named Resident #1) has given me a long list of dislikes on her tray cards .she is very picky, complains a lot about the food .we make frequent trips to the grocery for her meals . Interview with Resident #1 on 7/11/18 at 12 Noon, in the resident room, Resident #1 stated, .I have given the dietary manager a list of my likes and dislikes but they can't get that right . Interview with the Dietary Manager on 7/15/18 at 12:05 PM, in the Conference room, the Dietary Manager was asked to provide evidence such as notes and receipts of foods purchased to address the complaints/preferences of Resident #1 and stated, I don't have any receipts where I've bought food for her . Interview with the Director of Nursing (DON) on 7/18/18 at 11:15 AM, the DON was asked who completed the care plans related to dietary/food issues and stated, .Dietary would put those on the care plan. The DON was asked the care plan expectations regarding Resident #1's frequent food complaints and stated, I would expect all her dietary complaints, preferences and all that has been done to address them to be on the care plan. The facility failed to provide evidence the food complaints/preferences of Resident #1 were addressed, failed to ensure that food preferences were honored for Resident #1, and failed to ensure a variety of foods were served to Resident #1.",2020-09-01
529,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2017-08-24,157,D,0,1,5LE311,"**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 significant change in status for 1 of 17 (Resident #24) sampled residents reviewed of the 35 residents included in the stage 2 review. The findings included: Closed medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].HumaLOG Solution .Inject as per sliding scale .For blood glucose .300-349 = (equal) 20 (units); 350 + (plus) (=) 24 If BS (Blood Sugar) over 349 give 24 units and call physician, subcutaneously before meals . A physician's orders [REDACTED].inject as per sliding scale .300-349 = 20 units, 350-600 = 24units and call MD (Medical Doctor), subcutaneously before meals and at bedtime for DM (Diabetes Mellitus) . Review of the Medication Administration Records (MARs) for 7/8/17 through 7/15/17 revealed the following blood sugar levels greater than 349: 7/8/17 at 9:00 PM = 376 7/11/17 at 4:00 PM = 450 7/13/17 at 9:00 PM = 571 7/15/17 at 5:00 AM = 454 The facility was unable to provide any documentation that the physician or nurse practitioner was notified regarding the elevated blood sugar levels on 7/8/17, 7/11/17, 7/13/17, and 7/15/17. Interview with the Director of Nursing (DON) on 8/24/17 at 9:55 AM, in the restorative dining room, the DON was asked what the protocol was for elevated blood sugar levels. The DON stated, Follow physician's orders [REDACTED]. The DON was asked if the nurses should document that the physician was notified. The DON stated Yes .in the progress notes . The DON was unable to find any documentation that the physician had been notified for the elevated blood sugar levels. Interview with the Doctor of Nursing Practice (DNP) on 8/24/17 at 11:37 AM, in the conference room, the DNP was asked when she expected to be notified regarding elevated blood sugar levels. The DNP stated, .there are standing orders that they are supposed to call me if their blood sugar is greater than 350 . The DNP was asked if she could remember being notified by the nursing staff that Resident #24's blood sugar was greater than 350. The DNP stated, At home? No .",2020-09-01
530,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2017-08-24,282,D,0,1,5LE311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to follow care plan interventions for medications and nutritional supplements for 3 of 17 (Resident #51, 55 and 100) sampled residents reviewed of the 35 residents included in the stage 2 review. The findings included: 1. Medical record review revealed Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The signed physician's orders [REDACTED].Laboratory .[MEDICATION NAME] (blood level) . q (every) 6 months November/May . Medical record review revealed no documentation that Resident #51's [MEDICATION NAME] level had been checked since 5/2/16. The care plan dated 8/11/17 documented, .Obtain and monitor lab/diagnostic work as ordered . Interview with the Doctor of Nursing Practice (DNP) on 8/24/17 at 12:02 PM, in the conference room, the DNP was asked if she expected her orders to be followed. The DNP stated, I expect them to be done . Interview with the Director of Nursing (DON) on 8/23/17 at 11:21 AM, in the conference room, the DON was asked if she expected staff to follow the care plan. The DON stated, Yes. 2. Medical record review revealed Resident #55 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] Oxalate Tablet 10mg (milligram) Give 1 tablet by mouth one time a day for Depression . The care plan dated 8/3/17 documented, .uses antidepressant .r/t (related to) Depression .Monitor/document side effects and effectiveness . The facility was unable to provide any documentation that Resident #55 was monitored for medication side effects or effectiveness. Interview with the DON on 8/24/17 at 2:37 PM, in the conference room, the DON was asked if the staff should have been monitoring and documenting for side effects for antidepressant use. The DON stated, Yes. The DON was asked if the care plan had been followed for Resident #55. The DON stated, No. 3. Medical record review revealed Resident #100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan for nutrition dated 8/3/17 included the intervention to provide supplements as ordered. The physician's orders [REDACTED].Med Pass (a nutritional supplement) four times a day for Weight Loss Give 8 oz (ounces) .4 x (times) a day . Review of the Medication Administration Record [REDACTED]. Interview with the DON on 8/23/17 at 10:06 AM, in the conference room, the DON was shown Resident #100's MARs and was asked what does the empty blank mean. The DON stated, .not documented. The DON was asked did Resident #100 receive the Med Pass as ordered. The DON stated, .not documented, not done . Interview with the DON on 8/23/17 at 11:21 AM, in the conference room, the DON was shown Resident #100's care plan and was asked if Resident #100 had received all of her supplements as ordered (med pass) would her care plan have been followed. The DON stated, No. The DON was asked if that was acceptable. The DON stated, No.",2020-09-01
531,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2017-08-24,309,D,0,1,5LE311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to follow physician's orders related to diabetic care for 1 of 17 (Resident #24) sampled residents reviewed of the 35 residents included in the stage 2 review. The findings included: Closed medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #24 was severely cognitively impaired, had [DIAGNOSES REDACTED]. A physician's order dated 7/5/17 documented, Insulin NPH (Human) ([MEDICATION NAME]) Suspension Pen injector 100 UNIT/ ML (units per milliliter) Inject 50 units subcutaneously two times a day for DM (Diabetes Mellitus) . A physician's order dated 7/8/17 documented, .HumaLOG Solution .Inject as per sliding scale .For blood glucose .300-349 = (equal) 20 (units); 350 + (plus)=24 If BS (Blood Sugar) over 349 give 24 units and call physician, subcutaneously before meals . A physician's order dated 7/14/17 documented, HumaLOG Solution .inject as per sliding scale .300-349 = 20 units, 350-600 = 24units and call MD (Medical Doctor), subcutaneously before meals and at bedtime for DM . Review of the Medication Administration Records (MARs) for 7/5/17 through 7/15/17 revealed the following: a. Blood Sugar Levels greater than 349 with no physician notification documented: 7/8/17 at 9:00 PM = 376 7/11/17 at 4:00 PM = 450 7/13/17 at 9:00 PM = 571 7/15/17 at 5:00 AM = 454 The facility was unable to provide any documentation that the physician or nurse practitioner was notified regarding the elevated blood sugar levels on 7/8/17, 7/11/17, 7/13/17, and 7/15/17. b. There was no documentation that Resident #24 received his 50 units of NPH insulin as scheduled on 7/14/17 at 8:00 AM. c. There was no documentation that Resident #24's blood sugar was checked on 7/14/17 at 11:00 AM and 4:00 PM as ordered. Interview with the Director of Nursing (DON) on 8/24/17 at 9:55 AM, in the restorative dining room, the DON was asked what the protocol was for elevated blood sugar levels. The DON stated, Follow physician's orders .I believe if it's (the blood sugar level) is over 400 notify the physician . The DON was asked if the nurses should document that the physician was notified. The DON stated Yes .in the progress notes . The DON was unable to find any documentation that the physician had been notified for the elevated blood sugar levels. The DON confirmed there was no documentation that Resident #24 received his scheduled morning dose of NPH insulin at 8:00AM, 11:00 AM, or 4:00 PM and Resident #24 did not receive any of the scheduled blood sugar checks on 7/14/17. Interview with the Doctor of Nursing Practice (DNP) on 8/24/17 at 11:37 AM, in the conference room, the DNP was asked when she expected to be notified regarding elevated blood sugar levels. The DNP stated, .there are standing orders that they are supposed to call me if their blood sugar is greater than 350 . The DNP was asked if she could remember being notified by the nursing staff that Resident #24's blood sugar was greater than 350. The DNP stated, At home, No .",2020-09-01
532,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2017-08-24,312,D,0,1,5LE311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure Activities of Daily Living (ADL) assistance was provided for 1 of 4 (Resident #37) sampled residents reviewed of the 35 included in the stage 2 review. The findings included: Medical record review revealed Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE], and the annual MDS dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 11, which indicated Resident #37 was moderately impaired cognitively, had no behaviors, did not refuse care, and required limited staff assistance with 1 person physical assist for dressing and personal hygiene, and was totally dependent on staff for bathing. Observation in the lobby on 8/21/17 at 1:42 PM, revealed Resident #37 seated in a wheelchair, dressed in a pair of dirty, unhemmed pants, a dirty sweatshirt, with a collared shirt underneath. The white-colored collar was gray and dirty. Observation in the lobby on 8/22/17 at 4:26 PM, revealed Resident #37 seated in a wheelchair dressed in the same dirty clothing he had on the day before. Interview with Licensed Practical Nurse (LPN) #2 on 8/22/17 at 5:45 PM, at the 200 hall nurses' station, LPN #2 was asked whether it was acceptable for a resident to wear the same dirty clothing 2 days in a row. LPN #2 stated, No. LPN #2 was asked how often Resident #37 was bathed. LPN #2 reviewed the shower schedule and confirmed Resident #37 should have been showered on the night shift last night. At 5:50 PM, in Resident #37's room, LPN #2 confirmed Resident #37 was wearing dirty clothing. LPN #2 was asked if that was acceptable. LPN #2 stated, No. Interview with the Director of Nursing (DON) on 8/24/17 at 8:15 AM, in the conference room, the DON was asked whether it was acceptable for a resident to be dressed in the same dirty clothing 2 days in a row. The DON stated, No, it is not acceptable .",2020-09-01
533,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2017-08-24,315,D,0,1,5LE311,"**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 appropriate care and services related to indwelling urinary catheters were provided for 1 of 1 (Resident #138) sampled residents reviewed with indwelling urinary catheters. The findings included: The facility's Foley Catheter Policy documented, .Do not leave the bag laying on the floor . Medical record review revealed Resident #138 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 2, which indicated Resident #138 was severely impaired cognitively, required extensive to total staff assistance for all activities of daily living, and had an indwelling urinary catheter. The care plan dated 6/9/17 documented, .Indwelling Catheter due to Pressure Ulcer Stage IV (4), sacrum . Observations in Resident #138's room on 8/21/17 at 2:47 PM and 5:51 PM, revealed the indwelling catheter tubing and bag were touching the floor. Observations in Resident #138's room on 8/22/17 at 4:16 PM, 8/23/17 at 8:22 AM and 10:41 AM, revealed the indwelling catheter tubing was touching the floor. Interview with Licensed Practical Nurse (LPN) #3 on 8/22/17 at 4:27 PM, in Resident #138's room, LPN #3 was asked whether it was acceptable for the indwelling catheter bag or tubing to be touching the floor. LPN #3 stated, It's not supposed to be .They do that sometimes . Interview with Registered Nurse (RN) #1 on 8/23/17 at 11:00 AM, in Resident #138's room, RN #1 was asked whether the indwelling catheter bag should be touching the floor. RN #1 did not answer. RN #1 picked up the indwelling catheter bag, placed it back on the floor, walked to the other side of the bed, raised the bed, walked back around the bed, picked up the catheter bag and hung it on the side of the bed with the catheter bag still touching the floor. Interview with the Director of Nursing (DON) on 8/24/17 at 8:15 AM, in the conference room, the DON was asked whether it was acceptable for an indwelling urinary catheter bag or catheter tubing to be touching the floor. The DON stated, No.",2020-09-01
534,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2017-08-24,322,D,0,1,5LE311,"**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 1 of 1 (Resident #4) sampled residents with a Percutaneous Endoscopic Gastrostomy (PEG) tube received enteral feeding according to physician's orders [REDACTED].#2) nurses observed during medication administration failed to administer medications through a PEG tube according to the facility policy. The findings included: 1. Medical record review revealed Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].Enteral Feed Order every shift Glucerna 1.5 @ (at) 80ml/hr (milliliters per hour) x (times) 20 hours . Observations in Resident #4's room on 8/21/17 at 9:52 AM, 1:03 PM, and on 8/22/17 at 9:05 PM, revealed Resident #4 was in his room with no enteral nutrition infusing. On 8/22/17 PM at 1:18 PM and 2:00 PM, revealed Resident #4 was resting in his bed with Glucerna 1.5 Cal infusing per pump at 70 ml/hr. Interview with the Director of Nursing (DON) on 8/22/17 at 2:12 PM, in Resident #4's room regarding the infusion rate of the feeding, the DON confirmed the tube feeding was infusing at 70 ml/hr instead of the ordered 80 cc per hour. Interview with the DON on 8/24/17 at 8:30 PM, in the conference room, the DON was asked how she expected the nurses to ensure the correct rate for the enteral nutrition was infusing. The DON stated, Check the order, and check the rate . 2. The facility's SPECIFIC MEDICATION ADMINISTRATION PR[NAME]EDURES: ENTERAL TUBE MEDICATION ADMINISTRATION policy documented, .3) Crush tablets and dissolve in 30 ml (milliliters) of warm water or other appropriate liquid. 4) Empty capsule contents into 30 ml of warm water or other appropriate liquid. 5) Dilute liquid medications with 10-30 ml of warm water or enteral formula .Administer liquid medications first . Observations in Resident #4's room on 8/24/17 at 9:10 AM, revealed LPN #2 crushed Aspirin 81 mg (milligrams) 1 tablet, and Multiple Vitamin 1 tablet, emptied 2 [MEDICATION NAME] Sprinkles capsules, and placed each medication in a separate medicine cup. LPN #2 then poured Levetiracetam 100 mg/ml 15 ml in a medicine cup, carried the medications into the room and placed them on the over bed table. LPN #2 attempted to flush the PEG tube with 30 ml of water and discovered it clogged. LPN #2 used the plunger of the syringe to clear the tube. LPN #2 then poured a dry medication into the 60 ml syringe followed by 5 ml water, placed the next dry medication into the syringe and followed it with 5 ml of water, placed the 3rd dry medication into the syringe and followed if with 5 ml of water. LPN #2 then poured the 15 ml of undiluted Levetiracetam into the syringe and flushed with 30 ml water. LPN #2 failed to dissolve the dry medications with water, failed to dilute the liquid medication prior to administering them and failed to administer the liquid medication first. Interview with the DON on 8/24/17 at 3:40 PM, in the conference room, the DON was asked when administering PEG medications should they put dry powder into the PEG tube. The DON stated, No. The DON was asked should liquid medications be administered without diluting. The DON stated, No.",2020-09-01
535,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2017-08-24,323,E,0,1,5LE311,"**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 the environment was free from accident hazards when unsecured medications, sharps, and chemicals were observed in 1 of 70 (Resident #132) resident rooms, 4 of 64 (Resident #67, 122, 143 and 144) resident bathrooms, and in 1 of 4 (100 hall) common shower rooms. The findings included: 1. The facility's MEDICATION STORAGE IN THE FACILITY policy documented, .Medications and biologicals are stored safely, securely, and properly .The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications . 2. The facility's Prohibited Items List policy documented, .list is not all inclusive .Medications: (Includes all Prescription and Over-the-Counter drugs .Rubbing alcohol or any liniments .any laxative .Many of our residents, due to mental impairments or poor eyesight might inadvertently drink or eat some of me (the) above items causing irreparable harm .SAFETY HAZARDS .AEROSOL CANS of any product are combustible .GLASS ITEMS .RAZORS AND BLADES . 3. Medical record review revealed resident #132 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #132 had a Brief Interview of Mental Status (BIMS) score of 10 which indicated Resident #132 was moderately impaired cognitively. Observation in Resident #132's room on 8/21/17 at 7:55 AM, revealed 1 bottle of milk of magnesia laxative on the bedside table and 1 bottle of witch hazel astringent on the overbed table unsecured and in reach of the resident. Interview with the Director of Nursing (DON) on 8/21/17 at 8:15 AM, in the conference room, the DON was asked if it was acceptable for residents to have medications and chemicals stored at the bedside. The DON stated, Absolutely not . 4. Medical record review revealed Resident #67 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS dated [DATE] revealed a BIMS score of 11, which indicated Resident #67 was moderately impaired cognitively. Observations in Resident #67's bathroom on 8/21/17 at 12:59 PM and 6:25 PM, revealed 2 cans of spray paint contained in a clear ziplock bag, and 2 disposable razors. Interview with Licensed Practical Nurse (LPN) #3 on 8/21/17 at 6:20 PM, at the 100 hall Nurses' Station, LPN #3 was asked whether it was acceptable for residents to have spray paint or disposable razors unsecured in the bathroom. LPN #3 stated, No. 5. Medical record review revealed Resident #122 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed Resident #122 had a BIMS score of 7, which indicated Resident #132 was moderately impaired cognitively. Medical record review revealed Resident #144 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in the shared bathroom of Resident #122 and #144 on 8/21/17 at 9:35 AM, revealed an uncovered disposable razor, and a plastic glass of an unknown white powder on the bathroom sink. Interview with Certified Nursing Assistant (CNA) #2 on 8/21/17 at 9:36 AM, in the shared bathroom of Resident #122 and #144, CNA # 2 confirmed she did not know what the white powder was. CNA # 2 was asked whether it was appropriate for the razor and the unknown white powder to be stored in the residents' bathroom. CNA # 2 stated, No . Interview with the Occupational Therapist (OT) on 8/21/17 at 9:37 AM, in the shared bathroom of Resident #122 and #144, the OT confirmed she did not know what the white powder was. The OT was asked whether it was appropriate for an unknown white powder to be stored in a resident's bathroom. The OT stated, I'm going to just go ahead and throw this away . 6. Medical record review revealed Resident #143 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #143's bathroom on 8/21/17 at 10:18 AM and 6:30 PM, revealed a container of liquid laundry detergent. Interview with LPN #3 on 8/21/17 at 6:20 PM, at the 100 hall Nurses' Station, LPN #3 was asked whether it was acceptable for residents to have unsecured liquid laundry detergent stored in the bathroom. LPN #3 stated, No. 7. Observation in the 100 hall common shower room on 8/21/17 at 6:23 AM, revealed the shower door was not secured and the room contained an unlocked cabinet that had 1 bottle of cleaning liquid that was marked do not remove from shower room wheelchair cleaning only. Observation in the 100 hall common shower room on 8/22/17 at 2:25 PM, revealed the shower door unsecured which contained an unlocked cabinet that had 1 disposable razor. Interview with LPN #3 on 8/22/17 at 2:32 PM, on the 100 East hall. LPN #3 was asked do residents use this shower room. LPN #3 stated, Yes. LPN #3 was asked should you have unsecured disposable razors and chemicals in the cabinet. LPN #3 stated, No .needs to be locked up . Interview with the Director of Nursing (DON) on 8/24/17 at 9:20 AM, in the conference room, the DON was asked should the cabinet in the common shower be kept secure if they contain cleaning supplies and disposable razors. The DON stated, Yes.",2020-09-01
536,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2017-08-24,325,E,0,1,5LE311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to follow their policy for nutritional assessments and failed to implement physician's orders [REDACTED].#88 and 100) sampled residents reviewed of the 6 residents with nutritional concerns. The findings included: 1. The facility's NUTRITION ASSESSMENT policy documented, A nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident .The Dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current initial assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition . 2. Medical record review revealed Resident #88 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The (admission) Nutrition assessment dated [DATE] was incomplete and only documented Resident #88's height of 58 inches and weight of 178.2 pounds. The facility failed to complete a nutritional assessment for Resident #88 until 1/2/17, a total of 2 months after her date of admission. Interview with the Director of Nursing, (DON) on 8/23/17 at 2:46 PM, in the conference room, the DON was asked if she was aware that there was no nutritional assessment completed on admission for Resident #88. The DON stated, Yes, I saw that . The DON was asked if the admission nutritional assessment should have been completed. The DON stated, Yes . 3. Medical record review revealed Resident #100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician order [REDACTED]. Review of the Medication Administration Record (MAR) for the months of (MONTH) and (MONTH) (YEAR) revealed Resident #100 did not receive supplements as ordered on [DATE] at 4 PM, on 8/1/17 at 8 PM, on 8/4/17 at 12 PM, on 8/8/17 at 8 AM, 12 PM, and 4 PM, and on 8/11/17 at 8 AM, 12 PM, and 4 PM. Interview with the DON on 8/23/17 at 10:06 AM, in the conference room, the DON was shown Resident #100's (MONTH) (YEAR) MAR and was asked what does the empty blank mean. The DON stated, .not documented. The DON was asked did Resident #100 receive Med Pass as ordered. The DON stated, .not documented, not done .",2020-09-01
537,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2017-08-24,329,D,0,1,5LE311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to follow physician's orders for anticonvulsant medication use and failed to monitor for [MEDICAL CONDITION] medication side effects for 2 of 5 (Resident #51 and 55) sampled residents reviewed for unnecessary medication use. The findings included: 1. Medical record review revealed Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The signed physician's orders for (MONTH) (YEAR) with a start date of 4/24/14 documented, .Laboratory .[MEDICATION NAME] (blood level) . q (every) 6 months November/May . Medical record review revealed no documentation that Resident #51's [MEDICATION NAME] level had been checked since 5/2/16. Interview with the Doctor of Nursing Practice (DNP) on 8/24/17 at 12:02 PM, in the conference room, the DNP was asked if she expected her orders to be followed. The DNP stated, I expect them to be done . 2. Medical record review revealed Resident #55 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The physician's orders for (MONTH) (YEAR) documented, .[MEDICATION NAME] Oxalate Tablet 10mg (milligram) Give 1 tablet by mouth one time a day for Depression . The care plan dated 8/3/17 documented, .uses antidepressant .r/t (related to) Depression .Monitor/document side effects and effectiveness . The facility was unable to provide any documentation that Resident #55 was monitored for medication side effects or effectiveness. Interview with the Director of Nursing (DON) on 8/24/17 at 2:37 PM, in the conference room, the DON was asked if the staff should have been monitoring and documenting for side effects for antidepressant use. The DON stated, Yes.",2020-09-01
538,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2017-08-24,361,D,0,1,5LE311,"Based on review of job descriptions, personnel file review, observation, and interview, the facility failed to ensure the availability of qualified nutritional services as evidenced by 1 of 1 Certified Dietary Manager (DM) personnel files reviewed and 1 of 1 Registered Dietician (RD) personnel files reviewed to oversee the daily functioning and maintenance of the kitchen/dietary department or resident nutritional services. The findings included: The Registered Dietician Job Description documented, .Responsibilities include .Complete nutritional initial, quarterly, annual and significant change reviews on residents .Monitor food service operations to ensure conformance to nutritional, safety, sanitation and quality standards . The Dietary Manager Job Description documented, .Responsible for daily operations of food service department .Specify standards and procedures for preparing food .Assure safe receiving, storage, preparation, and service of food .Prepare cleaning schedules and maintain equipment to ensure food safety .Ensure proper sanitation and safety practices of staff .Determine client diet needs and develop appropriate dietary plans in cooperation with RD and in compliance with physicians' orders . RD #1's personnel file documented the last day of employment was 5/10/17. RD #2's personnel file documented a hire date of 6/16/17. The DM's personnel file documented a hire date of 3/24/14 as Assistant DM, and a promotion to the position of DM on 11/27/16. The facility was unable to provide documentation the DM was either certified or currently enrolled in a certification program. Interview with the current uncertified DM on 8/24/17 at 9:22 AM, in the conference room, the DM was asked who he directed his questions related to nutrition or the kitchen during the period of time between 5/10/17 and 6/16/17. The DM stated, Really I didn't have anyone to talk to. I just took care of it the best I could. The facility was unable to provide documentation that a certified DM or an RD was available for consultation from 5/10/17 until 6/16/17. Refer to F325 and F371.",2020-09-01
539,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2017-08-24,371,F,0,1,5LE311,"Based on policy review, observation and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by pots and pans and an oven with carbon build-up, dirty food carts, a mixer with dried food particles, thick build up of food crumbs on a toaster, water leaking out from under a refrigerator, thick dirt and dust on the floor and walls in the kitchen, a broken seal on a refrigerator door, a dirty steam table in the dining room, improper thawing of frozen food in the sink, foods stored at an improper temperature in a refrigerator, and undated and unlabeled foods stored in a nourishment room refrigerator; and 1 of 18 (Certified Nursing Assistant (CNA) #1) staff members failed to use appropriate hand hygiene during dining. The facility had a census of 96, with 84 of those residents receiving a meal tray from the kitchen. The findings included: 1. The facility's Sanitary Conditions policy documented, .The facility will store, prepare, distribute and serve food under sanitary conditions .All staff will follow safe food preparation procedures .This includes proper thawing, cooking, and reheating . The facility's Dish Cleaning with Dish Machine policy documented, .Dishes, utensils, pots, pans and other cookware will be washed and sanitized after each meal they are in use .Dishware is rinsed and pots scrubbed if needed . Observations in the kitchen on 8/21/17 during initial tour, beginning at 6:20 AM, revealed the following: a. Oven with greasy black/brown build-up with splatter/drip stains b. 2 skillets, 14 deep baking dishes, 2 shallow baking pans with black build-up; 1 skillet in use on stove with black build-up c. 2 food carts with dirty brownish substances on shelf edges and wheels d. Half a Chef Piece Key Lime Meringue Pie and 4 covered individual bowls on counter, all undated e. Stand mixer with dirty brown object and crumbs in bottom of bowl f. Ice machine with dirty whitish splatter stains on outside of machine g. Walls with brown dirty splatter/drip stains h. 1 of 2 handwashing sinks loose from wall with pipes resting on a plastic milk crate turned upside down on floor underneath the sink i. Paper towel holder off the wall and not functioning for 1 of 2 handwashing sinks j. Water leaking out from under a reach-in freezer k. Toaster with thick brown dirty crumbs and build up l. 1 dented can of cream of chicken soup in dry storage area (not in dented can area) m. Dirty kitchen floor Observations in the kitchen on 8/22/17 beginning at 1:15 PM, revealed the following: a. Oven with greasy black/brown build-up with splatter/drip stains b. 1 skillet, 4 deep baking dishes with black build-up; c. 2 food carts with dirty brownish substances on shelf edges and wheels d. Stand mixer with dirty brown discoloration and crumbs in bottom of bowl e. Ice machine with dirty whitish splatter stains on outside of machine f. Walls with brown dirty platter/drip stains g. 1 of 2 handwashing sinks loose from wall with pipes resting on a plastic milk crate turned upside down on floor underneath the sink h. Paper towel holder off the wall and positioned so that it was not functioning for 1 of 2 handwashing sinks i. Toaster with thick brown dirty crumbs and build up j. 1 dented can cream of chicken soup in dry storage area (not in dented can area) k. Dirty kitchen floor Interview with the Dietary Manager (DM) on 8/22/17 during a kitchen tour beginning at 1:20 PM, the DM was asked how often the oven is cleaned. The DM stated, Once a week. It's up for cleaning now. The DM was asked whether the brown/black build-up and splatter stains on the oven were acceptable. The DM stated, No. The DM was asked about the carbon build-up on the cookware. The DM stated, They've been in use for almost 3 years. The DM was asked what should be done when they become coated with the black build-up. The DM stated, Toss them and get new ones . The DM was asked whether the dirty brown discolored stains and food crumbs in bottom of the mixer bowl were acceptable. The DM stated, No. The DM was asked about the dirty ice machine. The DM stated, That won't come off . The DM was asked whether the dirty walls and floors were acceptable. The DM stated, No. The DM was asked about the handwashing sink loose from the wall. The DM stated, Let me show you (pointed to a plastic milk crate on the floor underneath the sink) .The only thing holding it up is this crate .Maintenance is aware . The DM was asked about the paper towel holder off the wall for the other handwashing sink. The DM stated, It just fell off. The DM was asked whether the toaster was clean. The DM stated, No, it's not clean. It should be . 2. The facility's Food Storage Policy documented, .The kitchen shall contain sufficient refrigeration equipment .All refrigerators and freezers shall have thermometers .Refrigerators shall be kept at a temperature not to exceed 45 (degrees) F (Fahrenheit) . The REFRIGERATOR/FREEZER TEMPERATURE RECORD DIETARY DEPARTMENT form for (MONTH) (YEAR) documented the following temperatures: August 1 at 5:30 AM 50 August 7 at 8:00 PM 45 August 8 at 8:00 PM 48 Observations in the kitchen on 8/22/17 at 1:10 PM, revealed the refrigerator with an outside temperature reading of 50 degrees F, and an inside thermometer reading of 58 degrees F, with a broken seal around the door. The refrigerator contained the following foods: a. 75 slices watermelon b. 4 individual containers applesauce c. 86 individual milk cartons d. 70 individual containers juice e. 30 individual containers thickening liquid f. 1 gallon mustard g. 1 gallon mayonnaise h. 3 rolls of 30 pounds each raw ground beef i. 1/2 case bacon j. 1 gallon sweet relish k. 1 gallon Italian dressing Interview with the DM on 8/22/17 at 1:12 PM, in the kitchen, the DM was asked if the refrigerator was too warm. The DM stated, Yes, it is. The DM was asked what should happen with the food if the refrigerator was too warm. The DM stated, Move it out and put it in another refrigerator. 3. Observations in the Main Dining Room on 8/22/17 at 1:12 PM, revealed the steam table had food crumbs, brownish greasy build-up on the steam pans, and thick dried brown drip build-up on the side of the table. Interview with the DM on 8/22/17 at 1:30 PM, in the Main Dining Room, the DM was asked how often the steam table was cleaned. The DM stated, Once a week. The DM confirmed the steam table was dirty, and confirmed it was not cleaned daily or after meals. 4. The facility's Thawing Food Products policy documented, .Potentially hazardous foods shall be thawed using one of the following methods .placing the item completely submerged under running water .Provided the water is .Temperature is below 70 degrees F .Of a sufficient velocity to agitate and float off loose particles in an overflow . Observations in the kitchen on 8/22/17 at 3:50 PM, revealed a large pan of roast beef thawing in the sink, with no water running over the roast beef. Interview with the DM on 8/22/17 at 3:52 PM, in the kitchen, the DM was asked whether the meat was thawing properly. The DM stated, No. Cold water should be running . 5. Review of the Dietary Manual on 8/24/17 at 4:14 PM, revealed it was signed by the Administrator on 5/24/17. There were no other signatures or documentation the manual was approved by a physician or by a dietician. Interview with the DM on 8/24/17 at 4:15 PM, in the Main Dining Room, the DM was asked whether there were any other signatures for the Dietary Manual. The DM asked whether he was supposed to have signed it, and stated, I wish you would have told me the other day . The DM was asked who approved the menus in the dietary manual. The DM stated, (named the former Registered Dietician). The facility was unable to provide any documentation that the dietary manual was reviewed or approved by any physician or a dietician. 6. Observations in the 200 hall nourishment refrigerator on 8/24/17 at 10:40 AM, revealed a Styrofoam container of food in a clear plastic bag with no date or label. Interview with Licensed Practical Nurse (LPN) #4 on 8/24/17 at 10:42 AM, in the 200 hall nourishment room, LPN #4 was asked what was in the unlabeled, undated Styrofoam container. LPN #4 stated, I don't know .It should be dated and have a name on it. 7. Observations in the 300 hall on 8/21/17 beginning at 7:51 AM, revealed Certified Nursing Assistant (CNA) #1 delivered the meal tray to Resident #51 and placed it on the overbed table. CNA #1 then pulled the resident up in the bed, raised the head of the bed, opened the tray, and then used her bare hands to hold the toast while she spread jelly on it. CNA #1 then washed her hands, left the room, gathered another meal tray and delivered it to Resident #5, positioned the bed, set up the tray, and used her bare hands to hold the toast while she spread jelly on it. Interview with the Director of Nursing (DON) on 8/24/17 at 8:14 AM, in the conference room, the DON was asked if it was acceptable for staff to handle food with their bare hands during dining. The DON stated, Absolutely not.",2020-09-01
540,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2017-08-24,372,D,0,1,5LE311,"Based on observation and interview, the facility failed to ensure sanitary garbage and refuse disposal on 1 of 4 (8/22/17) days of observation of the dumpster area. The findings included: Observations of the dumpster area on 8/22/17 at 4:00 PM and 6:15 PM, revealed paper trash on the ground surrounding the dumpsters, an open sliding door on one of the dumpsters, 10 large cardboard boxes stacked around the dumpsters, and a 55 gallon, uncovered trash container beside the dumpster full of trash with a foul odor. Interview with the Dietary Manager (DM) on 8/22/17 at 4:02 PM, at the dumpster area, the DM was asked whether the dumpster area was acceptable. The DM stated, No.",2020-09-01
541,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2017-08-24,431,E,0,1,5LE311,"Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored, secured, and labeled in 3 of 70 (Resident #32, 71, and 132) resident rooms and 4 of 7 (300 split and 1 west medication carts, and 1 west and 1 east medication rooms) medication storage areas. The findings included: 1. The facility's MEDICATION STORAGE IN THE FACILITY policy documented, .Medications and biologicals are stored safely, securely, and properly .The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications . 2. The facility's Prohibited Items List documented, .medications: [REDACTED].any laxative .Many of our residents, due to mental impairments or poor eyesight might inadvertently drink or eat some of me (the) above items causing irreparable harm . 3. Observation in Resident #132's room on 8/21/17 at 7:55 AM, revealed 1 bottle of milk of magnesia laxative on the bedside table in reach of the resident. Interview with the Director of Nursing (DON) on 8/21/17 at 8:15 AM, in the conference room, the DON was asked if it was acceptable for residents to have medications stored at the bedside. The DON stated, Absolutely not . 4. Observation in Resident #32's room, on 8/23/17 at 9:03 AM, revealed Licensed Practical Nurse (LPN) #5, left the Combivent inhaler on the overbed table while she went into the bathroom to wash her hands leaving the medication out of sight and unattended. 5. Observation in Resident #71's room on 8/24/17 at 8:21 AM, revealed LPN #4 left the medication cups of Aspirin, Multivitamins, Depakote sprinkles, and liquid Keppra on the table at bedside while she went into the bathroom to wash her hands leaving the medications out of sight and unattended. Interview with the DON on 8/24/17 at 3:40 PM, in the conference room, the DON was asked would you expect the nurses to leave the medications at the bedside out of sight to wash their hands. The DON stated, No, it's to remain in sight at all times. 6. Observation in the 300 split medication cart on 8/24/17 at 7:54 AM, revealed the following expired medications: [REDACTED] a. 1 Symbicort inhaler with open date 7/3/17 and expired 8/3/17. b. 28 Albuterol nebulizer vials with open date 7/13/17 and expired 8/13/17. c. 17 Albuterol nebulizer vials with open date 8/14/17 and expired 8/14/17. d. 28 Albuterol nebulizer vials with open date 7/13/17 and expired 8/13/17. Interview with Licensed Practical Nurse (LPN) #5 on 8/24/17 at 7:54 AM, at the 300 split cart, LPN #5 confirmed the medications were expired. 7. Observation in the 1 west medication cart on 8/24/17 at 2:45 PM revealed the following expired medications: [REDACTED] a. 29 Albuterol nebulizer vials with dated 6/22/17 with no open date. b. 1 Combivent inhaler dated 7/7/17 with no open date. c. 1 box labeled Symbicort that contained a Symbicort inhaler with no open date and a Proventil inhaler with no open date d. 1 Symbicort inhaler 80 - 4.5 mcg (micrograms) with no open date g. 1 opened tube of Bengay ointment with no resident name Interview with LPN #4 on 8/24/17 at 2:45 PM, at the 1 west medication cart, LPN #4 confirmed the medications were expired and unlabeled. 8. Observation in the 1 west medication room on 8/24/17 at 3:10 PM, revealed Vanco Powder 25 mg/ml (milligrams/milliliter) oral 300 milliliter with an expiration date of 8/5/17. Interview with LPN #4 on 8/24/17 at 3:10 PM, in the 1 west medication room, LPN #4 confirmed the medication was expired. 9. Observations in the 1 east medication room on 8/24/17 at 3:25 PM, in the medication refrigerator, revealed 19 prefilled syringes of Fluarix Quadrivalent 0.5 ml dose with an expiration date of 6/30/17. Interview with LPN #6 on 8/24/17 at 3:25 PM, in the 1 east medication room, LPN #6 confirmed the medications were expired. Interview with the DON on 8/24/17 at 3:40 PM, in the conference room, the DON was asked would you expect to have expired medications and medications with no open dates on the medication carts and in the medication rooms. The DON stated, No, ma'am.",2020-09-01
542,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2017-08-24,441,D,0,1,5LE311,"Based on policy review, observation, and interview, the facility failed to ensure 2 of 5 (Licensed Practical Nurse (LPN) #1 and 4) nurses observed during medication administration followed proper infection control practices to prevent the potential spread of infection. The findings included: 1. The facility's SPECIFIC MEDICATION ADMINISTRATION PR[NAME]EDURES .EYE DROP ADMINISTRATION policy documented, .Remove the cap, taking care to avoid touching the dropper tip. Place the cap on an (a) clean, dry surface . 2. The facility's SPECIFIC MEDICATION ADMINISTRATION PR[NAME]EDURES .ENTERAL TUBE MEDICATION ADMINISTRATION policy documented, Clean feeding syringe and return to bedside stand. Observations in Resident #83's room on 8/23/17 at 8:11 AM, revealed LPN #4 removed the cap from the eye drops and laid it on the nightstand without a clean barrier. Observations in Resident #71's room on 8/24/17 at 8:21 AM, revealed LPN #4 took the stethoscope from around her neck and used on the resident, put the stethoscope back around her neck without cleaning the stethoscope before or after using. LPN #4 failed to rinse the syringe plunger after administering medications via a Percutaneous Endoscopic Gastrostomy (PEG) tube. 3. Observations in Resident #4's room on 8/24/17 at 9:16 AM, revealed LPN #1 entered the room for PEG medication administration with a stethoscope around her neck, placed the stethoscope on the bed, picked the stethoscope back up, and, while attempting to position the stethoscope in her ears, placed one ear tube of the stethoscope on her mouth. LPN #1 did not clean the stethoscope before or after use. Interview with the Director of Nursing (DON) on 8/24/17 at 3:40 PM, in the conference room, the DON was asked what she expected staff to do when administering eye drops. The DON stated, .put the lid on a barrier . The DON was asked what her expectations were for cleaning the stethoscope during PEG medication administration. The DON stated, Prior to checking for placement wipe with alcohol pad and when finished wipe off the stethoscope with alcohol pad.",2020-09-01
543,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2018-09-25,584,D,0,1,B1UN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation and interview, the facility failed to provide effective housekeeping services to maintain a sanitary, orderly, and comfortable environment by disrepair, trash and debris in resident rooms, strong urine odors and dirty toilets in resident bathrooms, and leaking air conditioners in 14 of 111 (room [ROOM NUMBER], 303, 304, 305, 309, 311, 312, 313, 315, 320, 325, 327, 331, and 332) rooms. The findings included: 1. The facility's OSHA (Occupational Safety and Health Administration) Environmental Rules and State Regulations policy documented, .35. Dust all vents .39. Be proactive with all odors . The facility's Cleaning and Disinfection of Environmental Surfaces policy (undated) documented, .Housekeeping surfaces (e.g. (example), floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visably soiled . 2. Observations in resident rooms during initial tour on 9/10/18 beginning at 9:40 AM, on 9/11/18 beginning at 8:25 AM, and on 9/12/18 beginning at 7:15 AM, revealed the following: a. room [ROOM NUMBER]: Large amount of unknown liquid spilled on the floor at the foot of the A bed and the B bed the top layer of the over-bed table flaking off b. room [ROOM NUMBER]: Wet, stained blanket on the floor under the air conditioner unit, a 60 cc (cubic centimeter) syringe under the A bed. Trash and debris on the floor around the A and B beds. Two 60 cc syringes on the floor by the B bed. The bathroom threshold was missing. An unknown brown substance at the entrance to the resident's room and bathroom. Clothes, an opened package of disposable briefs, shoes (men's) were stacked in the floor of the B bed's closet. The bottom drawer on B bed side dresser laying on the floor by the dresser c. room [ROOM NUMBER]: A wet, stained blanket under the air conditioner. A wet gown in the floor of the A bed's closet with gnats d. room [ROOM NUMBER]: Yellow/orange build up around the base of the toilet with a strong urine odor e. room [ROOM NUMBER]: Clothes, linens, and an open package of disposable brief in the floor in bed B's closet f. room [ROOM NUMBER]: Sink in the bathroom was covered with a plastic bag because it was leaking g. room [ROOM NUMBER]: Toilet with yellow/orange rings in the toilet bowl and stains on the seat h. room [ROOM NUMBER]: Dirty toilet i. room [ROOM NUMBER]: A wet brief and paper in the bathroom floor j. room [ROOM NUMBER]: Strong urine odor in bathroom k. room [ROOM NUMBER]: Large amount of unknown fluid in floor by the air conditioner l. room [ROOM NUMBER]: Strong urine odor m. room [ROOM NUMBER]:[NAME]robe door leaning against the wall in the bathroom n. room [ROOM NUMBER]: Strong urine odor in the bathroom. 3. Interview with the Director of Nursing (DON) on 9/12/18 at 7:15 AM, on the 300 hall, the DON stated .I need to get a team to come up and clean these rooms and maintenance to fix these leaks .room [ROOM NUMBER]'s floor has to be cleaned up .room [ROOM NUMBER]'s bathroom smells of urine and has to be cleaned .clothes and diapers should not be in the floor .room [ROOM NUMBER] .same thing . The surveyor pointed at the sink in room [ROOM NUMBER]'s bathroom and asked the DON why the plastic bag was on the sink. The DON stated, .I've had enough .I trust you .I don't need to see the rest of the rooms .I've never seen this hall this bad . Interview with Director of Maintenance (DOM) on 9/13/18 at 11:30 AM, in the conference room, the DOM was asked how maintenance is aware of issues that need to be fixed in the facility. The DOM stated, .have been in this position less than 3 weeks. Staff is supposed to be putting issues down in a log at each nursing station but sometimes they will stop one of us in the hall and it doesn't end up getting put in the log. The maintenance team now turns in a list of what they have taken care of each day and before I leave for the day, I make rounds to make sure they have done it right. I have talked with the Administrator and DON about having staff document issues in the log books .",2020-09-01
544,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2018-09-25,684,D,1,1,B1UN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation and interview, the facility failed to follow physician's orders for medication administration for 2 of 3 (Resident #102 and 108) residents reviewed for administration of medications and failed to follow physician's orders for treatment for 1 of 6 (Resident #108) residents reviewed for wound care and treatment. The findings include: 1. The facility's MEDICATION ADMINISTRATING - GENERAL GUIDELINES policy documented, .Medications are administered as prescribed . 2. Closed medical record review revealed Resident #102 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's comprehensive plan of care dated 3/23/18 documented, . 3/23/18 Arterial Ulcer to L (left) and R (right) lower legs .Surgical incision to the chest .Resident keeps pulling dressing off to bilateral legs and mid chest causing areas to reopen after healing .8/3/18 Resident rubbing right foot against sheets, causing blister (even after being redirected and educated by wound nurse) .non compliant with keeping heel Protectors on feet, and removing dressing from right foot . A physician's order dated 8/15/18 documented, .[MEDICATION NAME] Capsule 100 mg (milligram) .Give 1 capsule by mouth two times a day for anti-infective for 7 Days . Review of the medication administration record (MAR) dated 8/1/18 - 8/31/18 revealed the [MEDICATION NAME] was only documented as given on 8/15/18 and 8/22/18. Interview with the Director of Nursing (DON) on 9/25/18 at 3:30 PM in the Medical Director's Office, the DON confirmed the lack of documentation on the MAR and when asked why the [MEDICATION NAME] was not administered as ordered, the DON stated, .That I can not explain . 3. Medical record review revealed Resident #108 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's comprehensive plan of care dated 6/30/16 reviewed quarterly and updated as needed documented, .(Named Resident #108) has Chronic [MEDICAL CONDITION] of the BLE (bilateral lower extremity) placing her at risk for repeated infections .9/30/18 [MEDICATION NAME] (anti-infective) BID (twice daily) x (times) 14 days for infection .Perform wound care as per order . The plan of care addressing inappropriate behaviors dated 3/31/17 documented, .(Named Resident #108) has a behavior of refusing care/refusing to take a shower .10/2/17 Not consistently allowing staff to change her - saturated briefs or dressings - leading to possibility of infections . a. The physician's order dated 9/16/18 documented, .[MEDICATION NAME] Tablet 500 - 125 MG .Give 1 tablet by mouth two times a day for Infection .x 14 days .Order Date .09/16/2018 .Start Date .09/30/2018 . Review of the MAR dated 9/1/18 - 9/30/18 revealed the [MEDICATION NAME] had not been documented as given. Interview with LPN #3, on 9/19/18 at 10:45 AM in the Administrator's Office, LPN #3 stated on 9/16/18 she had received a telephone order from the physician to begin [MEDICATION NAME] 500-125 mg twice daily for 14 days [MEDICATION NAME] (a preventive measure). LPN #3 continued the interview and revealed she had given the order to Resident #108's nurse, Registered Nurse (RN) #2 to enter into the electronic ordering system. Observation and interview with LPN #4 on 9/25/18 at 11:45 AM at the 300 hall nurses station, LPN #4 was asked if Resident #108 was receiving [MEDICATION NAME]. LPN #4 revealed the medication was in the resident's medication drawer and stated she had administered one that morning. LPN #4 opened the drawer which contained a prescription box of 26 [MEDICATION NAME] tablets. LPN #4 counted the tablets and there were 18 tablets left to count. Eight tablets of the prescription had been administered. The resident should have received 18 tablets by 9/25/18. LPN #4 checked the resident's electronic MAR to verify she had given the medication and then stated according to the MAR, the [MEDICATION NAME] could not be documented as given until 9/30/18. LPN #4 then stated, .I guess I didn't (give the medication) . The order was entered into the electronic physician's ordering system incorrectly with a start date of 9/30/18 instead of 9/16/18. Interview with the DON on 9/25/18 at 1:07 PM in the DON Office, the DON was asked if Resident #108's [MEDICATION NAME] had not been administered. The DON stated, .It was ordered [MEDICATION NAME] . When asked, if ordered [MEDICATION NAME] or not, should the medication have been given, the DON stated, Yes. Interview with LPN #3 on 9/25/18 at 2:05 PM in the Medical Director's Office, LPN #3 stated RN #2 had entered Resident #108's [MEDICATION NAME] order into the electronic ordering system incorrectly and the resident should have been receiving the medication twice daily starting 9/16/18. b. Review of the physician's wound treatment orders dated 8/9/18 revealed Resident #108's right and left lower leg arterial/venous ulcers were to be cleansed with wound cleanser, patted dry, Mafenide (a prescription anti-infective) applied to the wound bed, a barrier cream applied to the skin surrounding the wounds, covered with collagen dressings (promotes healthy tissue growth) and wrapped with Kerlix (gauze) daily. Review of the MAR dated 9/1/18-9/30/18 revealed Resident #108's wound treatments had not been documented as administered on 9/15/18. Observations in Resident #108's room on 9/20/18 at 2:00 PM revealed the treatment nurse, Licensed Practical Nurse (LPN) #3 performing wound care for the resident. The resident's right lower extremity had a large irregularly shaped open wound on the back and sides of the leg from inner ankle area to the upper calf/shin area with the tendon exposed at the back of the leg between the ankle and mid-calf. The wound measurements were: Length: 28.4 centimeters (cm) x (by) Width 18.5 cm x Depth 0.1 cm. There were scattered areas of necrotic tissue noted. However, approximately 95 percent of the wound was pink/granulation tissue. There was little drainage and no foul odor noted. The left lower extremity had 3 smaller scattered wounds with pink healthy tissue exposed, the largest of which measured: Length 1.8 cm x Width 1.8 cm x Depth 0.1 cm. There was little drainage and no foul odor was noted. Deficient practice was not observed during wound care. Interview with RN #2 on 9/19/18 at 10:45 AM in the Administrator's Office, RN #2 revealed she had been Resident #108's nurse on 9/15/18 and had not completed her wound care as ordered. Telephone interview with RN #3 on 9/20/18 at 11:23 AM, RN #3 was asked if she had completed the wound treatments for Resident #108. RN #3 revealed she had not. Continuing the interview RN #3 revealed she had worked as the Facility House Supervisor on 9/15/18. When asked if she was responsible for performing wound treatments as House Supervisor, RN #3 stated the nurses were responsible for treatments.",2020-09-01
545,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2018-09-25,689,D,0,1,B1UN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure the resident's environment remained free from accident hazards when pools of water were observed in 3 of 111 (room [ROOM NUMBER],325, and 421) resident rooms, and 1 of 2 (100 hall) janitor closets was observed unlocked. The findings included: 1. The facility's OSHA (Occupational Safety and Health Administration) Environmental Rules and State Regulations policy documented, .3. Keep all chemicals locked away or on your person at all times .5. Check to make sure a door is locked at all times before leaving .janitor closet doors must be closed and locked AT ALL TIMES . 2. Observations on 9/10/18 beginning at 9:40 AM revealed the following: a. room [ROOM NUMBER]: A large amount of unknown liquid on the floor at the foot of the A bed and the B bed b. room [ROOM NUMBER]: A large amount of unknown fluid in floor by the air conditioner Observations in room [ROOM NUMBER] on 9/11/18 at 11:34 AM, and 3:10 PM, revealed a large amount of water on the floor and along the wall, under the dresser across from Bed A and B beds, and in the middle of the room. Both of the residents were in their beds. There was no signage warning of the wet floor. Interview with Certified Nursing Assistant (CNA) #1 on 9/11/18 at 3:22 PM, in the 400 hallway outside of room [ROOM NUMBER], CNA #1 was asked how long there had been a problem with the water leak in room [ROOM NUMBER]. CNA #1 stated, Off and on for about a month . Interview with the Director of Nursing (DON) on 9/12/18 at 7:25 AM, in room [ROOM NUMBER], the DON was asked to explain the water in the floor. The DON stated, .what is this water? I can't leave this room because a resident could slip and fall . 3. Observations on the 100 hall on 9/10/18 at 10:29 AM, revealed the janitor closet door was unlocked with (named all purpose cleaning solution) in the closet. Observations on the 100 hall on 9/11/18 at 11:44 AM, revealed the same janitor closet was unlocked with a (named floor cleaner) in the closet. Interview with the DON on 9/11/18 at 11:49 AM the DON was asked if the door should be locked. The DON stated, Yes, it should. The DON was asked if the room contained chemicals. The DON stated, Yes.",2020-09-01
546,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2018-09-25,812,E,0,1,B1UN11,"Based on policy review, observation, and interview the facility failed to ensure that the nourishment refrigerators did not have ice build up in the freezer compartment, that there were thermometers in the freezers and refrigerators, that the temperature logs were maintained, and that the freezer compartments had functioning doors for 4 of 4 (400 hall, 100 hall, 200 hall, and the 300 hall) nourishment refrigerators. The findings included: 1. The facility's OSHA (Occupational Safety and Health Administration) Environmental Rules and State Regulations policy documented .All refrigerators must be clean and logged accordingly, also must have a tempature (temperature) log . 2. Observations in the 400 hall medication room on 9/11/18 at 11:30 AM, revealed that there was no thermometer in the freezer compartment of the refrigerator. The freezer had ice build up on the sides and bottom of the freezer and there was no door to the freezer section of the refrigerator. There were 5 magic cup supplements in the freezer compartment. The magic cups were not frozen. Interview with Licensed Practical Nurse (LPN) #1 on 9/11/18 at 11:30 AM in the 400 hall medication room, LPN #1 was asked if the magic cup supplements were frozen solid. LPN #1 stated, No. LPN #1 confirmed there was no thermometer in the freezer compartment of the refrigerator. 3. Observations in the 100 hall nourishment room on 9/12/18 at 8:08 AM revealed the nourishment refrigerator did not have a door to the freezer compartment, there was no thermometer in the freezer compartment, and there was ice buildup on the sides and bottom of the freezer compartment. There was one container of orange sherbet in the freezer that was liquid. Interview with LPN #2 on 9/12/18 at 8:08 AM, in the 100 hall nourishment room LPN #2 confirmed there was ice build up in the freezer compartment, the sherbet was liquid, and there was no door on the freezer compartment. 4. Observations in the 200 hall nourishment room on 9/12/18 at 8:13 AM revealed there was no thermometer in the freezer compartment of the nourishment refrigerator. There was one magic cup supplement and 1 carton of liquid milk in the freezer. Interview with LPN #3 on 9/12/18 at 8:13 AM, in the 200 hall nourishment room, LPN #3 confirmed there was no thermometer in the freezer compartment of the nourishment refrigerator. 5. Observations in the 400 hall medication room on 9/12/18 at 8:38 AM revealed there was no thermometer in the freezer compartment of the refrigerator. Interview with LPN #1 on 9/12/18 at 8:38 AM in the 400 hall medication room, LPN #1 was asked if there was a door on the freezer compartment of the nourishment refrigerator. LPN #1 stated, We need a cover for it (freezer) . 6. Observations in the 300 hall break room on 9/12/18 at 9:20 AM revealed the resident's nourishment refrigerator freezer door would not open and there was no thermometer in the refrigerator section. The refrigerator temperature had not been documented for 9/11/18 on the Resident Refrigerator Temperature Log. Interview with Registered Nurse (RN) #1 on 9/12/18 at 9:20 AM in the 300 hall break room, RN #1 confirmed the door to the freezer compartment would not open, there was no thermometer in the refrigerator, and the temperatures had not been checked on 9/11/18. RN #1 was asked if there should be a thermometer in the refrigerator. RN #1 stated, Yes, it should be . Interview with the Certified Dietary Manager (CDM) on 9/12/18 at 9:31 AM in her office, the CDM was asked if every refrigerator and freezer should have a thermometer. The CDM stated, Yes ma'am The CDM was asked if every nourishment freezer should have a door on the compartment and if it was acceptable to have ice build up in the freezers. The CDM confirmed the freezers should have doors and there should not be ice build up.",2020-09-01
547,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2018-09-25,880,E,0,1,B1UN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure practices to prevent cross contamination and the potential spread of infection were maintained for 12 of 111 (room [ROOM NUMBER],303, 304, 307, 309, 311, 313, 316, 323, 324, 325, 331) shared resident rooms, that contained unlabeled toothbrushes, urinals, denture cups, wash basins, and open packages of briefs stored on the floor. The findings included: 1. The facility's .D. Urinals, Graduates and Bedpan policy documented, .To provide clean personal supplies for the residents and help prevent transmission of diseases . 2. Observations in semi-private (shared) resident rooms during tour on 9/10/18 at 10:25 AM, on 9/11/18 beginning at 8:20 AM, and on 9/12/18 at 7:15 AM, revealed: a. room [ROOM NUMBER]: An unlabeled urinal on the floor An unlabeled wash basin on the bathroom floor next to the toilet and wall b. room [ROOM NUMBER]: An emesis basin in the floor by the A bed c. room [ROOM NUMBER]: 2 Unlabeled toothbrushes and 4 tubes of unlabeled tooth paste in a cup An unlabeled denture cup on the ledge of the sink An unlabeled urinal and wash basin on the floor of the bathroom An unlabeled calibrated canister sitting on the back of the toilet d. room [ROOM NUMBER]: An unlabeled wash basin on top of the bathroom light fixture above the sink e. room [ROOM NUMBER]: An unlabeled urinal in the bathroom An opened package of disposable briefs f. room [ROOM NUMBER]: 2 unlabeled toothbrushes on the ledge over the sink g. room [ROOM NUMBER]: An unlabeled calibrated canister on the floor by the toilet An uncovered plunger on the bathroom floor by the toilet A roll of toilet paper on the floor next to the toilet An open package of briefs on the floor by the A bed h. room [ROOM NUMBER]: An uncovered plunger on the bathroom floor by the toilet i. room [ROOM NUMBER]: An unlabeled toothbrush and tube of toothpaste on the ledge over the sink j. room [ROOM NUMBER]: An unlabeled washbasin and a bedpan on the bathroom floor k. room [ROOM NUMBER]: 2 unlabeled wash basins in the same bag hanging in the bathroom l. room [ROOM NUMBER]: An unlabeled washbasin on the bathroom floor 3. Interview with the Director of Nursing (DON) on 9/12/18 at 7:20 AM on the 300 Hall, the DON was asked how the urinals, toothbrushes, and wash basins should be labeled and stored. The DON stated, .I see it's an infection control issue, its not labeled and don't know who it belongs to .These items should be labeled and in bags .the plungers should be covered and the resident's brief should not be on the floor .",2020-09-01
548,QUALITY CENTER FOR REHABILITATION AND HEALING LLC,445154,932 BADDOUR PARKWAY,LEBANON,TN,37087,2018-01-24,607,D,1,0,BRJH11,"> Based on review of facility policy, and interview, the facility abuse policy failed to accurately identify the reporting time of an abuse allegation. The findings included: Review of the undated facility policy entitled Abuse, Neglect and Exploitation of Residents revealed .Investigating and Reporting .Once an allegation of abuse has been made, the supervisor who initially received the report must inform the Administrator as soon as possible .An investigation MUST be directed by the Administrator, designee immediately and no later than twenty-four (24) hours of their knowledge of the alleged incident .The Administrator, Director of Nursing or designee will notify the appropriate state agencies per state regulation .The facility shall report not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury . Review of the facility policy entitled Abuse Reporting revealed .Reporting Guidance Federal Regulation .requires reporting of alleged violations of abuse .immediately to the administrator and to the appropriate state agencies in accordance with state law .CMS (Centers for Medicare & Medicaid Services) has defined 'immediately' as as soon as possible, but not to exceed 24 hours after forming suspicion .The facility must report abuse .within 24 hours after the reasonable cause threshold (suspicion) is concluded. If serious bodily injury has been sustained by a resident, the incident will be reported immediately but not later than 2 hours after forming suspicion . Interview with the Administrator and the Regional Nurse on 1/24/18 at 9:00 AM in the conference room confirmed the facility policy failed to .Ensure that all alleged violations involving abuse .are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury .",2020-09-01
549,QUALITY CENTER FOR REHABILITATION AND HEALING LLC,445154,932 BADDOUR PARKWAY,LEBANON,TN,37087,2018-01-24,609,D,1,0,BRJH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of the investigation documentation, and interview, the facility failed to report an allegation of abuse immediately or no later than 2 hours for 3 residents (#4, #8, #9) of 7 residents reviewed for abuse. The findings included: Review of the undated facility policy entitled Abuse, Neglect and Exploitation of Residents revealed .Investigating and Reporting .Once an allegation of abuse has been made, the supervisor who initially received the report must inform the Administrator as soon as possible .An investigation MUST be directed by the Administrator, designee immediately and no later than twenty-four (24) hours of their knowledge of the alleged incident .The Administrator, Director of Nursing or designee will notify the appropriate state agencies per state regulation .The facility shall report not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury . Review of the facility policy entitled Abuse Reporting revealed .Reporting Guidance Federal Regulation .requires reporting of alleged violations of abuse .immediately to the administrator and to the appropriate state agencies in accordance with state law .CMS (Centers for Medicare & Medicaid Services) has defined 'immediately' as as soon as possible, but not to exceed 24 hours after forming suspicion .The facility must report abuse .within 24 hours after the reasonable cause threshold (suspicion) is concluded. If serious bodily injury has been sustained by a resident, the incident will be reported immediately but not later than 2 hours after forming suspicion . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility investigation documentation involving Resident #4 revealed the staff to resident abuse allegation occurred on 10/21/17 at 6:00 PM and the Administrator was notified on 10/22/17 at 4:00 PM, 22 hours after the occurrence. The State Agency was notified on 10/23/17 at 4:47 PM, 46 3/4 hours after the occurrence. The facility failed to report the abuse allegation to the Administrator and the State Agency immediately or not later than 2 hours. Interview with the Administrator and the Regional Nurse on 1/24/18 at 9:00 AM in the conference room confirmed the facility failed to timely report an allegation of abuse to the Administrator and the State Agency. Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Nursing Progress Note dated 11/30/17 at 7:20 PM revealed .Received result of Left shoulder x-ray. Results read, fracture involving distal clavicle with minimal displacement. Message sent to NP (Nurse Practitioner). Call placed to on call for primary physician. On call MD (Medical Doctor) returned call and order received to place a sling to LUE (Left Upper Extremity) and leave in place until further notice . Review of facility investigation documentation revealed the Administrator was not notified on 11/30/17 when the facility received Resident #8's x-ray results. Interview with the Administrator and Director of Nursing (DON) on 1/23/18 at 3:15 PM in the Administrator's office confirmed the Administrator and the State Agency were not notified of Resident #8's injury of unknown origin immediately or within the 2 hour timeframe per the regulatory requirement. Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Nursing Progress Note dated 11/6/17 at 6:12 AM for Resident #9 revealed .New order for xray of left humerus and left ulnar radial on 11/6/17 for swelling and discoloration . Medical record review of a Nursing Progress Note dated 11/7/17 at 2:31 AM for Resident #9 revealed .On 11/6 residents x-ray results came back around 930p (PM) showing Acute moderate displaced (L) (Left) humeral neck fracture. No fracture, destructive [MEDICAL CONDITION] or other abnormalities of the (L) forearm. Made DON and night time supervisor aware . Further review revealed at 10:00 PM the on-call physician had been notified and at 10:20 PM the resident's daughter had been notified. Medical record review of an assessment dated [DATE] signed by the Attending Physician revealed Resident #9 had an .acute left humerus fracture without fall. Possibly when rolled to clean her, fracture with underlying [MEDICAL CONDITION] . Review of the facility investigation documentation and the medical record revealed the Administrator had not been notified of the xray results, received by the facility on 11/6/17 at around 9:30 PM, until the morning of 11/7/17, when the incident was reported to the State Agency. Interview of the facility Administrator and DON on 1/23/18 at 3:15 PM in the Administrator's office, confirmed the Administrator and the State Agency were not notified of the injury of unknown origin immediately or within the 2 hour timeframe per the regulatory requirement.",2020-09-01
550,QUALITY CENTER FOR REHABILITATION AND HEALING LLC,445154,932 BADDOUR PARKWAY,LEBANON,TN,37087,2018-01-24,656,D,1,0,BRJH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, and interview, the facility failed to develop a comprehensive plan of care for 1 resident (#9) of 9 sampled residents. The findings included: Review of facility Policy and Procedure MDS/Care Plans undated, revealed .The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetable to meet a resident's medical, nursing, mental and psychological needs which are identified in the comprehensive assessment and lead to the resident's highest obtainable level of independence .Procedure .When making decisions about the care plan .a. Determine whether the problem needs an intervention. b. Evaluate the resident's goals, wishes, (advance directives), strengths and needs. c. Design interventions that address cause, not symptoms. d. Establish which items need further assessment or review . Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A [DIAGNOSES REDACTED]. Medical record review revealed an assessment of Resident #9 signed by the Attending Physician dated 11/7/17 of an .acute left humerus fracture without fall. Possibly when rolled to clean her, fracture with underlying [MEDICAL CONDITION] . Medical record review of the Plan of Care initiated 9/2/16 and revised on 11/17/17 revealed no objectives, goals, or interventions to direct staff in providing care and services to Resident #9 whose condition was compromised after a fracture and who had a [DIAGNOSES REDACTED]. Interview with the Administrator and the Director of Nursing in the Administrator's office on 1/24/18 at 11:30 AM confirmed the care plan for Resident #9 failed to identify objectives, goals, and interventions to direct the staff in the care of the resident with a compromised condition.",2020-09-01
551,QUALITY CENTER FOR REHABILITATION AND HEALING LLC,445154,932 BADDOUR PARKWAY,LEBANON,TN,37087,2017-03-29,225,D,0,1,M4T411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility documentation review, and interview, the facility failed to report alleged abuse timely to the Department of Health and failed to provide a safe environment during the investigation of alleged abuse for 1 resident (#41) of 3 residents reviewed for abuse. The findings included: Review of the facility's Abuse of Residents Policy and Procedure (undated) revealed .Identification: .The resident might: have bruises .Facility employees, who have been accused of or are suspected of resident abuse, will be immediately suspended without pay and subject to dismissal and possible criminal prosecution pending outcome of an investigation. If the allegations are unsubstantiated, the employee will be reinstated and may be paid for the time out due to the suspension. The facility shall immediately submit to the Department of Health or notice of the suspension of the affected staff person(s), as appropriate as part of the event report . Medical record review revealed Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE], revealed Resident #41 was moderately impaired cognitively, required moderate assist of 2 staff to ambulate in her room, and was frequently incontinent of urine. Review of the facility's documentation of an ongoing investigation revealed on 3/26/17 at approximately 11:30 PM, the Administrator was notified of an allegation of abuse involving Resident #41, and Certified Nurse Assistant (CNA) #1. Continued review revealed the CNA was sent home when the allegations were reported. Interview with Resident #41 on 3/29/17 at 2:25 PM, revealed the resident was sleepy and unable to answer questions appropriately. Interview with Resident #201 (Resident #41's roommate with a BIMS score of 15 out of 15 indicating the resident is cognitively intact) on 3/29/17 at 2:30 PM, in the resident's room revealed Resident #201 was present when Resident #41 was allegedly abused by CNA #1 on Sunday night. Continued interview revealed Resident #41 was ambulating from the bathroom to the bed when CNA #1 entered the room, .grabbed the resident's wheel chair from over there by the closet, threw her in it .made it rough, instead of letting her ease into it .(CNA #1 told Resident #41) If you don't sleep and keep getting up, I'm going to put you by the desk all night . Review of the written statement from Registered Nurse (RN) #1 revealed .pts (patient) Roommate stated CNA said very nasty things to (Resident #41) and was very mean to her . Interview with the Administrator on 3/29/17 at 3:00 PM in the conference room confirmed the facility failed to notify the Department of Health of the alleged abuse within 2 hours. Continued interview revealed CNA #1 was allowed to return to work and provided care for Resident #41 on 3/28/17. Further interview confirmed the facility's investigation was ongoing and the facility had not interviewed the staff working when the alleged abuse happened, prior to allowing CNA #1 to return to work at the facility.",2020-09-01
552,QUALITY CENTER FOR REHABILITATION AND HEALING LLC,445154,932 BADDOUR PARKWAY,LEBANON,TN,37087,2018-05-03,550,D,0,1,X9ZT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observations, and interview, the facility failed to ensure dignity for 2 of 10 residents (Resident #193 and Resident #209) with catheters. Findings include: Review of the facility policy Dignity undated revealed, .Demeaning practices and standards of care that compromise dignity will not be allowed, for example: helping the resident to keep urinary catheter bags covered . Medical record review revealed Resident #193 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 14 Day Minimum Data Set ((MDS) dated [DATE] revealed Resident #193's Brief Interview for Mental Status (BIMS) score of 6 indicating severe cognitive impairment. Observations of Resident #193 in the resident's room on 5/1/18 at 9:55 AM, at 10:50 AM and at 12:10 PM revealed the resident's catheter drainage bag was not covered with a dignity bag. Medical record review revealed Resident #209 was admitted to facility on 3/23/18 with [DIAGNOSES REDACTED]. Medical record review of the 30 day MDS for Resident #209 dated 4/20/18 revealed a BIMS score of 15 which indicated the resident was cognitively intact. Observations of Resident #209 on 5/1/18 at 9:39 AM and on 5/1/18 at 10:52 AM revealed the resident's catheter bag was hanging on the left side of the bed facing the door not covered with a dignity bag, the dignity bag was attached to the walker at the foot of the bed. Interview with Registered Nurse (RN) #1 on 5/1/18 at 12:25 PM at the South II nurse station confirmed catheter bags should always be covered with a dignity bag. Further interview confirmed catheter drainage bags for Resident #193 and Resident #209 should have been covered with a dignity bag. Interview with Director of Nursing (DON) on 5/2/18 at 9:40 AM at the South II nurse station confirmed catheter bags should be covered with a dignity bag at all times.",2020-09-01
553,QUALITY CENTER FOR REHABILITATION AND HEALING LLC,445154,932 BADDOUR PARKWAY,LEBANON,TN,37087,2018-05-03,558,D,0,1,X9ZT11,"**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 keep the call light within reach for 1 of 16 residents (Resident #242) observed on the 400 hall. Findings include: Review of facility policy, Call [NAME] System undated, revealed, .It is the policy of the facility to make every effort to respond to the residents' requests and needs .The call bell will be placed within reach when the resident is in bed or sitting in a chair in the room . Medical record review revealed Resident #242 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #242 had a Brief Interview for Mental Status score of 15 indicating the resident was cognitively intact. Continued review revealed the resident required extensive assist of one person to transfer or walk in the room. Observations on 5/2/18 at 1:24 PM and at 3:10 PM revealed Resident #242 sitting in the recliner in her room. Continued observation revealed the call light was looped on the bed rail and out of reach of the resident. Observation and interview with Licensed Practical Nurse (LPN) #7 on 5/2/18 at 3:20 PM in Resident #242's room revealed the resident was sitting in the recliner. Continued observation revealed the call light was looped on the bed rail and out of reach of the resident. Interview with LPN #7 confirmed the facility failed to keep the call light within reach for Resident #242.",2020-09-01
554,QUALITY CENTER FOR REHABILITATION AND HEALING LLC,445154,932 BADDOUR PARKWAY,LEBANON,TN,37087,2018-05-03,657,D,0,1,X9ZT11,"**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 care plans were updated for 3 of 68 residents (Resident # 164, Resident # 209, and Resident #253) reviewed. Findings include: Review of facility policy MDS/Care Plans undated, revealed .Goals and objectives are reviewed and/or revised: when there has been a significant change in the resident's condition .when the desired outcome has and/or has not been achieved .when the resident has been readmitted to the facility from the hospital .at least quarterly . Medical record review revealed Resident #164 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 14 Day Minimum Data Set ((MDS) dated [DATE] revealed Resident #164 to have a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. Medical record review of physician's orders [REDACTED].contact isolation for [DIAGNOSES REDACTED]icile (infection of the bowel) . Medical record review of Resident #164's care plan dated 3/1/18 revealed no revision or updates for [DIAGNOSES REDACTED]. Medical record review revealed Resident #209 was admitted to facility on 3/23/18 with [DIAGNOSES REDACTED]. Medical record review of the 30 day MDS for Resident #209 dated 4/20/18 revealed a BIMS score of 15 which indicated the resident was cognitively intact. Medical record review of lab results for Resident #209 dated 4/16/18 revealed positive stool results for [MEDICAL CONDITION]. Medical record review of physician's orders [REDACTED].contact isolation/[MEDICAL CONDITION] every shift . Medical record review of Resident #209's care plan dated 3/23/18 revealed the facility failed to update the care plan for [MEDICAL CONDITION] or contact isolation. Interview with the MDS Director on 5/2/18 at 4:34 PM in the business office confirmed care plans were updated daily and Resident #164's and Resident #209's care plan should have been updated due to [MEDICAL CONDITION] and contact isolation. Interview with the Director of Nursing (DON) on 5/2/18 at 4:23 PM in the business office confirmed she would expect the care plan to be updated to reflect [MEDICAL CONDITION] and contact isolation. Medical record revealed Resident #253 was admitted to the facility on on 2/13/14 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Significant Change MDS dated [DATE] revealed Resident #253 had a BIMS score of 10, indicating moderate cognitive impairment. The resident required extensive physical assistance of 1 person for bed mobility, transfers, walking in room, locomotion on/off unit and toileting. Continued review revealed Resident #253 was not steady and only able to stabilize with staff assistance. Further review revealed the resident had had falls to occur since admission. Medical record review of a Fall Risk assessment dated [DATE] revealed Resident #253 received a score of 44, indicating a high fall risk. Medical record review of a Facility Incident Report revealed Resident #253 had a fall on 3/18/18 at 11:10 PM in her room resulting in a [MEDICAL CONDITION]. Medical record review of the care plan revised 4/17/18 revealed Resident #253 was identified at risk for falls. Further review revealed no additional interventions after the resident's fall on 3/18/18. Interview with the DON on 5/3/18 at 2:37 PM in the conference room stated the intervention put in placed after Resident #253 fell on [DATE] was for Physical Therapy. The DON confirm the facility failed to updated the care Ppan after a fall for Resident #253.",2020-09-01
555,QUALITY CENTER FOR REHABILITATION AND HEALING LLC,445154,932 BADDOUR PARKWAY,LEBANON,TN,37087,2018-05-03,761,D,0,1,X9ZT11,"**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 store wound cleanser in a locked medication cart for 1 of 18 residents (Resident #201) reviewed on the 500 hall. Findings include: Review of facility policy Storage of Medications - General undated, revealed .Medication rooms, carts and medication supplies are locked or attended by person with authorized access . Medical record review revealed Resident #201 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Observation on 4/30/18 at 9:00 AM and at 12:28 PM in Resident #201's room revealed a bottle of wound cleanser on the bedside table. Observation and interview with Licensed Practical Nurse (LPN) #8 on 4/30/18 at 12:34 PM in Resident #201's room revealed a bottle of wound cleanser on the bedside table. Continued interview with LPN #8 stated It shouldn't be there and confirmed the facility failed to keep the wound cleanser in a locked medication cart.",2020-09-01
556,QUALITY CENTER FOR REHABILITATION AND HEALING LLC,445154,932 BADDOUR PARKWAY,LEBANON,TN,37087,2018-05-03,803,C,0,1,X9ZT11,"Based on review of nutritional guidelines, menu review, and interview, the facility menu failed to meet nutritionally adequate standards for 3 of 4 weeks in the menu cycle. Findings include: Review of the Nutritional Guidelines and Menu Checklist for Residential and Nursing Home, 2014, revealed 5 or more servings of fruit and vegetables should be served daily. Further review revealed food high in fat should be used sparingly. Review of the 4 week cycle menu revealed the following: Week 1 Sunday Supper was Hamburger on Bun, French Fries, Fudge Round, and Lettuce/[NAME]to/Onion. Week 1 Monday Lunch was Tuna Salad on Bun, Tator Tots, Soup, Donuts. Week 1 Tuesday Lunch was Corn Dog Nuggets, French Fries, Cookie. Week 1 Friday Lunch was Grilled Chicken Breast, Macaroni Salad, Waffle Fries. Supper was Pizza, Tossed Salad (no tomato), Fruit. Week 1 Saturday Lunch was Hot Dog on Bun, Chili, Saltine Crackers, Tator Tots, Donut. Week 3 Sunday Lunch was Fish Sandwich, French Fries, Macaroni Salad, Cookie. Week 3 Wednesday Lunch Corn Dog, Tator Tots, Baked Beans, Cookie. Supper was Chicken Nuggets, French Fries, Mixed Vegetables, Honey Bun. Week 3 Thursday Lunch was[NAME]Wagon Burger, French Fries, Lettuce/[NAME]to/Onion, Fig Newton. Week 4 Sunday Lunch was Fish Sandwich, French Fries, Fruit Cup, Fig Newton. Week 4 Tuesday Lunch was Cheese Pizza, Tossed Salad, (no tomato) Cookie. Supper was Corn Dog Nuggets, French Fries, Baked Beans, Fruit Parfait. Week 4 Thursday Supper was Hamburger on Bun, Fries, Lettuce/[NAME]to/Onion, Donuts. Week 4 Saturday Supper was Corn Dog, Tator Tots, Fruit Salad, Italian Ice. Review of the menu cycle revealed the menu failed to have 5 or more servings of fruit and vegetables daily. Interview with 13 Resident Council members on 4/30/18 at 2:00 PM in the Dining Room revealed the residents complained of meals being served cold on a daily basis. Further interview revealed the residents also complained of fried foods and sandwiches frequently served. Interview with the Dietary Manager (DM) on 5/1/18 at 1:35 PM in the dietary department revealed the DM determined what food needed to be ordered, the food order went to the corporate office and the corporate office determined what to actually order. Further interview revealed .Sometimes get a totally different product and not match what (DM) requested . Further interview revealed .a Resident had requested a chuck wagon sandwich (breaded pork patti), and I requested the product called 'chuck wagon' but what we got looked like a breaded hot dog, it was really red on the inside and looked just like a hot dog insides . Further interview revealed one meat product, once it was cut up, looked unappealing, the DM checked the ingredients and noted meat by-products and red dye and would not serve the product. Further interview revealed .We have fresh fruit in-house, and we have canned and frozen vegetables . Further interview revealed the .Resident Council meeting stated they wanted more food like what had 'outside' before they came here, fun food like corn dogs, hot dogs, hamburgers, chicken nuggets, fries, so Registered Dietitian #2 then adjusted menu . Interview with Registered Dietitian #1 on 5/2/18 at 11:15 AM in the Conference Room confirmed the menu was not based on nutritional standard regarding fruit and vegetables and fried foods. Confirmed menu looks like .kids menu items . and .a lot of carbohydrates .",2020-09-01
557,QUALITY CENTER FOR REHABILITATION AND HEALING LLC,445154,932 BADDOUR PARKWAY,LEBANON,TN,37087,2018-05-03,804,E,0,1,X9ZT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility dietary department failed to ensure the resident received food preferences and failed to receive food at a safe and appetizing temperature. Findings include: Observation on 5/2/18 at 7:30 AM of the resident morning meal service revealed the tray line was in progress. Further observation revealed Dietary Staff #1 obtaining food temperatures at 7:42 AM prior to the service of the B Hall tray cart. Further observation revealed the following temperatures in degrees Fahrenheit (F). The sausage patti was 152.1 degrees, ground sausage was 178 degrees, and pureed sausage was 181 degrees; scrambled eggs were 187 degrees, pureed eggs were 168 degrees, and fried eggs were 151 degrees; oatmeal was 146 degrees, and the gravy was 168 degrees. Observation on 5/2/18 revealed the following: At 7:55 AM - 2 carts with a total of 21 resident trays and a test tray for B Hall left the dietary department. At 8:00 AM - 2 carts arrived to B hall and nursing staff signed the sheet of the carts arrival. At 8:02 AM - first tray delivered. At 8:28 AM the last resident tray was delivered and the resident was provided assistance. All residents observed to see if eating or provided assisted with eating. At 8:30 AM the test tray food temperatures, in F, were obtained by Dietary Staff #1 as followed: The sausage patti was 103 degrees, a decrease of 49.1 degrees. The ground sausage was103 degrees, a decrease of 75 degrees. The pureed sausage was 110 degrees, a decrease of 71 degrees. The scrambled eggs were 109.3, a decrease of 77.7 degrees. The pureed eggs were 113 degrees, a decrease of 55 degrees. The oatmeal was 112.6 degrees, a decrease of 33.4 degrees. Observation on 5/2/18 at 8:35 AM by the test tray on B Hall revealed Registered Dietitian (RD) #1 and Dietary Staff #1 checking the temperature of the plate and the heated plate pellet base by touching them. Interview with the RD and Dietary Staff #1 revealed the plate .did not feel warm . and the heated pellet base was warm to the touch. Further interview confirmed the plate and plate pellet base failed to maintain the food temperature at an acceptable level. Interview with 13 Resident Council members on 4/30/18 at 2:00 PM in the Dining Room revealed the residents complained of meals being served cold on a daily basis. Further interview revealed the residents also complained of fried foods and sandwiches frequently served. Medical record review revealed Resident #104 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician order [REDACTED]. Medical record review of the 30 day Minimum Data Set ((MDS) dated [DATE] revealed Resident #104 had adequate hearing, clear speech, made self understood, and understood others, and had impaired vision. Further review revealed the resident scored 13/15 on the Brief Interview for Mental Status (BIMS), indicating she was cognitively intact, and she exhibited no change in mental status, [MEDICAL CONDITION], mood, [MEDICAL CONDITION], or in behavior. Further review revealed the resident required limited 1 person assistance for eating and had no significant weight loss or gain during the review period. Interview with Resident #104 on 5/1/18 at 2:24 PM in the resident's room revealed .sometimes food hot, sometimes not . Medical record review revealed Resident #233 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Lumbar Region. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #233 had adequate hearing and vision, clear speech, was able to make self understood and understood others. Further review revealed a BIMS score of 13/15, indicating she was cognitively intact, and exhibited no acute change in mental status, [MEDICAL CONDITION], mood, [MEDICAL CONDITION] or behaviors. Further review revealed the resident was not receiving a mechanically altered or therapeutic diet. Interview with Resident #233 on 5/1/18 at 10:36 AM in the resident's room revealed .get a lot of hamburgers, hot dogs, fries, a lot of fried food and when you get it, it's cold .butter not melt in oats in morning it was so cold . Medical record review revealed Resident #186 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly MDS dated [DATE] revealed Resident #186 had a BIMS of 15, indicating she was cognitively intact, had clear speech, could make herself understood and understood others. Continued review revealed the resident did not require a therapeutic diet. Medical record review of the resident's comprehensive care plan dated 4/16/18 revealed a focus of nutritional problem or potential nutritional problem with interventions including .Provide, serve diet as ordered .Regular diet, thin liquids-selective menu daily .Registered Dietitian to evaluate and make diet change recommendations as needed . Interview with Resident #186 on 5/1/18 at 8:53 AM in her room stated, .The food is terrible. They don't know how to cook vegetables. They taste like they've poured a box of salt in them. I don't eat the meat. They say it's meat, but it doesn't look like it to me. I eat biscuits and gravy for breakfast (observed). I eat a pimento cheese sandwich and tomato soup for lunch and dinner every day because there is nothing else worth eating . Interview with Resident #186 on 5/2/18 at 9:40 AM in her room stated she would like some fresh vegetables. Continued interview revealed the resident stated, .I love brussel sprouts and I haven't seen a brussel sprout in years . She stated she loved cabbage and slaw but gets 2 tablespoons. I'd rather eat a whole bowl of something I like. When asked if she has spoken to the Registered Dietitian (RD) or Dietary Manager regarding her preferences Resident #186 stated, .Oh, I've told them, lots of times . When asked who she specifically talked to the resident said, .I don't know who they were, they just come in here and I told them . Further interview revealed she would like a piece of roast beef but had never seen that served either and some broccoli soup with yellow onions and stated.Since I only eat soup because the meat isn't real meat . Medical record review of a Nutritional assessment dated [DATE] by the RD revealed: .daily food preferences from dietary-resident writes the same thing on each meal ticket-meals in room, snacks in room, resident not eating snacks as much .alert/oriented (times 3) some confusion noted at times .resident complains daily about wanting fresh vegetables . Interview with RD #1 on 5/2/18 at 11:40 AM in the conference room confirmed Resident #186 was not served vegetables and her preferences for meals. Continued interview confirmed the facility failed to provide adequate protein based on the nutritional assessment due to budget and menu constraints. Medical record review revealed Resident #154 was re-admitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly MDS dated [DATE] for Resident #154 revealed a BIMS score of 14 indicating no cognitive impairment. Continued review revealed no behaviors or moods exhibited. Further review revealed adequate hearing and vision with the ability to be understood and understood others. Medical record review of Physician order [REDACTED].#154 revealed a Regular diet, Regular texture and thin liquid consistency. Interview with Resident #154 on 4/30/18 at 10:00 AM in the resident's room revealed complaints of cold food served mostly for lunch and supper. Continued interview revealed Resident #154 had been receiving cold food most of the time since she returned from the hospital about 3 weeks ago. Interview with Resident #154 on 5/1/18 at 7:40 AM in the resident's room revealed sandwiches and fried food had been served a lot. Continued interview revealed the resident stated she was tired of getting sandwiches for lunch and supper. Medical record review revealed Resident #221 was admitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly MDS dated [DATE] for Resident #221 revealed a BIMS score of 15 indicating no cognitive impairment. Continue review revealed no behaviors or moods exhibited. Further review revealed adequate hearing, vision, and clear speech with the ability to make herself understood and understood others. Medical record review of the Physician order [REDACTED].#221 revealed a Regular diet, Regular consistency, and thin liquid consistency. Interview with Resident #221 on 4/30/18 at 9:18 AM in the resident's room revealed the resident stated .since after the first of the year (January (YEAR)) the taste of the food has gone down . Continued interview revealed the .food does not taste good especially since it is cold by the time the trays are served . Futher review revealed .they (Dietary Department) give us sandwiches and fried nuggets most of the time for lunch and supper . Resident #221 also stated she was getting .real tired of sandwiches and fried nuggets . Continued interview revealed the resident stated Certified Nurse Aide (CNA) #4 had reheated her food in the microwave several times in the past when requested. Interview with CNA #4 on 4/30/18 at 10:00 AM in the A hall revealed she had reheated Resident #221's food several times at lunch and supper. Continued interview revealed she had reheated food for the other residents at lunch and supper when requested. Interview with Resident #221 on 4/30/18 at 3:40 PM in the resident's room revealed lunch was served about an hour late and lunch was cold and in a foam tray. Continued interview revealed CNA #4 reheated the food for her in the microwave. Medical record review revealed Resident #607 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 5 Day MDS for Resident #607 dated 4/25/18 revealed a BIMS score of 4 which indicated severe cognitive impairment. Further review revealed Resident #607 could be understood and understood others. Interview with Resident #607 on 4/30/18 at 9:48 AM and 11:26 AM in her room revealed .her food is barely warm when she gets it . Medical record review revealed Resident #109 was readmitted to facility on 4/25/18 with [DIAGNOSES REDACTED]. Medical record review of the 30 day MDS for Resident #109 dated 3/28/18 revealed a BIMS score of 13 which indicated the resident was cognitively intact. Further review revealed Resident #109 had clear speech, adequate hearing and vision, could understand others and be understood, and had no weight loss or gain. Interview with Resident #109 on 4/30/18 at 10:29 AM in her room confirmed .her food is cold when she gets it . Further interview with Resident #109 on 05/01/18 at 9:31 AM in her room revealed her breakfast .was cold when brought to her this morning . Medical record review revealed Resident #211 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 60 day MDS for Resident #211 dated 4/6/18 revealed a BIMS score of 15 which indicated the resident was cognitively intact. Further review revealed Resident #109 had clear speech, adequate hearing and vision, could understand others and be understood, and had no weight loss or gain. Interview with Resident #211 on 4/30/18 AM at 8:22 AM in her room confirmed .her food is cold when it gets to her room . Medical record reveiw revealed Resident #209 was admitted to facility on 3/23/18 with [DIAGNOSES REDACTED]. Medical record review of the 30 day MDS for Resident #209 dated 4/20/18 revealed a BIMS score of 15 which indicated the resident was cognitively intact. Further review revealed Resident #209 had clear speech, adequate hearing and vision, could understand others and be understood, and had no weight loss or gain. Interview with Resident #209 on 4/30/18 at 10:23 AM in her room confirmed her food was cold at times. Further interview on 05/01/18 at 9:39 AM in the resident's room confirmed her food was cold when it comes to her room and she reported breakfast was cold this morning. Medical record review revealed Resident #660 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with Resident #660 on 5/1/18 at 7:50 AM in the resident's room revealed .food is always cold . Observation on 5/1/18 at 8:08 AM revealed the staff brought Resident #660's breakfast tray into the resident's room, the resident raised the lid on the tray, felt of the eggs and asked the staff to reheat the food. Further observation revealed Resident #660 stated .the food is cold .",2020-09-01
558,QUALITY CENTER FOR REHABILITATION AND HEALING LLC,445154,932 BADDOUR PARKWAY,LEBANON,TN,37087,2018-05-03,812,F,0,1,X9ZT11,"Based on review of the manufacturer's recommendations, observation and interview, the facility dietary department failed to operate the dish machine in safe operating condition. Findings include: Review of the manufacturer's recommendations revealed the minimum wash temperature was 140 degrees Fahrenheit (F) and the minimum rinse temperature was 120 degrees F. Observation on 4/30/18 at 11:38 AM in the dietary department revealed the resident mid-day meal tray line was in progress. Further observation revealed the dietary staff were manually washing dishes, used for breakfast, in the 3 compartment sink. Observation on 5/1/18 at 2:50 PM of 7 consecutive cycles of the dish machine in the dietary department dish room, included 5 racks with resident meal service trays and 2 racks with plate domes and bases, revealed the wash temperature went from 130 degrees F and dropped to 126 degrees F. Further observation revealed the rinse temperature was 128 degrees F for all 7 racks processed and the temperature gauge never moved. Further observation revealed the dietary staff stored the contents of all 7 racks. Interview with the Dietary Manager on 5/1/18 at 2:50 PM in the dish room confirmed the wash and rinse temperatures did not reach the minimum level recommended by the manufacturer. Observation on 5/2/18 at 12:30 PM in various resident hallways revealed the resident meals were served in styrofoam or paper containers. Interview with the Dietary Manger on 5/2/18 at 6:45 PM in the dietary department dish room confirmed the dish machine failed to reach the minimum wash and minimum rinse temperatures specified by the manufacturer, therefore, the resident meals were served on styrofoam or paper.",2020-09-01
559,QUALITY CENTER FOR REHABILITATION AND HEALING LLC,445154,932 BADDOUR PARKWAY,LEBANON,TN,37087,2018-05-03,880,D,0,1,X9ZT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, interview, and medical record review, the facility failed to follow transmission based precautions and hand washing protocols between residents during meal tray pass on the 200 hall and South skilled hall; failed to change a PICC (peripherally inserted central catheter) dressing timely for 1 of 5 sampled residents (Resident #109) requiring dressing changes. Findings include: Review of facility policy Isolation - Categories of Transmission - Based Precautions revised (MONTH) 2012 revealed, .Standard Precautions shall be used when caring for residents at all times regardless of their suspected or confirmed infections status. Transmission - Based precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others .Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment .Examples of infections requiring Contact Precautions include .Diarrhea associated with [MEDICAL CONDITIONS] . Observation of tray pass for lunch on 4/30/18 from 12:25 PM-12:40 PM on the 200 hall revealed Certified Nurse Aide (CNA) #5 delivered a meal tray to the resident in room [ROOM NUMBER] [NAME] Continued observation revealed the door to room [ROOM NUMBER] had personal protective equipment (PPE) on it and a sign indicating to use contact precautions before entering the room. Continued observation revealed CNA #5 entered the residents room without any PPE in use, placed the meal tray on the over bed table, adjusted the residents bed and table without gloves in use. Interview with CNA #5 on 4/30/18 at 12:27 PM in the 200 hall outside of room [ROOM NUMBER] A was asked if she was supposed to use PPE when entering room [ROOM NUMBER] and stated, They told me he was just a set up. Further interview when asked about the PPE on the door and the sign for contact precautions and why she failed to use PPE when entering the room CNA #5 stated, I should have. I know better. I was in a hurry I guess. Interview with Licensed Practical Nurse (LPN) #8 (nurse for resident in 125 A) on 4/30/18 at 12:30 PM at the 200 nurse station confirmed the resident was on contact isolation precautions for [MEDICAL CONDITION]. Continued interview revealed when asked when staff were to use PPE, the LPN stated, Every time you enter the room. Not using it is not an acceptable practice. Review of facility Hand Washing Policy undated, revealed, .Hand washing is an effective method for prevention and control of infection .Hands should be washed .Before eating or handling food .Before direct patient contact .After contact with objects .located in the patient's environment . Observation of tray pass for lunch on 4/30/18 from 12:41 PM-12:55 PM on the South skilled hall revealed Housekeeper (HK) #1 carried a meal tray into room [ROOM NUMBER] B, placed the tray on the over bed table and positioned it close to the resident. Continued observation revealed the HK exited the room without washing or sanitizing her hands. Continued observation revealed the HK obtained a meal tray from the food cart and carried it to room [ROOM NUMBER] A, placed it on the over bed table, assisted with set up, cut the food using the residents utensils and positioned the table closer to the resident. Further observation revealed HK #1 exited the room without washing or sanitizing her hands. Continued observation revealed the HK went back to the food cart in the hall wiped her nose and touched her hair with her left hand, obtained a meal tray and carried it to room [ROOM NUMBER] [NAME] Further observation revealed HK #1 was seated at the bedside assisting the resident with her pureed diet. Interview with HK #1 on 4/30/18 at 1:00 PM on the South skilled hall by room [ROOM NUMBER] when asked when she was to wash her hands stated, Before and after I start feeding. The HK was asked if she was trained in hand washing and stated, Yes, I forgot what I'm supposed to do. When asked what she was supposed to do she stated, I guess I should wash my hands. Further observation revealed HK #1 continued to feed the resident without washing or sanitizing her hands. Interview with LPN #9 (Unit Manager for the South skilled hall) on 4/30/18 at 1:07 PM in the South skilled hall by room [ROOM NUMBER] when explained the actions of HK #1 stated, They know better than that. Continued interview with the LPN confirmed hand washing should be done between contact with each resident, and definitely before assisting a resident with dining. Interview with Registered Nurse (RN) #4 (Infection Control Preventionist) on 5/3/18 at 4:10 PM in her office when notified of the tray pass observations on 4/30/18 stated she was already aware of the concerns. Continued interview with RN #4 confirmed the facility failed to follow transmission based precautions, and proper hand washing to prevent contamination to the residents. Review of facility policy Central Venous Catheter Dressing Changes revised (MONTH) (YEAR), revealed .Change transparent semi-permeable membrane (TSM) dressings at least every 5-7 days and PRN (as needed) (when wet, soiled, or not intact) . Medical record review revealed Resident #109 was readmitted to facility on 4/25/18 with [DIAGNOSES REDACTED]. Medical record review of the 30 day Minimum Data Set for Resident #109 dated 3/28/18 revealed a BIMS score of 13 which indicated the resident was cognitively intact. Medical record review of Physician order [REDACTED].#109 revealed .change PICC line dressing every day shift every Friday . Medical record review of the care plan dated 4/26/18 for Resident #109 revealed .Change PICC line dressing per facility protocol . Observation of on 4/30/18 at 10:29 AM, 12:10 PM, and 4:00 PM and on 5/1/18 at 9:31 AM and 2:29 PM of Resident #109 in her room revealed the resident had a PICC line dressing to upper right arm dated 4/20/18. Interview with Resident #109 on 4/30/18 at 10:29 AM in the resident's room confirmed the PICC line dressing was dated 4/20/18, and .it hasn't been changed . Interview with LPN #1 on 5/1/18 at 2:29 PM in Resident #109's room confirmed the PICC line dressing to Resident #109's right upper arm was dated 4/20/18. Further interview with LPN #1 confirmed PICC line dressings were changed weekly on Fridays by the treatment nurse. Interview with LPN #2 (treatment nurse) responsible for dressing changes, on 5/1/18 at 2:54 PM in the South 2 nurse's station confirmed PICC line dressings are changed on Fridays. LPN #2 stated .I'm sure I changed it Friday, I must have put the wrong date on it . Interview with the Director of Nursing (DON) on 5/2/18 at 9:43 AM in the South 2 nurse's station confirmed PICC line dressings were changed weekly or as needed. Further interview with the DON confirmed she would expect staff to change the dressings at least weekly or as needed if the dressings become soiled or dirty.",2020-09-01
560,QUALITY CENTER FOR REHABILITATION AND HEALING LLC,445154,932 BADDOUR PARKWAY,LEBANON,TN,37087,2018-05-03,908,D,0,1,X9ZT11,"Based on review of the manufacturer's recommendations, observation and interview, the facility dietary department failed to maintain the dish machine in safe operating condition, and failed to maintain the dish room door in a safe manner. Findings include: Review of the manufacturer's recommendations revealed the minimum wash temperature was 140 degrees Fahrenheit (F) and the minimum rinse temperature was 120 degrees F. Observation on 4/30/18 at 11:38 AM in the dietary department revealed the resident mid-day meal tray line was in progress. Further observation revealed the dietary staff were manually washing dishes, used for breakfast, in the 3 compartment sink. Interview with the Dietary Manager on 4/30/18 at 11:38 AM in the dietary department revealed the dish machine sanitizer solution would not prime, therefore not dispense, in the dish machine and the service company had been contacted. Observation on 5/1/18 at 2:50 PM of 7 consecutive cycles of the dish machine in the dietary department dish room, included 5 racks with resident meal service trays and 2 racks with plate domes and bases, revealed the wash temperature went from 130 degrees F and dropped to 126 degrees F. Further observation revealed the rinse temperature was 128 degrees F for all 7 racks processed and the temperature gauge never moved. Interview with the Dietary Manager on 5/1/18 at 2:50 PM in the dish room confirmed the wash and rinse temperatures did not reach the minimum level recommended by the manufacturer. Observation on 5/2/18 at 12:30 PM in various resident hallways revealed the resident meals were served in styrofoam or paper containers. Observation on 5/2/18 at 6:45 PM in the dietary department dish room revealed the interior bottom section of the dish room door was rusted and some areas were gone. Interview with the Dietary Manger on 5/2/18 at 6:45 PM in the dietary department dish room confirmed the dish machine failed to reach the minimum wash and rinse temperatures specified by the manufacturer therefore the resident meals were served on styrofoam or paper. Further interview confirmed the dish room door leading into the dining room bottom section was rusted.",2020-09-01
561,QUALITY CENTER FOR REHABILITATION AND HEALING LLC,445154,932 BADDOUR PARKWAY,LEBANON,TN,37087,2019-05-08,583,D,0,1,G8QZ11,"**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 secure the personal privacy and confidentiality of 1 narcotic book containing narcotic sign out sheets for Resident #48. The findings include: Review of facility policy, Confidentiality of Information, undated revealed .Our facility shall treat all resident information confidentially and shall access protected information only as necessary . Medical record review revealed Resident #48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Order Summary Report revealed .[MEDICATION NAME] HCI ([MEDICATION NAME]) Tablet 10 MG (milligrams), Give 1 tablet by mouth every 6 hours as needed for pain related to ACUTE HEMATOGENOUS OSTEO[DIAGNOSES REDACTED], RIGHT FEMUR . Observation of the medication cart on 5/8/19 at 4:40 PM on the Skilled Hall revealed the medication cart was unattended and the narcotic sign out book was opened exposing Resident #48's name and medication information. Further observation of the narcotic sign out book revealed the medication for Resident #48 was signed out on 5/8/19 at 4:00 PM. Observation on 5/8/19 at 4:42 PM on the Skilled Hall revealed Registered Nurse (RN) #2 walking casually past the medication cart carrying linens then walked into a resident room and closed the door. Interview with RN #2 on 5/8/19 at 4:47 PM in the Skilled Hall stated .in the real world I would have put everything away (close narcotic sign out book) . Interview with the Director of Nursing on 5/8/19 at 5:20 PM in her office confirmed .the narcotic sign out book should be closed when unattended .",2020-09-01
562,QUALITY CENTER FOR REHABILITATION AND HEALING LLC,445154,932 BADDOUR PARKWAY,LEBANON,TN,37087,2019-05-08,812,E,0,1,G8QZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, manufacturer guidelines, observation, facility maintenance reports and interview, the facility failed to ensure clean and sanitary conditions of the main kitchen ice machine, food contact surfaces (dishes), failed to maintain the dish machine in proper working order to prevent cross contamination and failed to date, label and monitor refrigerated and dry foods. The findings include: Review of facility policy, Ice Machines and Ice Storage, undated revealed .Ice machines will be used and maintained to assure a safe and sanitary supply of ice . Review of manufacturer guidelines titled, Scotsman Ice systems, revealed .Clean or replace air filter and clean the air condenser .It is the users responsibility to keep the ice machine and storage bin in a sanitary condition .Without human intervention, sanitation will not be maintained . Observation of the ice machine on [DATE] at 8:52 AM, in the kitchen revealed green debris on the ice. Interview with the Dietary Manager on [DATE] at 8:53 AM in the kitchen revealed . I don't know what that is, it should not be there . Interview with Nurse Consultant #1 on [DATE] at 9:04 AM in the Administrators office revealed .that looks like trash . Interview with the Assistant Dietary Manager on [DATE] at 11:08 AM revealed .we use this ice machine for all the resident drinks as we plate the food for the dining room and all the hall carts .but it is shut down now to be cleaned . Review of the maintenance results for the main kitchen ice machine dated [DATE] at 6:26 AM revealed .I found calcium and lime build up .We have decided to start a new preventative maintenance schedule for these machines . Review of the Ice Machine Work Report from named Appliance Service dated [DATE] revealed .Cleaned units and replaced bin sensor in Dietary area . Review of facility policy, Cleaning Dishes/Dishwasher, undated revealed .Dish machines will be checked prior to meals to assure proper functioning .During the unloading process, visually inspect all items for cleanliness . Review of manufacture guidelines titled named Dish service revealed .Normal Checks to include; Screens and trays are all in good order .drains are clear .Spray patterns are consistent and typical .Lime build up on any conveyor can be a problem . Observation on [DATE] at 8:55 PM in the kitchen, in the presence of the Dietary Manager revealed 6 plate covers on the clean plate cover drying rack splattered with obvious dried debris. Observation of the dishroom on [DATE] at 9:00 PM in the kitchen, in the presence of the Dietary Manager revealed a full rack of plates, cups and bowls that just came through the dish machine splattered with green and yellow debris. Interview with the Dietary Manager on [DATE] at 9:05 PM in the kitchen revealed .I don't know what that is, but it shouldn't be on there .it needs to be scrubbed . Observation of the dishroom on [DATE] at 11:00 AM in the presence of the Dietary Manager revealed green and yellow splattered debris on 6 of 23 plates that just emerged from the dish machine. Observation of the clean plate cover rack on [DATE] at 11:02 AM, in the presence of the Dietary Manager revealed 2 plate covers located on the clean rack with large areas of splattered dried debris. Observation of the clean plate Low-Rater on [DATE] at 11:04 AM beside the tray line, ready for plating the food, and in the presence of the Assistant Dietary Manager revealed 12 of 15 randomly selected plates were covered with splattered dried green and yellow debris. Interview with the Dietary Manager on [DATE] at 11:03 AM in the kitchen revealed, when asked by the surveyor if these looked clean, the Dietary Manager stated, .no they are not . Interview with the Assistant Dietary Manager on [DATE] at 11:06 AM in the kitchen confirmed .these plates are all dirty and must be rewashed before the food can be plated . Further interview revealed . something is definitely wrong today with the dish washer, the washing process, or both . Interview with the Administrator on [DATE] at 2:10 PM outside the conference room confirmed We have taken the dish machine apart . Continued interview revealed .We will find out what the problem is before the day is over . Review of the maintenance report for the kitchen dish machine dated [DATE] at 6:54 AM revealed .I proceeded to shut the dishwasher down and start deep cleaning and sanitation .The drain line was noticed to be slow draining .The dietary Manager is in charge of de-liming and de-scaling the machine .We will be doing a deep clean on this machine once a month to prevent large amounts of scale and lime from occurring in the future . Continued review of the facility investigative note dated [DATE] regarding the dish machine revealed .Team noticed lime build up within the machine as well as a few pieces of flatware within the machine preventing it from draining adequately . Review of facility policy, Food Receiving and Storage, dated 2001 and revised (MONTH) (YEAR) revealed .Foods shall be received and stored in a manner that complies with safe food handling practices .All foods stored in the refrigerator or freezer will be covered, labeled and dated . Observation of the walk in refrigerator on [DATE] at 8:29 PM in the presence of the Dietary Manager revealed half a block of margarine uncovered lying on the shelf, opened and not dated or labeled. Further observation revealed red grapes stored loose in the bottom of a box. Observation of the walk in freezer on [DATE] at 8:35 PM in the presence of the Dietary Manager revealed 3 bags of chicken tenders opened, not dated and not labeled, 1 bag of french fries opened, not dated, not labeled and 1 bag of frozen hamburger patties opened, not labeled and not dated. Observation of the dry storage area on [DATE] at 8:40 PM in the presence of the Dietary Manager revealed 1 bag of hamburger buns opened and not dated,1 bag of rolls opened and not dated, 1 bag of penne noodles (5 pound bag) opened and not dated,1 bag of pasta noodles (5 pound bag) opened and not dated, ,[DATE] ounce containers of thickened lemon water expired on [DATE] and ,[DATE] ounce containers of honey light consistency thickened cranberry cocktail expired on [DATE], [DATE], and [DATE]. Interview with the Dietary Manager on [DATE] at 8:46 PM in the dry storage area revealed .I would rather have not found any foods opened and not dated .but I would rather have found them in the refrigerator than in the dry storage . Interview with the Registered Dietician on [DATE] at 7:00 PM outside the conference room confirmed .There should never be any type of debris in the ice at any time . Continued interview confirmed .The dish machine was stopped up and was not functioning properly .The food, especially green beans and other food which had been collecting in the bottom of the dish machine was splattering back up onto the dishes as they were going through the dish machine .The dishes were coming out more soiled than when they were going in .So we shut it down and sent out styrofoam plates and cups until we can get it repaired . Continued interview confirmed .opened, undated, unlabeled or expired foods should never be found in the refrigerators, the walk in freezer, or in the dry storage areas at any time . Interview with the Administrator on [DATE] at 8:10 PM in her office confirmed .The dish machine was not working correctly .but it is fixed now and working fine . Continued interview confirmed .We also had someone to come in and clean and fix the ice machine in the kitchen .",2020-09-01
563,QUALITY CENTER FOR REHABILITATION AND HEALING LLC,445154,932 BADDOUR PARKWAY,LEBANON,TN,37087,2018-07-18,600,D,1,0,9S4C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to prevent physical abuse of 1 (Resident #2) of 4 residents reviewed for abuse/neglect. Findings include: Review of facility policy Abuse, Neglect, and Exploitation of Residents, revealed .The facility will not condone resident abuse by anyone including staff members, other residents, consultants, volunteers, staff of other agencies serving the resident, resident representative, family members, legal guardians, sponsors, friends or other individuals .All personnel are required to promptly report any incident or suspected incident of resident abuse .Upon receiving reports of physical or sexual abuse the nursing supervisor will immediately examine the resident .An immediate investigation will commence and a stated and signed statement from the person reporting the incident will be obtained .It is the responsibility of all staff to identify inappropriate behavior towards residents, which may include but is not limited to use of derogatory language; rough handling of residents; ignoring residents while giving care; directing residents who need toileting assistance to urinate/defecate in their clothing, etc .Physical abuse is the inappropriate physical contact with a resident which harms or is likely to harm a resident. This includes but is not limited to hitting, slapping, pinching, spitting at, kicking, etc .The facility will provide abuse prohibition training to all new employees and volunteers. All staff will receive this training on an annual basis . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 scored 0 on the Brief Interview for Mental Status indicating he was unable to answer the questions. Continued review of the MDS revealed Resident #2 required extensive assistance of 2 people for transfers, dressing, toileting, and grooming; was dependent on 2 people for bathing; and was always incontinent of bowel and bladder. Review of facility investigation of a written statement by Certified Nurse Aide (CNA) #1 revealed she was .in the middle of a round walking up to the front when she heard yelling. She heard a nurse yell at a resident as she looked down the hall and heard her say let go of my necklace you stupid [***] . She had him by the hands and had bite him was continuing yelling had his hands up to his neck and this point I had went back to my hall. I came back up to the front to her walking out the doors and was gone for about 30 minutes. Continued review revealed a clarification note by the Administrator in which CNA #1 was asked if she saw Licensed Practical Nurse (LPN) #1 actually bite down with teeth showing or did she see nurse's mouth on resident's hand. Further review revealed CNA #1 did not see the nurse actually bite but rather her lips on the resident's hand. Further review revealed the Administrator asked CNA #1 if she saw the resident had a grip on the nurse and CNA #1 said it appeared the resident had a hold of something with the nurse. Continued review revealed the Administrator asked CNA #1 if the nurse had the resident by the hands or the resident had the nurse by the hands and she said it looked like the nurse had the resident but couldn't see that clearly to say 100%. Review of facility investigation of an interview dated 6/4/18 between the Administrator, Acting Assistant Director of Nursing, and LPN #1 revealed LPN #1 stated a resident had his hands around her neck. Continued review revealed the Administrator asked if the LPN did anything inappropriate to the resident and LPN #1 stated I yelled at him to let me go. Further interview revealed the Administrator asked LPN #1 if she touched the resident in any way and she stated she had bitten the resident because I panicked and didn't know what to do because he was choking me. Continued interview revealed the Administrator clarified with LPN #1 if she bit down or put her mouth on resident hand and she said she put her mouth on his hand and her teeth did make contact with resident's hand. Further interview revealed the Administrator asked how the resident got his hands around her neck and LPN #1 stated I was behind him locking his wheelchair and he reached behind him and grabbed my throat. I didn't know how to get free. We were in the hallway and nobody was coming to help. Continued interview revealed the Administrator watched the video there were several staff members in the hallway and the description of the event did not make sense with the nurse being able to bite the resident while his hands were around her neck. Further interview revealed LPN #1 was suspended immediately. Review of facility investigation of a written statement by LPN #1 revealed I went up to the resident to help move him. I reach around the back of his wheelchair to unlock his wheels to move him when he reached backward and grabbed me by the neck. I panicked at that time and tried to release his hands from me but was unable causing me to panic further. I was at him to let go but he would not. Nobody was coming to help so I bite his hand to try and see if he would let go. He loosed his grip at that time and I was able to slip away. He had the necklace I had on in his hands so I grab the necklace and got it away from him. Interview with the Administrator and DON on 7/18/18 at 10:40 AM in the conference room revealed revealed there were no teeth marks, abrasions, or skin issues with the resident. Further interview revealed LPN #1 stated her teeth made contact with his hand because she had panicked. Continued interview revealed the Administrator terminated LPN #1 to err on the side of the resident even though she could not prove the nurse bit the resident because there were no teeth marks, but the nurse had yelled at the resident and called him a [***] which the Administrator confirmed constituted verbal abuse.",2020-09-01
564,QUALITY CENTER FOR REHABILITATION AND HEALING LLC,445154,932 BADDOUR PARKWAY,LEBANON,TN,37087,2018-10-18,802,E,1,0,J1T311,"> Based on facility document review, observation, and interview, the facility failed to deliver meal trays to residents in a timely manner resulting in late meals and cold food for 95 residents of 259 residents. The findings included: Review of the Meal Cart Order revealed breakfast trays are to be served from 6:40 AM - 8:10 AM; lunch trays are to be served from 11:10 AM - 12:40 PM; and dinner trays are to be served from 4:35 PM - 5:55 PM. Observation of tray delivery on 10/9/18 revealed trays which were supposed to be delivered to A Hall at 12:05 PM arrived at 12:25 PM; trays supposed to be delivered to B Hall at 12:20 PM arrived at 12:27 PM; trays supposed to be delivered to C Hall at 12:30 PM arrived at 12:45 PM; and trays supposed to be delivered to D Hall at 12:40 PM arrived at 12:55 PM. Observation of tray delivery on 10/17/18 revealed trays which were supposed to be delivered to A Hall at 12:05 PM arrived at 12:35 PM; trays supposed to be delivered to B Hall at 12:20 PM arrived at 12:52 PM; trays which were supposed to be delivered to C Hall at 12:30 PM arrived at 12:55 PM; and trays which were supposed to be delivered to D Hall at 12:40 PM arrived at 1:00 PM. Observation of tray delivery on 10/18/18 revealed trays which were supposed to be delivered to B Hall at 12:20 PM were delivered at 12:40 PM; trays which were to be delivered to C Hall at 12:30 PM were delivered at 12:55 PM; and trays to be delivered to D Hall were delivered at 1:07 PM. Observation of residents on the C and D Halls on 10/17/18 revealed the staff offered them fluids and snacks while they waited for lunch. Review of facility census revealed there were 25 residents on A Hall; 23 residents on B Hall; 26 residents on C Hall; and 21 residents on D Hall during the 3 observations. Observation of the food temperatures for all 3 meals for 9/2018 and 10/2018 revealed they were appropriate when the food was placed on the plates in the dietary department. Interviews with 10 residents on the A, B, C, and D halls on 10/17/18 and 10/18/18 revealed their meal trays were late frequently and sometimes the food was cool when they received their trays. Telephone interview with the complainant on 10/8/18 at 4:33 PM revealed she has had complaints for 5 months about food being delivered late. Continued interview revealed, on Memory Care, they had not received lunch at 1:15 PM and the complainant was told it would be close to 2:00 PM when they would eat. Further interview revealed the complainant asked the Administrator if the evening meal would be pushed back from 4:30 PM because they ate so late and she responded Absolutely not. They have plenty of snacks on Memory Care. And this is a one time thing. Interview with the Administrator and DON on 10/17/18 at 3:25 PM in the conference room revealed there were issues with food cart delivery. Continued interview revealed the Administrator sat in the kitchen for a day to observe the tray line and food preparation. Further interview revealed the problem was the staff did not start the tray line on time since they started it at 11:30 AM which was the time the first cart was to be delivered. Continued interview revealed the dietary staff now starts the tray line at 10:50 AM so the trays can be delivered on time. Further interview revealed there were complaints about the food being cold when it was delivered and the Administrator found the warmers in the bottom of the covered food worked but the overall plate warmers were not turned on soon enough so the bottom plates were warm but the top ones were cold. Continued interview revealed one of the dietary staff now watched the clock to alert staff how much time they have left before the next cart is due to be delivered. Further interview revealed the dietary staff is now documenting the time the carts get to the units so the Administrator can trend which halls, which meals, and which deliverer have problems. Continued interview the Administrator confirmed the times at which the trays reached the halls were not consistent with the expected times of arrival. Interview with the Dietary Manager on 10/18/18 at 10:50 AM in the conference room revealed there had been concerns with the food delivery but hours were changed in the department and she is in the kitchen making sure the tray line is started on time and trays are going out on time. Continued interview revealed often the trays sit on the halls for a while after they leave the kitchen and before they are passed to the residents. Further interview revealed the food is sent out hot; is temped before it leaves the kitchen; and the plates have a warmer and dome lid. Continued interview revealed the Dietary Manager felt the problem with residents complaining of cold food lies not with dietary but with the hall staff not passing out the trays in a timely manner.",2020-09-01
565,DIVERSICARE OF DOVER,445155,"537 SPRING STREET, PO BOX 399",DOVER,TN,37058,2020-01-09,686,D,1,0,5J8E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation, and interview, the facility failed to provide complete and weekly assessments for pressure ulcers for 1 of 3 sampled residents (Resident #2) reviewed with pressure ulcers. The findings include: The facility's undated policy titled, Skin Care Guideline, documented, .When an open area is identified .Document evaluation of wound in electronic medical record including .Location and staging .Size (length .width .depth .Weekly skin evaluations are completed and documented . Review of the medical record, showed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Plan documented, .Focus .11/23/2019 stage 2 right ankle .Interventions .Weekly Wound Assessment . The Progress Notes dated 11/22/19 documented, .resident has open area on right outer foot .measures 0.4 cm (centimeters) x (by) 1 cm . There was no stage of the pressure injury. The Progress Notes dated 12/5/19 documented, .has stage 2 pressure ulcer on right mid outer foot, white center with pink edges, no drainage . There were no measurements of the pressure injury. The Progress Notes dated 1/2/20 documented, .outer right foot .measures 0.5 cm x 0.5 cm . There was no stage of the pressure injury. The Progress Notes dated 1/6/20 documented, .wound to right outer foot is 1 cm x 1 cm . There was no stage of the pressure injury. Medical record review from 11/22/19 - 1/6/20, showed the only wound assessments performed were on 11/22/19, 12/5/19, 1/2/20, and 1/6/20. Observation in the resident's room on 12/27/19 at 10:07 AM, showed Resident #2 had 2 small open areas to the right outer foot. The facility was unable to provide documentation that weekly wound assessments and complete wound assessments with measurements and staging were performed for Resident #2's pressure injury. During an interview conducted on 12/27/19 at 12:10 PM, the Wound Care Nurse was asked about Resident #2's pressure injury on her right foot. The Wound Care Nurse stated, .started (MONTH) 23rd .one is almost healed .still working on the other spot .is a stage 2 . During a phone interview conducted on 1/9/20 at 9:30 AM, the Director of Nursing (DON) confirmed weekly wound assessments and complete wound assessments with measurements and staging were not performed and stated, .not getting assessed correctly .",2020-09-01
566,DIVERSICARE OF DOVER,445155,"537 SPRING STREET, PO BOX 399",DOVER,TN,37058,2019-08-27,759,D,0,1,HPLV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure 2 of 4 (Licensed Practical Nurse (LPN) #1 and 2) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 2 errors were observed out of 29 opportunities, resulting in an error rate of 6.89%. The findings include: 1. Medical record review revealed Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] HandiHaler Capsule 18 MCG (Microgram) .2 puff inhale orally one time a day . Observations in Resident #58's room on 8/27/19 beginning at 8:27 AM, revealed LPN #1 administered the [MEDICATION NAME] Handihaler to Resident #58. Resident #58 inhaled 1 puff and handed the Handihaler back to LPN #1. LPN #1 stated, That's right, 1 puff. Interview with the Director of Nursing (DON) on 8/27/19 at 4:38 PM, in the DON office, the DON confirmed Resident #58 should have received 2 puffs of [MEDICATION NAME]. The failure of the nurse to administer 2 puffs of the [MEDICATION NAME] resulted in medication error #1. 2. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] Suspension 50 MCG .2 spray in both nostrils one time a day . Observations in Resident #16's room on 8/27/19 at 8:44 AM, revealed LPN #2 administered [MEDICATION NAME] Suspension to Resident #16 with 1 spray to each nostril. Interview with the DON on 8/27/19 at 4:40 PM, in the DON office, the DON confirmed Resident #16 should have received 2 sprays of [MEDICATION NAME] to each nostril. The failure of the nurse to administer 2 sprays of the [MEDICATION NAME] resulted in medication error #2. Interview with the DON on 8/27/19 at 4:40 PM, in the DON office, the DON confirmed Resident #16 should have received 2 sprays of [MEDICATION NAME] to each nostril. The DON was asked if the nurses should administer medications as ordered. The DON stated, Yes, Ma'am.",2020-09-01
567,DIVERSICARE OF DOVER,445155,"537 SPRING STREET, PO BOX 399",DOVER,TN,37058,2019-08-27,880,D,0,1,HPLV11,"Based on observation and interview, the facility failed to ensure infection control practices to prevent the potential spread of infection in 1 of 1 laundry room. The findings include: Observations in the clean linen room of the laundry room on 8/26/19 at 1:35 PM, revealed a dirty empty mop bucket with a black thick substance on the top and on the bottom of the mop bucket and black thick substance on the wringer of the mop bucket. Interview with the Environmental Manager on 8/26/19 at 1:40 PM, in the clean linen room of the laundry room, the Environmental Manger was asked if the mop bucket was dirty. The Environmental Manager stated, .Yes . The Environmental Manager was asked if the dirty mop bucket should have been stored in the clean linen room. The Environmental Manager stated, No. Observations in the washing machine room of the laundry room on 8/26/19 at 1:45 PM and 2:55 PM, and on 8/27/19 at 1:45 PM and 2:55 PM, revealed an exhaust fan with thick white and gray debris stuck to the fan. The gray debris was blowing over the clean, uncovered linen. Observations in the dryer machine room of the laundry room on 8/26/19 at 1:55 PM and 3:00 PM, revealed uncovered clean dry laundry piled in wire baskets. A clean sheet was hanging out of the basket touching the floor. Interview with the Environmental Manager on 8/26/19 at 3:04 PM, in the dryer room of the laundry room, the Environmental Manager was asked if the laundry in the wire baskets was clean. The Environmental Manager stated, Yes. Observations in the clean linen room of the laundry room on 8/27/19 at 1:40 PM, revealed a dirty empty mop bucket with a black thick substance on the rim of a mop bucket and on the bottom of the mop bucket. Interview with the Environmental Manager on 8/27/19 at 2:57 PM, in the drying machine room of the laundry room, the Environmental Manager was asked if the clothes in the uncovered baskets, and if the sheet touching the floor were clean. The Environmental Manager stated, Yes . the clean clothes should be covered and not touching the floor . Interview with the Environmental Manager on 8/27/19 at 3:03 PM, in the washing machine room of the laundry room, the Environmental Manager was asked what was on the exhaust fan, and what was blowing off of the fan. The Environmental Manager stated, .it's coated with dirt and dust, shouldn't be blowing in the room .",2020-09-01
568,DIVERSICARE OF DOVER,445155,"537 SPRING STREET, PO BOX 399",DOVER,TN,37058,2017-10-04,164,D,0,1,QOES11,"Based on policy review, observation, and interview, 1 of 5 (Licensed Practical Nurse (LPN) #3) nurses failed to provide confidentiality of medical records during medication pass observations. The findings included: The facility's SAFEGUARDING PROTECTED HEALTH INFORMATION . policy documented, .Safeguards for Written Uses .C. Active Clinical Records shall not be left unattended on the nurses' station desk or other areas where residents, visitors and unauthorized individuals could easily view the records. D. Medication Administration Records, Treatment Administration Records, report sheets and other documents containing PHI (Protected Health Information) shall not be left open and/or unattended . Observations at the medication cart in front of Resident #59's room on 10/3/17 beginning at 9:10 AM, revealed LPN #3 was getting ready to prepare medications for Resident #59 with the computer screen open with resident information visible, stepped away from the medication cart and wheeled a resident down the hall. LPN #3 left the computer screen on with the resident information still visible in the hallway. LPN #3 then walked down the hall to obtain a medication and left this screen on visible again. Interview with the Director of Nursing (DON) on 10/4/17 at 9:05 AM, in the DON office, the DON was asked what should be done with the computer screen when walking away from the medication cart. The DON stated, .should close it or lock the screen.",2020-09-01
569,DIVERSICARE OF DOVER,445155,"537 SPRING STREET, PO BOX 399",DOVER,TN,37058,2017-10-04,241,D,0,1,QOES11,"Based on observation and interview, the facility failed to provide care in a manner that ensured the residents' dignity, respect, and quality of life was maintained when 1 of 10 (Certified Nursing Assistant (CNA) #1) staff members stood over a resident while assisting them to eat during dining observations. The findings included: Observations in Resident #41's room on 10/2/17 at 12:25 PM, CNA #1 stood over Resident #41 and fed the resident. Observations in Resident #43's room on 10/3/17 at 7:57 AM, CNA #1 stood over Resident #43 and fed her. Interview with the Director of Nursing (DON) on 10/3/17 at 3:50 PM, at the entrance to the Administrative office, the DON was asked if it was acceptable to stand over a resident while feeding the resident. The DON stated, No ma'am.",2020-09-01
570,DIVERSICARE OF DOVER,445155,"537 SPRING STREET, PO BOX 399",DOVER,TN,37058,2017-10-04,280,D,0,1,QOES11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to review the care plan quarterly for Behaviors, Depression, [MEDICAL CONDITION], Diabetes, [MEDICAL CONDITION] medication use, and Diuretic medication use for 1 of 14 (Resident #36) sampled residents reviewed of the 16 residents included in the Stage 2 review. The findings included: 1. Medical record review revealed Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 6/16/15 documented, .(Named Resident #35) displays sexually inappropriate behavior, and makes false allegations against staff/residents . with a goal date of 5/14/17. The care plan dated 8/8/16 documented, .Mr. (Named Resident #35) had a [DIAGNOSES REDACTED]. with a goal date of 5/14/17. The care plan dated 7/31/16 documented, .Mr. (Named Resident #35) has a DX. (diagnosis) of [MEDICAL CONDITIONS] . with a goal date of 5/14/17. The care plan dated 2/20/17 documented, .Mr. (Named Resident) has a DX of Diabetes type II and is insulin dependent and at risk for hypo/hyperglycemic (high/low blood glucose) episodes and or complications secondary to diabetes He is often non-compliant with diet . with a goal date of 5/14/17. The care plan dated 2/20/12 documented, .(Named Resident) is at risk for side effects from [MEDICAL CONDITION] medication drug use RT (related to)/Dx. of Depression . with a goal date of 5/14/17 The care plan dated 2/20/12 documented, .(Named Resident) is at risk for dehydration r/t use of diuretics . with a goal date of 5/14/17. Interview with the Minimum Data Set (MDS) Coordinator on 10/3/17 at 2:40 PM, in the MDS office, the MDS Coordinator was asked about the goal date of 5/14/17 for the care plan related to inappropriate sexual behaviors. The MDS Coordinator stated, It should have been updated on 6/13/17. The MDS Coordinator was asked if the care plan had been reviewed timely. The MDS Coordinator stated,That particular one was not . The MDS was asked about the care plan related to the [DIAGNOSES REDACTED]. The MDS Coordinator stated, It was not updated either. The MDS Coordinator was asked when it should have been reviewed . The MDS Coordinator stated, Same date 6/13/17. He is behind on his MDS. The MDS Coordinator was asked if the care plans should have another review date of 9/13/17. The MDS Coordinator stated, Yes, ma'am. The MDS Coordinator was asked about the care plan related to Diabetes Mellitus with a goal date of 5/14/17. The MDS Coordinator stated, Same case on that one. The MDS Coordinator was asked about the care plan related to [MEDICAL CONDITION] medication side effects with a goal date of 5/14/17. The MDS Coordinator stated, It is the same. The MDS Coordinator was asked about the care plan related to diuretic use with a goal date of 5/14/17. The MDS Coordinator stated, It is the same. The MDS Coordinator confirmed these care plans were not reviewed quarterly.",2020-09-01
571,DIVERSICARE OF DOVER,445155,"537 SPRING STREET, PO BOX 399",DOVER,TN,37058,2017-10-04,309,D,0,1,QOES11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide physician's orders for 1 of 1 (Resident #45) sampled resident reviewed receiving hospice and 1 of 1 (Resident #68) sampled resident reviewed receiving [MEDICAL TREATMENT] services of the sampled residents. The findings included: 1. Medical record review revealed Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The significant change Minimum Data Set (MDS) assessment dated [DATE] documented that the resident was receiving hospice care. Review of the physician orders dated 9/27/17 revealed there were no current orders for hospice. Interview with Licensed Practical Nurse (LPN) #2 on 10/3/17 at 2:48 PM, at the central nurses station, LPN #2 was asked if Resident #45 was on hospice. LPN #2 stated, Yes. LPN #2 was asked if there were current orders for hospice. LPN #2 stated, I don't see one. LPN #2 was asked if there should be current orders for hospice. LPN #2 stated, Yes. 2. Medical record review revealed Residet #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual MDS assessment dated [DATE] and the quarterly MDS dated [DATE] received [MEDICAL TREATMENT]. The care plan dated 1/27/16 documented Resident #68 required [MEDICAL TREATMENT]. Review of the physician orders for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) revealed there were no current orders for [MEDICAL TREATMENT]. Interview with the Director of Nursing (DON) on 10/3/17 at 11:35 AM, in the DON office, the DON confirmed there were no current orders for [MEDICAL TREATMENT] for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR).",2020-09-01
572,DIVERSICARE OF DOVER,445155,"537 SPRING STREET, PO BOX 399",DOVER,TN,37058,2017-10-04,431,E,0,1,QOES11,"Based on observation and interview, the facility failed to ensure medications were properly stored as evidenced by 5 of 7 (Central Nursing Station, Riverview, Dogwood Lane, Lakeview, and Riverside) Medication Storage Areas with expired medications, open and undated medications. The findings included: 1. Observations at the Central Nursing Station on 10/3/17 at 2:29 PM, revealed 1 bottle of Zinc Sulfate 220 mg (milligram), 100 tablets with an expiration date of 9/2017. 2. Observations at the Riverview Hall medication cart on 10/3/17 at 2:51 PM, revealed 1 bottle of Ranitidine syrup, 1 bottle of Nystatin elixir, and 1 bottle of Potassium liquid that were opened and not dated. 3. Observations at the Dogwood hall medication cart on 10/3/17 at 3:03 PM, revealed 1 bottle of Potassium liquid that was opened and not dated. 4. Observations at the Lakeview hall medication cart on 10/3/17 at 3:15 PM, revealed 1 bottle of Promod liquid protein opened and not dated. 5. Observations at the Riverside medication cart on 10/3/17 at 3:22 PM, revealed 1 bottle of Geri Tussin liquid, Geri Lanta liquid, and 1 bottle of Potassium that was opened and not dated. There was 1 bottle of Zinc Sulfate tablets with an expiration date of 9/2017. Interview with Registered Nurse (RN) #1 on 10/3/17 at 2:33 PM, in the Central Storage area, RN #1 was asked if it was acceptable to have expired medication in the storage area. RN #1 stated, No. Interview with Licensed Practical Nurse (LPN) #1 on 10/3/17 at 2:51 PM, at the Riverview hall medication cart, LPN #1 was asked if it was acceptable to have open and undated medication on the medication cart. LPN #1 stated, .No .it's supposed to be dated . Interview with RN #2 on 10/3/2017 at 3:03 PM, at the Dogwood medication cart, RN #2 was asked if it was acceptable to have open and undated medication on the medication cart. RN #2 stated, .No ma'am . Interview with LPN #2 on 10/3/17 at 3:22 PM, at the Riverside medication cart, LPN #2 was asked if it was acceptable to have open, undated, and expired medications on the medication cart. LPN #2 stated, .No ma'am . Interview with the Director of Nursing (DON) on 10/3/17 at 5:09 PM, in the Restorative office, the DON was asked is it acceptable to have open, undated medication, and expired medication in the medication storage areas. The DON stated, .No ma'am .",2020-09-01
573,DIVERSICARE OF DOVER,445155,"537 SPRING STREET, PO BOX 399",DOVER,TN,37058,2017-10-04,441,D,0,1,QOES11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, 1 of 5 (Licensed Practical Nurse (LPN) #4) nurses failed to follow appropriate infection control practices to prevent the potential spread of infection during medication pass observations. The findings included: The facility's Hand Hygiene Care Audit policy documented, .3. Hand washing is done every time you remove gloves .9. Washes hands every time gloves are removed . Observations at the medication cart in front of Resident #62's room on 10/3/17 beginning at 11:08 AM, revealed LPN #4 cleaned a glucometer and removed her gloves, without performing hand hygiene. LPN #4 then prepared insulin at the medication cart, went into Resident #62's room, applied gloves without performing hand hygiene, and administered insulin to Resident #62. Observations in Resident #16's room on 10/3/17 beginning at 12:39 PM, revealed LPN #4 took a nebulizer mask out of a labeled ziplock bag and there was clear solution in the reservoir. LPN #4 emptied this out into tissues, without rinsing the reservoir. LPN #4 poured the unit dose of [MEDICATION NAME] into the reservoir and administered the breathing treatment. After the breathing treatment was administered, LPN #4 dried the reservoir with a clean tissue, but did not rinse the reservoir. Interview with LPN #4 on 10/3/17 at 12:46 PM, Resident #16's room, LPN #4 was asked what the solution was that she emptied onto the tissues from the reservoir. LPN #4 stated, Was probably some ([MEDICATION NAME] solution) they had put in early this morning, not my shift. Interview with the Director of Nursing (DON) on 10/4/17 at 9:05 AM, in the DON office, the DON was asked what should be done after removing gloves and prior to donning new gloves. The DON stated, Should perform hand hygiene. The DON was asked what should be done with the nebulizer reservoir after completing a nebulizer treatment. The DON stated, Should clean and dry it.",2020-09-01
574,DIVERSICARE OF DOVER,445155,"537 SPRING STREET, PO BOX 399",DOVER,TN,37058,2017-10-04,465,E,0,1,QOES11,"Based on observation and interview, the facility failed to ensure the enviroment was in good repair, clean, and sanitary as evidenced by a soiled laundry room with dirty wet floors, foul odor, and a dirty metal double sink in 1 of 1 laundry room. The findings included: Observations in the soiled laundry room on 10/3/17 at 9:15 AM, revealed dirty wet floors with a pool of dirty water with wet towels and blankets gathered around the floor and around the metal double sink with a foul odor present. A dirty metal double sink was observed with brown discoloration in the sink, on the the sides of the sink, with scattered smears of brown and black debris, rust, and old used bandaids with strong odors present. Interview with Laundry Aide #1 on 10/3/17 at 9:15 AM, in the soiled laundry room, Laundry Aide #1 was asked what was this sink used for. Laundry Aide #1 stated, .we used a bucket and rinse resident's dirty clothes and linen in there . Interview with the Administrator on 10/3/17 at 9:30 AM, in the soiled laundry room, the Administrator was asked what was in the metal double sink. The Administrator stated, .looks like rust, bandaid, trash . The Administrator was asked what was lying around the the double metal sink. The Administrator stated, .wet blankets and towels, looks like the sink is leaking . The Administrator was asked what were the brown marks in the floor. The Administrator stated, .that is dirt, rust, and trash . The Administrator was asked if that was acceptable. The Administrator stated, No. The Administrator was asked was it sanitary to rinse out dirty linen in a sink that is leaking. The Administrator stated, No. The Administrator was asked should the sink be cleaned after each use. The Adminstrator stated, Yes. Observations in the soiled laundry room on 10/3/17 at 2:20 PM, revealed dirty water under and around the double metal sink, and brown and black particles in the double metal sink. Interview with the Housekeeping District Manager at 10/3/17 on 2:20 PM, in the soiled laundry room, the Housekeeping District Manager was asked what was in the double metal sink. The Housekeeping District Manager stated, Rust and paint. The Housekeeping District Manager was asked what was under and around the sink. The District Manager stated, .water thats leaking out of the sink, we are preparing to correct the situation . Observations in the soiled laundry room on 10/4/17 at 8:00 AM, revealed dirty water in front of the sink in the floor and on the right side of the sink in the floor. Laundry Aide #1 stated, .it still leaks on the right side of the sink, we were told not to use that side . Interview with Assistant Housekeeper #1 on 10/4/17 at 8:45 AM, at the Central Nurses station, the Assistant Housekeeper was asked if there was a hopper room on the A Hall Dogwood Lane. Assistant Housekeeper #1 stated, .we use the soiled laundry room as our hopper room to rinse out dirty linen on that hall . Interview with the Director of Nursing (DON) on 10/4/17 at 10:30 AM, in the DON office, the DON was asked how many hopper rooms does the facility have. The DON stated, We have 1 .one beside Central Nurses on B Hall, the other area we use is on A Hall .we use the double sink in the soiled laundry room to rinse out the dirty linen on the A Hall .",2020-09-01
575,DIVERSICARE OF CLAIBORNE,445156,902 BUCHANAN RD,NEW TAZEWELL,TN,37825,2018-03-21,600,K,1,0,TIWR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility investigations, review of personnel files, review of employee attendance records (time punch), and interview, the facility failed to prevent mental, physical, and verbal abuse for 6 residents (#4, #2, #3, #1, #17 and #18) of 15 residents reviewed. The facility's failure to prevent abuse resulted in psychological abuse to Resident #4 and placed Residents #4, #2, #3, #1, #17 and #18 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 was cited F 600 at a scope and severity of K, which constitutes Substandard Quality of Care (SQC). The Immediate Jeopardy was effective 2/14/18 and is ongoing. The findings included: Review of the facility's Abuse Policy effective (MONTH) (YEAR), revealed, . 'Abuse' means the willful (the individual must have acted deliberately, not that they must have intent to injury or harm) infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish .'Verbal abuse' is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to resident/patients or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident/patient .'Physical abuse' includes hitting, slapping .It also includes controlling behavior through corporal punishment .'Mental Abuse' includes but is not limited to, humiliation, harassment, threats of punishment or deprivation .'Neglect' means failure to provide goods and services necessary to avoid physical harm, mental anguish, or emotional distress .It is the policy of the center to take appropriate steps to prevent the occurrence of abuse, neglect . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15, indicating Resident #4 was moderately cognitively impaired. Continued review revealed Resident #4 required limited assistance for all Activities of Daily Living (ADLs). Medical record review of Resident #4's current Care Plan initiated on 5/15/17 indicated the resident was at risk for dehydration and was to be provided diet and liquids as ordered. Medical record review of Physician Recapitulation Orders dated (MONTH) (YEAR)-March (YEAR) revealed Resident #4 was on a regular diet and not on fluid restrictions. Review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed several team members were interviewed on 2/16/18, and Certified Nursing Assistant (CNA) #7 and CNA #2 denied seeing anything that would be considered abusive behavior toward a resident and denied witnessing any food or drink being withheld from a resident. Continued review of the facility's investigation for allegations of abuse which began on 2/16/18, revealed Licensed Practical Nurse (LPN) #1 was talking in a demeaning way and restricting drinks from Resident #4. Continued review revealed on 2/20/18, CNA #4 reported .I have not witnessed any form of abuse to any of the residents .I do not know of any instances that residents are talked to rudely .There have been several occasions that (LPN #1) told (Resident #4) that she had to come out of her room to eat .(LPN #1) also told CNAs that (Resident #4) is not allowed to have coffee. I would take it to her anyways .Anytime that (LPN #1) tells me that residents can't do or have certain things, I always check with someone else .(Resident #4) has said that she does not want to go and take a shower because every time she does (LPN #1) would raid her room and take everything out .(Resident #4) has said 'I don't understand why (LPN #1) treats me this way, if you could find out will you please let me know' .(LPN #1) will not let (Resident #2) or (Resident #4) lay in bed during the day, she tells them this is not a resort. (LPN #1) allows other residents to lie in bed throughout the day but not (Resident #2) or (Resident #4) .(LPN #1) is a good nurse but she does seem to focus on the two residents (Resident #2) and (Resident #4) . Further review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed CNA #2, who initially denied witnessing any abusive behaviors on 2/16/18, reported on 2/20/18 .(LPN #1) will not allow (Resident #4) to have (artificial sweetener) or any packet in her room. (LPN #1) recently made the rule that residents are not allowed to have coffee only at meal time. I have been sneaking and giving coffee to the residents if they ask. (Resident #4) asked the staff to find out what she did to (LPN #1) and she would try to fix it. Since (LPN #1) has been gone (Resident #4) now takes a shower . Continued review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed CNA #7 reported on 2/20/18 she was not aware of any abuse in the facility, but LPN #1 would not allow Resident #4 to keep her drinks in her room, .(Resident #4) got to where she would not come out of her room because she was afraid (LPN #1) would go into her room and take her things . Further review revealed LPN #4 reported on 2/20/18 . (LPN #1) would make me go into (Resident #4's) room and clean out her room. (LPN #1) would make me take any food item out of the room such as food, pops, creamer, sugar, cakes, pop tarts, etc. (Resident #4) got to where she would not come out of her room .Since (LPN #1) has not been here (Resident #4) now attends activities and comes out of her room more. (Resident #4) now takes a shower since (LPN #1) has been gone . Further review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed, in an interview conducted on 2/21/18 between Resident #4 and the Director of Nursing (DON), Resident #4 was crying and reported she felt like LPN #1 did not like her. Resident #4 further reported she did not leave her room while LPN #1 was working because LPN #1 would go through her stuff and when she would come out of her room to ask for a drink, LPN #1 would tell her to go back to her room. Further review revealed Resident #4 did not report it to anyone sooner because she was afraid of retaliation from LPN #1. Continued review of the facility investigation revealed the facility substantiated the allegation of abuse and terminated LPN #1. Interview with Resident #4 on 3/13/18 at 11:20 AM, in the resident's room, confirmed, .The only challenge I had .1 of the nurses was less than nice to me .(LPN #1) .she was always so mean .I asked others have I done something to her .once I had a rash and she reached across grabbed my arm and almost jerked me out of bed to look at it . Continued interview confirmed, while she was at physical therapy, .someone had ransacked my purse .garment bag .happened 2-3 times .the CNAs told me who it was .and it was (LPN #1) .it got to where I was refusing to go to physical therapy .refusing to go out to eat .I felt so violated .now that I am working out (working with physical therapy) my headaches are getting better .less intense .activities helping .and coffee .(LPN #1) would say 'you didn't eat your meal so no coffee' .went a week or two without coffee .if she was here I wouldn't come out of my room .didn't say anything initially because I didn't want to have repercussions .I honestly felt hatred from her .I asked to make a call .she just yelled and pointed 'go back to your room' . Continued interview confirmed Resident #4 told LPN #1 about her room being .ransacked . and LPN #1 responded .well is anything missing . and when Resident #4 said No LPN #1 responded .well what's the problem then . Further interview confirmed since LPN #1 had been gone, Resident #4 had been getting out of her room for meals and physical therapy. Interview with the DON on 3/14/18 at 10:40 AM, in the conference room, confirmed she was made aware of abuse allegations by LPN #1 during an interview with Resident #4 on 2/21/18. Continued interview confirmed .a lot of these girls (on the locked unit) are new .no excuse .(LPN #1's abusive behavior) was brought to my attention on the 21st .brought (Resident #4) to my office on the 21st . where Resident #4 alleged LPN #1 had restricted her fluids, verbally abused her, and made her fearful to leave her room. Further interview confirmed LPN #1 had been dealing with stress and the facility offered her counseling and .provided her with everything we (the facility) could for stress . Continued interview confirmed the facility discussed allegations of abuse in morning meetings with department heads and clinical staff, did daily rounds where she talked with staff and residents, and did not know why the staff did not report LPN #1's abusive behavior prior to her investigation. Further interview confirmed Resident #4 had been more active in therapy and the DON had noticed a difference in Resident #4's mood since LPN #1 had been terminated. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review the Quarterly MDS dated [DATE] revealed Resident #2 had a BIMS score of 6 out of a possible 15, indicating the resident was severely cognitively impaired. Continued review revealed Resident #2 required limited assistance for all ADLs except toileting, which required extensive assistance. Further review revealed Resident #2 did not have a swallowing disorder. Medical record review of Resident #2's current Care Plan initiated on 8/12/16 indicated the resident was at risk for dehydration. Continued review revealed Resident #2 was a vegetarian, under her ideal body weight, prefers to sleep late, and likes to eat paper and styrofoam. Medical record review of Physician Recapitulation Orders dated (MONTH) (YEAR)-March (YEAR) revealed Resident #2 was on a vegetarian diet, not on fluid restrictions, and was to be provided diet and liquids as ordered. Review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed several team members were interviewed on 2/16/18, and LPN #4 and CNA #2 denied seeing anything that would be considered abusive behavior toward a resident and denied witnessing any food or drink being withheld from a resident. Continued review of the facility's investigation for allegations of abuse which began on 2/16/18, revealed LPN #1 was talking in a demeaning way and restricting drinks from Resident #2. Continued review revealed on 2/20/18, CNA #4 reported .I have not witnessed any form of abuse to any of the residents .I do not know of any instances that residents are talked to rudely .Anytime that (LPN #1) tells me that residents can't do or have certain things, I always check with someone else .(LPN #1) will not let (Resident #2) or (Resident #4) lay in bed during the day, she tells them this is not a resort. (LPN #1) allows other residents to lie in bed throughout the day but not (Resident #2) or (Resident #4) .(LPN #1) is a good nurse but she does seem to focus on the two residents (Resident #2) and (Resident #4) . Further review revealed CNA #4 reported .I have seen (LPN #1) take water away from (Resident #2) and tell her she can't have it .(LPN #1) says that (Resident #2) plays in the drinking water that she is given but I have never seen her playing in it . Further review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed CNA #2, who initially denied witnessing any abusive behaviors on 2/16/18, reported on 2/20/18 .(LPN #1) screams at (Resident #2) and you can hear her yelling at her from down the hallway if you are standing at the nurse's station .(LPN #1) will yell for (Resident #2) not to do that because she knows better, to get closer to her walker, and stop screaming. (LPN #1) talks to her sternly and talks to her rudely. (LPN #1) will not allow her to have any water other than at meal times . Further review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed LPN #4, who initially denied witnessing any abusive behaviors on 2/16/18, reported on 2/19/18 .(LPN #1) talks mean to (Resident #2) .will not give (Resident #2) any water when she asks for it .understands (LPN #1) will not give her water in her room because (Resident #2) picks at her buttock and will wash her hands in her drinking water but she does not pick her buttock when she is at a table .not sure why (Resident #2) was not allowed to have water when she was in the dining room . Further review revealed in a second interview, LPN #4 reported on 2/20/18 .(Resident #2) was not allowed to have water (LPN #1) would not let her. (LPN #1) would yell at (Resident #2) and tell her to go to her room, be quiet, don't do that you know better, stand up straight, or don't do your feet like that . Continued review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed CNA #8 reported on 2/19/18 .(LPN #1) was verbally abusive to (Resident #2) .(LPN #1) is mean to her and she has seen her 'jerk her up from a chair, grab her walker' and push (Resident #2) and the walker very fast to her room . Interview with CNA #3 on 3/12/18 at 11:04 AM, in the Lighthouse Dining Room, confirmed the CNA had knowledge of the facility's abuse policies. Continued interview confirmed .One of the nurses that worked here .(LPN #1) .it's a fine line as far as verbal .she would make her (Resident #2) get out of bed .she (Resident #2) didn't want to get up .kind of thought it was abuse .thought they (Administration) knew .(Resident #2) likes to play in water .I gave it to her anyway . Continued interview confirmed CNA #3 did not report the abuse but .we've (CNAs on the Lighthouse unit) all talked about it .yeah .that's abuse .still gave it (water to Resident #2) .(continued) for 2 weeks .(LPN #1) has a stern voice . Interview with CNA #4 on 3/12/18 at 11:14 AM, in the Lighthouse Dining Room, confirmed the CNA had knowledge of the facility's abuse policies .It's not tolerated .see it stop it .remove the abuse and report it . Continued interview confirmed .(LPN#1) used to work here .she'd tell us (Resident #2) couldn't have water because she would play in it .I gave it anyway .(LPN #1) would make (Resident #2) get out of bed and come out of her room every morning .every time it happened I reported it to (Assistant Director of Nursing (ADON)) .she would just say 'ok' .happened a couple of times .I don't know what they would do or done with situation .told (DON) twice .then (LPN #1) wasn't here after that . Interview with CNA #6 on 3/13/18 at 10:27 AM, at the Lighthouse nurses' station, confirmed the CNA had knowledge of the facility abuse policy and chain of command. Continued interview confirmed she was instructed to withhold fluids from Resident #2 who .likes to wash her hands (in her drinking water) .doesn't like anything sticky . Continued interview confirmed CNA #6 .didn't tell anyone .other CNAs say they told them (Administration) before and it doesn't get fixed . Medical record review revealed Resident #3 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review the Annual MDS dated [DATE] revealed Resident #3 had a BIMS score of 12 indicating the resident was moderately cognitively impaired. Continued review revealed Resident #3 required limited assistance for all ADLs except personal hygiene, which required extensive assistance. Further review revealed Resident #3 did not have a swallowing disorder. Medical record review of Resident #3's current Care Plan initiated on 3/20/18 indicated the resident was at risk for dehydration and was to be provided diet and liquids as ordered. Medical record review of Physician Recapitulation Orders dated (MONTH) (YEAR)-March (YEAR) revealed Resident #3 was not on fluid restrictions. Review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed several team members were interviewed on 2/16/18, and LPN #4 denied seeing anything that would be considered abusive behavior toward a resident and denied witnessing any food or drink being withheld from a resident. Further review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed LPN #4, who initially denied witnessing any abusive behaviors on 2/16/18, reported on 2/20/18 .(LPN #1) would not allow (Resident #3) anything to drink other than at meal times. I would sneak and give (Resident #3) water but if (LPN #1) caught you she would make us go and take it away from the resident . Continued review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed CNA #5 reported he had not witnessed any abuse occur in the facility and had no knowledge of anyone not being allowed food or drink when the residents ask. CNA #5 continued to report Resident #3's fluids were limited per LPN #1, because she was washing out her medication (diluting her medication from drinking too much water). Interview with CNA #5 on 3/13/18 at 10:13 AM, at the Lighthouse nurses' station, confirmed .in-services (education) quarterly .go over what would be considered abuse .denying rights .deny food drink .going outside .I have not witnessed abuse .have heard about it . Continued interview confirmed he was instructed by LPN #1 to restrict fluids for Resident #3 because she was .flushing out her medication (diluting medication effects by drinking too much water) .I didn't feel well with it .I talked to other nurses .they told me that we really cannot deny that .I proceeded giving it (water) to (Resident #3) .not sure if there was a (physician's) order .I took her word for it . Continued interview confirmed he did not report an allegation of abuse to anyone .I have not talked with anyone .I trusted the nurse .I didn't really like it .but there's a lot of things in the nursing field .don't like it but do it anyway .Only happened a couple of times .month or so ago .don't remember the time period .it was a once or twice type of thing .everybody here are very good people . Review of LPN #1's Personnel File revealed LPN #1 was employed at the facility beginning 10/23/09, was placed on administrative leave on 2/20/18, and terminated on 3/8/18, following a planned medical leave initiated on 2/17/18. Continued review revealed LPN #1's last day worked was 2/16/18. Further review revealed LPN #1 completed Preventing, Recognizing, and Reporting Abuse education on 1/12/18 and Resident Rights education on 12/6/17. Continued review revealed no documentation a background check had been completed. Interview with the Administrator on 3/14/18 at 5:23 PM, in the conference room, confirmed he was made aware of abuse allegations .from a call on the hotline .it was verbally given to me .didn't have a whole lot of information at that time .first time hearing about it was on Friday (2/16/18) based on telephone call from the hotline . Continued interview confirmed .come to believe at different occasions (LPN #1) has lied to me .had to move her .it was related to interactions with other staff members . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #1's BIMS score was 3, indicating the resident was severely cognitively impaired. Continued review revealed Resident #1 required extensive 2 person physical assistance for bed mobility, transfers, dressing, bathing, and required limited assistance for eating. Medical record review of Resident #1's current Care Plan initiated on 9/22/17 indicated the resident required assistance from staff with grooming and personal hygiene, displayed socially inappropriate/disruptive behavior, and frequently yelled out. Continued review revealed interventions including .Do not argue with (Resident #1) .Discuss with (Resident #1) options for appropriate channeling of anger .Talk with (Resident #1) in calm voice when behavior is disruptive . Review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed CNA Trainee #1 witnessed CNA #1 smack Resident #1's hand twice during a shower on 2/14/18, and after Resident #1 smacked CNA #1 back, CNA #1 said .don't smack me, I smack back . Further review revealed CNA Trainee #1 reported the allegation to the Activities Director on 2/15/18. Further review revealed CNA #6 witnessed the alleged abuse of Resident #1 in the shower, but did not report it to anyone until an interview with Registered Nurse (RN) #1 on 2/16/18. Continued review revealed the facility terminated CNA #1 for violation of the facility abuse policy. Telephone interview with CNA Trainee #1 on 3/14/18 at 9:47 PM, confirmed .I was helping in shower room (on 2/14/18) .(CNA #6) was giving (Resident #1) a bath .(Resident #1) was being combative .I was holding the water sprayer and trying to block (Resident #1's) hand because she was trying to hit (CNA #6) then (CNA #1) comes in stands there for just a second .takes sprayer out of my hand and then I step back observing them give her a bath .(Resident #1) went down to touch her private area and (CNA #1) smacks her hand .(Resident #1) smacks (CNA #1) back .and then (CNA #1) smacks (Resident #1) back again and says 'don't smack me I smack back' .in a stern manner . Further interview confirmed CNA Trainee #1 stated .didn't really discuss it with (CNA #6) .I already knew I was going to make a report .don't know how (CNA #6) could not have heard it .maybe she didn't see it . Interview with CNA #6 on 3/14/18 at 9:32 AM, in the conference room, confirmed .it was me and a student (CNA Trainee #1) at the time .I could hear a slap .I can't remember if the resident reacted .I didn't say anything .I know I should have .I was kind of shocked at first .I work with her (CNA #1) every day .(ADON) came to me .I told her everything .the truth .I'm not going to lie .honestly I have no excuse .I apologized to the resident and the facility . Medical record review revealed Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #17 was severely cognitively impaired. Continued review revealed Resident #17 required extensive 2 person physical assistance for all ADLs. Medical record review of Resident #17's current Care Plan initiated on 6/2/14 indicated the resident was at risk for decline in social interaction related to Dementia and at risk for elopement. Continued review revealed Resident #17 required staff to approach resident in a positive and calm accepting manner. Medical record review of the Physician Recapitulation orders dated (MONTH) (YEAR) revealed Resident #17 was ordered an appetite stimulant by mouth twice daily to increase appetite for 30 days. Continued review revealed Resident #17 was on a pureed diet with nectar thick liquid and not on fluid restrictions. Review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed CNA Trainee #1 witnessed CNA #1 smack Resident #17's hand in the dining room on 2/14/18. Further review revealed CNA Trainee #1 reported the allegation to the Activities Director on 2/15/18. Telephone interview with CNA Trainee #1 on 3/14/18 at 9:47 PM, confirmed .(2/14/18) after breakfast .saw (CNA #1) .and she was taking lunch tray from (Resident #17) .(Resident #17) had her finger hooked into (CNA#1's) scrub pocket .(CNA #1) looked down at (Resident #17's) hand and smacked it really hard .(Resident #17) said 'oooh' .I could describe (Resident #17's) reaction as surprised .it all happened so fast .I made eye contact with (CNA #1) .(Resident #17) didn't scream or yell .was like 'ooooh' . Medical record review revealed Resident #18 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review the Quarterly MDS dated [DATE] revealed Resident #18 was severely cognitively impaired. Continued review revealed Resident #18 required extensive assistance for all ADLs and 1 person physical assistance for eating. Further review revealed Resident #18 did not have a swallowing disorder and was on a mechanically altered therapeutic diet. Medical record review of Resident #18's current Care Plan initiated on 7/13/16 indicated the resident was at risk for dehydration and required encouragement for good nutritional intake and was to be provided diet, snacks, and liquids as ordered. Continued review revealed Resident #18 had a history of [REDACTED]. Medical record review of Physician Recapitulation Orders dated (MONTH) (YEAR)-March (YEAR) revealed Resident #18 was on a pureed no added salt diet with low concentrated sweets, nectar thick liquid and not on fluid restrictions. Review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed CNA Trainee #1 witnessed CNA #1 take a food tray from Resident #18 before her meal was finished on 2/14/18, and Resident #18 became upset. Further review revealed CNA Trainee #1 reported the allegation to the Activities Director on 2/15/18. Continued review revealed the facility terminated CNA #1 for violation of the facility abuse policy. Telephone interview with CNA Trainee #1 on 3/14/18 at 9:47 PM, confirmed .(2/14/18) lunch time .(CNA #1) was taking up lunch trays .(CNA #1) took (Resident #18's) tray away from her .(Resident #18) said 'I'm not done with it' .(CNA #1) was leaning across the table and said 'you're playing, you're done' .then hands were flying .(Resident #18) was trying to get her tray .(CNA #1) appeared to go to smack at her .didn't hear or see contact. Review of CNA #1's Personnel File revealed CNA #1 was employed at the facility beginning 4/12/16, was placed on administrative leave on 2/15/18, and terminated on 2/23/18. Further review revealed CNA #1 completed Preventing, Recognizing, and Reporting Abuse education on 3/16/17. Review of CNA #1's employee attendance record ending the week of 2/21/18 revealed her last shift ended on 2/15/18 at 2:05 PM, 1 day after the allegations of abuse on 2/14/18 occurred. Interview with the ADON on 3/13/18 at 2:59 PM, in the conference room, confirmed .I was told by (LPN #5) that (CNA Trainee #1) reported (CNA #1) smacked a resident .not sure if that was the correct terminology .was not 100% sure . Interview with the Activities Director on 3/14/18 at 8:45 AM, in the conference room, confirmed .(CNA Trainee #1) went to (Activities Assistant) on 2/15/18 .then me .it happened the day before .(CNA Trainee #1) came to me on Thursday .she wasn't 100% sure if she witnessed abuse .I asked her why she did not come and report even if you thought it .she said she went home and thought about it .I then took it to .her floor supervisor (LPN #5) . Interview with RN #1 (RN responsible for the CNA Training Program) on 3/14/18 at 9:02 AM, in the conference room, confirmed, .(CNA Trainee #1) .went through the CNA class here .before they go on the floor they are trained .2 times .hand in hand when hired on and review abuse policy . Continued interview confirmed RN #1 and the ADON were investigating the hot line call allegation of abuse for LPN #1 when allegations of CNA #1's abuse were brought to their attention .I didn't know until later that night . Continued interview confirmed RN #1 had a telephone conversation with CNA Trainee #1 and was told about 3 different incidents of abuse .2 where she was sure (CNA #1) made contact . Further interview confirmed CNA #6 also witnessed abuse on the 2/14/18. Continued interview confirmed RN #1 did not ask why CNA Trainee #1 and CNA #6 did not report abuse. Further interview confirmed during her last in-service education held on 2/16/18, she felt the staff were not able to identify specific examples of abuse, such as restricting fluids, because it is .kind of a fine line . Telephone interview with CNA Trainee #1 on 3/14/18 at 9:47 PM, revealed .when you report to the person you're supposed to .it gets swept under the rug .wanted to go to the highest person .only one in her office .(DON or ADON) that's who I tried to go to first but they were not in . Interview with the DON on 3/14/18 at 10:40 AM, in the conference room, confirmed .I didn't understand it (the allegations reported by CNA Trainee #1) to be abuse at that time .I took it as a complaint .I can't remember the specifics .she could've said smacked .never asked specifics . Interview with the Administrator on 3/14/18 at 5:23 PM, in the conference room, confirmed he did not know why staff on the locked unit did not report abusive behaviors. Further interview revealed the Administrator stated, staff were educated to .observe .teach .only way you can do that is through observation .they watch videos .give you tips on how to do that .we don't have cameras .I don't know why .they have been told .they take the same education I do .3 times I had to see an abuse video .no reason why somebody wouldn't know that was abuse .",2020-09-01
576,DIVERSICARE OF CLAIBORNE,445156,902 BUCHANAN RD,NEW TAZEWELL,TN,37825,2018-03-21,609,K,1,0,TIWR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of facility investigations, medical record review, review of personnel files, and interview, the facility failed to report in a timely manner mental, physical, and verbal abuse for 6 residents (#4, #2, #3, #1, #17 and #18) of 15 residents reviewed for abuse. The facility's systematic failure to report allegations of abuse immediately to administration, and within 2 hours to the state authorities, including the State Survey Agency, as required by Federal regulations, placed Residents #4, #2, #3, #1, #17 and #18 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 was cited F 609 at a scope and severity of K, which constitutes Substandard Quality of Care (SQC). The Immediate Jeopardy is effective 2/14/18 and is ongoing. The findings included: Review of the facility's Abuse Policy effective (MONTH) (YEAR), revealed, .Purpose .Reporting and Investigation of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of resident/patient's property .It is the policy of the center to take appropriate steps to prevent the occurrence of abuse, neglect .and to insure that all alleged violations of Federal or State Laws which involve mistreatment, neglect, abuse .(alleged violations), are reported immediately to the Administrator/Director of Nursing of the center . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15, indicating Resident #4 was moderately cognitively impaired. Continued review revealed Resident #4 required limited assistance for all Activities of Daily Living (ADLs). Medical record review of Resident #4's current Care Plan initiated on 5/15/17 indicated the resident was at risk for dehydration and was to be provided diet and liquids as ordered. Medical record review of Physician Recapitulation Orders dated (MONTH) (YEAR)-March (YEAR) revealed Resident #4 was on a regular diet and not on fluid restrictions. Review of the facility's investigation for allegations of abuse which began on 2/16/18, revealed Licensed Practical Nurse (LPN) #1 was talking in a demeaning way and restricting drinks from Resident #4. Continued review revealed on 2/20/18, Certified Nursing Assistant (CNA) #4 reported .There have been several occasions that (LPN #1) told (Resident #4) that she had to come out of her room to eat .(LPN #1) also told CNAs that (Resident #4) is not allowed to have coffee .(Resident #4) has said that she does not want to go and take a shower because every time she does (LPN #1) would raid her room and take everything out .(Resident #4) has said 'I don't understand why (LPN #1) treats me this way, if you could find out will you please let me know' .(LPN #1) will not let (Resident #2) or (Resident #4) lay in bed during the day, she tells them this is not a resort. (LPN #1) allows other residents to lie in bed throughout the day but not (Resident #2) or (Resident #4) . Further review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed CNA #2 reported on 2/20/18 .(LPN #1) will not allow (Resident #4) to have (artificial sweetener) or any packet in her room. (LPN #1) recently made the rule that residents are not allowed to have coffee only at meal time .(Resident #4) asked the staff to find out what she did to (LPN #1) and she would try to fix it . Continued review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed CNA #7 reported on 2/20/18 LPN #1 would not allow Resident #4 to keep her drinks in her room, .(Resident #4) got to where she would not come out of her room because she was afraid (LPN #1) would go into her room and take her things .(LPN #1) would make me go into (Resident #4's) room and clean out her room. (LPN #1) would make me take any food item out of the room such as food, pops, creamer, sugar, cakes, pop tarts, etc. (Resident #4) got to where she would not come out of her room . Further review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed, in an interview conducted on 2/21/18 between Resident #4 and the Director of Nursing (DON), Resident #4 was crying and reported she felt like LPN #1 did not like her. Resident #4 further reported she did not leave her room while LPN #1 was working because LPN #1 would go through her stuff and when she would come out of her room to ask for a drink, LPN #1 would tell her to go back to her room. Further review revealed Resident #4 did not report it to anyone sooner because she was afraid of retaliation from LPN #1. Continued review of the facility investigation revealed the facility substantiated the allegation of abuse and terminated LPN #1. Further review revealed staff did not immediately report abuse by LPN #1 to administration. Continued review revealed after the facility became aware on 2/21/18 LPN #1 had mentally abused Resident #4, the facility did not report the abuse to the state authorities, including the State Survey Agency. Interview with the DON on 3/14/18 at 10:40 AM, in the conference room, confirmed she was made aware of abuse allegations by LPN #1 during an interview with Resident #4 on 2/21/18 where Resident #4 alleged LPN #1 had restricted her fluids, verbally abused her, and made her fearful to leave her room. Continued interview confirmed the facility discussed allegations of abuse in morning meetings with department heads and clinical staff, did daily rounds where she talked with staff and residents, and did not know why the staff did not report LPN #1's abusive behavior prior to her investigation. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review the Quarterly MDS dated [DATE] revealed Resident #2 had a BIMS score of 6 out of a possible 15, indicating the resident was severely cognitively impaired. Continued review revealed Resident #2 required limited assistance for all ADLs except toileting, which required extensive assistance. Further review revealed Resident #2 did not have a swallowing disorder. Medical record review of Resident #2's current Care Plan initiated on 8/12/16 indicated the resident was at risk for dehydration. Continued review revealed Resident #2 was a vegetarian, under her ideal body weight, prefers to sleep late, and likes to eat paper and styrofoam. Medical record review of Physician Recapitulation Orders dated (MONTH) (YEAR)-March (YEAR) revealed Resident #2 was on a vegetarian diet, not on fluid restrictions, and was to be provided diet and liquids as ordered. Review of the facility's investigation for allegations of abuse which began on 2/16/18, revealed LPN #1 was talking in a demeaning way and restricting drinks from Resident #2. Continued review revealed on 2/20/18, CNA #4 reported . (LPN #1) will not let (Resident #2) or (Resident #4) lay in bed during the day, she tells them this is not a resort. (LPN #1) allows other residents to lie in bed throughout the day but not (Resident #2) or (Resident #4) .I have seen (LPN #1) take water away from (Resident #2) and tell her she can't have it .(LPN #1) says that (Resident #2) plays in the drinking water that she is given but I have never seen her playing in it . Further review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed CNA #2 reported on 2/20/18 .(LPN #1) screams at (Resident #2) and you can hear her yelling at her from down the hallway if you are standing at the nurse's station .(LPN #1) will yell for (Resident #2) not to do that because she knows better, to get closer to her walker, and stop screaming. (LPN #1) talks to her sternly and talks to her rudely. (LPN #1) will not allow her to have any water other than at meal times . Further review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed LPN #4 reported on 2/19/18 .(LPN #1) talks mean to (Resident #2) .will not give (Resident #2) any water when she asks for it .understands (LPN #1) will not give her water in her room because (Resident #2) picks at her buttock and will wash her hands in her drinking water but she does not pick her buttock when she is at a table .not sure why (Resident #2) was not allowed to have water when she was in the dining room . Further review revealed in a second interview, LPN #4 reported on 2/20/18 .(Resident #2) was not allowed to have water (LPN #1) would not let her. (LPN #1) would yell at (Resident #2) and tell her to go to her room, be quiet, don't do that you know better, stand up straight, or don't do your feet like that . Continued review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed CNA #8 reported on 2/19/18 .(LPN #1) was verbally abusive to (Resident #2) .(LPN #1) is mean to her and she has seen her 'jerk her up from a chair, grab her walker' and push (Resident #2) and the walker very fast to her room . Further review revealed staff did not immediately report abuse by LPN #1 to administration. Continued review revealed the facility did not report the abuse of Resident #2 by LPN #1 to the state authorities, including the State Survey Agency until 2/21/18, 2 days after the facility became aware. Interview with CNA #3 on 3/12/18 at 11:04 AM, in the Lighthouse Dining Room, confirmed the CNA had knowledge of the facility's abuse policies. Continued interview confirmed .(LPN #1) would make her (Resident #2) get out of bed .she (Resident #2) didn't want to get up .kind of thought it was abuse .thought they (Administration) knew . Continued interview confirmed CNA #3 did not report the abuse but .we've (CNAs on the Lighthouse unit) all talked about it .yeah .that's abuse .(continued) for 2 weeks . Interview with CNA #4 on 3/12/18 at 11:14 AM, in the Lighthouse Dining Room, confirmed the CNA had knowledge of the facility's abuse policies .It's not tolerated .see it stop it .remove the abuse and report it . Continued interview confirmed .(LPN#1) used to work here .she'd tell us (Resident #2) couldn't have water because she would play in it .(LPN #1) would make (Resident #2) get out of bed and come out of her room every morning .every time it happened I reported it to (Assistant Director of Nursing (ADON)) .she would just say 'ok' .happened a couple of times .I don't know what they would do or done with situation .told (DON) twice . Interview with CNA #6 on 3/13/18 at 10:27 AM, at the Lighthouse nurses' station, confirmed the CNA had knowledge of the facility abuse policy and chain of command. Continued interview confirmed she was instructed to withhold fluids from Resident #2 who .likes to wash her hands (in her drinking water) .doesn't like anything sticky . Continued interview confirmed CNA #6 .didn't tell anyone .other CNAs say they told them (Administration) before and it doesn't get fixed . Medical record review revealed Resident #3 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review the Annual MDS dated [DATE] revealed Resident #3 had a BIMS score of 12 indicating the resident was moderately cognitively impaired. Continued review revealed Resident #3 required limited assistance for all ADLs except personal hygiene, which required extensive assistance. Further review revealed Resident #3 did not have a swallowing disorder. Medical record review of Resident #3's current Care Plan initiated on 3/20/18 indicated the resident was at risk for dehydration and was to be provided diet and liquids as ordered. Medical record review of Physician Recapitulation Orders dated (MONTH) (YEAR)-March (YEAR) revealed Resident #3 was not on fluid restrictions. Review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed LPN #4 reported on 2/20/18 .(LPN #1) would not allow (Resident #3) anything to drink other than at meal times. I would sneak and give (Resident #3) water but if (LPN #1) caught you she would make us go and take it away from the resident . Further review revealed staff did not immediately report abuse by LPN #1 to administration. Continued review revealed the facility did not report the abuse of Resident #3 by LPN #1 to the state authorities, including the State Survey Agency until 2/21/18, 2 days after the facility became aware. Interview with CNA #5 on 3/13/18 at 10:13 AM, at the Lighthouse nurses' station, confirmed .in-services (education) quarterly .go over what would be considered abuse .denying rights .deny food drink .going outside .I have not witnessed abuse .have heard about it . Continued interview confirmed he was instructed by LPN #1 to restrict fluids for Resident #3 because she was .flushing out her medication (diluting medication effects by drinking too much water) .I didn't feel well with it .I talked to other nurses .they told me that we really cannot deny that . Continued interview confirmed he did not report an allegation of abuse to anyone .I have not talked with anyone .I trusted the nurse .I didn't really like it .Only happened a couple of times .month or so ago .don't remember the time period .it was a once or twice type of thing . Review of LPN #1's Personnel File revealed LPN #1 was employed at the facility beginning 10/23/09, was placed on administrative leave on 2/20/18, and terminated on 3/8/18. Continued review revealed LPN #1's last day worked was 2/16/18. Interview with the Administrator on 3/14/18 at 5:23 PM, in the conference room, confirmed he was made aware of abuse allegations .from a call on the hotline .it was verbally given to me .didn't have a whole lot of information at that time .first time hearing about it was on Friday (2/16/18) based on telephone call from the hotline . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #1's BIMS score was 3, indicating the resident was severely cognitively impaired. Continued review revealed Resident #1 required extensive 2 person physical assistance for bed mobility, transfers, dressing, bathing, and required limited assistance for eating. Medical record review of Resident #1's current Care Plan initiated on 9/22/17 indicated the resident required assistance from staff with grooming and personal hygiene, displayed socially inappropriate/disruptive behavior, and frequently yelled out. Continued review revealed interventions including .Do not argue with (Resident #1) .Discuss with (Resident #1) options for appropriate channeling of anger .Talk with (Resident #1) in calm voice when behavior is disruptive . Review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed CNA Trainee #1 witnessed CNA #1 smack Resident #1's hand twice during a shower on 2/14/18, and after Resident #1 smacked CNA #1 back, CNA #1 said .don't smack me, I smack back . Further review revealed CNA Trainee #1 reported the allegation to the Activities Director on 2/15/18. Further review revealed CNA #6 witnessed the alleged abuse of Resident #1 in the shower, but did not report it to anyone until an interview with Registered Nurse (RN) #1 on 2/16/18. Continued review revealed staff did not report the abuse by CNA #1 until 2/15/18, 1 day after the abuse occurred. Further review revealed the facility did not report the abuse by CNA #1 to the state authorities, including the State Survey Agency until 2/16/18, 2 days after the abuse occurred. Telephone interview with CNA Trainee #1 on 3/14/18 at 9:47 PM, confirmed .I was helping in shower room .(CNA #6) was giving (Resident #1) a bath .(Resident #1) was being combative .I was holding the water sprayer and trying to block (Resident #1's) hand because she was trying to hit (CNA #6) then (CNA #1) comes in stands there for just a second .takes sprayer out of my hand and then I step back observing them give her a bath .(Resident #1) went down to touch her private area and (CNA #1) smacks her hand .(Resident #1) smacks (CNA #1) back .and then (CNA #1) smacks (Resident #1) back again and says 'don't smack me I smack back' .in a stern manner . Further interview confirmed CNA Trainee #1 stated .didn't really discuss it with (CNA #6) .I already knew I was going to make a report .don't know how (CNA #6) could not have heard it .maybe she didn't see it . Interview with CNA #6 on 3/14/18 at 9:32 AM, in the conference room, confirmed .it was me and a student (CNA Trainee #1) at the time .I could hear a slap .I can't remember if the resident reacted .I didn't say anything .I know I should have .(ADON) came to me .I told her everything . Medical record review revealed Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #17 was severely cognitively impaired. Continued review revealed Resident #17 required extensive 2 person physical assistance for all ADLs. Medical record review of Resident #17's current Care Plan initiated on 6/2/14 indicated the resident was at risk for decline in social interaction related to Dementia and at risk for elopement. Continued review revealed Resident #17 required staff to approach resident in a positive and calm accepting manner. Medical record review of the Physician Recapitulation orders dated (MONTH) (YEAR) revealed Resident #17 was ordered an appetite stimulant by mouth twice daily to increase appetite for 30 days. Continued review revealed Resident #17 was on a pureed diet with nectar thick liquid and not on fluid restrictions. Review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed CNA Trainee #1 witnessed CNA #1 smack Resident #17's hand in the dining room on 2/14/18. Further review revealed CNA Trainee #1 reported the allegation to the Activities Director on 2/15/18. Continued review revealed staff did not report the abuse by CNA #1 until 2/15/18, 1 day after the abuse occurred. Further review revealed the facility did not report the abuse by CNA #1 to the state authorities, including the State Survey Agency until 2/16/18, 2 days after the abuse occurred. Telephone interview with CNA Trainee #1 on 3/14/18 at 9:47 PM, confirmed .(2/14/18) after breakfast .saw (CNA #1) .and she was taking lunch tray from (Resident #17) .(Resident #17) had her finger hooked into (CNA#1's) scrub pocket .(CNA #1) looked down at (Resident #17's) hand and smacked it really hard .(Resident #17) said 'oooh' . Medical record review revealed Resident #18 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review the Quarterly MDS dated [DATE] revealed Resident #18 was severely cognitively impaired. Continued review revealed Resident #18 required extensive assistance for all ADLs and 1 person physical assistance for eating. Further review revealed Resident #18 did not have a swallowing disorder and was on a mechanically altered therapeutic diet. Medical record review of Resident #18's current Care Plan initiated on 7/13/16 indicated the resident was at risk for dehydration and required encouragement for good nutritional intake and was to be provided diet, snacks, and liquids as ordered. Continued review revealed Resident #18 had a history of [REDACTED]. Medical record review of Physician Recapitulation Orders dated (MONTH) (YEAR)-March (YEAR) revealed Resident #18 was on a pureed no added salt diet with low concentrated sweets, nectar thick liquid and not on fluid restrictions. Review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed CNA Trainee #1 witnessed CNA #1 take a food tray from Resident #18 before her meal was finished on 2/14/18, and Resident #18 became upset. Further review revealed CNA Trainee #1 reported the allegation to the Activities Director on 2/15/18. Continued review revealed staff did not report the abuse by CNA #1 until 2/15/18, 1 day after the abuse occurred. Further review revealed the facility did not report the abuse by CNA #1 to the state authorities, including the State Survey Agency until 2/16/18, 2 days after the abuse occurred. Telephone interview with CNA Trainee #1 on 3/14/18 at 9:47 PM, confirmed .(2/14/18) lunch time .(CNA #1) was taking up lunch trays .(CNA #1) took (Resident #18's) tray away from her .(Resident #18) said 'I'm not done with it' .(CNA #1) was leaning across the table and said 'you're playing, you're done' .then hands were flying .(Resident #18) was trying to get her tray .(CNA #1) appeared to go to smack at her .didn't hear or see contact. Review of CNA #1's Personnel File revealed CNA #1 was employed at the facility beginning 4/12/16, was placed on administrative leave on 2/15/18, and terminated on 2/23/18. Review of CNA #1's employee attendance record ending the week of 2/21/18 revealed her last shift ended on 2/15/18 at 2:05 PM, 1 day after the allegations of abuse on 2/14/18 occurred. Interview with the Activities Director on 3/14/18 at 8:45 AM, in the conference room, confirmed .(CNA Trainee #1) went to (Activities Assistant) on 2/15/18 .then me .it happened the day before .(CNA Trainee #1) came to me on Thursday .she wasn't 100% sure if she witnessed abuse .I asked her why she did not come and report even if you thought it .she said she went home and thought about it . Interview with RN #1 (RN responsible for the CNA Training Program) on 3/14/18 at 9:02 AM, in the conference room, confirmed, .(CNA Trainee #1) .went through the CNA class here .before they go on the floor they are trained .2 times . Continued interview confirmed RN #1 and the ADON were investigating the hot line call allegation of abuse for LPN #1 when allegations of CNA #1's abuse were brought to their attention .I didn't know until later that night . Continued interview confirmed RN #1 had a telephone conversation with CNA Trainee #1 and was told about 3 different incidents of abuse .2 where she was sure (CNA #1) made contact . Further interview confirmed CNA #6 also witnessed abuse on the 2/14/18. Continued interview confirmed RN #1 did not ask why CNA Trainee #1 and CNA #6 did not report abuse. Telephone interview with CNA Trainee #1 on 3/14/18 at 9:47 PM, confirmed she did not report CNA #1's abuse immediately because .had to get my daughter from daycare, so I left and went home and knew I was working again the next day .that's when I reported it . Continued interview confirmed she did not know why she did not report it immediately stating .Honestly no, I don't know .we were really busy .I was a little bit nervous .hadn't been there very long .only on the floor a week or two .whenever this happened .made the report with a woman .I don't know her name .the very next day (RN #1) called me for more information .wanted to go to the highest person I could .there's been a lot of talk .when you report to the person you're supposed to .it gets swept under the rug .wanted to go to the highest person .only one in her office .(DON or ADON) that's who I tried to go to first but they were not in . Interview with the DON on 3/14/18, at 10:40 AM, in the conference room confirmed .(ADON) tried calling me on the 15th at night .I was picking up my grandson .was out of cell service at that point in time .at 8:30 PM-9:00 PM I was made aware of reports of inappropriate treatment .didn't write down when I was called .I didn't tell (ADON) to report it (the State Survey Agency) .I didn't understand it to be abuse at that time .I took it as a complaint .we reported it (the State Survey Agency) .on the 16th .got a hotline call too .on the 16th .started investigation Interview with DON on 3/20/18 at 12:50 PM, in the conference room, confirmed she did not know why staff did not immediately report LPN #1's abuse to administration. Continued interview confirmed the facility did not report the allegation of abuse for Resident #2 and #3 by LPN #1 to the to the state authorities, including the State Survey Agency until 2/21/18, 2 days after the facility became aware. Further interview confirmed the facility did not report the allegation of abuse to the State Authorities including the State Survey Agency for Resident #4 by LPN #1 after they became aware on 2/19/18. Continued interview confirmed the facility failed to follow their abuse policy. Refer to F-600",2020-09-01
577,DIVERSICARE OF CLAIBORNE,445156,902 BUCHANAN RD,NEW TAZEWELL,TN,37825,2018-03-21,835,K,1,0,TIWR11,"> Based on facility policy review, review of facility investigations, and interview, the Administer failed to ensure residents were free from mental, physical, and verbal abuse; to ensure allegations of abuse were reported immediately to facility administration and within two hours to State Authorities, including the State Survey Agency; and to ensure facility training was implemented to prevent abuse. The Administrator's failure placed 6 residents (#4, #2, #3, #1, #17, #18) 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 Immediate Jeopardy is effective 2/14/18 and was removed 3/21/18. The facility provided an acceptable Allegation of Compliance (AoC), with a compliance date of 3/21/18, and a revisit survey conducted 4/9/18 - 4/10/18 validated the corrective actions implemented by the facility removed the Immediacy of the Jeopardy. Noncompliance continues for F-835 at an [NAME] level for the facility's monitoring of the effectiveness of corrective actions in order to ensure sustained compliance and evaluation of the processes implemented by the facility. The findings included: Review of the facility's Abuse Policy effective (MONTH) (YEAR), revealed, .Purpose .Reporting and Investigation of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of unknown Source and Misappropriation of resident/ patient's property .'Abuse' means the willful (the individual must have acted deliberately, not that they must have intent to injury or harm) infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish .'Verbal abuse' is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to resident/ patients or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident/ patient .'Physical abuse' includes hitting, slapping .It also includes controlling behavior through corporal punishment .'Mental Abuse' includes but is not limited to, humiliation, harassment, threats of punishment or deprivation .'Neglect' means failure to provide goods and services necessary to avoid physical harm, mental anguish, or emotional distress .It is the policy of the center to take appropriate steps to prevent the occurrence of abuse, neglect .and to insure that all alleged violations of Federal or State Laws which involve mistreatment, neglect, abuse .( alleged violations), are reported immediately to the Administrator/ Director of Nursing of the center. Review of the facility's investigation for allegations of abuse which began on 2/16/18, revealed on 2/14/18, Certified Nursing Assistant (CNA) #1 physically abused Residents #1 and #17 and removed a food tray from Resident #18 who had not finished her meal. Continued review revealed staff witnessed the abuse and did not report the abuse by CNA #1 until 2/15/18, 1 day after the abuse occurred. Further review revealed the facility did not report the abuse by CNA #1 to the State Survey Agency until 2/16/18, 2 days after the abuse occurred. Continued review revealed the facility became aware on 2/19/18 that Licensed Practical Nurse (LPN) #1 was instructing staff to withhold fluids from Residents #2, #3, and #4 and staff witnessed LPN #1 verbally abusing Resident #2 and #4. Further review revealed staff did not immediately report abuse by LPN #1 to administration. Continued review revealed the facility did not report the abuse of Resident #2 and #3 by LPN #1 to State Authorities, including the State Survey Agency until 2/21/18, 2 days after the facility became aware. Continued review revealed after the facility became aware on 2/21/18 LPN #1 had mentally abused Resident #4, the facility did not report the abuse to the State Authority. Interviews with CNA #3, CNA #4, CNA #5, CNA #6 on 3/12/18 and 3/13/18 revealed they all witnessed actions by LPN #1 that met the facility's definitions of abuse but did not stop the LPN from abusing residents and did not report the LPN's actions to administration. Interviews with CNA #4 and CNA #6 revealed they did not report abuse to administrative staff because they thought facility administration did not act on allegations of abuse. Interview with Registered Nurse (RN) #1 (RN responsible for the CNA Training Program) on 3/14/18, at 9:02 AM, in the conference room confirmed, RN #1 had a telephone conversation with (CNA Trainee #1) and was told about 3 different incidents of abuse .2 where she was sure (CNA #1) made contact . Further interview confirmed CNA #6 also witnessed abuse on the 2/14/18. Continued interview confirmed RN #1 did not ask why CNA Trainee #1 and CNA #6 did not report abuse. Further interview confirmed during her last in-service education held on 2/16/18 she felt the staff were not able to identify specific examples of abuse such as restricting fluids because it is .kind of a fine line . Continued interview confirmed she had discussions with staff about abuse but had .nothing in writing . Interview with CNA #6 on 3/14/18, at 9:32 AM in the conference room confirmed she and CNA Trainee #1 witnessed CNA #1 slap Resident #1. CNA #6 stated .I didn't say anything .I know I should have . Telephone interview with CNA Trainee #1 on 3/14/18 at 9:47 PM, confirmed she witnessed CNA #1 slap Resident #17's hand and Resident #1's hand on separate occasions. Further interview confirmed CNA Trainee #1 was trained on abuse, and did not report it immediately because .had to get my daughter from daycare, so I left and went home and knew I was working again the next day .that's when I reported it . Continued interview confirmed she did not know why she did not report it immediately stating . when you report to the person you're supposed to .it gets swept under the rug . Interview with the Administrator on 3/14/18 at 5:23 PM, in the conference room, confirmed he was made aware of abuse allegations .from a call on the hotline .it was verbally given to me .didn't have a whole lot of information at that time .first time hearing about it was on Friday (2/16/18) based on telephone call from the hotline . Further interview confirmed he did not know why staff on the locked unit did not report abusive behaviors .observe .teach .only way you can do that is through observation .they watch videos .give you tips on how to do that .I don't know why .they have been told .they take the same education I do .3 times I had to see an abuse video .no reason why somebody wouldn't know that was abuse . Interview with the DON on 3/20/18 at 12:41 PM, in the conference room, confirmed the DON was aware of alleged abuse on 2/15/18 and did not start an investigation until 2/16/18. Interview confirmed the DON was aware on 2/19/18 of an ongoing concern with staff understanding of abuse and reporting, but no change was implemented to correct the issue. Telephone interview with the Administrator on 3/21/18 at 8:42 AM, confirmed the Administrator identified a concern with staff understanding and reporting abuse on 2/16/18, but no change had been implemented. Refer to F-600 (K); F-609 (K); F-841 (K); F-867 (K); F-943 (K). Validation of the AoC was completed 4/9/18 - 4/10/18 through review of facility documentation, observations, and interviews. Surveyors verified the AoC by: 1. Review of the facility's documentation revealed leadership staff conducted interviews with 100% of all alert and oriented residents with on 3/15/18 as part of their investigation for allegations of abuse. Continued review revealed there were no concerns on 3/15/18 regarding any further allegation of abuse. 2. Review of the facility education log book ensuring that 100% of all staff, including contract employees, was educated by the Activity Director, Director of Clinical Education, and Human Resource Director utilizing the Team Member Interview Tool was completed on 3/21/18. Education occurred between 3/15/18 - 3/21/18. Further review revealed 100% of staff were educated on the facility abuse policy and completed an interactive posttest with a score of 100% on 3/21/18, with the exception of 1 staff member who was unavailable. The staff member was educated on 3/21/18 via telephone by Director of Nursing and was not permitted to work until completion of the interactive posttest which was completed on 3/23/18. Review of the Team Member Interview Tool, posttest, and interviews with the facility leadership staff on 4/9/18 and 4/10/18 confirmed 100% of the active staff had been educated on abuse and facility policies by 3/21/18. 3. Review of the facility's Skin and Body Audit documentation revealed all residents underwent a body audit on 3/15/18, completed by the MDS Coordinators, Wound Care Nurse, ADON, and Unit Manager and no concerns related to abuse were identified. 4. Review of facility documentation revealed every resident representative was contacted either in person or by phone to determine if the resident they represented had ever been abused or ever witnessed abuse at the facility. Further review revealed the Activity Director completed the interviews of 60 out of the 82 resident representatives on 3/15/18, 22 representatives did not return the facility's 2 contact attempts. 5. Review of facility documentation revealed every resident representative was mailed information including a summary of Resident Rights, name and telephone number of the local Ombudsman, education regarding abuse and how to report abuse, and facility's Care Line number and website. 6. Review of facility in-service documentation revealed the Governing Body was provided education by the Regional Vice President (RVP) regarding clarification of the facility abuse policy and Abuse Coordinator on 3/15/18 at 9:00 AM. Interviews conducted on 4/9/18 and 4/10/18 with the Governing Body confirmed knowledge of the facility abuse policy, state, and federal regulations for reporting abuse, and the role of the abuse coordinator. 7. Review of facility in-service documentation revealed the Medical Director was provided education by the administrator on 3/28/18 regarding his roles and responsibilities. Telephone interview with the Medical Director on 4/10/18, at 10:50 AM confirmed knowledge of the facility abuse policy and his responsibilities. Further interview confirmed has been in attendance for QAPI meetings on 3/14/18 and 3/21/18, and has given the facility recommendations for educating staff on the importance of abuse and abuse reporting, as verified in meeting minutes. 8. Review of facility orientation packet revealed the addition of a new 50 question Abuse Test and Abuse Education Posttest. Interviews with the facility leadership on 4/9/18 and 4/10/18 confirmed the education will be verified by the DON or a Registered Nurse before staff can provide direct patient care. 9. Review of the Resident Council Meeting Minutes dated 3/16/18 and interview with the Resident Council President on 4/9/18, at 3:05 PM, in the dining hall confirmed all 20 residents in attendance were educated on Resident Rights and abuse. Interviews conducted on 4/9/18 and 4/10/18 with 4 cognitively intact residents who did not attend the resident council meeting on 3/16/18 confirmed they were recently informed of their rights and abuse by facility staff. 10. Review the facility log book of continuing audits which began on 3/15/18 included interviews with 10 staff members per week regarding abuse and abuse reporting and will continue every week for 8 weeks. Interview with the RVP on 4/10/18 at 12:50 PM confirmed the weekly audits will continue after the 8 weeks, as long as they are needed, but no less than quarterly. Observation on 4/9/18 at 10:30 PM revealed the Clinical Educator and ADON were conducting staff interviews as part of the facility audit process in relation to abuse and abuse reporting. 11. Review of the facility Quality Assurance Performance Improvement (QAPI) meeting minutes dated 3/14/18, 3/21/18, 3/27/18, and 3/29/18, revealed the facility continued to review audits regarding staff knowledge of abuse and abuse reporting. 12. Observation on 4/9/18 and 4/10/18 revealed the RVP and Director of Clinical Operations were present at the facility. 13. Verification through interviews with 5 contracted Housekeeping and Physical Therapy employees was conducted during the revisit survey on 4/9/18 to confirm the staff's understanding of facility policies for abuse and abuse reporting. 14. Verification through interviews with 1st shift licensed nurses and Certified Nurse Assistants (CNAs) was conducted during the revisit survey on 4/9/18 between 10:00 AM and 2:45 PM to confirm the staff's understanding of abuse and abuse prohibition. 15. Verification through interviews with 2st shift licensed nurses and CNAs was conducted during the revisit survey on 4/9/18 between 2:00 PM and 4:00 PM to confirm the staff's understanding of abuse and abuse prohibition. 16. Verification through interviews with 3st shift licensed nurses and CNAs was conducted during the revisit survey on 4/9/18 between 10:00 PM and 11:30 PM to confirm the staff's understanding of abuse and abuse prohibition. 17. Verification through interviews with Leadership Staff, including the Medical Director and RVP, on 4/9/18 and 4/10/18 were conducted to confirm understanding of the facility's abuse policy, their role and responsibility in ensuring resident safety, abuse reporting, and the facility's system for monitoring compliance. 18. Interviews were conducted with 8 residents during the revisit survey on 4/9/18 and 4/10/18 revealed no residents had concerns about being abused or seeing any other resident being abused. 19. Attempts made to contact 3 resident representatives with 1 successful interview on 4/10/18 at 2:31 PM revealed no concerns regarding abuse or witnessed abuse. Further interview confirmed the representative was recently educated by facility staff on abuse and how to report abuse. 20. During the revisit survey conducted on 4/9/18 and 4/10/18, the facility was made aware of an allegation of neglect by a family member of a former resident. The facility followed state and federal regulations in reporting the allegation of neglect in a timely manner.",2020-09-01
578,DIVERSICARE OF CLAIBORNE,445156,902 BUCHANAN RD,NEW TAZEWELL,TN,37825,2018-03-21,841,K,1,0,TIWR11,"> Based on facility policy review, review of facility investigations, Quality Assurance and Performance Improvement (QAPI) committee documentation, and interview, the Medical Director failed to participate in the implementation of resident care policies to ensure all residents were protected from abuse. The Medical Director's failure placed 6 residents (#4, #2, #3, #1, #17, #18) 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 IJ was effective on 2/14/18 and is ongoing. The findings included: Review of the facility's Abuse Policy effective (MONTH) (YEAR), revealed, .Purpose .Reporting and Investigation of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of unknown Source and Misappropriation of resident/ patient's property .'Abuse' means the willful (the individual must have acted deliberately, not that they must have intent to injury or harm) infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish .'Verbal abuse' is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to resident/ patients or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident/ patient .'Physical abuse' includes hitting, slapping .It also includes controlling behavior through corporal punishment .'Mental Abuse' includes but is not limited to, humiliation, harassment, threats of punishment or deprivation .'Neglect' means failure to provide goods and services necessary to avoid physical harm, mental anguish, or emotional distress .It is the policy of the center to take appropriate steps to prevent the occurrence of abuse, neglect .and to insure that all alleged violations of Federal or State Laws which involve mistreatment, neglect, abuse .( alleged violations), are reported immediately to the Administrator/ Director of Nursing of the center . Review of the facility's investigation for allegations of abuse which began on 2/16/18, revealed on 2/14/18, Certified Nursing Assistant (CNA) #1 physically abused Resident #1 and #17 and removed a food tray from Resident #18 who had not finished her meal. Continued review revealed staff wtinessed the abuse and did not report the abuse by CNA #1 until 2/15/18, 1 day after the abuse occurred. Continued review revealed the facility became aware on 2/19/18 that Licensed Practical Nurse (LPN) #1 was instructing staff to withhold fluids from Residents #2, #3, and #4 and staff witnessed LPN #1 verbally abusing Resident #2 and #4. Further review revealed staff did not immediately report abuse by LPN #1 to administration. Review of facility Quality Assurance and Process Improvement Meeting (QAPI) meeting minutes dated 2/21/18 revealed the Medical Director attended the QAPI meeting. Telephone interview with the Medical Director on 3/21/18 at 9:12 AM, confirmed he had been made aware of residents not being provided water and he reviewed labs for those residents. Continued interview revealed the Medical Director was a member of the QAPI program and stated he had knowledge of .a couple of staff fired due to abuse . The Medical Director stated he had no further input, other than the medical assessment, into any other facility changes or updates to facility policy as a result of alleged abuse. The Medical Director stated, .I leave that up to them . Refer to F-600 (K); F-609 (K); F-867 (K); F-943 (K).",2020-09-01
579,DIVERSICARE OF CLAIBORNE,445156,902 BUCHANAN RD,NEW TAZEWELL,TN,37825,2018-03-21,867,K,1,0,TIWR11,"> Based on facility policy review, review of facility investigations, review of Quality Assurance and Performance Improvement (QAPI) meeting documentation, and interview, the QAPI committee failed to identify and report abuse, as well as, implement corrective action plans to prevent abuse. The QAPI's failure placed 6 residents (#4, #2, #3, #1, #17, #18) 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 IJ was effective on 2/14/18 and is ongoing. The findings included: Review of the facility's Abuse Policy effective (MONTH) (YEAR), revealed, .Purpose .Reporting and Investigation of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of unknown Source and Misappropriation of resident/ patient's property .'Abuse' means the willful (the individual must have acted deliberately, not that they must have intent to injury or harm) infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish .'Verbal abuse' is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to resident/ patients or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident/ patient .'Physical abuse' includes hitting, slapping .It also includes controlling behavior through corporal punishment .'Mental Abuse' includes but is not limited to, humiliation, harassment, threats of punishment or deprivation .'Neglect' means failure to provide goods and services necessary to avoid physical harm, mental anguish, or emotional distress .It is the policy of the center to take appropriate steps to prevent the occurrence of abuse, neglect .and to insure that all alleged violations of Federal or State Laws which involve mistreatment, neglect, abuse .( alleged violations), are reported immediately to the Administrator/ Director of Nursing of the center . Review of the facility's investigation for allegations of abuse which began on 2/16/18, revealed on 2/14/18, Certified Nursing Assistant (CNA) #1 physically abused Resident #1 and #17 and removed a food tray from Resident #18 who had not finished her meal. Continued review revealed staff witnessed the abuse and did not report the abuse by CNA #1 until 2/15/18, 1 day after the abuse occurred. Further review revealed the facility did not report the abuse by CNA #1 to state authorities, including the State Survey Agency until 2/16/18, 2 days after the abuse occurred. Continued review revealed the facility became aware on 2/19/18 that Licensed Practical Nurse (LPN) #1 was instructing staff to withhold fluids from Residents #2, #3, and #4 and staff witnessed LPN #1 verbally abusing Resident #2 and #4. Further review revealed staff did not immediately report abuse by LPN #1 to administration. Continued review revealed the facility did not report the abuse of Resident #2 and #3 by LPN #1 to state authorities, including the State Survey Agency until 2/21/18, 2 days after the facility became aware. Continued review revealed after the facility became aware on 2/21/18 LPN #1 had mentally abused Resident #4, the facility did not report the abuse to state authorities, including the State Survey Agency. Interview with the Director of Nursing (DON) on 3/20/18 at 12:41 PM, in the conference room, confirmed the DON was aware of alleged abuse on 2/15/18 and did not start an investigation until 2/16/18. Interview confirmed the DON was aware on 2/19/18 of an ongoing concern with staff understanding of what constituted abuse and staff reporting of abuse. Interview with the DON on 3/20/18 at 12:48 PM, in the conference room, and review of the QAPI meeting attendees and meeting minutes, confirmed the DON was part of the QAPI team and a meeting was held on 2/21/18. During the QAPI meeting the identified concern with staff understanding and reporting of abuse was not brought to QAPI for discussion and implementation of a corrective action plan. Telephone interview with the Administrator on 3/21/18 at 8:42 AM, confirmed the Administrator identified a concern with staff understanding and reporting abuse on 2/16/18. Review of the QAPI meeting minutes with the Administrator on 3/21/18 at 8:48 AM, by phone, confirmed the Administrator was part of the QAPI team and attended the meeting held on 2/21/18. The Administrator confirmed the concern of staff understanding and reporting of abuse was not discussed in QAPI for implementation of a corrective action plan. Refer to F-600 (K); F-609 (K); F-835 (K); F-841 (K); F-943 (K).",2020-09-01
580,DIVERSICARE OF CLAIBORNE,445156,902 BUCHANAN RD,NEW TAZEWELL,TN,37825,2018-03-21,943,K,1,0,TIWR11,"> Based on review of facility investigation, review of facility abuse training documentation, review of personnel files, and interview, the facility failed to implement an effective training program for staff on the prohibition and reporting of all forms of abuse and neglect. The facility's systematic failure placed 6 Residents (#4, #1, #2, #3, #17, and #18) 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 Immediate Jeopardy was effective 2/14/18 and is ongoing. The findings included: Review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed on 2/20/18, Certified Nursing Assistant (CNA) #4 reported .I have not witnessed any form of abuse to any of the residents .I do not know of any instances that residents are talked to rudely .There have been several occasions that (Licensed Practical Nurse (LPN) #1) told (Resident #4) that she had to come out of her room to eat .(LPN #1) also told CNAs that (Resident #4) is not allowed to have coffee. I would take it to her anyways .(Resident #4) has said that she does not want to go and take a shower because every time she does (LPN #1) would raid her room and take everything out .(Resident #4) has said 'I don't understand why (LPN #1) treats me this way, if you could find out will you please let me know' .(LPN #1) will not let (Resident #2) or (Resident #4) lay in bed during the day, she tells them this is not a resort. (LPN #1) allows other residents to lie in bed throughout the day but not (Resident #2) or (Resident #4) .I have seen (LPN #1) take water away from (Resident #2) and tell her she can't have it .(LPN #1) says that (Resident #2) plays in the drinking water that she is given but I have never seen her playing in it . Further review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed CNA #2, who initially denied witnessing any abusive behaviors on 2/16/18, reported on 2/20/18 .(LPN #1) will not allow (Resident #4) to have (artificial sweetener) or any packet in her room. (LPN #1) recently made the rule that residents are not allowed to have coffee only at meal time. I have been sneaking and giving coffee to the residents if they ask. (Resident #4) asked the staff to find out what she did to (LPN #1) and she would try to fix it. Since (LPN #1) has been gone (Resident #4) now takes a shower .(LPN #1) screams at (Resident #2) and you can hear her yelling at her from down the hallway if you are standing at the nurse's station .(LPN #1) will yell for (Resident #2) not to do that because she knows better, to get closer to her walker, and stop screaming. (LPN #1) talks to (Resident #2) sternly and talks to her rudely. (LPN #1) will not allow (Resident #2) to have any water other than at meal times . Further review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed CNA #7 reported on 2/20/18 she was not aware of any abuse in the facility but LPN #1 would not allow Resident #4 to keep her drinks in her room, .(Resident #4) got to where she would not come out of her room because she was afraid (LPN #1) would go into her room and take her things . Further review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed LPN #4 initially denied witnessing anything she considered abuse on 2/16/18 but reported on 2/19/18 . (LPN #1) would make me go into (Resident #4's) room and clean out her room. (LPN #1) would make me take any food item out of the room such as food, pops, creamer, sugar, cakes, pop tarts, etc. (Resident #4) got to where she would not come out of her room .Since (LPN #1) has not been here (Resident #4) now attends activities and comes out of her room more. (Resident #4) now takes a shower since (LPN #1) has been gone . Continued review revealed on 2/19/18, LPN #4 reported .(LPN #1) talks mean to (Resident #2) . will not give (Resident #2) any water when she asks for it .understands (LPN #1) will not give her water in her room because (Resident #2) picks at her buttock and will wash her hands in her drinking water but she does not pick her buttock when she is at a table .not sure why (Resident #2) was not allowed to have water when she was in the dining room . Continued review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed on 2/20/18 CNA #5 reported he had not witnessed any abuse occur in the facility and had no knowledge of anyone not being allowed food or drink when they asked. CNA #5 continued to report Resident #3's fluids were limited per LPN #1, because she was washing out her medication (diluted medication effects from drinking too much water). Further review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed in an interview conducted on 2/21/18, between Resident #4 and the Director of Nursing (DON), Resident #4 was crying and reported she felt like LPN #1 did not like her. Resident #4 further reported she did not leave her room while LPN #1 was working because LPN #1 would go through her stuff and when she would come out of her room to ask for a drink, LPN #1 would tell her to go back to her room. Further review of the facility abuse investigation initiated on 2/16/18 revealed on 2/14/18, CNA Trainee #1 witnessed CNA #1 smack Resident #17's hand in the dining room, took a food tray from Resident #18 before her meal was finished, and smacked Resident #1's hand twice during a shower. Continued review revealed CNA Trainee #1 reported CNA #1 saying to Resident #1 in the shower after Resident #1 smacked CNA #1 .don't smack me, I smack back . Further review revealed CNA Trainee #1 reported the allegation to the Activities Director on 2/15/18. Further review revealed CNA #6 witnessed the shower allegation but did not report it to anyone until an interview with Registered Nurse (RN) #1 on 2/16/18. Review of the facility's required education orientation revealed it consisted of review of the facility's abuse policy and Hand in Hand training. Continued review revealed an annual computer based training course Preventing, Recognizing, and Reporting Abuse which included definitions of abuse, how to report abuse, scenarios regarding abuse, and a post test. Review of LPN #1's Personnel File revealed LPN #1 was hired on 10/23/09, started a planned medical leave on 2/17/18, was placed on administrative leave on 2/20/18, and terminated on 3/8/18. Continued review revealed LPN #1's last day worked was 2/16/18. Further review revealed LPN #1 completed the required Preventing, Recognizing, and Reporting Abuse education on 1/12/18. Review of CNA #1's Personnel File revealed CNA #1 was hired on 4/12/16, was placed on administrative leave on 2/15/18, and terminated on 2/23/18. Further review revealed CNA #1 completed the required Preventing, Recognizing, and Reporting Abuse education on 3/16/17. Review of CNA Trainee #1's Personnel File revealed CNA Trainee #1 was hired on 1/22/18 and had not started the Preventing, Recognizing, and Reporting Abuse computer based education prior to working on the unit but completed the required abuse training provided in orientation. Interview with CNA #3 on 3/12/18, at 11:04 AM, in the Lighthouse Dining Room confirmed .One of the nurses that worked here .(LPN #1) .it's a fine line as far as verbal .she would make her (Resident #2) get out of bed .she didn't want to get up .make her get up .kind of thought it was abuse .thought they (Administration) knew .(Resident #2) likes to play in water .I gave it to her anyway Continued interview confirmed CNA #3 did not report the abuse but .we've (CNAs on the Lighthouse unit) all talked about it .yeah .that's abuse .still gave it (water to Resident #2) .(went on) for 2 weeks .(LPN #1) has a stern voice . Review of CNA #3's education documentation revealed CNA #3 completed the facility required computer based training Preventing, Recognizing, and Reporting Abuse on 1/4/18. Interview with CNA #4 on 3/12/18, at 11:14 AM in the Lighthouse Dining Room confirmed abuse .It's not tolerated .see it stop it .remove the abuse and report it . Continued interview confirmed .(LPN#1) used to work here .she'd tell us (Resident #2) couldn't have water .because she would play in it .I gave anyway .(LPN #1) would make (Resident #2) get out of bed and come out of her room every morning .every time it happened I reported it to (Assistant Director of Nursing (ADON)) .she would just say 'ok' .happened a couple of times .I don't know what they would do or done with situation .told (DON) twice .then (LPN #1) wasn't here after that . Review of CNA #4's education documentation revealed CNA #4 completed the facility required computer based training Preventing, Recognizing, and Reporting Abuse on 1/12/18. Interview with CNA #5 on 3/13/18, at 10:13 AM, at Lighthouse nurses' station confirmed .in-services (education) quarterly .go over what would be considered abuse .denying rights .deny food drink .going outside .I have not witnessed abuse .have heard . Continued interview confirmed he was instructed by LPN #1 to restrict fluids for Resident #3 because she was .flushing out her medication (diluting medication from drinking too much water) .I didn't feel well with it .I talked to other nurses .they told me that we really cannot deny that (water) .I proceeded giving it to her .not sure if there was a (physician's) order .I took her word for it . Continued interview confirmed he did not report (allegations of abuse) to anyone .I have not talked with anyone .I trusted the nurse .I didn't really like it .but there's a lot of things in the nursing field .don't like it but do it anyway .Only happened a couple of times .month or so ago .don't remember the time period .it was a once or twice type of thing .everybody here are very good people . Review of CNA #5's education documentation revealed CNA #5 completed the facility required computer based training Preventing, Recognizing, and Reporting Abuse on 1/12/18. Interview with CNA #6 on 3/13/18, at 10:27 AM, at the Lighthouse nurss' station confirmed she was instructed to withhold fluids from Resident #2 who .likes to wash her hands (in her drinking water) .doesn't like anything sticky . Continued interview confirmed CNA #6 .didn't tell anyone .other CNA's say they told them before and it doesn't get fixed . Review of CNA #6's education documentation revealed CNA #6 completed the facility required computer based training Preventing, Recognizing, and Reporting Abuse on 1/12/18. Interview with the Activities Director on 3/14/18, 8:45 AM in the conference room confirmed .(CNA Trainee #1) went to (Activities Assistant) on 2/15/18 .then me .it happened the day before .(CNA Trainee #1) came to me on Thursday .she wasn't 100% sure if she witnessed abuse .I asked her why she did not come and report even if you she thought it .she said she went home and thought about it .I then took it to .her floor supervisor (LPN #5) .did not report it to (the administrator) .reported it to her supervisor . Interview with RN #1 on 3/14/18, at 9:02 AM, in the conference room confirmed, .(CNA Trainee #1) .went through the CNA class here .before they go on the floor they are trained .2 times .hand in hand when hired on and review abuse policy .do (computer based) training .usually go around .in-services .reviewing with them different types of abuse and how to report it .when just reviewing .go over the policy .in classes more in depth . Continued interview confirmed RN #1 had a telephone conversation with (CNA Trainee #1) and was told about 3 different incidents of abuse .2 where she was sure (CNA #1) made contact . Further interview confirmed CNA #6 also witnessed abuse on the 2/14/18. Further interview confirmed during her last in-service education held on 2/16/18 she felt the staff were not able to identify specific examples of abuse such as restricting fluids because it is .kind of a fine line . Continued interview confirmed she had discussions with staff about abuse but had .nothing in writing . Interview with CNA #6 on 3/14/18, at 9:32 AM in the conference room confirmed .it was me and a student at the time .I could hear slap .I don't think she said anything .I can't remember if the resident reacted .I didn't say anything .I know I should have .I was kind of shocked at first .I work with her every day .(ADON) came to me .I told her everything .the truth .I'm not going to lie .honestly I have no excuse .I apologized to the resident and the facility . Review of CNA #6's education documentation revealed CNA #6 completed the facility required computer based training Preventing, Recognizing, and Reporting Abuse on 1/12/18. Telephone interview with CNA Trainee #1 on 3/14/18, at 9:47 PM, confirmed .I was helping in the shower room that day (2/14/18) .after breakfast .saw (CNA #1) .and she was taking lunch tray from (Resident #17) .(Resident #17) had finger hooked into (CNA#1's) scrub pocket .(CNA #1) looked down at her hand and smacked it really hard .(Resident #17) said 'oooh' .I could describe (Resident #17's) reaction as surprised .it all happened so fast .couldn't tell you what (Resident #17's) face looked like .I made eye contact with (CNA #1) .(Resident #17) didn't scream or yell .was like 'ooooh' . Continued interview confirmed .I was helping in shower room again .(CNA #6) was giving (Resident #1) a bath .(Resident #1) was being combative .I was holding the water sprayer and trying to block (Resident #1's) hand because she was trying to hit (CNA #6) then (CNA #1) comes in stands there for just a second .takes sprayer out of my hand and then I step back observing them give her a bath .(Resident #1) went down to touch her private area and (CNA #1) smacks her hand .(Resident #1) smacks (CNA #1) back .and then (CNA #1) smacks (Resident #1) back again and says 'don't smack me I smack back' .in a stern manner . Further interview confirmed CNA Trainee #1 .didn't really discuss it with (CNA #6) .I already knew I was going to make a report .don't know how (CNA #6) could not have heard it .maybe she didn't see it . Continued interview confirmed the next time she witnessed abuse was .lunch time .(CNA #1) was taking up lunch trays .(CNA #1) took (Resident #18's) tray away from her .(Resident #18) said 'I'm not done with it' .(CNA #1) was leaning across the table and said 'you're playing, you're done' .then hands were flying .(Resident #18) was trying to get her tray .(CNA #1) appeared to go to smack at her .didn't hear or see contact . Further interview confirmed CNA Trainee #1 was trained on abuse, and did not report it immediately because .had to get my daughter from daycare, so I left and went home and knew I was working again the next day .that's when I reported it . Continued interview confirmed she did not know why she did not report it immediately stating .Honestly no, I don't know .we were really busy .I was a little bit nervous .hadn't been there very long .only on the floor a week or 2 .whenever this happened .made the report with a woman .I don't know her name .the very next day (RN #1) called me for more information . Interview with the DON on 3/14/18, at 10:40 AM, in the conference room confirmed .at 8:30 PM-9:00 PM I was made aware of reports of inappropriate treatment .didn't know it was an allegation of abuse .(CNA Trainee #1) came forth and gave some information .I didn't understand it to be abuse at that time .I took it as a complaint .I can't remember the specifics .she could've said smacked .never asked specifics . Further interview confirmed the staff was educated on abuse by computer based training which had tests. Continued interview confirmed .a lot of these girls (on the locked unit) are new .no excuse .(LPN #1's abusive behavior) was brought to my attention on the 21st .brought (Resident #4) to my office on the 21st . where Resident #4 alleged LPN #1 had restricted her fluids, verbally abused her and made her fearful to leave her room. Further interview confirmed the DON conducted daily rounds where she talked with staff and residents and did not know why the staff did not report LPN #1's abusive behavior prior to her investigation. Interview with the Administrator on 3/14/18, at 5:23 PM, in the conference room confirmed he did not know why staff on the locked unit did not report abusive behaviors. Further interview confirmed staff were educated to .observe .teach .only way you can do that is through observation .they watch videos .give you tips on how to do that .I don't know why .they have been told .they take the same education I do .3 times I had to see an abuse video .no reason why somebody wouldn't know that was abuse . Refer to F-600 and F-609",2020-09-01
581,DIVERSICARE OF CLAIBORNE,445156,902 BUCHANAN RD,NEW TAZEWELL,TN,37825,2017-06-01,309,D,0,1,50PF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to monitor fluid intake for a resident on [MEDICAL TREATMENT] with fluid restrictions for 1 resident (#124) of 2 residents receiving [MEDICAL TREATMENT], of 19 residents reviewed. The findings included: Medical record review revealed Resident #124 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #124's Care Plan dated 1/6/17 revealed, .(Resident #124) is on fluid restriction 1000 ml (milliliters) per [MEDICAL TREATMENT] .Evaluate .hydration status .Provide diet and liquids as ordered . Medical record review of the Physician's Recapitulation Orders for (MONTH) (YEAR) revealed, .1000 CC (cubic centimeters) FLUID RESTRICTION .600 CC/DAY FROM DIETARY .240 CC/DAY FROM CAN OF NEPHRO (liquid therapeutic nutrition for residents on [MEDICAL TREATMENT]) .160 CC/DAY FROM NURSES WITH MEDICATIONS .NEPHRO -1 CAN DAILY .D[NAME]UMENT PERCENT CONSUMED .PROSTAT (liquid protein supplement) - 40CC THREE TIMES DAILY .D[NAME]UMENT PERCENT CONSUMED .[MEDICAL TREATMENT] TUESDAY, THURSDAY, SATURDAY . Medical record review revealed no documentation regarding Resident #124's percentage of dietary fluid intake. Interview with Certified Nursing Assistant (CNA) #1 on 6/1/17 at 8:30 AM on the C Hallway confirmed, .nurses tell us how much they can have .I don't know the limit on anybody .we set it (tray) up .pick them up . Further interview confirmed CNA's did not document the percent of dietary fluids consumed for Resident #124. Interview with Licensed Practical Nurse (LPN) #1 on 6/1/17 at 11:40 AM at the Harbor Side Nurse's Station, confirmed the facility was not monitoring Resident #124's fluid intake. Interview with the facility's Corporate Nurse Consultant on 6/1/17 at 1:42 PM in the Director of Nurse's office confirmed, .fluids are broken down with meals (for residents on fluid restrictions) . we're charting for one (resident) .on paper .and not the other .there lies the problem . Continued interview confirmed the facility failed to monitor the percent of dietary fluids consumed for Resident #124.",2020-09-01
582,DIVERSICARE OF CLAIBORNE,445156,902 BUCHANAN RD,NEW TAZEWELL,TN,37825,2019-06-25,661,C,0,1,D0TQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to complete a discharge summary, which included a recapitulation of the resident's stay, a final summary of the resident's status at the time of discharge for 3 residents (#92, #94, #248) of 6 residents reviewed for transfer/discharge requirements. The findings include: Medical record review revealed Resident #92 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Medical record review of the facility' discharge transfer/discharge documentation dated 5/10/19, revealed no documentation of the recapitulation of the resident's stay or final summary of time of discharge. Medical record review revealed Resident #94 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the facility's transfer/discharge documentation dated 4/19/19, revealed no documentation of the recapitulation of the resident's stay or final summary of time of discharge. Medical record review revealed Resident #248 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the facility's transfer/discharge documentation dated 1/24/19, revealed no documentation of the recapitulation of the resident's stay or final summary of time of discharge. Interview with the Minimum Data Set Coordinator on 6/25/19 at 12:20 PM, in the conference room, confirmed the transfer/discharge form was the only documentation the facility completed with the Physician's signature.",2020-09-01
583,DIVERSICARE OF CLAIBORNE,445156,902 BUCHANAN RD,NEW TAZEWELL,TN,37825,2019-06-25,693,D,0,1,D0TQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility policy, observation, and interview, the facility failed to check the gastric tube placement for 1 resident (#24) of 1 resident observed for medication administration by gastric tube; and failed to follow physician's orders [REDACTED].#43) of 6 residents observed for enteral tube feeding. The findings include: Medical record review revealed Resident #24 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of facility policy, Medication Administered through an Enteral Tube, effective date 4/4/19, revealed .Procedure .(14) .Verify that the tube is functioning before administering medications, which may include: 14.1 checking gastric residual volume . Observation of a medication administration on 6/24/19, at 8:50 AM, revealed Licensed Practical Nurse (LPN) #2 prepared medication for Resident #24. Continued observation revealed the LPN #2 administered 10 milliliter (ml) water and listened with a stethoscope for placement of the gastric tube. Continued observation revealed the LPN #2 administered the medication. Interview with the LPN #2 on 6/25/19 at 8:35 AM, in the hallway, confirmed she had not the check placement of the gastric tube correctly before administering the medication. LPN #2 confirmed she had not followed the facility's policy to check the gastric residual. Interview with the Director of Nursing (DON) on 6/25/19 at 8:40 AM, in the DON's office, confirmed the gastric residual was to be checked prior to administering medication. Medical record review revealed Resident #43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #43 scored a 99 on the Brief Interview for Mental Status (BIMS) indicating the resident had severe cognitive impairment. Continued review revealed the resident received enteral feeding. Medical record review of the Comprehensive Care Plan dated 4/17/19 revealed the resident required enteral feeding related to swallowing problems and was NPO (nothing by mouth) with the intervention .See MD (Medical Doctor) orders for current feeding orders . Medical record review of dietary notes dated 4/17/19 and 6/24/19 revealed the resident received enteral feeding of [MEDICATION NAME] 1.5 (nutritional supplement) at 45 cubic centimeters per hour (cc/hr) with 30 cc/hr water flushes with no further recommendations. Medical record review of the physician's orders [REDACTED]. Observation of Resident #43 on 6/23/19 at 9:19 AM, 11:55 AM, 12:10 PM, 2:53 PM, and on 6/24/19 at 7:35 AM, and 8:13 AM, in the resident's room, revealed the resident was lying in bed with the Head of the Bed (HOB) elevated 45 degrees. Continued observation revealed the resident had an enteral tube feeding which infused [MEDICATION NAME] 1.5 at 60 ccl/hr and the water flush at 45 cc/hr. Observation of Resident #43 and interview with Registered Nurse (RN) #1 on 6/23/19 at 8:13 AM, in the resident's room, revealed the enteral feeding pump was set to deliver the [MEDICATION NAME] 1.5 at 60 cc/hr with the water flush at 45 cc/hr. Continued interview confirmed the rate of the enteral feeding was not administered at the correct rate as ordered by the Physician. Interview with the DON on 6/24/19 at 11:15 AM, in the DON's office, confirmed the facility failed to administer the tube feeding as ordered by the Physician for Resident #43.",2020-09-01
584,DIVERSICARE OF CLAIBORNE,445156,902 BUCHANAN RD,NEW TAZEWELL,TN,37825,2019-06-25,880,D,0,1,D0TQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, medical record review, observation and interview the facility failed to maintain infection control practices during [MEDICAL CONDITION] (surgical formation of an opening into the trachea through the neck to allow passage of air) care for 1 resident (#69) of 1 resident observed for [MEDICAL CONDITION] care. The findings include: Review of the facility policy, Performing [MEDICAL CONDITION] Care, dated (YEAR) revealed .Performed hand hygiene, gathered supplies .removed soiled dressing, discarded in glove .Performed hand hygiene, prepared equipment on bedside table .Opened sterile kit .Opened sterile [MEDICAL CONDITION] dressing package .Opened inner cannula package .Applied sterile glove . Medical record review revealed Resident #69 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Physician's Order dated 5/16/19 [MEDICAL CONDITION] every day shift and every 24 hours as needed. Observation of Resident #69's [MEDICAL CONDITION] care on 6/25/19 at 10:50 AM, in the resident's room, with Licensed Practical Nurse (LPN) #1 revealed with gloved hands the LPN, removed the [MEDICAL CONDITION], removed the inner cannula, inserted the new inner cannula, removed the gloves, opened and donned sterile gloves without disinfecting the hands. Interview with the Infection Control Nurse on 6/25/19 at 11:07 AM in the conference room, confirmed LPN #1 failed to follow the facility policy and failed to disinfect the hands after glove removal during [MEDICAL CONDITION] care.",2020-09-01
585,DIVERSICARE OF CLAIBORNE,445156,902 BUCHANAN RD,NEW TAZEWELL,TN,37825,2018-08-01,609,D,1,1,JJ9N11,"**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 report an allegation of abuse timely to the Administrator and the State Survey Agency for 1 resident (#83) of 26 residents reviewed for abuse. The findings include: Review of the facility's Abuse Policy with an effective date of (MONTH) (YEAR) revealed .Abuse means the willful (the individual must have acted deliberately, not that they must have intent to injury or harm) infliction of injury .All alleged violations involving mistreatment, neglect, abuse, or exploitation including injuries of unknown source .are reported immediately to the Administrator/Director of Nursing and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). Immediately means as soon as possible: 1. Any allegation of abuse within two hours . Resident #83 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #83 had severe cognitive impairment and had no mood or behavior issues. Further review revealed the resident required limited assistance with transfers, walking in room, and toilet use. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly MDS assessment dated [DATE] revealed Resident #10 had severe cognitive impairment and no mood or behavior issues. Further review revealed the resident required limited assistance with transfers and walking in room. Observation of resident #83 on 7/30/18 at 10:40 AM, in her room, revealed her left hand and thumb wrapped with an ace wrap. Interview with Resident #83 on 7/30/18 at 10:40 AM, in her room, revealed when asked why her left hand and thumb were wrapped in an ace wrap, she stated a woman knocked me down over there (pointed at the bathroom door) and it hurt my hand. Interview with Licensed Practical Nurse (LPN) #1 on 7/30/18 at 11:50 AM, at the Harbor side nurse's station, revealed she had been the nurse on duty 7/28/18 and Resident #83 had been involved in a resident to resident altercation with her roommate (Resident #10) on this date. Continued interview revealed Resident #10 pushed Resident #83 down in the residents' room and Resident #83 had to be transferred to the emergency room for evaluation. Review of a nursing progress note for Resident #83 dated 7/28/18 at 1:00 PM revealed .resident stated she was walking back from the bathroom and stopped in front of her room mates television and room mate thought she was messing with her television and pushed resident down to the floor on her buttock . Review of a nursing progress note for Resident #10 dated 7/28/18 at 1:31 PM, revealed .Resident stated I pushed her down cause she was messing with my television . Interview with Resident #10 on 7/30/18 at 12:10 PM, in her room, revealed the resident did not remember having an altercation with Resident #83 on 7/28/18. Interview with the Administrator on 7/31/18 at 2:53 PM, in his office, confirmed he had no knowledge of a resident to resident altercation between Resident #10 and Resident #83. Further interview confirmed the altercation had not been reported to the state agency. Telephone interview with the Director of Nursing on 8/1/18 at 9:49 AM, confirmed she had been notified of a resident to resident altercation between Resident #10 and Resident #83 on 7/28/18. Further interview confirmed the altercation had not been reported to the state agency.",2020-09-01
586,DIVERSICARE OF CLAIBORNE,445156,902 BUCHANAN RD,NEW TAZEWELL,TN,37825,2018-08-01,610,D,1,1,JJ9N11,"**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 investigate a resident to resident altercation for 2 residents (#10 and #83) of 26 residents reviewed for abuse. The findings include: Review of the facility's Abuse Policy with an effective date of (MONTH) (YEAR) revealed .Anytime there is any allegation of abuse, neglect, exploitation, injuries of unknown origin or misappropriation, the center must report the alleged violation to the Administrator/DON (Director of Nursing) and initiate an immediate investigation and prevent further potential abuse. Based on the investigation findings, the center will implement corrective actions to prevent recurrence .All investigations shall be conducted by the Administrator/Director of Nursing or subject matter expert . Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had severe cognitive impairment and no mood or behavior issues. Further review revealed the resident required limited assistance with transfers and walking in room. Resident #83 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly MDS assessment dated [DATE] revealed Resident #83 had severe cognitive impairment and had no mood or behavior issues. Further review revealed the resident required limited assistance with transfers, walking in room, and toilet use. Observation of Resident #83 on 7/30/18 at 10:40 AM, in her room, revealed her left hand and thumb had an ace wrap in place. Interview with Resident #83 on 7/30/18 at 10:40 AM, in her room, revealed when asked why her left hand and thumb were wrapped in an ace wrap, she stated a woman knocked me down over there (pointed at the bathroom door) and it hurt my hand. Interview with Licensed Practical Nurse (LPN) #1 on 7/30/18 at 11:50 AM, at the Harbor side nurse's station, revealed she was the nurse on duty 7/28/18 and Resident #83 had been involved in a resident to resident altercation on 7/28/18 with her roommate (Resident #10). Continued interview revealed Resident #10 pushed Resident #83 down in the residents' room and Resident #83 had to be transferred to the emergency room for evaluation. Review of a nursing progress note for Resident #83 dated 7/28/18 at 1:00 PM revealed .resident stated she was walking back from the bathroom and stopped in front of her room mates television and room mate thought she was messing with her television and pushed resident down to the floor on her buttock . Review of a nursing progress note for Resident #10 dated 7/28/18 at 1:31 PM revealed .Resident stated I pushed her down cause she was messing with my television . Interview with Resident #10 on 7/30/18 at 12:10 PM, in her room, revealed she had no recollection of an altercation with her roommate on 7/28/18. Interview with the Administrator on 7/31/18 at 2:53 PM, in his office, confirmed he had no knowledge of a resident to resident altercation between Resident #10 and Resident #83. Further interview confirmed the altercation had not been investigated. Telephone interview with the Director of Nursing on 8/1/18 at 9:49 AM, confirmed she had been notified of a resident to resident altercation between Resident #10 and Resident #83 on 7/28/18. Further interview confirmed the altercation had not been investigated.",2020-09-01
587,DIVERSICARE OF CLAIBORNE,445156,902 BUCHANAN RD,NEW TAZEWELL,TN,37825,2018-08-01,657,D,0,1,JJ9N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to revise a care plan for 1 resident (#76) of 26 residents reviewed. The findings include: Medical record review revealed Resident #76 was re-admitted to the facility on [DATE] with Rectal Prolapse and Polyp of Colon. Medical record review of the resident's care plan dated with an onset date of [DATE] revealed the resident's code status was Full Code. Further review revealed the staff was to administer CPR (cardiopulmonary resuscitation) if resident had an arrest. Medical record review of a physician's orders [REDACTED]. Medical record review of a POST (Physician order [REDACTED]. Interview with the Assistant Director of Nurses (ADON) on [DATE] at 3:30 PM, in the ADON's office, confirmed the care plan did not accurately reflect the resident's current code status.",2020-09-01
588,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2019-01-10,550,D,0,1,IXKF11,"Based on policy review, observation, and interview, the facility failed to ensure residents were treated with respect and dignity when they were called Momma, Baby, and Feeder by 2 of 13 (Certified Nursing Assistant (CNA) #1 and Licensed Practical Nurse (LPN) #1) staff during the dining observation, and were called Honey, Sweetie, and Baby by 1 of 6 (LPN # 2) nurses during medication administration, and when the facility displayed signage that named residents as Feeders. The findings include: 1. The facility's undated S[NAME]IAL SERVICE POLICIES .Dignity . policy documented, .Respecting resident's social status, speaking respectfully .addressing the resident with a name of the resident's choice . 2. Observations in the 2 West Dining Room on 1/7/19 at 12:25 PM, revealed CNA #1 called Resident #33 by the name, Momma. Review of Resident #33's care plan revealed there was no documentation that Resident #33 preferred to be called Momma. 3. Observations in the 2 West Dining Room on 1/7/19 at 12:25 PM, revealed CNA #1 called Resident #72 by the name, Momma. Review of Resident #72's care plan revealed there was no documentation that Resident #72 preferred to be called Momma. 4. Observations in the 2 West Dining Room on 1/7/19 at 12:34 PM, revealed CNA #1 called Resident #66 by the name, Momma. Review of Resident #66's care plan revealed there was no documentation that Resident #66 preferred to be called Momma. 5. Observations in the 2 West Dining Room on 1/7/19 at 12:44 PM, revealed CNA #1 spoke to LPN #1 who was across the dining room and referred to Resident #96 and said, She's a feeder. The dining room was full with other residents. LPN #1 then called Resident #96 Momma. Review of Resident #96's care plan revealed there was no documentation that Resident #96 preferred to be called Momma. 6. Observations in the 2 West Dining Room on 1/8/19 at 7:34 AM, revealed CNA #1 called Resident #29 by the name, Baby. Review of Resident #29's care plan revealed there was no documentation that Resident #29 preferred to be called Baby. 7. Observations in the 2 West Dining Room on 1/8/19 at 7:34 AM, revealed CNA #1 called Resident #4 by the name, Baby. Review of Resident #4's care plan revealed there was no documentation that Resident #4 preferred to be called Baby. 8. Observations in the 2 West Dining Room on 1/8/19 at 7:34 AM, revealed CNA #1 called Resident #41 by the name, Baby. Review of Resident #41's care plan revealed there was no documentation that Resident #41 preferred to be called Baby. 9. Observations in the 2 West Dining Room on 1/8/19 at 7:59 AM, revealed CNA #1 called Resident #21 by the name, Baby. Review of Resident #21's care plan revealed there was no documentation that Resident #21 preferred to be called Baby. Interview with the Administrator on 1/8/19 at 4:46 PM, in the Conference Room, the Administrator was asked if it was appropriate to call residents by pet names such as Momma, Baby, or Feeders. The Administrator stated, Absolutely not. 10. Observations in Resident #98's room on 1/9/19 at 9:50 AM, LPN #2 called Resident #98 by the names of Honey, Sweetie, and Baby multiple times while she administered medications. Interview with the Director of Nursing (DON) on 1/10/19 at 3:05 PM, in her office, the DON was asked if it was acceptable for a resident to be addressed as Sweetie, Baby, and Honey during medication administration. The DON stated, No, it's not acceptable. 11. Observations in the hallway by the 1 West Nurses Station on 1/9/18 at 7:38 AM, 10:30 AM, and 11:45 AM, revealed a posted sign which listed Feeders in rooms 101, 106, 108, 112, 124, 125, 131,132 and 138. Interview with the Administrator on 1/9/18 at 1:30 PM, at the 1 West Nurses Station, the Administrator was asked if it was appropriate to list residents as feeders and have it displayed in a hallway where any resident or visitor could see it. The Administrator stated, No.",2020-09-01
589,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2019-01-10,623,D,0,1,IXKF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to send the Ombudsman a notice of transfer or discharge for 1 of 1 (Resident #74) sampled residents reviewed for transfer/discharge requirements. The findings include: Medical record review revealed Resident #74 was admitted on [DATE] with [DIAGNOSES REDACTED]. The progress notes dated 10/13/18 documented, .resident noted to be in respiratory distress .very weak and hard to arouse .Physician notified .called 911 for emergency transport .resident transferred to stretcher and taken from facility to ER (emergency room ) . The physician's orders [REDACTED].SEND TO (named) ER FOR EVAL (evaluation)/ TX (treatment) Review of the medical record revealed Resident #74 was admitted to the hospital and returned to facility on 10/19/18. The facility was unable to provide documentation that the Ombudsman had been notified of the transfer to the hospital on [DATE]. Interview with the Administrator on 1/9/19 at 5:10 PM, at the 1 West Nurses Station, the Administrator was asked if the Ombudsman had been notified of Resident #74's transfer to the hospital. The Administrator stated, We don't send a transfer list to the Ombudsman, we only send the involuntary discharges to the Ombudsman.",2020-09-01
590,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2019-01-10,655,E,0,1,IXKF11,"**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 within 48 hours for 5 of 8 (Resident #10, 22, 57, 77, and 93) sampled residents reviewed for baseline care plans. The findings include: 1. Medical record review revealed Resident #10 was admitted on [DATE] with [DIAGNOSES REDACTED]. The facility was unable to provide documentation a baseline care plan had been develped or provided to the resident or his family within 48 hours of admission. 2. Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility was unable to provide documentation a baseline care plan had been develped or provided to the resident or his family within 48 hours of admission. 3. Medical record review revealed Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An INITIAL CARE PLAN form in the medical record was blank. The facility was unable to provide documentation that a baseline care plan had been developed within 48 hours of admission. 4. Medical record review revealed Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility was unable to provide documentation that a baseline care plan had been developed within 48 hours of admission. 5. Medical record review revealed Resident #93 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility was unable to provide documentation a baseline care plan had been develped or provided to the resident or his family within 48 hours of admission. Interview with Director of Nursing (DON) on 1/10/19 at 3:45 PM, in the DON's office, the DON was asked if 48 hour care plans were developed, and if residents and families received a written summary of the baseline care plan. The DON stated, No.",2020-09-01
591,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2019-01-10,656,D,0,1,IXKF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to ensure 1 of 2 (Resident #55) residents were free from accident hazards by not following their interventions after the resident experienced a fall. The findings include: 1. The facility's undated Fall Prevention policy documented, .To identify residents 'at risk for falls' and utilize proactive approach to decrease the incidence of falls .Rehabilitation .Evaluate for appropriate positioning devices . 2. Medical record review revealed Resident #55 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 9, which indicated moderate cognitive impairment, required extensive staff assistance with transfers, and walking did not occur. The Care Plan dated 8/26/18 documented, .10/15/18 - eval (evaluation) for reacher use . Review of the Occurrence Report dated 10/15/18 revealed Resident #55 was not referred to therapy for screening after experiencing a fall without injury. Interview with the Physical Therapist (PT) #1 was asked for verification that Resident #55 had received a evaluation for a reacher. The PT #1 was unable to confirm that an evaluation had been performed. Interview with the Director of Nursing (DON) on 1/10/19 at 3:30 PM, in her office, the DON was asked if Resident #55 had a fall on 10/15/18, and the new interventions was to be evaluated for a reacher, should there have been an evaluation after the fall on 10/15/19 The DON stated, Yes.",2020-09-01
592,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2019-01-10,657,D,0,1,IXKF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident rights, medical record review, and interview, the facility failed to ensure each resident was involved in developing the care plan and making decisions about his or her care for 1 of23 (Resident #19) sampled residents reviewed for participation in care planning. The findings include: The facility's .Resident's Rights . documented, .Each resident has the right to be informed of, and participate in, his or her treatment, including .The right to participate in the development and implementation of his or her person-centered plan of care . Medical record review revealed Resident #19 was admitted to the faciity on 3/27/18 with [DIAGNOSES REDACTED]. Interview with Resident #19 on 1/7/19 at 4:42 PM, Resident #19 was asked if she was allowed to attend the care plan meetings. Resident #19 stated, No. Interview with the Social Worker on 1/9/19 at 4:52 PM, in her office, the Social Worker was asked if there was documentation that Resident #19 was asked to attend the care plan meetings. The Social Worker stated, I do not have a signed document saying her or her family were invited to a care plan meeting .We do not have proof of that.",2020-09-01
593,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2019-01-10,686,E,0,1,IXKF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to provide accurate and timely assessments and treatments for pressure ulcers for 2 of 4 (Resident #22 and #100) sampled residents reviewed for pressure ulcers. The findings include: 1. The facility's undated Wound Care Management policy documented, .When a pressure ulcer is identified, the licensed nurse will document the wound in the Wound Assessment Module (WAM). Documentation to include size, stage, location, drainage, odor and pain . The facility's undated Pressure Ulcer Prevention/Management Program policy documented, .Pressure Ulcer Staging Definitions .STAGE II: Blister or other skin opening. Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater .SUSPECTED DEEP TISSUE INJURY (SDTI): A purple discolored, firm, and slightly warm area . SUSPECTED DEEP TISSUE INJURY (SDTI) of the HEEL: .SDTI of the heel appears as a intact blister that is blood-filled or underlying discoloration from necrotic tissue . 2. Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented Resident #22 had a Brief Interview Status (BIMS) of 99 with cognitive skills moderately impaired, required staff assistance with all activities of daily living, and was at risk for pressure ulcers. The care plan dated 12/29/18, documented, .resident has a DTI (Deep Tissue Injury) to his left heel .assess characteristics of ulcer daily during treatment care and document findings weekly .apply local treatments as ordered by MD . Review of wound assessments revealed Resident #22 acquired a wound that was first identified on 12/27/18. A WEEKLY SKIN assessment dated [DATE] documented skin prep left heel. A INITIAL WOUND EVALUATION & MANAGEMENT SUMMARY dated 1/6/19 documented, .unstageable DTI of left heel with intact skin .wound size (LxWxD) (LengthxWidthx Depth) 4.0 x 5.0 x not measurable cm (centimeters) . Observations on 1/9/18 at 11:35 AM in Resident #22's room revealed Resident #22 in bed during wound care with a left heel deep tissue injury, measurements obtained by staff of 4.7 cm length by 4.5 cm width depth was undetermined. The wound was dry hard and black with a tinge of redness in the middle, skin intact no odor. Interview with Licensed Practical Nurse (LPN) #6 on 1/9/19 at 11:26 AM, at the 2 East Nurses Station, LPN #6 was asked if the initial wound assessment was completed for Resident #22. LPN #6 stated, No it was not charted that day .we failed to chart the measurements . The facility was unable to provide documentation that wound assessments were completed on 12/27/18. Review of a physician order [REDACTED].skin prep to left heel Q (every) shift . Review of the Resident #22's Treatment Administration Records (TARs) for (MONTH) (YEAR) through (MONTH) 2019 revealed the treatment was not provided as ordered on [DATE] on the 3-11 shift, 12/29/18 on the 11-7 shift, 12/31/18 on the 3-11 shift, 1/2/19 on the 3-11 shift, 1/3/19 on the 3-11 shift, and 1/3/19 on the 11-7 shift. Interview with the Director of Nursing (DON) on 1/10/19 at 2:45 PM in the DON's office, the DON was asked if it was acceptable for staff to not provide wound treatments as ordered by the physician. The DON stated, No. The DON was asked if it was acceptable for staff to not assess a deep tissue injury pressure wound on the day it was observed. The DON stated, No. 3. Medical record review revealed Resident #100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] documented a BIMS score of 13, which indicated no cognitive impairment, required staff assistance with all activities of daily living and had a stage 4 pressure ulcer. The care plan dated 9/24/19 and updated 1/8/19 documented, .PRESSURE ULCER/INJURY .Resident has wound to right heel .Apply local treatments as ordered . A WEEKLY SKIN assessment dated [DATE] documented N.O. (New Order) skin prep .SKIN INTACT (marked to indicate YES) .Boggy (symbol for right) heel . A Progress Note dated 9/24/18 documented .Resident noted to have a large fluid filled blister to R (right) heel . Review of a wound report dated 9/26/18 revealed Resident #100 had a Deep Tissue Injury (DTI) to the R heel measuring 9x11 cm. The facility was unable to provide wound measurements of the wound when it was discovered on 9/24/18. Review of a physician order [REDACTED].SKIN PREP LEFT HEEL DAILY .cleanse R (right) heel daily with NS (Normal Saline), pat dry, apply [MEDICATION NAME] cover with ABD (abdominal) and wrap with Kerlix daily . Review of the TARs for (MONTH) (YEAR) through (MONTH) (YEAR) revealed the wound treatment was not provided as ordered on the following dates: 9/26, 9/29, 9/30, 10/3, 10/11, 10/19, 10/24, 10/29, 11/14, and 11/23. Review of a physician order [REDACTED].Cleanse R heel with Dakins, pat dry, apply Santyl, calcium alginate and cover with ABD and wrap with Kerlix daily . Review of the (MONTH) (YEAR) TAR revealed the wound treatment was not provided on the following dates: 12/1, 12/5, 12/6, 12/7, 12/11, and 12/15. Observation during wound care on 1/9/19 at 11:07 AM revealed the L (Left) foot was turned out and the ankle was down. The wound bed was clean and moist. The wound measurements were obtained by the Unit Manager and were 6.5 cm. length by 7 cm. wide. Interview with LPN #6 on 1/10/19 at 1:41 PM, in the Conference Room, LPN #6 was asked if new pressure areas should be documented when they are identified. LPN #6 stated, We document it in the progress notes. If it's something that requires measuring, the nurses will not measure nor will they stage it .(named the Director of Nursing) and I measure them when we come in .the wound care doctor comes in once a week and measures it and gives us an accurate stage. LPN #6 was asked who was responsible for assessing new wounds on weekends or when she and the DON are not present. LPN #6 stated, We have a weekend supervisor now .they call the on call nurse, notify the family, and call the doctor to get orders . Interview with LPN #6 on 1/10/19 at 2:36 PM, in the Conference Room, LPN #6 was asked if she could find wound measurements for Resident #100's right heel wound from 9/24/18 when the wound was identified. LPN #6 stated I was unsuccessful.",2020-09-01
594,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2019-01-10,698,D,0,1,IXKF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a [MEDICAL TREATMENT] service agreement, policy review, medical record review, and interview, the facility failed to provide appropriate care and services for 1 of 1 (Resident #63) residents reviewed for [MEDICAL TREATMENT]. The findings include: 1. The facility's LONG TERM CARE OUTPATIENT [MEDICAL TREATMENT] SERVICES COORDINATION AGREEMENT . documented, .The Long Term Care Facility shall provide for the interchange of information useful or necessary .Obligations of the [MEDICAL CONDITIONS] [MEDICAL TREATMENT] Unit .To provide to the Long Term Care Facility information on all aspects of the management of the [MEDICAL CONDITION] Resident's care . The facility's policy [MEDICAL TREATMENT] with a revised date of 4/4/18 documented, .Dietician will address .fluid restrictions .Residents will be issued a [MEDICAL TREATMENT] tool that will accompany them to [MEDICAL TREATMENT]. The primary nurse receiving the resident back from [MEDICAL TREATMENT] will review the [MEDICAL TREATMENT] tool for any pertinent information from [MEDICAL TREATMENT] . 3. Medical record review revealed Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented Resident #63 received [MEDICAL TREATMENT]. The (MONTH) physician's orders [REDACTED].Every Day . [MEDICAL TREATMENT] MON, WED, FRI (Monday, Wednesday,Friday) . The Care Plan dated 6/15/17 documented, .(Named Resident #63) .Resident is currently on [MEDICAL TREATMENT] .Monitor/record fluid intake .as ordered by MD . Interview with Licensed Practical Nurse (LPN) #4 on 1/9/19 at 11:10 AM, at the 2nd floor West Nurses' Station, LPN #4 was asked where documentation of fluid restrictions would be located. LPN #4 stated, I don't. LPN #4 was asked what type of communication form goes with Resident #63 to [MEDICAL TREATMENT]. LPN #4 stated, Nothing .well we used to do that but, they ([MEDICAL TREATMENT] clinic) were not sending the form back so we stopped that .[MEDICAL TREATMENT] calls us every month or so and asked us for a copy of their medications . Interview with LPN #6 on 1/10/19 at 1:50 PM, in the Conference Room, LPN #6 was asked where documentation of fluid restrictions would be located. LPN #6 stated, We have no .documentation for fluid restrictions .",2020-09-01
595,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2019-01-10,790,D,0,1,IXKF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on consent for treatment, medical record review, observations and interviews the facility failed to provide dental services for 1 of 1 (Resident #87) residents reviewed for dental services. The findings include: 1. The facility's Special Care Dental .Consent consent for treatment dated 3/10/16 documented, .By signing below you authorize the provider indicated above to provide treatment .For dentistry . 2. Medical record review revealed Resident #87 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Plan dated 3/9/17 documented, .(Named Resident #87) .DENTAL CARE IMPAIRMENT RISK .at high risk for further decline in dentition .refer for dental services as needed . Observations in Resident 87's room on 1/8/19 at 10:21 AM, revealed missing and broken teeth covered with plaque, a colored dark brown sticky film of undigested food particles. Interview with Resident #87's Power of Attorney on 1/8/19 at 10:21 AM, in Resident's #87's room, Resident #87's Power of Attorney was asked if Resident #87 had any dental issues and had she been seen by a dentist at the facility. Resident #86's Power of Attorney stated, .She has not seen the dentist since she was admitted here and it will be 3 years in (MONTH) . Interview with the Social Worker on 1/9/19 at 2:05 PM, at the 1 East Nurses Station, the Social Worker was asked about Resident #87's dental records. The Social Worker stated, She is being seen by vision but not by dental. The Social Worker was asked has Resident #87 been seen by a dentist since admission. The Social Worker stated, No .",2020-09-01
596,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2019-01-10,812,F,0,1,IXKF11,"Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by wet dishes on the serving line, dirty storage racks, chipped plates and trays, a dirty microwave, dirty trash cans, a dirty silverware holder, carbon build-up on pots and pans, broken tiles off the wall in the dish room, dirty dish racks, large black patches on the dish room walls, pipes with a large amount of chipped paint with a large amount of rusty discoloration in the dish room, a large rack with dark build up in the dish room, dirty kitchen floors, the deep fryer with carbon build-up with food particles and dark grease, a large dirty plastic bin, carbon build-up on the hood and ceiling above the hood, carbon build-up on the flat grill, carbon build-up on the 6 eye burner, dirty drawers on the prep table, broken drawer the on prep table, food stains on the outside of the garbage disposal, reddish brown stains on the can storage rack in the stock room, missing threshold and seal on the walk-in freezer with ice build-up, and a large amount of grease on the floor under the equipment and pipes. The facility had a census of 111 with 110 of those residents receiving a meal tray from the kitchen and when 1 of 13 (Certified Nursing Assistant (CNA) #2) staff lifted a chair over the resident before assisting the resident with his food and failed to perform hand hygiene during the dining observation. The findings include: 1. The facility's Sanitization policy dated (MONTH) 2008 documented, .All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped area that may affect their use or proper cleaning .The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen .Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment . 2. The facility's undated Cleaning of Miscellaneous Equipment and Utensils policy documented, .Carts, Food Delivery & (and) Utility .Daily Cleaning Wipe with clean cloth soaked in sanitizing solution, after each meal .Dish Carts and Dollies .(weekly and as needed) .Drawers (as needed) .empty drawers; place utensils in clean container .Floors .Sweep floor after each meal service .Move wheeled carts and other movable objects; clean under stationary equipment as much as possible .Deep Fat Fryer .After each use .drain liquid fat from fryer .Wipe fryer to clean exposed surfaces .Scrub fryer, both inside and outside .Garbage Pails and Cans .daily .Wash can and lid with hot detergent solution .Range and Grill: (daily) .The cook on each shift is responsible to keeping the stove as clean as possible during the preparation of the meal .Hood exhaust shafts should be cleansed semi-annually by an outside contact company .Microwave Oven: (daily and as needed) .Wipe up spills as they occur .Wash walls inside and out .Shelving-Metal and [NAME]: (monthly or as needed) .Remove contents from shelves .Wash and scrub .Walls and Ceilings: (as needed) .Walls and ceilings should be washed thoroughly at least twice each year .Heavily soiled surfaces should be cleaned frequently and as required . 3. Observations in the kitchen on 1/7/19 at 10:50 AM, revealed the following: a. 5 large wet trays with the corners chipped off with the metal portion exposed on the serving line. b. 18 wet soup bowls in a dish rack with large a large amount of black build-up on the outside. c. 3 large plate racks with a large amount of food particles and trash on the bottom shelves. d. A large storage rack full of plates had 40 plates with large chips out of then on the serving line. e. A microwave with a large amount of dried brown and red stains inside. f. 3 hand sinks with a large amount of black build-up and the foot pedals with thick black build-up. Observations on the serving line on 1/8/19 at 12:37 PM, revealed the following: a. 8 wet soup bowls on a serving tray. b. 48 chipped plates sitting on a large storage rack with a large amount of black build-up on the outside of the rack with food particles. c. 3 large plate racks with a large amount of food particles and trash on the bottom shelves. d. A microwave with a large amount of dried brown and red stains inside. Observations in the kitchen on 1/7/19 at 10:47 AM and 1/8/19 at 12:27 PM, revealed the following: a. 3 small trash cans at the hand sinks with the entire inside of the lids covered with black patches of substance and black build-up on the outside of the trash cans. b. 3 large trash cans with dark black build-up and food splattered on the outside. c. A dish rack with a large amount of dark black build-up and a cracker wrapper stuck to the inside of a rack full of clean silverware on the serving line. d. A 2 compartment silverware holder with a large amount of dark black build-up on the outside full of silverware on the serving line. e. A large storage rack with food particles on the shelves and a large amount of black build-up on the outside of the rack with 78 clean plates and 38 plates with large chips out of them on the serving line . Observations on the serving line on 1/9/19 at 12:11 PM, revealed the following: a. 85 wet soup bowls in dish racks on the serving line with black build-up on the outside of the racks. b. A large storage cart with clean dishes with food particles on the shelves with black build-up on the outside of the cart containing 66 clean plates with 28 of them with large chips out of them, c. A large sheet pan containing cornbread had a large amount of carbon build-up outside and inside of the sheet pan sitting on a prep table. Observations in the kitchen on 1/7/19 at 11:05 AM, 1/8/19 at 12:51 PM and 1/9/19 at 11:44 AM, revealed the following: a. 11 broken tile pieces under the hand sink on the dish room floor. b. 8 dish racks with a large amount of dark black buildup on the outside of racks. c. Several large black patches on the walls around the dish machine. d. Drainage pipes with a large amount of chipped paint and with a large amount of dark reddish discoloration. e. A large rack holding the dish racks with a large amount of dark black build-up. f. A large amount of black build-up on the floors under the kitchen equipment and in the dish room. e. A deep fryer with a large amount of carbon build-up and food particles around the sides, full of dark grease and a drain in front of the fryer with a large amount of black build-up. f. A large plastic bin with deep fryer parts under the prep table with a large amount of light brown greasey substance on the inside of the plastic bin. g. Kitchen hoods with large amount of carbon build-up on the metal frame and the ceiling. h. A Flat grill with large amount of carbon build-up along the sides. i. 6 eye burner with large a large amount of carbon build-up on the back wall. j. The floors under the 2 compartment prep sink had several brown paper towels, gloves, and food particles. k. Prep table with 3 pull out drawers noted with a large amount of brown liquid stains and food particles inside of the drawers with utensils and with the top drawer broken on the left side. l. A Garbage disposal under the 3 compartment sink had a large amount of food splatter on the outside and down the table legs. m. The can rack in the stock room nearest the door had a large amount of brownish liquid stain down the entire shelves of the rack. n. The floors under the kitchen equipment and prep tables had a large amount of black build-up. o. The freezer threshold was missing with a large amount of ice build-up, and large pieces of the door seal was missing around the freezer door. p. 2 large serving racks with food particle and brown stains on the selves of the rack. q. A small metal bowl on the serving line with a large amount of carbon build-up. r. 6 large steam table pans, 7 large sheet pans, 1 large stock pot, 1 large roasting pan and a half pan with a large amount of carbon build-up. s. A large amount of mounted greasy build-up on the floor and pipes behind the double stacked convection ovens, flat grill and 6 eye burners. 4. Interview with the Assistant Dietary Manager on 1/8/18 at 12:44 PM, in the kitchen, The Assistant Dietary Manager was asked how long the tile pieces had been lying on the dish room floor. The Assistant Dietary Manager stated, It's been like that for a while. The Assistant Dietary Manager was asked if it was acceptable to have a large amount of carbon build-up and dark grease in the deep fryer. The Assistant Dietary Manager stated, No. The Assistant Dietary Manager was asked if it was acceptable to have a missing threshold plate with ice build-up and parts of the seal missing on the lower part of the walk-in freezer door. The Assistant Dietary Manager stated, No. The Assistant Dietary Manager was asked how often are the pots and pans cleaned in the kitchen. The Assistant Dietary Manager stated, Once a week. Interview with the Dietary Manager (DM) on 1/9/19 at 12:13 AM, in the kitchen the DM was asked what the dark patches on the dish room wall were. The DM stated, It looks like mold to me. The DM was asked what the reddish discoloration on the drainage pipes might be. The DM stated, The paint is chipping off with rust underneath. The DM stated, No. The DM was asked if it was acceptable to have carbon build-up on the equipment, walls and pots and pans, wet dishes on the serving line, chipped plates on the serving line, clean dishes on dirty storage carts on the serving line, utensils in dirty storage drawers, dirty equipment, dirty floors, dirty carts, dirty trash cans, dirty dish racks, paint chipping off of the pipes in the dish room with reddish stains, dark patches on the walls of the dish room, broken tiles in the dish room, missing threshold plate and seal on the freezer. The DM stated, No ma'am. 5. Observations in the 2 West Dining Room on 1/7/19 at 12:46 PM, revealed CNA #2 moved Resident #10's chair, lifted a chair over Resident #10 and his food, sat down to assist him to eat, without performing hand hygiene. Interview with the Administrator on 1/8/19 at 4:46 PM, in the Conference Room, the Administrator was asked if it was appropriate to lift a chair over a resident and his food and sit down to assist him with his food and not perform hand hygiene. The Administrator stated, No.",2020-09-01
597,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2019-01-10,838,D,0,1,IXKF11,"Based on interview, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for the residents competently during day to day operations and emergencies. The findings included: The facility was unable to provide a facility assessment. Interview with the Administrator on 1/10/19 at 9:53 AM, in the Director of Nursing's office, the Administrator was asked to provide the facility assessment. The Administrator confirmed there was no facility assessment.",2020-09-01
598,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2019-01-10,880,D,0,1,IXKF11,"Based on policy review, medical record review, observation and interviews, the facility failed to ensure practices were maintained to prevent the spread of infection and cross-contamination when a resident's water pitcher was dirty for 3 of 3 (1/7/19, 1/8/19, and 1/9/19) days, when a nebulizer mask was not stored properly for 1 of 1 (Resident #57) residents reviewed for respiratory care, and 2 of 6 (Licensed Practical Nurse (LPN) #5 and 7) nurses did not perform hand hygiene during medication administration. The findings included: 1. Observations in Resident #302's room on 1/7/19 at 11:00 AM, 1/8/19 at 10:00 AM, and 1/9/18 at 7:38 AM, revealed a water pitcher with a brown to reddish substance smeared all over the top of the water pitcher. Interview with Licensed Practical Nurse (LPN) #6 on 1/9/19 at 2:20 PM, at Resident #302's bedside, LPN #6 was asked is it acceptable for the water pitcher to have dried brown substance on it. LPN #6 stated, No . Observations in Resident #57's room on 1/7/19 at 12:03 PM, revealed an uncovered nebulizer mask lying on the floor between the bed and the bedside table. Observations in Resident #57's room on 1/8/19 at 7:55 AM, revealed an uncovered nebulizer mask hanging from the bed side table. Observations in Resident #57's room on 1/08/19 at 3:32 PM, revealed an uncovered nebulizer mask lying on top of the bedside table. Observations in Resident #57's room on 1/9/18 at 8:35 AM, revealed an uncovered nebulizer mask hanging from nebulizer machine. Interview with the Director of Nursing (DON) on 1/9/19 at 2:50 PM, at the 1 West Nursing Station, the DON was asked if it was acceptable to have a nebulizer mask in the residents room uncovered. The DON stated, No ma'am .the mask should be covered and dated. 2. The facility's undated .Hand-hygiene . policy documented, .To prevent and to control the spread of infectious diseases .The purpose of this procedure is to provide guidelines .in the prevention of the transmission of infections . Observations in Resident #98's room on 1/9/19 at 8:45 AM, revealed LPN #5 failed to perform hand hygiene multiple times after glove removal during the preparation of medications. Observations in Resident #7's room on 1/9/19 at 5:05 PM, revealed LPN #7 failed to perform correct hand hygiene by turning off the water faucet with her bare hands during medication administration. Interview with the Administrator on 1/10/19 at 10:30 AM, in the Administrator's office, the Administrator was asked if was acceptable for staff to remove their gloves and not perform hand hygiene. The Administrator stated, No. The Administrator was asked if it was acceptable for staff to turn the water faucet off with their bare hands. The Administrator stated, No.",2020-09-01
599,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2018-01-31,583,D,0,1,G3SM11,"Based on policy review, observation, and interview, the facility failed to ensure privacy and interruptions by 2 staff members (Director of Nursing (DON ) and Dietary Aide #1) during the Resident Council meeting. The findings included: 1. The Resident Rights Policy and Procedure documented .ensure that every resident can exercise his or her rights without interference .from facility . 2. Observations in the dining room on 1/31/18 from 1:40 PM to 2:30 PM, during the Resident Council Meeting, revealed the DON and Dietary Aide #2 entered the dining room. The Resident Council meeting was stopped with each interruption and resumed when the staff members left. 3. Interview with Social Services Director on 1/31/18 at 4:50 PM, in the Social Service Office, the Social Services Director was asked who was responsible for making sure the Resident Council meetings were private and not interrupted. The Social Services Director stated, I put a sign up on one door and no one is allowed to enter during the meeting .but there were no signs put on all the entrances to the dining room, just one. The Social Services Director was asked if signs should be put on all the dining room doors to respect the privacy of the Resident Council meeting. The Social Services Director stated, Yes.",2020-09-01
600,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2018-01-31,584,D,0,1,G3SM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the environment was clean, comfortable, and sanitary when an uncovered and unlabeled toothbrush and bed pan were found in 1 of 77 (room [ROOM NUMBER]A) resident rooms and the facility failed to maintain comfortable sound levels that did not interfere with the resident's hearing, privacy, and social interaction during 1 of 1 Resident Council meeting. The findings included: 1. Observations in room [ROOM NUMBER]A on 1/30/18 at 10:00 AM, revealed an unlabeled, uncovered toothbrush lying on the windowsill without a barrier. Interview with Certified Nursing Assistant (CNA) #1 on 1/30/18 at 10:05 AM, in room [ROOM NUMBER]A, CNA #1 was asked whether it was sanitary for the toothbrush to be lying open on the windowsill. CNA #1 stated,No . 2. Observations in room [ROOM NUMBER]A bathroom on 1/30/18 at 4:49 PM, revealed an uncovered and unlabeled bed pan on the trash can. Interview with CNA #2 on 1/30/18 at 5:29 PM, in room [ROOM NUMBER]A bathroom, CNA #2 was shown the bedpan that was uncovered and unlabeled lying on top of the trash can and was asked should the bed pan be on the trash can. CNA #2 stated, .no ma'am . Interview with the Director of Nursing (DON) on 1/31/18 at 1:16 PM, in the DON's office, the DON was asked how should a resident's bedpan be stored. The DON stated, It should be stored in a bag .rinsed and clean .should have the room number . The DON was asked should a bedpan be stored on the trash can uncovered or unlabeled. The DON stated, That would not be appropriate . The DON was asked where a resident's toothbrush should be stored. The DON stated, .should be rinsed and stored in the resident's mouth basin. The DON was asked is it acceptable for a resident's tooth brush to be left on a windowsill. The DON stated, No . 3. Observations in the dining room on 1/31/18 from 1:40 PM to 2:15 PM, during the Resident Council Meeting, revealed 16 overhead announcements that interrupted the Resident Council meeting. The meeting was stopped with each interruption and resumed when the overhead announcements were completed. Interview with the Resident Council members on 1/31/18 from 1:40 PM to 2:15 PM, in the dining room, Resident #30 stated, The intercom interruption happens all the time. Interview with the Administrator on 1/31/18 at 4:28 PM, in the hallway outside the Administrator's office, the Administrator confirmed the paging system should be checked for comfortable sound levels.",2020-09-01
601,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2018-01-31,689,D,0,1,G3SM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the environment was free of accident hazards when unsecured sharps and chemicals were observed in 1 of 77 (room [ROOM NUMBER]) resident rooms and unsecured chemicals were observed in 1 of 2 (200 hall) mop closets. The findings included: Observations in room [ROOM NUMBER] on 1/29/18 at 11:38 AM, 12:59 PM, and 3:26 PM, revealed an unlocked door with 2 spray cans of contact adhesive sitting on the floor to the right of the doorway, an unlocked maintenance cart inside the room, with a box cutter lying on top, 5 small open compartments along the front with screws present, a small saw like tool hanging on the right side of the cart, and a strip of wood with 15 nails, sharp side facing out, leaning against the wall to the left of the door. Observations in the 200 hallway on 1/29/18 at 11:39 AM, 1:00 PM, and 3:25 PM, revealed an unlocked mop closet with a bottle of disinfectant, a bottle of floor cleaner with no lid, a bottle of glass cleaner on a shelf along the right wall, a shelf on the floor inside the room with 2 bags of antimicrobial soap on the top shelf, a bottle of floor cleaner, and a bottle of disinfectant on the bottom shelf. Interview with Licensed Practical Nurse (LPN) #1 on 1/29/18 at 1:03 PM, at the 200 West nurses station, LPN #1 confirmed there were wandering residents in rooms 201, 203, 208 and 214. Interview with the Administrator on 1/29/18 at 4:24 PM, in the 200 hallway, the Administrator confirmed room [ROOM NUMBER] and the 200 hall mop closet should be locked.",2020-09-01
602,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2018-01-31,801,F,0,1,G3SM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Registered Dietician contract review, policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by employees not wearing beard guards, dust and dirt above preparation tables, dust, dirt, and dead insects in the windowsills above clean dishes, debris on clean lid drying racks, dirty gloves in floor in the kitchen, a dead insect in the silver wear bin, dried debris in a large flour bin, unlabeled storage bins, meat slicer with dried debris, mixer with dry and moist debris, carbon build-up on pots, pans, stove, and grill, dried debris on the bread warmer, a case of ice cream on the floor outside the freezer, opened, undated, unlabeled foods in walk in the freezer, expired foods in the walk in refrigerator, dented cans, undated and unlabeled food items, expired foods in the dry storage, expired foods in the emergency food supply, and the dishwasher not operating properly. The facility had a census of 85, with 85 of those residents receiving a meal tray from the kitchen. The findings included: 1. The SERVICES AGREEMENT BETWEEN (NAMED FACILITY) AND (NAMED NUTRITION COMPANY) documented, .(Named Facility) requires the Services of an on-site consulting dietician .(Named Nutrition Company) agrees to be responsible for providing the following Services .Scheduling visits to assure that the professional dietetic service needs of the facility are met .Being knowledgeable in all state and federal regulations with regard to the operation of the Food Service Department, and work closely with and through both the Director of (Named Facility) and the Food Service Director to ensure that (Named Facility) is in compliance with all such state and federal regulations . 2. The facility's UNIFORM POLICY policy documented, .MEN/FACIAL HAIR: Must be maintained in a clean and well-groomed manner. Excessive facial hair could present a Universal Precautions issue .When in food preparation area, a beard must be contained by a hairnet . 3. The facility's Cleaning of Miscellaneous Equipment and Utensils policy documented, .Carts, Food Delivery & Utility .Daily Cleaning Wipe with clean cloth soaked in sanitizing solution, after each meal .Dishes .When a low temperature machine is used, use chemical sanitizing agents according to manufacture's instructions .Maintain wash temperature at minimum of 150 degrees F (Fahrenheit) for 40 seconds or per manufacture's directions .Mixer: (after each use) .Thoroughly scrub machine (including motor housing), Rinse and sanitize .Range and Grill: (daily) .The cook on each shift is responsible to keeping the stove as clean as possible during the preparation of the meal .brush burners: check for clogs by lighting burners .Toaster .daily .remove crumb tray and wash .move toaster and wipe counter underneath . 4. The facility's Food Receipt and Storage policy documented, .Storage of Foods .Items should be dated with the month, day, and year when put in storage; items should not be stored longer than a year .Place dented, bulging, or rusty cans, and opened or torn packages in a separate area to be returned to vendor .refrigerated and frozen items should be labeled, dated and covered . 5. Observations in the kitchen on [DATE] beginning at 8:40 AM, revealed the following: a. The Assistant Dietary Manager was working without a beard guard on. b. Dust and dirt on pipes above the food preparation table. c. Dust, dirt, and dead insects in the windowsill above the clean dish drying racks loaded with clean dishes. d. Dried debris on clean lid drying racks. e. Dirty gloves in the center of the kitchen floor. f. Dirty gloves in the floor in front of the sanitation sink. g. A dead insect in a wrapped silverware bin. h. Dried debris in a large storage bin of flour with black particles. Interview with Dietary Aide #1 on [DATE] at 9:05 AM, in the kitchen, Dietary Aide #1 was asked to pull out debris in the flour. The matter was hard in form. The Dietary Aide was asked if the particles should be in the flour. The Dietary Aide stated, No. i. Unlabeled storage bins containing flour and corn meal. Interview with Dietary Aide #1 on [DATE] at 9:05 AM, in the kitchen, Dietary Aide #1 was asked if he thought the flour and corn meal should be labeled and dated. He stated, Yes. j. The meat slicer was covered. After removing the cover, there was dried debris stuck to the slicer pan, the blade, and the base. Interview with Cook #1 on [DATE], at 9:00 AM, in the kitchen, Cook #1 stated, It is clean when it is covered. Interview with Cook #1 on [DATE] at 9:10 AM, in the kitchen, Cook #1 stated, The slicer should be cleaned after each use and should not be dirty. k. The mixer was covered. After removing the cover the mixer was covered in dried debris of varying substances (some solid and some liquid). Interview with Cook #1 on [DATE] at 9:15 AM, in the kitchen, Cook #1 stated, It is clean when covered. Interview with Cook #1 on [DATE] at 9:20 AM, in the kitchen, Cook #1 stated. The mixer should be cleaned after each use and should not be dirty l. Carbon build up on the following kitchen cooking ware: 2 large frying pans. 1 small soup pot. 1 medium soup pot. 1 large soup pot. 8 baking pans. 1 small steam table pan. 4 cupcake pans. m. Dried debris on the bread warmer and on the table surface around and under the warmer. n. A case of ice cream was sitting on the kitchen floor outside the freezer in a cardboard box. o. Foods were found opened, not dated, and unlabeled in the walk in freezer as follows: 1 bag of broccoli 1/2 full. 1 bag of okra 1/4 full. 1 bag of corn nuggets. 1 bag of carrots 1/2 full. 1 bag of snap peas. 1 bag of carrots. 5 bags of various frozen unidentified foods opened, in a box unlabeled and not dated. 1 bag of zucchini slices opened, not dated, and spilled out in a box. 6. Observations of the walk in refrigerator on [DATE] at 9:40 AM, revealed the following: 6 cartons of buttermilk expired (dated [DATE]). 7. Observations of the dry storage room at [DATE] at 9:50 AM, revealed the following: a. 4 large (6) pound cans of lima beans on the shelf dented along the rims and sides. b. 1 bag Raisin bran cereal opened and not dated. c. 1 box quick oats of opened and not dated. d. 3 bags of raspberry gelatin opened and not dated. e. 1 bag of cocoa opened and not dated. f. 2 bags of classic cornbread mix opened and not dated. g. 1 gallon teriyaki sauce opened, and not dated. h. 2 gallon containers of molasses dated [DATE]. i. 2 gallon containers of molasses opened and dated [DATE]. j. 9 jars of capers dated [DATE] with a manufacturer's expiration date of ,[DATE]. 8. Observations in the dry storage room of the emergency food supply on [DATE] at 10:30 AM, revealed the following: (1) 10 pound canister of baking powder opened, 1/2 full and dated [DATE]. (1) 5 pound can of mashed potatoes dented around the top rim. Interview with the Assistant Dietary Manager on [DATE], at 10:40 AM, in the kitchen, the Assistant Dietary Manager was asked where should the dented cans be stored. The Assistant Dietary Manager stated, Dented cans are put on this shelf (pointed at shelf of dented cans in kitchen) when they come in so they don't get stocked on the regular shelves. 9. Observations in the dishwashing room, on [DATE] at 10:00 AM, revealed the following: (1) The low temperature dishwasher was watched through 3 sets of dishes. No temperatures went above 100 degrees in the wash or rinse cycle. (2)The sanitary strip did not change colors, which indicated there was no sanitizer in the machine. Interview with the Assistant Dietary Manager on [DATE] at 10:00 AM, in the kitchen, the Assistant Dietary Manager was asked should the dishwasher be used if the temperatures and sanitation were not working properly. He stated, No. I will call the (Named Company) to come fix, and use the 3 compartment sink for dishes. There were no temperatures documented for [DATE], [DATE], and [DATE] on the temperature log form for the low-temperature dishwasher machine. Interview with the Assistant Dietary Manager on [DATE] at 1:10 PM, in the kitchen, the Assistant Dietary Manager was asked how often should the dish machine temperatures be checked. He stated, Three times a day, breakfast, lunch and dinner. When he was shown the empty dates on the form, he stated, They should be filled out through out sheet. Interview with the Registered Dietitian (RD) on [DATE] at 3:34 PM, in the kitchen, the RD confirmed she would not expect to find open foods undated and unlabeled, in the walk in refrigerator and freezer, or to have cans with dented rims on the shelves. The RD confirmed she would not expect to find dead insects and dirt on the window sill above the clean dishes, over the triple sink, or on the pipes over the food preparation tables. The RD confirmed she would not expect to find dried food debris on the mixer, meat slicer, or on the various tables and carts throughout the kitchen. The RD stated, I'm shocked the kitchen is in this condition. Interview with the Administrator on [DATE] at 3:50 PM, in the kitchen, I was not aware of this, I did not expect to find the kitchen in this condition.",2020-09-01
603,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2018-01-31,812,F,0,1,G3SM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by employees not wearing beard guards, dust and dirt above preparation tables, dust, dirt, and dead insects in the windowsills above clean dishes, debris on clean lid drying racks, dirty gloves in floor in the kitchen, a dead insect in the silver wear bin, dried debris in a large flour bin, unlabeled storage bins, meat slicer with dried debris, mixer with dry and moist debris, carbon build-up on pots, pans, stove, and grill, dried debris on the bread warmer, a case of ice cream on the floor outside the freezer, opened, undated, unlabeled foods in the walk in freezer, expired foods in the walk in the refrigerator, dented cans, undated and unlabeled food items, expired foods in the dry storage, expired foods in the emergency food supply, and the dishwasher not operating properly. The facility had a census of 85, with 85 of those residents receiving a meal tray from the kitchen. The findings included: 1. The facility's UNIFORM POLICY policy documented, .MEN/FACIAL HAIR: Must be maintained in a clean and well-groomed manner. Excessive facial hair could present a Universal Precautions issue .When in food preparation area, a beard must be contained by a hairnet . 2. The facility's Cleaning of Miscellaneous Equipment and Utensils policy documented, .Carts, Food Delivery & Utility .Daily Cleaning Wipe with clean cloth soaked in sanitizing solution, after each meal .Dishes .When a low temperature machine is used, use chemical sanitizing agents according to manufacture's instructions .Maintain wash temperature at minimum of 150 degrees F (Fahrenheit) for 40 seconds or per manufacture's directions .Mixer: (after each use) .Thoroughly scrub machine (including motor housing), Rinse and sanitize .Range and Grill: (daily) .The cook on each shift is responsible to keeping the stove as clean as possible during the preparation of the meal .brush burners: check for clogs by lighting burners .Toaster .daily .remove crumb tray and wash .move toaster and wipe counter underneath . 3. The facility's Food Receipt and Storage policy documented, .Storage of Foods .Items should be dated with the month, day, and year when put in storage; items should not be stored longer than a year .Place dented, bulging, or rusty cans, and opened or torn packages in a separate area to be returned to vendor .refrigerated and frozen items should be labeled, dated and covered . 4. Observations in the kitchen on [DATE] beginning at 8:40 AM, revealed the following: a. The Assistant Dietary Manager was working without a beard guard on. b. Dust and dirt on pipes above the food preparation table. c. Dust, dirt, and dead insects in the windowsill above the clean dish drying racks loaded with clean dishes. d. Dried debris on clean lid drying racks. e. Dirty gloves in the center of the kitchen floor. f. Dirty gloves in the floor in front of the sanitation sink. g. A dead insect in a wrapped silverware bin. h. Dried debris in a large storage bin of flour with black particles. Interview with Dietary Aide #1 on [DATE] at 9:05 AM, in the kitchen, Dietary Aide #1 was asked to pull out debris in the flour. The matter was hard in form. The Dietary Aide was asked if the particles should be in the flour. The Dietary Aide stated, No. i. Unlabeled storage bins containing flour and corn meal. Interview with Dietary Aide #1 on [DATE] at 9:05 AM, in the kitchen, Dietary Aide #1 was asked if he thought the flour and corn meal should be labeled and dated. He stated, Yes. j. The meat slicer was covered. After removing the cover, there was dried debris stuck to the slicer pan, the blade, and the base. Interview with Cook #1 on [DATE], at 9:00 AM, in the kitchen, Cook #1 stated, It is clean when it is covered. Interview with Cook #1 on [DATE] at 9:10 AM, in the kitchen, Cook #1 stated, The slicer should be cleaned after each use and should not be dirty. k. The mixer was covered. After removing the cover the mixer was covered in dried debris of varying substances (some solid and some liquid). Interview with Cook #1 on [DATE] at 9:15 AM, in the kitchen, Cook #1 stated, It is clean when covered. Interview with Cook #1 on [DATE] at 9:20 AM, in the kitchen, Cook #1 stated. The mixer should be cleaned after each use and should not be dirty l. Carbon build up on the following kitchen cooking ware: 2 large frying pans. 1 small soup pot. 1 medium soup pot. 1 large soup pot. 8 baking pans. 1 small steam table pan. 4 cupcake pans. m. Dried debris on the bread warmer and on the table surface around and under the warmer. n. A case of ice cream was sitting on the kitchen floor outside the freezer in a cardboard box. o. Foods were found opened, not dated, and unlabeled in the walk in freezer as follows: 1 bag of broccoli 1/2 full. 1 bag of okra 1/4 full. 1 bag of corn nuggets. 1 bag of carrots 1/2 full. 1 bag of snap peas. 1 bag of carrots. 5 bags of various frozen unidentified food opened, in a box unlabeled and not dated. 1 bag of zucchini slices opened, not dated, and spilled out in a box. 5. Observations of the walk in refrigerator on [DATE] at 9:40 AM, revealed the following: 6 cartons of buttermilk expired (dated [DATE]). 6. Observations of the dry storage room at [DATE] at 9:50 AM, revealed the following: a. 4 large (6) pound cans of lima beans on the shelf dented along the rims and sides. b. 1 bag Raisin bran cereal opened and not dated. c. 1 box of quick oats opened and not dated. d. 3 bags of raspberry gelatin opened and not dated. e. 1 bag of cocoa opened and not dated. f. 2 bags of classic cornbread mix opened and not dated. g. 1 gallon teriyaki sauce opened, and not dated. h. 2 gallon containers of molasses dated [DATE]. i. 2 gallon containers of molasses opened and dated [DATE]. j. 9 jars of capers dated [DATE] with a manufacturer's expiration date of ,[DATE]. 7. Observations in the dry storage room of the emergency food supply on [DATE] at 10:30 AM, revealed the following: (1) 10 pound canister of baking powder opened, 1/2 full and dated [DATE]. (1) 5 pound can of mashed potatoes dented around the top rim. Interview with the Assistant Dietary Manager on [DATE], at 10:40 AM, in the kitchen, the Assistant Dietary Manager was asked where should the dented cans be stored. The Assistant Dietary Manager stated, Dented cans are put on this shelf (pointed at shelf of dented cans in kitchen) when they come in so they don't get stocked on the regular shelves. 8. Observations in the dishwashing room, on [DATE] at 10:00 AM, revealed the following: (1) The low temperature dishwasher was watched through 3 sets of dishes. No temperatures went above 100 degrees in the wash or rinse cycle. (2)The sanitary strip did not change colors, which indicated there was no sanitizer in the dishwasher. Interview with the Assistant Dietary Manager on [DATE] at 10:00 AM, in the kitchen, the Assistant Dietary Manager was asked should the dishwasher be used if the temperatures and sanitation were not working properly. He stated, No. I will call the (Named Company) to come fix, and use the 3 compartment sink for dishes. There were no temperatures documented for [DATE], [DATE], and [DATE] on the temperature log form for the low-temperature dishwasher machine. Interview with the Assistant Dietary Manager on [DATE] at 1:10 PM, in the kitchen, the Assistant Dietary Manager was asked how often should the dish machine temperatures be checked. He stated, Three times a day, breakfast, lunch and dinner. When he was shown the empty dates on the form, he stated, They should be filled out through out sheet. Interview with the Registered Dietitian (RD) on [DATE] at 3:34 PM, in the kitchen, the RD confirmed she would not expect to find open foods undated and unlabeled, in the walk in refrigerator and freezer, or to have cans with dented rims on the shelves. The RD confirmed she would not expect to find dead insects and dirt on the window sill above the clean dishes, over the triple sink, or on the pipes over the food preparation tables. The RD confirmed she would not expect to find dried food debris on the mixer, meat slicer, or on the various tables and carts throughout the kitchen. The RD stated, I'm shocked the kitchen is in this condition. Interview with the Administrator on [DATE] at 3:50 PM, in the kitchen, I was not aware of this, I did not expect to find the kitchen in this condition.",2020-09-01
604,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2017-05-10,157,D,1,0,DC3711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to notify the physician the ordered urine analysis (U/A) and culture was not obtained for 1 resident (#1) of 8 residents reviewed. The findings included: Review of facility policy, Policy for MD/RP (Medical Doctor/Responsible Party) Notifications, undated revealed .PURPOSE: To keep the physician, who is in charge of the medical care .informed of the resident's medical condition .STANDARD: Notification of the physician .should occur promptly, according to federal regulations, when there is a change in the resident's condition . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Telephone Physician order [REDACTED].U/A + (and) culture . Medical record review of the Lab Log, with Licensed Practical Nurses (LPN's) #2 and #3 present, revealed the 3/23/17 U/A order was documented in the Lab Log to be obtained on 3/24/17. Further review revealed a written notation .Unable to Obtain . Interview with LPN's #2 and #3 on 5/9/17 at 3:00 PM at the 1 East nursing station confirmed the 3/23/17 U/A and culture order had been documented in the Lab Log and the facility was not able to obtain a specimen. When the LPN's were asked if the physician had been notified the U/A had not been obtained, the LPN's confirmed the facility failed to notify the physician until 5/8/17. Interview with the Administrator and the Director of Nursing on 5/9/17 at 4:25 PM in the Administrator's office confirmed the facility failed to notify the physician the U/A had not been obtained and seek further instructions.",2020-09-01
605,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2017-05-10,225,E,1,0,DC3711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to report an allegation of abuse for 1 resident (#1), failed to report 2 allegations of abuse timely for 2 residents (#3, #4), and failed to thoroughly investigate allegations of abuse for 3 residents (#1, #3, #4) of 5 residents reviewed for abuse. The findings included: Review of facility policy, Abuse Prevention and Intervention Strategies, dated 11/16 revealed .It is the policy of this facility to protect its residents from abuse .has implemented a program of abuse prevention and intervention strategies .Investigation: The facility will investigate all injuries of unknown origin and all allegations of mistreatment, neglect or abuse. All investigations will be conducted in a timely, thorough and objective manner .Any incidents of substantiated abuse and neglect are reported and analyzed and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State or Federal law . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility investigation dated 3/24/17 revealed the Director of Nursing (DON) had interviewed Resident #1 regarding statements of .(Licensed Practical Nurse (LPN) #3) .repositioning in bed .slammed her head . Further review of the facility investigation revealed 2 written statements, one was dated 3/31/17 signed by LPN #3 and the second was dated 4/5/17 signed by LPN #5. Interview with LPN #3 on 5/8/17 at 11:10 AM in the Social Worker's office revealed the LPN was aware of the allegations and wrote a statement of not transferring or repositioning Resident #1 on 3/24/17. Interview with the DON on 5/8/17 at 4:30 PM in the conference room revealed LPN #5 had informed the DON of the incident on 3/24/17. Interview with LPN #5 on 5/9/17 at 4:25 PM at the 1 East nursing station revealed he had been in Resident #1's room providing care and the resident repeatedly stated LPN #3 had .slammed me in the bed . and .grabbed me for no reason . Further interview revealed LPN #5 informed the DON the day of the incident. Further interview revealed LPN #5 checked the resident for any marks and found none. Further interview confirmed LPN #5 failed to document the resident's physical condition and the alleged incident on 3/24/17. Interview with the Administrator and the DON on 5/10/17 at 4:00 PM in the conference room confirmed the incident of alleged abuse occurred on 3/24/17. Further interview confirmed the facility failed to report the allegation of abuse to the State Agency. When the Administrator and DON were asked if other staff and residents were interviewed, were non-interviewable residents checked for safety, did the facility get statements on the day of the event, was Resident #1 physically and mentally checked out, did the facility complete a thorough investigation of the allegation, the Administrator stated .We steered in the wrong direction . Further interview confirmed the facility failed to complete a thorough investigation of the abuse allegation. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 had a Brief Interview of Mental Status (BIMS) of 10 indicating the resident was moderately cognitively impaired. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed the BIMS could not be conducted because the resident was rarely/never understood. Further review revealed the resident had trouble concentrating nearly every day and had no behavioral symptoms. Further review revealed the the resident had short and long term memory problems and the cognitive skills for daily decision making were severely impaired. Review of the facility investigation included an Occurence Report signed by the DON on 4/11/17 and revealed Resident #3 was slapped by Resident #5 on 4/8/17. Continued review revealed the investigation included a statement from Licensed Practical Nurse (LPN) #1 recounting the event, and skin assessments for Residents #3 and #5 on 4/11/17. Interview with the Administrator and the DON on 5/10/17 at 4:15 PM in the conference room confirmed the facility failed to report the allegation of abuse from 4/8/17 to the State Agency for Resident #3 until 4/14/17 and therefore was not reported in the required time frame. Continued interview with the Administrator and DON revealed the facility failed to conduct additional interviews with staff and interviewable residents, and failed to check non-interviewable residents for safety on the day of the incident. Further interview with the Administrator confirmed the facility failed to thoroughly investigate the allegation for Resident #3. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #4 had a BIMS of 7 indicating the resident was severely cognitively impaired. Review of the facility investigation included an Occurrence Report for Resident #4 and Resident #5. Further review revealed Resident #4 was hit by Resident #5 on 4/14/17. Continued review revealed the investigation included a statement recounting the incident, a skin assessment on Resident #4 dated 4/14/17, and the record of ongoing 15 minute checks of Resident #5 dated 4/11/17 to 4/14/17. Interview with the Administrator and DON on 5/10/17 at 4:20 PM in the conference room confirmed the facility failed to report the allegation of abuse from 4/14/17 to the State Agency until 4/21/17 and therefore was not reported in the required time frame. Continued interview with the Administrator and DON revealed the facility failed to conduct additional interviews with staff and interviewable residents and failed to check non-interviewable residents for safety on the day of the incident. Further interview with the Administrator confirmed the facility failed to thoroughly investigate the allegation of abuse for Resident #4.",2020-09-01
606,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2017-05-10,226,D,1,0,DC3711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to report an allegation of abuse timely to the supervisor/administrator/abuse coordinator for 1 resident (#3) of 5 residents reviewed for abuse. The findings included: Review of facility policy, Abuse Prevention and Intervention Strategies, dated 11/16 revealed .It is the policy of this facility to protect its residents from abuse .has implemented a program of abuse prevention and intervention strategies .All investigations will be conducted in a timely, thorough and objective manner . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 had a Brief Interview of Mental Status (BIMS) of 10 indicating the resident was moderately cognitively impaired. Medical record review of the Initial Wound & Skin Record for Resident #3 dated 4/11/17 revealed .No bruises, marks or injuries noted on skin . Medical record review of a nurse's note dated 4/13/17 at 6:42 PM and written by the Director Of Nursing (DON) revealed .Late entry for 4/11/17. Resident was sitting in her room on 4/8/17 when another resident entered her room. Resident attempted to get him out of room and when she approached the resident, he slapped her in her face . Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed the BIMS could not be conducted because the resident was rarely/never understood. Further review revealed the resident had trouble concentrating nearly every day and had no behavioral symptoms. Further review revealed the resident had short and long term memory problems and the cognitive skills for daily decision making were severely impaired. Review of the facility investigation revealed on 4/8/17 Resident #5 went into Resident #3's room and slapped Resident #3 on the face. Continued review of the facility investigation revealed an undated statement written by LPN #1 recounting the events of the incident on 4/8/17. Further review of the investigation revealed the occurrence report was not written until 4/11/17 by the DON. Interview with the Administrator and the DON on 5/10/17 at 3:55 PM in the conference room revealed they were not made aware of the incident involving Resident #5 hitting Resident #3 until 4/11/17. Further interview revealed it was the expectation of the administrator, who was also the abuse coordinator, for all allegations of abuse to be reported immediately to the supervisor and/or abuse coordinator. Continued interview revealed the Administrator confirmed LPN #1 failed to report the incident immediately to the supervisor and/or abuse coordinator.",2020-09-01
607,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2017-05-10,279,D,1,0,DC3711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy, medical record review, and interview, the facility failed to develop a comprehensive care plan for 1 resident (#4) of 8 residents reviewed. The findings included: Review of facility policy, Care Plans-Comprehensive, revised 10/2010 revealed .An individualized comprehensive care plan that included measureable objectives .to meet the resident's medical, nursing, mental and psychological needs is developed for each resident Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Care Plan dated 2/13/17 revealed .BEHAVIORS: (Resident #4) displays disruptive behaviors with yelling out at times . Further review revealed there was no goal for the care plan. Interview with the Minimum Data Set (MDS) Coordinator on 5/9/17 at 2:13 PM in her office revealed she did not list a goal for the Behavior Care Plan for Resident #4 because she was unsure at the time of the reason for the yelling and stated she was unsure if it was psych (psychiatric) or pain or something else. Interview with the Director of Nursing on 5/10/17 at 11:00 AM in the MDS office, with the MDS Coordinator present revealed there should have been a goal even if the reason for the behaviors was uncertain. Further interview with the DON confirmed it was inappropriate and the facility had failed to develop a comprehensive care plan for Resident #4.",2020-09-01
608,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2017-05-10,280,D,1,0,DC3711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to complete a care plan within 7 days after the completion of the comprehensive assessment and failed to revise a care plan for behaviors involving hallucinations for 1 resident (#1) of 8 residents reviewed. The findings included: Review of facility policy, Care Plans-Comprehensive, revised 10/2010 revealed .Our facility's Care Planning/Interdisciplinary Team .develops and maintains a comprehensive care plan .The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS (Minimum Data Set) .Assessments of the residents are ongoing and care plans are revised as information about the resident and the resident's condition change .The Care Planning/Interdisciplinary Team is responsible for the review and updating of the care plans . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual MDS dated [DATE] revealed Resident #1's Brief Interview for Mental Status was 12/15 indicating she was moderately cognitively impaired; had no mood, psychotic episodes or behaviors; she could hear adequately, and she could make herself understood and understood others. Medical record review revealed the care plan following the comprehensive MDS was dated 3/3/17, exceeding the 7 days after the assessment. Medical record review of the nursing notes revealed on 3/9/17 Resident #1 had experienced .hallucinations . Further review of nursing notes revealed the resident was seeing 1 or more children in her room or in her bed. Medical record review of the Social Service progress note dated 3/31/17 revealed .Res (Resident) continues to verbalize hallucinations according to nursing staff . Interview with the MDS Coordinator on 5/8/17 at 4:15 PM in the conference room confirmed Resident #1 had been experiencing visual hallucinations since 3/9/17 and the facility failed to revise the care plan until 4/3/17. Interview with the MDS Coordinator on 5/9/17 at 3:15 PM in the MDS office confirmed the MDS was completed on 2/8/17 and the facility failed to complete the care plan within 7 days of the MDS. Interview with the Administrator and the Director of Nursing on 5/9/17 at 4:05 PM in the Administrator's office, confirmed the facility failed to complete a care plan timely after a comprehensive assessment per facility policy. Further interview confirmed the facility failed to revise the care plan timely to address the hallucination per facility policy.",2020-09-01
609,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2017-05-10,281,D,1,0,DC3711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to obtain a physician order [REDACTED]. The findings included: Review of facility policy, Medication and Treatment Orders, revised 2/2014 revealed .Orders for medications and treatments will be consistent with principles of safe and effective order writing .shall be administered only upon the written order . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Telephone Physician order [REDACTED].DC (discontinue) zinc oxide cream (ointment for skin treatment) to buttock and groin q (every) shift and as needed . Further review revealed no physician signed telephone order or physician signed computerized order to initiate the the zinc oxide treatment. Medical record review of the 2/2017 and 3/2017 Treatment Administration Records revealed the zinc oxide treatment was administered from 2/15/17 to 3/13/17. Interview with Licensed Practical Nurse (LPN) #2 on 5/10/17 at 9:30 AM at 1 East nursing station confirmed she had written the 3/13/17 discontinuation of zinc oxide order. LPN #2 reviewed the telephone and computerized physician orders [REDACTED]. Interview with the Administrator on 5/10/17 at 10:45 AM in the conference room confirmed the facility failed to follow the facility policy to only administer medications and treatments after a physician order [REDACTED].",2020-09-01
610,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2017-05-10,323,D,1,0,DC3711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy, medical record review, facility investigation review, and interview the facility failed to prevent an altercation for 2 residents (#3, #4) of 5 residents reviewed. The findings included: Review of facility policy, Abuse Prevention and Intervention Strategies, dated 11/16 revealed .It is the policy of this facility to protect its residents from abuse .has implemented a program of abuse prevention and intervention strategies .Investigation: The facility will investigate all injuries of unknown origin and all allegations of mistreatment, neglect or abuse. All investigations will be conducted in a timely, thorough and objective manner .Any incidents of substantiated abuse and neglect are reported and analyzed and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State or Federal law . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 had a Brief Interview of Mental Status (BIMS) of 10 indicating the resident was moderately cognitively impaired. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed the BIMS could not be conducted because the resident was rarely/never understood. Further review revealed the resident had trouble concentrating nearly every day and had no behavioral symptoms. Further review revealed the resident had short and long term memory problems and the cognitive skills for daily decision making were severely impaired. Review of the facility investigation included an Occurence Report signed by the DON on 4/11/17 and revealed Resident #3 was slapped by Resident #5 on 4/8/17. Continued review revealed the investigation included a statement from Licensed Practical Nurse (LPN) #1 recounting the event, and skin assessments for Residents #3 and #5 on 4/11/17. Interview with the Administrator and the DON on 5/10/17 at 4:15 PM in the conference room confirmed the facility failed to prevent an altercation between the two residents. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #4 had a BIMS of 7 indicating the resident was severely cognitively impaired. Review of the facility investigation included an Occurrence Report for Resident #4 and Resident #5. Further review revealed Resident #4 was hit by Resident #5 on 4/14/17. Continued review revealed the investigation included a statement recounting the incident, a skin assessment on Resident #4 dated 4/14/17, and the record of ongoing 15 minute checks of Resident #5 dated 4/11/17 to 4/14/17. Interview with the Administrator and DON on 5/10/17 at 4:20 PM in the conference room confirmed the facility failed to prevent an altercation between the two residents.",2020-09-01
611,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2017-05-10,356,C,1,0,DC3711,"> Based on observation and interview, the facility failed to post the nurse staffing information for 3 of 6 days. The findings included: Observation on 5/8/17 at 8:25 AM revealed the nurse staffing information form posted by the main entrance lobby area was dated 5/4/17, Thursday. Interview with the Main Entrance Receptionist on 5/8/17 at 8:45 AM by the posted nurse staffing information form in the main entrance lobby area confirmed the form was dated 5/4/17. Further interview revealed the Receptionist posted the nursing staff information form Monday through Friday. Further interview revealed the Receptionist did not receive the nurse staffing information forms in order to post them on Friday. Interview with the Staff Development Director (SDD) on 5/9/17 at 10:45 AM by the posted nurse staffing information in the main entrance area confirmed the SDD was responsible to fill out the nurse staffing information forms. Further interview revealed the SDD was to give the nurse staffing information forms to the receptionist on Thursday to post for Friday, Saturday and Sunday. Further interview confirmed the SDD failed to provide the staffing information forms to the receptionist for 5/5/17, 5/6/17, and 5/7/17 and the information was not posted.",2020-09-01
612,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2017-05-10,520,E,1,0,DC3711,"> Based on medical record review, facility investigation review, and interview, the facility Quality Assurance Committee failed to identify an allegation of abuse for Resident #1; failed to report allegations of abuse to the Abuse Coordinator/Administrator timely for Resident #3; failed to report allegations of abuse to the State Agency for Resident #1; failed to report allegations of abuse to the State Agency timely for Resident #3 and #4; failed to thoroughly investigate allegations of abuse for Resident #1, #3, and #4; and for failure to ensure ongoing complaince of the Plan of Correction dated 12/30/16 for F225 and F226 was maintained and monitored by the Quality Assurance Performance Improvement (QAPI) Committee. The findings included: Interview with the Administrator and the Director of Nursing (DON) on 5/10/17 beginning at 3:55 PM in the conference room revealed the (MONTH) (YEAR) QAPI Committee reviewed the (MONTH) (YEAR) concerns which included 1 allegation of abuse. Further interview confirmed the facility failed to identify the 3/24/17 incident involving Resident #1 as an allegation of abuse, failed to thoroughly investigate the allegation, and failed to report the allegation to the State Agency. Continued interview confirmed the facility failed to report the allegation of abuse on 4/8/17 to the facility administration involving Residents #3 and #5 until 4/11/17, failed to report the incident to the State Agency until 4/14/17, and failed to thoroughly investigate the allegation. Further interview confirmed the facility failed to report an allegation of abuse on 4/14/17 to the State Agency until 4/21/17 involving Residents #4 and #5, and failed to thoroughly investigate the allegation. Further interview confirmed the facility failed to ensure ongoing compliance of the Plan of Correction dated 12/30/16 for F225 and F226 was maintained and monitored by the Quality Assurance Performance Improvement Committee. Refer to F225, F226.",2020-09-01
613,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2019-07-11,609,D,1,0,CCNJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview, it was determined the facility failed to report allegations of abuse within 2 hours for 2 of 2 (Resident #1 and #2) sampled residents reviewed for alleged abuse. The findings include: The facility's Abuse, Neglect and Exploitation policy documented, .Report allegations or suspected abuse, neglect or exploitation immediately to State Agencies . Medical record review revealed Resident #1 was admitted to facility 6/20/18 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 scored 15 on the Brief Interview for Mental Status (BIMS), which indicated no cognitive impairment for decision making. Interview with Resident #1 on 7/9/19 at 11:00 AM, in the Social Service office, Resident #1 stated, He hit me in the back of the head two times so I let go of walker and his wheelchair fell backwards into the grass . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed Resident #2 scored 15 on the BIMS, which indicated no cognitive impairment for decision making. Review of the Occurrence Report dated 6/20/19 documented, .(Resident #2) was push (pushed) by another resident (#1) causing wheel (wheelchair) to go off pavement cause (causing) him (Resident #2) to fall . Interview with the Director of Nursing (DON) on 7/11/19 at 1:00 PM, in her office, the DON confirmed the date of the incident was 6/20/19 and was not reported until 6/22/19. The DON was asked if the alleged abuse was reported timely. The DON stated, Probably not.",2020-09-01
614,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2019-11-19,677,E,1,1,H2CG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation, and interview, the facility failed to provide nail care for 3 of 3 (Resident #30, #39, and #55) sampled residents reviewed for Activities of Daily Living (ADL) care. The findings include: 1. The facility's Care of Fingernails/Toenails policy with a revision date of (MONTH) 2010 documented, .to clean the nail bed, to keep nails trimmed and to prevent infection .daily cleaning and regular trimming . 2. Medical record review revealed Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #30 required extensive staff assistance for personal hygiene. Observations in Resident #30's room on 11/17/19 at 10:52 AM, 11/17/19 at 4:49 PM, and on 11/18/19 at 9:43 AM, revealed Resident #30 had long thick toe nails and the right great toe nail was curled upward back toward the resident. Interview with Licensed Practical Nurse (LPN) #6 on 11/19/19 at 2:21 PM, in Resident #30's room, LPN #6 was asked to describe Resident #30's toenails. LPN #6 stated, Thick and fungal .didn't know they were like that . 3. Medical record review revealed Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed Resident #39 required total dependence of staff for personal hygiene. Observations in Resident #39's room on 11/17/19 at 10:00 AM, revealed Resident #39's fingernails were long with a dark brown substance under the nails. Interview with LPN #3 on 11/19/19 at 3:23 PM, at the 1 East Nurses' Station, LPN #3 stated Resident #39's fingernails are dirty. LPN #3 was asked how the nurses were made aware residents nails needed trimming. LPN #3 stated .the CNAs (Certified Nursing Assistants) and nurses should assess resident's skin and nails and determine if the nails need trimming . 4. Medical record review Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed Resident #55 required extensive staff assistance for his personal hygiene. Observations in Resident #55's room on 11/17/19 at 10:35 AM and 4:40 PM, 11/18/19 at 8:04 AM, 11/19/19 at 7:25 AM, and on 11/19/19 at 4:13 PM, revealed Resident #55 had long, thick toe nails. Interview with CNA #3 on 11/19/19 at 1:40 PM, at the 1 West Nurses' Station, CNA #3 was asked about Resident #55's toenails CNA #3 stated, .they look awful .need to be cut . Interview with LPN #5 on 11/19/19 at 1:55 PM, in Resident #55's room, LPN #3 was asked to look at Resident #55's toenails. LPN #5 stated, .yes they need to be trimmed . Interview with the Director of Nursing (DON) on 11/19/19 at 6:22 PM, in the Conference Room, the DON was asked should nails be clean and neatly trimmed. The DON stated, .Yes .",2020-09-01
615,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2019-11-19,689,E,0,1,H2CG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure the environment was free of accident hazards when unsecured sharps and chemicals were observed in 2 of 74 (room [ROOM NUMBER] and room [ROOM NUMBER]) resident rooms, 1 of 6 (1 East Hall) storage rooms, 2 of 4 (1 East Hall and 1 West Hall) supply rooms, and 2 of 6 (1 West Hall bathroom and 1 East Hall shower room) common resident bathrooms. The findings include: 1. The Sharps Disposal policy with a revision date of (MONTH) 2012 documented, .Whoever uses contaminated sharps will discard them immediately or as soon as feasible into designated containers .Contaminated sharps will be discarded into containers that are .Closable .Puncture resistant .Leakproof on sides and bottom .Labeled .Impermeable and capable of maintaining impermeability through final waste disposal . 2. Observations in the unsecured 1 West Hall supply room on 11/17/19 at 10:20 AM, revealed the following items: a. 1 container of floor cleaner. b. 2 containers of neutral floor cleaner. c. 6 bags of liquid hand sanitizer refills. 3. Observations in the 1 West Hall common patient bathroom on 11/17/19 at 10:34 AM, 11:43 AM, 1:15 PM, and 4:53 PM, 11/18/19 at 8:01 AM and 3:14 PM, and 11/19/19 at 8:02 AM, revealed a used disposable razor lying on top of the sharps container. Interview with Licensed Practical Nurse (LPN) #2 on 11/19/19 at 8:15 AM, in the 1 West Hall common patient bathroom, LPN #2 was asked if it disposable razors should be unsecured. LPN #2 stated, No . 4. Observations in the unsecured 1 East Hall supply room on 11/17/19 at 10:36 AM, revealed the following items: a. 50 disposable razors b. 168 denture cleanser tablets c. 2 canisters of super sani wipes d. 50 skin prep wipes e. 1 tube of ostomy paste f. 100 [MEDICATION NAME] syringes/needles g. 14 tubes of medicated barrier cream 5. Observations in the unsecured 1 East Hall shower room on 11/17/19 at 10:46 AM, revealed 3 disposable razors on the sink. Interview with LPN #2 on 11/19/19 at 8:12 AM, in the 1 East Hall storage room, LPN #2 was asked if disposable razors should be unsecured. LPN #2 stated, No . 6. Observations in room [ROOM NUMBER] on 11/17/19 at 10:51 AM, 12:38 PM, and 4:30 PM, 11/18/19 at 8:06 AM, and on 11/19/19 at 8:09 AM, revealed a bottle of nail polish remover on the bedside table. Interview with LPN #2 on 11/19/19 at 8:14 AM, outside of room [ROOM NUMBER], LPN #2 was asked if nail polish remover should be at the bedside. LPN #2 confirmed it should not be kept at bedside unsecured. 7. Observations in a vacant resident room [ROOM NUMBER] on 11/17/19 at 11:30 AM, and 11/18/19 at 8:25 AM, revealed a disposable razor and a 4 ounce tube of medicated barrier cream on the bedside table. 8. Observations in the unsecured 1 East Hall storage room on 11/17/19 at 11:41 AM, and 4:51 PM, 11/18/19 at 8:23 AM and 3:15 PM, revealed the following items: a. 1 canister of bleach wipes b. 1 spray bottle with 425 milliliters (ml) of disinfectant spray c. 1 spray bottle with 175 ml of an unknown/unlabeled red liquid d. 1 canister of disinfectant wipes e. 1 bottle of odor control liquid f. 1 bottle of floor cleaner g. 1 bottle of unknown/unlabeled blue liquid h. 1 bottle of heavy duty nonacid washroom cleaner/disinfectant Interview with Certified Nursing Assistant (CNA) #5 on 11/17/19 at 4:52 PM, in the 1 East Hall storage room, CNA #5 was asked if the storage room should be locked. CNA #5 stated, Yes . 9. Observations in the unsecured 1 East Hall storage room on 11/19/19 at 8:07 AM and 3:15 PM, revealed the following items: a. 1 canister radiance disinfectant wipes b. 1 bottle of odor control liquid c. 1 bottle of neutral floor cleaner d. 1 large bottle of an unknown/unlabeled blue liquid e. 1 bottle of heavy duty nonacid washroom cleaner/disinfectant Interview with LPN #2 on 11/19/19 at 8:12 AM, in the 1 East Hall storage room, LPN #2 was asked if the storage room should be locked. LPN #2 stated, It definitely should be locked. 10. Observations in the unsecured 1 East Hall supply room on 11/19/19 at 10:30 AM, revealed the following items: a. 1 opened suture removal kit containing scissors b. 800 alcohol prep pads c. 100 skin prep wipes d. 100 twin blade disposable razors e. 2 canisters super sani wipes f. 1 tube of ostomy paste g. 100 [MEDICATION NAME] syringes/needles h. 168 denture cleanser tablets i. 4 needles (24 gauge (G)) j. 3 vacutainer blood collection sets with 25 G needles k. 12 needles (18 G) Interview with LPN #2 on 11/19/19 at 10:34 AM, in the 1 East Hall supply room, LPN #2 confirmed the supply room should be locked. Interview with the Director of Nursing (DON) on 11/19/19 at 3:50 PM, in the DON Office, the DON was asked if the supply rooms and storage rooms should be locked. The DON stated, Yes.",2020-09-01
616,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2019-11-19,690,D,0,1,H2CG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services to maintain an indwelling urinary catheter when nursing staff failed to keep the drainage bag off the floor for 1 of 1 (Resident #207) sampled residents reviewed with indwelling urinary catheters. The findings include: 1. The facility's Catheter Care, Urinary policy with a revision date of (MONTH) 2014, documented, .The purpose of this procedure is to prevent catheter-associated urinary tract infections .Be sure the catheter tubing and drainage bag are kept off the floor . 2. Medical record review revealed Resident #207 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Foley Catheter . Observations in Resident #207's room on 11/17/19 at 4:31 PM and 11/18/19 at 8:26 AM, revealed Resident #207 was lying in the bed, with the indwelling urinary catheter drainage bag lying on the floor. Interview with the Director of Nursing (DON) on 11/19/19 at 3:50 PM, in the DON Office, the DON was asked if an indwelling urinary catheter drainage bag should be lying on the floor. The DON stated, No.",2020-09-01
617,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2019-11-19,759,D,0,1,H2CG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the GERIATRIC MEDICATION HANDBOOK, 11TH edition provided by the American Society of Consultant Pharmacists, policy review, medical record review, observation, and interview, the facility failed to ensure 1 of 5 (Licensed Practical Nurse (LPN) #3) nurses administered medications with an error rate of less than 5 percent. A total of 4 errors were observed out of 31 opportunities, resulting in an error rate of 12XXX 581 percent (%). The findings include: 1. The GERIATRIC MEDICATION HANDBOOK, 11TH edition provided by the American Society of Consultant Pharmacists documented, .Inhaled Medications .Check Medication Record for order .If another puff of the same or different medication is required, wait 1-2 minutes .then repeat . 2. The facility's Administering Medications policy with a revision date of (MONTH) 2012, documented, .Medications shall be administered in a safe and timely manner, and as prescribed .The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication right dosage, right time and right method (route) of administration before giving the medication . 3. Medical record review revealed Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].D/C (discontinue) [MEDICATION NAME] 5mg q (every) 12 hours PRN (as needed) . The physician's orders [REDACTED].[MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME]) 5 mg-325 mg .give 1 tablet by oral route every 6 hours as needed . The physician's orders [REDACTED].potassium chloride ER (extended release) 20 mEq (milliequivalents) tablet .give 2 tablets (40 meq) by oral route once daily with food . The physician's orders [REDACTED].[MEDICATION NAME] 160 mcg (micrograms)-4.5 mcg/actuation .inhale 1 puff by inhalation route 2 times per day . The physician's orders [REDACTED].[MEDICATION NAME] .90 mcg/actuation aerosol inhaler .inhale 1 puff (90 mcg) by inhalation route 3 times per day . Observations in Resident #27's room on 11/18/19 at 10:53 AM, revealed LPN #3 administered potassium chloride 20 mEq 1 tablet by mouth and [MEDICATION NAME] 5 mg 1 tablet by mouth. The administration of potassium Chloride 20 mEq instead of 40 mEq resulted in medication error #1. The administration of [MEDICATION NAME] 5 mg instead of the [MEDICATION NAME] 5 mg-325 mg resulted in medication error #2. Observations in Resident #27's room on 11/18/19 at 10:53 AM, revealed LPN #3 administered [MEDICATION NAME] 2 consecutive puffs to Resident #27. LPN #3 then immediately administered [MEDICATION NAME] 160/4.5 meq 2 consecutive puffs to Resident #27 on 11/18/19 at 10:54 AM. The administration of the incorrect number of puffs of [MEDICATION NAME] and [MEDICATION NAME] and the failure to wait 1 to 2 minutes between puffs resulted in medication error #3 and #4. Interview with LPN #2 (LPN #3 was unavailable) on 11/18/19 at 11:56 AM, at the 1 West Nurses' Station, LPN #2 confirmed Resident #27 should have received potassium chloride 20 mEq 2 tablets by mouth instead of 1 tablet. LPN #2 was asked if Resident #27 should have received an [MEDICATION NAME] 5 mg tablet, or a [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) tablet. LPN #2 stated, They DC'd [MEDICATION NAME] 5 (mg) on 10/29 (10/29/19). LPN #2 confirmed according to the physician's orders [REDACTED]. Interview with the Director of Nursing (DON) on 11/19/19 at 5:13 PM, in the DON Office, the DON was asked how long the nurse should wait between administration of 2 different inhalers. The DON stated, Two minutes .",2020-09-01
618,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2019-11-19,761,D,0,1,H2CG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, it was determined the facility failed to ensure medications were not stored past their expiration dates, medications were dated when opened, medication carts were kept secure, and medications were stored properly in 4 of 13 (1 East Treatment Cart, 2 West Medication Room, 2 West Medication Cart, and 1 West Medication Cart) medication storage areas. The findings include: 1. The facility's Storage of Medication policy with a revision date of (MONTH) 2007 documented, .The facility shall not use .outdated or deteriorated drugs or biologicals . The facility's Administering Medications policy with a revision date of (MONTH) 2012 documented, .During administration of medication, the medication cart will be kept closed and locked when out of sight of the medication nurse or aide .It may be kept in the doorway of the resident's room .with open drawers facing inward and all other sides closed .No medications are kept on top of the cart .The cart must be clearly visible to the personnel administering medications, and all outward side must be inaccessible to residents or to others passing buy . 2. Observations on the 1 East hall on 11/17/19 at 11:05 AM, 11:29 AM, and 11:45 AM, revealed the 1 East Treatment Cart was unsecured and unattended. Interview with Registered Nurse (RN) #1 at the 1 East Nurses' Station on 11/18/19 at 11:45 AM, RN #1 was asked if the treatment cart should be locked. RN #1 stated, Yes . 3. Observations in the 2 West Medication Room on 11/17/19 at 12:32 PM, revealed 1 opened bottle of [MEDICATION NAME] vaccine with no open date and 1 opened bottle of [MEDICATION NAME] vaccine with an open date of 8/1/19. Interview with Licensed Practical Nurse (LPN) #1 on 11/17/19 at 12:32 PM, in the 2 West Medication Room, LPN #1 was asked how long the [MEDICATION NAME] vaccine was good for after opening. LPN #1 stated, 60 days. LPN #1 was asked if the medication should be dated when opened. LPN #1 stated, Yes. Interview with the Director of Nursing (DON) on 11/19/19 at 6:23 PM, in the Conference Room, the DON was asked if she would expect to have open medications stored beyond the expiration date, or opened and undated medications stored in the medication storage areas. The DON stated, No. 4. Observations at the 2 West Medication Cart on 11/18/19 at 9:31 AM, revealed RN #2 pulled medications from the medication cart, entered Resident #355's room, and left the medication cart unsecured and unattended. Interview with RN #2 on 11/18/19 at 9:37 AM, outside of Resident #355's room, RN #2 was asked if she could see the 2 West Medication Cart from Resident #355's room. RN #2 stated, No . RN #2 was asked should the medication cart be left unsecured and unattended. RN #2 stated, No. 5. Observations at the 1 West Medication Cart on 11/18/19 at 10:51 AM, revealed LPN #3 prepared the medications for administration, and entered Resident #27's room. LPN #3 left a [MEDICATION NAME] (a narcotic medication patch) unsecured and unattended on top of the medication cart. Observations at the 1 West Medication Cart on 11/18/19 at 10:55 AM, revealed LPN #3 entered Resident #27's room to administer the [MEDICATION NAME], and left a [MEDICATION NAME] and [MEDICATION NAME] inhaler unsecured and unattended on top of the medication cart. Interview with LPN #3 on 11/18/19 at 10:55 AM, at the 1 West Medication Cart, LPN #3 was asked if she should have left the [MEDICATION NAME] unsecured and unattended on top of the medication cart. LPN stated, No. Interview with LPN #3 on 11/18/19 at 10:59 AM, at the 1 West Medication Cart, LPN #3 was asked if she should have left the inhalers unsecured and unattended on top of the medication cart. LPN #3 stated, No. Interview with the Director of Nursing (DON) on 11/19/19 at 3:50 PM, in the DON Office, the DON was asked if she expected nurses to keep the medications secured. The DON stated, Yes.",2020-09-01
619,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2019-11-19,924,D,0,1,H2CG11,"Based on observation and interview, the facility failed to maintain a safe environment when the handrails in the hallway were loose and hanging off the wall for 1 of 8 (1 West Hall) hallways. The findings include: Observations in the 1 West Hall on 11/17/19 at 10:38 AM, revealed the handrails were loose and broken between the resident common bathrooms and on the left and right side of the 1 West Nurses' Station. Interview with the Administrator on 11/19/19 at 11:51 AM, in the Administrator Office, the Administrator was asked if the handrails should be firmly attached to the wall. The Administrator confirmed the handrails should be firmly attached to the wall.",2020-09-01
620,BETHANY CENTER FOR REHABILITATION AND HEALING LLC,445159,421 OCALA DRIVE,NASHVILLE,TN,37211,2017-06-21,371,F,0,1,6LXI11,"Based on facility policy review, observation, and interview, the facility failed to maintain dietary equipment in a clean and sanitary manner, and failed to store and maintain frozen food in a sanitary manner in 1 of 1 dietary observations made; affecting 153 of 155 residents. The findings included: Review of a facility policy Food Storage dated 9/2007, revealed .Foods that are in direct contact with freezer burn (ice crystals) will be discarded .Items removed from the original container, should be .labeled with the contents and date placed in storage . Observation with the Dietary Manager (DM) on 6/19/17 at 9:20 AM, in the dietary department, revealed: [NAME] 1 of 4 work tables with dried food debris on the table top and bottom shelves. B. The tray line conveyor with dried debris on the rollers, sides, and bottom. C. 2 of 2 convection ovens with thick burnt debris on the bottom of the ovens. D. 3 of 6 dry food storage containers with dried debris. E. The meat slicer blade with rust colored debris on the blade. Observation with the DM, on 6/19/17 at 9:35 AM, in the freezer, revealed the freezer contained a build up of ice on the floor and on food items. Interview with the DM identified the food items as: [NAME] Two 10 pound (#) Buffet Hams B. Six 8# Pork Loins C. Five 5# rolls of Ground Beef Interview with the Dietary Manager on 6/19/17 at 9:50 AM, in the kitchen, confirmed the facility failed to maintain food service equipment in a clean and sanitary manner and failed to store and maintain frozen foods in a sanitary manner. Interview with the Administrator on 6/20/17 at 1:44 PM, outside the conference room, confirmed the failed to maintain the kitchen in a sanitary manner.",2020-09-01
621,BETHANY CENTER FOR REHABILITATION AND HEALING LLC,445159,421 OCALA DRIVE,NASHVILLE,TN,37211,2018-07-11,600,G,1,1,C2ER11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of a facility reported incident, medical record review, observation, review of a facility surveillance video, and interview, the facility failed to protect 2 (#316, #26 ) of 5 residents reviewed for physical abuse. The abuse resulted in actual Harm to Resident #316. Findings include: Review of facility policy Abuse Prevention, revised [DATE] revealed, .The facility has a zero tolerance policy for abuse .physical abuse .is prohibited .The Abuse Policy applies to anyone involved with Residents of this facility, including, but not limited to, all facility staff .Abuse .willful infliction of injury .with resulting .physical harm or mental anguish .willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Medical record review revealed Resident #316 was admitted to the facility on [DATE], was placed on Hospice [DATE] and expired on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #316 was rarely/never understood and had short and long term memory problems. She had unclear speech, and rarely/never understood others. She required extensive assistance of 2 or more people for bed mobility, and transfers. She required extensive assistance of 1 person for dressing and toileting. She was totally dependent with assistance of 1 person for locomotion on and off the unit, eating and bathing; and was dependent with assistance of 2 or more people for personal hygiene. She did not require pain medications. Review of a facility reported incident dated [DATE] revealed 2 Certified Nurse Assistants (CNAs) having a verbal argument and CNA #1 threw a plate lid at CNA #2. The plate lid hit Resident #316 in the face and she was transported to the hospital for care. CNA #1 was arrested on site by the local Police Department. Review of a hospital emergency department physician's note dated [DATE] at 9:18 AM revealed, .4 cm (centimeter) laceration with area of deep puncture extending below right eye, does not involve eye .facial plastics (plastic surgeon) at bedside .will repair laceration .discussed with nephew who is point of contact at bedside who is comfortable with patient's return to .facility . Review of a computed tomography (CT) scan report dated [DATE] revealed, .The patient has a [MEDICAL CONDITION] right nasal bone at the nasomaxillary junction (right side of the bridge of the nose) with subcutaneous [MEDICAL CONDITION] (gas or air in the layer under the skin) . Review of Discharge Instructions from the hospital dated [DATE] revealed the reason for the visit was a facial laceration. [DIAGNOSES REDACTED].Assault by striking with a [MEDICATION NAME] or thrown object, initial encounter .Alzheimer's dementia without behavioral disturbance .Closed fracture of nasal bone, initial encounter . Telephone interview with an Adult Protective Services (APS) Supervisor on [DATE] at 10:56 AM revealed they substantiated the alleged abuse based on the video. Further interview revealed, The video shows the CNA throwing the plate lid and it hit the resident . Observation on [DATE] at 8:00 AM in the State Survey office of a 1 minute digital video dated [DATE] at 7:30 AM recorded by the facility and provided by APS revealed 6 residents were in a day room along with 2 CNAs (CNA #1 and CNA #2) and 1 Licensed Practical Nurse (LPN) #2. 3 residents were seated in wheelchairs at one table and 3 residents were seated in wheelchairs at another table. LPN #2 had a medication cart at one doorway of the day room and was administering medications to a male resident seated at the table by CNA #2. CNA #1 was removing breakfast items from the breakfast tray and setting up the meal for a resident by placing used condiment wrappers and straw wrappers into an upside down hard plastic plate lid resting on the table. CNA #2 was at the other table approximately ,[DATE] feet away placing clothing protectors on the 3 residents. Both CNAs were seen talking to each other, CNA #1 stopped what she was doing, faced CNA #2 and put her left hand on her hip. CNA #2 kept talking to her. CNA #1 had the empty food tray in her left hand then picked up the plate lid with her right hand and threw it forcefully in the direction of CNA #2 who was standing between 2 residents; a male resident and Resident #316. The plate lid hit Resident #316 on the right side of her face. Her head was seen moving backward then forward. CNA #2 turned her head and right shoulder to the left to avoid being hit. The plate lid rolled out of another door of the day room. LPN #1 had her back to CNA #1 at the time she threw the lid and was giving medication to the male resident seated at the table by CNA #2. LPN #2 immediately stepped between the 2 CNAs and walked CNA #1 out of the room. As she was leaving the room, CNA #1 dropped the empty food tray on the floor by the door. There was no audio on the recording. Interview with the Administrator with the Director of Nursing (DON) present on [DATE] at 12:50 PM in the DON's office stated he was notified by phone sometime between 7:00 AM and 8:00 AM on [DATE] by LPN #5 that a resident was hit by a tray or something by CNA #1. The Administrator was driving to the facility at the time and instructed the nurse to bring CNA #1 to his office and have the Social Worker (SW) and LPN #5 view the video recording from the camera in the day room. After viewing the video, the police were notified and arrested CNA #1 at the facility. Interview with LPN #2 on [DATE] at 1:35 PM in the DON's office revealed the incident occurred in the F hall day room which is the secured dementia unit. Continued interview revealed, .The techs were setting up breakfast trays and one (CNA #2) told the other one (CNA #1) about not bringing drinks to the day room and (CNA #1) was like, 'I forgot.' I was in the room and I heard (CNA #1) say 'I'm gonna do something.' (CNA #2) said 'What you gonna do?' Then I told them to cool it or something to that effect. Next thing I heard a tray drop. I separated the 2 CNAs and called the supervisor. I put (CNA #1) on A hall and kept (CNA #2) on F hall. When I went back to F hall to finish my meds, (CNA #2) said, 'You need to look at (Resident #316's) face.' When I looked at it she had a gash on her face and it was bleeding a little bit at that time . Telephone interview with LPN #5 on [DATE] at 2:26 PM revealed she was the night supervisor and the only management person in the building on [DATE]. Continued interview revealed LPN #5 stated she received a phone call from LPN #2 telling me you need to come ASAP (as soon as possible) because I have 2 CNAs who aren't getting along and I have to have 2 CNAs on the secured unit .About ,[DATE] minutes later (LPN #2) comes to get me and tells me I need to come quick because a resident is hurt. The Nurse Practitioner (NP) was there, so I grabbed her and all 3 of us are in the elevator when (LPN #2) said she thinks CNA #1 threw a tray and she saw it bounce on the floor . Continued interview revealed LPN #5 stated, .(Resident #316) doesn't speak. She was in a high back wheelchair and I saw a laceration from her inner eye to her cheek approximately ,[DATE] centimeters .we called 911 .me and the Director of Maintenance viewed the video. There was no volume only video. I could see the CNA's hand gestures and (CNA #1) put her hands on her hip .the nurse was at the med cart .(CNA #1) threw the whole tray and the lid flew in (CNA #2's) direction and it hit the resident in the face. She can't verbally respond. Her head went back and forward and she can't move her arms very well, she's very, very weak Medical record review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Give ,[DATE] tablet (2XXX,[DATE].5 mg) by mouth every 4 hours as needed for pain. Continued review revealed Resident #316 received a dose of pain medication on [DATE], [DATE], and [DATE]. In summary, upon medical record review, observation and interview, the facility failed to protect Resident #316 from physical abuse resulting in actual Harm when CNA #1 injured the resident by throwing a plate lid in her direction on [DATE]. Medical record review revealed Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating he was cognitively intact with a resident mood interview indicating moods occurring ,[DATE] days and no behaviors documented. Continued review revealed Resident #26 was independent with eating requiring set-up only by 1 staff person. Further review revealed the resident's mobility was independent with set up by 1 staff person in his electric wheelchair. Review of the facility investigation dated [DATE] revealed Resident #26 made derogatory remarks and racial slurs to Dietary Aide #3 after she brought him the wrong food order from the alternative food menu. Continued review revealed when the resident persisted with the derogatory remarks and racial slurs Dietary Aide #3, with her closed fist, punched Resident #26 on the left side of his face. Continued review revealed the Unit Manager immediately removed Dietary Aide #3 from the situation and placed her in a room, took her statement, and terminated her employment in the facility. Continued review of the facility investigation revealed video footage from a surveillance camera (from the facility's investigation) in the main dining room and a written statement from LPN #7. The written statement revealed on [DATE] at 7:47 PM Resident #26 and Dietary Aide #3 appeared to be arguing with Dietary Aide #3 aggressively finger pointing in the resident's face. At 7:51 PM, the same evening, the Dietary Aide #3 struck Resident #26 with a closed fist to the left side of his face and left the main dining room. Medical record review of the Nurse's Notes dated [DATE] revealed the resident's left ear was reddened and ordered pain medication was given as requested by the resident. Continued review revealed the resident felt safe and unthreatened. Telephone interview with an Adult Protective Services counselor on [DATE] at 10:01 AM revealed Resident #26 ordered food from the alternative food menu for dinner. Continued interview revealed Dietary Aide #3 delivered the food to Resident #26. Further interview revealed upon receipt of the food Resident #26 told Dietary Aide #3 it was not what he ordered and began yelling the derogatory remarks and racial slurs at the teh Dietary Aide #3. As the yelling persisted Dietary Aide #3 hit Resident #26 with her closed fist on the left side of his face. Continued interview revealed the Unit Manager immediately removed Dietary Aide #3 from the situation and placed her in a room, took her statement, and terminated her. Interview with the DON on [DATE] at 10:40 AM in the DON's office confirmed Dietary Aide #3 did physically abuse Resident #26 after he made racial slurs and called her names. Continued interview confirmed as a facility employee Dietary Aide #3 represented the facility and did deliberately punch the resident with her closed fist instead of initially walking away from the situation. Further interview confirmed the facility failed to prevent physical abuse to Resident #26.",2020-09-01
622,BETHANY CENTER FOR REHABILITATION AND HEALING LLC,445159,421 OCALA DRIVE,NASHVILLE,TN,37211,2018-07-11,812,D,0,1,C2ER11,"Based on review of facility policy, observation, and interview, the facility failed to ensure food was served under sanitary conditions when a male dietary employee with facial hair was observed working on the tray line without wearing a beard net on 1 of 3 observations. Findings include: Review of facility policy, General Sanitation of Kitchen dated 2013 revealed .beard nets are required when facial hair is visible . Observation of the noon meal on 7/9/18 at 11:35 AM in the dietary department revealed one male dietary employee working on the residents tray line with visible facial hair not wearing a beard net. Interview with the Dietary Manager on 7/9/18 at 11:36 AM in the dietary department confirmed the male employee failed to wear a beard net to cover facial hair while working on the tray line.",2020-09-01
623,BETHANY CENTER FOR REHABILITATION AND HEALING LLC,445159,421 OCALA DRIVE,NASHVILLE,TN,37211,2018-07-11,880,D,1,1,C2ER11,"**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 change a soiled dressing Percutaneous Inserted Central Catheter (PICC) (a line that goes into your arm and runs all the way to a large vein near the heart for long term intravenous therapy) as ordered for 1 (#1) of 7 residents reviewed. Findings include: Review of facility policy IV Tubing and Dressing Changes dated 10/1/07 revealed .PICC line dressings will be changed weekly . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician order [REDACTED].change PICC line dressing 24-48 hours after insertion of line if dressing is soiled and then every 7 days . Observation on 7/10/18 at 9:50 AM in Resident #1's room revealed an old soiled transparent dressing, covering the PICC line of the upper left arm with a date of 6/20/18. Observation and interview with the Unit Manager on 7/10/18 at 9:52 AM in Resident #1's room confirmed the transparent dressing was dated 6/20/18 to Resident #1's PICC line. Further interview revealed the Unit Manger stated I see it and nodded her head in agreement that the facility failed to change the soiled dressing weekly as ordered.",2020-09-01
624,BETHANY CENTER FOR REHABILITATION AND HEALING LLC,445159,421 OCALA DRIVE,NASHVILLE,TN,37211,2019-10-23,804,E,0,1,JYS111,"**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 provide food and beverages at a palatable and appetizing temperature for 1 tray delivery cart, containing 22 resident meal trays, of 3 tray delivery carts delivered to the 1st floor. The findings include: Review of the undated facility policy, Food Temperatures, revealed .Foods should be transported as quickly as possible to maintain temperatures for delivery and service . Medical record review revealed Resident #54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #54's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 9 indicating the resident was moderately cognitively impaired. Interview with Resident #54's family member on 10/21/19 at 1:52 PM in Resident #54's room, on the 1st floor, revealed the food was not hot when it arrived and stated she was present for the lunch meal daily. Medical record review revealed Resident #93 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #93's Quarterly MDS dated [DATE] revealed the resident had a BIMS score of 14 indicating the resident was cognitively intact. Interview with Resident #93 on 10/21/19 at 9:45 AM in the resident's room, on the 1st floor, revealed during all meals the hot food was cold, the cold food was hot and the ice cream was always melted. Observation and interview with Resident #93 on 10/21/19 at 12:10 PM in the resident's room during the lunch meal revealed the food was warm and the ice cream was melted. Observation of the mid-day tray line meal service on 10/22/19 at 11:40 AM in the dietary department revealed the following food temperatures were obtained by the Food Service Director: 1. Pork Chop - 186 degrees Fahrenheit (F) 2. Pureed Chicken - 193 degrees F 3. Mechanical altered Pork - 177 degrees F 4. Cabbage - 199 degrees F 5. Pureed Cabbage - 158 degrees F 6. Pinto Beans - 192 degrees F 7. Pureed Pinto Beans - 190 degrees F 8. Milk - 41.6 degrees F, already above acceptable serving temperature of 40 degrees 9. Ice Cream - 16.5 degrees F Observation on 10/22/19 at 12:05 PM revealed the tray delivery cart, including the test tray, left the dietary department and was delivered to the 1st floor. All residents were served and eating at 12:49 PM. Continued observation revealed meal service delivery time was a total of 43 minutes. Observation on 10/22/19 at 12:49 PM, in the 1st floor common area, of the test tray temperatures taken by the Food Service Manager revealed the following: 1. Pork Chop - 119.8 degrees F, a loss of 66.2 degrees 2. Pureed Chicken - 115 degrees F, a loss of 78 degrees 3. Mechanical altered Pork - 116.8 degrees F, a loss of 60.2 degrees 4. Cabbage - 121.6 degrees F, a loss of 77.4 degrees 5. Pureed Cabbage - 119 degrees F, a loss of 39 degrees 6. Pinto Beans - 115.5 degrees F, a loss of 76.5 degrees 7. Pureed Pinto Beans - 114.8 degrees F, a loss of 75.2 degrees 8. Milk - 55 degrees F, an increase of 13.4 degrees 9. Ice Cream - 29.5 F, and was melted, an increase of 13 degrees Interview with the Food Service Director on 10/22/19 at 12:49 PM in the 1st floor common area confirmed temperatures weren't maintained on the 1st floor tray line meal service; the hot food was too cold; and the milk and ice cream were too warm.",2020-09-01
625,BETHANY CENTER FOR REHABILITATION AND HEALING LLC,445159,421 OCALA DRIVE,NASHVILLE,TN,37211,2019-10-23,880,K,0,1,JYS111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the glucometer manufacturer guideline, medical record review, observation and interview, the facility failed to follow standard precautions during the performance of routine fingerstick blood glucose testing resulting in potential exposure of residents who required blood glucose testing to the spread of bloodborne infections in the facility for 3 (#26, #99 and #117) of 32 diabetic residents. The Administrator was informed of the Immediate Jeopardy (IJ) on 10/22/19 at 1:15 PM in the Director of Nursing's office. F-880 was cited at a scope and severity of K. An extended survey was effective from 10/22/19 to 10/23/19. The Immediate Jeopardy was effective on 10/22/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the jeopardy was received on 10/23/19 at 11:34 AM and corrective actions were validated onsite by the surveyors on 10/23/19. The findings include: Review of the Glucometer manufacturer guideline, Caring for Your System undated, revealed .to minimize the risk of transmission of bloodborne pathogens, the cleaning and disinfection procedure should be performed as recommended .the meter should be cleaned and disinfected after use on each patient .Germicidal Disposable Wipe for disinfecting the meter which included bleach germicidal disposable wipe containing bleach 1:10 dilution . Medical record review revealed Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #26's Medication Administration Record [REDACTED]. Medical record review revealed Resident #99 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #99's Medication Administration Record [REDACTED]. Medical record review revealed Resident #117 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #117's Physician order [REDACTED].strict isolation-Urinary .ESBL (Extended Spectrum Beta-Lactamase) . Medical record review of Resident #117's Medication Administration Record [REDACTED]. Observation and interview on 10/22/19 at 9:25 AM in Resident #117's room revealed LPN #1 did not disinfect a glucometer prior to performing a fingerstick blood glucose testing on Resident #117. Continued observation revealed LPN #1 left the isolation room, cleaned the glucometer with an alcohol prep then placed the glucometer into the D/E Hall medication cart. When LPN #1 was asked what is the procedure for disinfecting the glucometer she stated, The night nurses clean the glucometer. Further interview when asked when she would clean the glucometer she stated I would clean it when visibly soiled. When asked what disinfectant she would use to clean the glucometer she stated I would clean it with alcohol. When asked if she had performed any other fingerstick blood glucose testing prior to Resident #117 she stated yes, on (named Resident #26). When asked if she had disinfected the glucometer after performing Resident #26's fingerstick blood glucose testing, she stated No, I don't think so. Interview with the DON on 10/23/19 at 8:28 AM in her office confirmed the process of disinfecting the glucometers was for the nurses to disinfect the glucometers with an appropriate cleaner/disinfecting wipe before and after each resident use. The DON stated, {named LPN #1} should have cleaned the glucometer before and after each use with a germicidal wipe. The surveyors verified the A[NAME] by: 1. On 10/22/19 the glucometer was immediately removed from the medication cart E, cleaned and disinfected by the Unit Manager according to the manufacturer's guidelines. All other glucometers in the facility were cleaned by the Unit Managers according to the manufacturer's guidelines. The nurse on D/E Hall medication cart was educated on 10/22/19 by the Unit Manager as well as a Glucometer Competency was completed. The 3 residents that received blood glucose monitoring by this nurse on D/E Hall were assessed by the Nurse Practitioner (NP) on 10/22/19. The surveyor observed the Unit Manager remove two (2) glucometers from D/E Hall medication cart and disinfect the 2 glucometers per manufacturer's guidelines. The surveyor reviewed the glucometer cleaning log performed by the Unit Managers dated 10/22/19. The surveyor reviewed D/E Hall nurse's education and glucometer competency. The surveyor reviewed the 3 residents NP Assessments which revealed no signs or symptoms of an infectious process was identified. 2. The Unit Managers educated all licensed nurses present on 10/22/19 regarding glucometer cleaning and performed competencies. The Director of Nursing (DON) and Unit Managers ensured each nursing medication cart had 2 glucometers on 10/22/19. An Adhoc Quality Assurance Performance Improvement (QAPI) meeting was conducted by the Administrator on 10/22/19 to ascertain root cause and discuss the facility plan. The surveyor reviewed all nurses present on 10/22/19 education and competencies. The surveyor observed 2 glucometers on each medication cart in the facility. The surveyor reviewed the QAPI meeting plan. The surveyor observed nurses perform fingerstick blood glucose with proper disinfecting technique of the glucometer per manufacturer's guideline. 3. Licensed Nurses were educated by Unit Managers/ADON on 10/22/19 related to proper disinfecting of glucose monitoring machines. The Unit Managers will audit all medication carts weekly for 12 weeks to ensure 2 glucometers are present. The Unit Managers or DON or ADON will observe 3 blood glucose accuchecks (fingerstck blood glucose testing) per shift for 5 days a week for 2 weeks, then 2 blood glucose accuchecks per shift for 5 days a week for a week, then 1 blood glucose accuchecks per shift for 5 days a week and finally 3 blood glucose accuchecks per shift monthly for 2 months. Audits will be reported to QAPI committee monthly for 2 months (Medical Director, Administrator, DON, ADON, Dietary Manager, Activity Director, Rehab Director, Environmental Director, HR Director, Business Office Manager, Social Services Director, Director of concierge, Discharge Planner, Registered Dietician, and Admissions Director) for review and recommendations. The noncompliance of F-880 continues at a scope and severity of [NAME] level for the monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.",2020-09-01
626,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2018-01-24,558,D,0,1,GH7811,"Based on facility policy review, observation, and interview, the facility failed to ensure call lights were within reach for 10 residents (#3, #27, #35, #37, #43, #44, #65, #68, #71, #80) of 93 residents reviewed. The findings included: Review of facility policy, Nurse Call System, dated 9/1/14, revealed .Each cord needs to be visible and reachable by the resident to which it operates for . Observation on 12/18/17 at 8:00 AM in Resident #68's room revealed his call light was clipped to a pillow in the floor and the cord was draped across his neck and out of reach. Observation on 12/18/17 at 8:05 AM in Resident #3's room revealed her call light was clipped to the left side rail. Resident #3 was unable to use her left hand and fingers, was unable to push the call light, and could not reach the call light with her right hand. Observation on 12/18/17 at 8:07 AM in Resident #43's room revealed her call light was clipped to the right side rail. Resident #43 was unable to use her right hand and could not reach the call light with her left hand. Observation on 12/18/17 at 8:07 AM in Resident #71's room revealed her call light was on the floor and out of her reach. Observation on 12/18/17 at 9:25 AM in Resident #27's room revealed she had a push pad call light and it was out of reach on the bedside table. Observation on 12/18/17 at 9:27 AM in Resident #37's room revealed her call light was clipped to the top of the back of the pillow which was under her head and was out of reach of the resident. Observation on 12/18/17 at 9:28 AM in Resident #35's room revealed her call light was on the floor at the head of the bed and out of reach of the resident. Observation on 12/18/17 at 9:29 AM in Resident #65's room revealed her call light was on the floor at the head of the bed and out of reach of the resident. Observation on 12/18/17 at 9:31 AM in Resident #80's room revealed her call light was on the floor at the head of the bed and out of reach of the resident. Observation on 12/18/17 at 12:50 PM in Resident #44's room revealed the resident was lying in bed and the call light was hanging on the wall on a thumb tack out of reach of the resident. Observation and interview with Licensed Practical Nurse (LPN) #3 on 12/18/17 at 9:20 AM at the North Nurse Station confirmed the facility failed to keep the call lights within reach for Resident #3, #43, #68, and #71. Observation and interview with LPN #1 on 12/18/17 at 10:20 AM on the 300 Hall confirmed the facility failed to keep the call lights within reach for Resident #27, #35, #37, #65, and #80. Observation and interview with LPN #2 on 12/18/17 at 12:52 PM in the hallway near Resident #44's room confirmed the facility failed to keep the call light within reach for Resident #44.",2020-09-01
627,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2018-01-24,580,G,0,1,GH7811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This REQUIREMENT is not met as evidenced by: Based on medical record review and interview, the facility failed to notify the Physician when Resident #68 incurred substantial injury related to a fall, had a decline in status, and needed treatment alterations regarding a [MEDICATION NAME] Lumbar Spinal Orthopedic (TLSO) brace. Failure for the facility to notify the Physician on 11/1/17 resulted in Resident #68 developing an axillae pressure ulcer while experiencing pain from the TLSO brace (HARM). The findings included: Medical record review revealed Resident #68 sustained an initial fall on 8/6/17 at 11:01 AM which was unwitnessed with no injury reported and no interventions added to the Care Plan. Further review of the medical record revealed Resident #68 incurred a second fall on 10/31/17 at 2:50 PM which was unwitnessed with injury. Resident #68 was sent out to the Emergency Department and transferred to a Level II hospital equipped to care for such injury. Further review of the medical record revealed the Attending Physician was not notified of Resident #68's injury which was: multiple acute fractures of the T1, T2, T12, L1, and fractures of the right anterior fourth through the seventh ribs near the costochondral junction. Medical record review revealed Resident #68 incurred a substantial decline in physical and mental status as discussed during the Care Plan meeting on 11/13/17 with Resident's family present. Further review of the medical record revealed a timeframe of 14 days passing before Physician intervention when the TLSO was discontinued along with other additional orders. Interview with the Wound Care Nurse on 12/20/17 at 7:55 AM in the 200 Hall Nurses Station revealed .It was the brace that caused his wound, it was not properly fitting and rubbed him . Interview with Licensed Practical Nurse (LPN) #3 on 12/20/17 at 10:41 AM on the 200 Hall Nurses Station revealed .Resident #68 is scheduled to have weekly skin assessments . Further interview with LPN #3 confirmed the facility failed to follow the care plan to complete weekly skin assessments. A total of 26 skin assessments were missed during 11/1/17 through 11/14/17 when pressure ulcer under armpit was found. Interview with the Director of Nursing (DON) on 12/20/17 at 4:30 PM in her office confirmed, Resident #68 was sent to the hospital after the fall dated 10/31/17 and returned on 11/1/17 with a [DIAGNOSES REDACTED]. Resident #68 returned on 11/1/17 with a [MEDICATION NAME] Lumbar Spinal Brace in place. Interview with the DON on 12/20/17 at 4:30 PM revealed Resident #68 .came back with the brace on . Further interview confirmed .we were trying to get his orders clarified . When asked what is a reasonable time period to get Physicians orders clarified the DON responded, .as quick as possible . The DON confirmed the facility failed to adequately notify the Physician and obtain instructions for the [MEDICATION NAME] Lumbar Spinal Orthopedic brace and continued use of the brace which resulted in a pressure ulcer to Resident #68 (HARM).",2020-09-01
628,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2018-01-24,641,G,0,1,GH7811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide skin assessments for Resident (#68). Resulting in development of skin pressure ulceration to the right axilla and arm resulting in (HARM). Medical record review revealed Resident #68 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 6/12/17, revealed the problem of .altered integument (skin) .fragile and poorly perfused skin . with approaches including .weekly skin assessment to be performed/documented by nursing . Further review of the Care Plan revealed Resident #68 was readmitted on [DATE] with intact, but fragile and poorly perfused skin. Medical record review revealed the last skin assessment documented was 9/27/17. Further review revealed 26 missed skin assessments between 11/1/17 through 11/14/17. Resident #68 observed lying in bed on 12/20/17 at 10:01AM in his room, with with a dressing intact to the right axilla area (armpit) and upper inner arm. Interview with Licensed Practical Nurse (LPN) #3 on 12/20/17 at 10:41 AM on the 200 Hall Nurses Station revealed .Resident #68 is scheduled to have weekly skin assessments . Further interview with LPN #3 confirmed the facility failed to follow the care plan to complete weekly skin assessments.",2020-09-01
629,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2018-01-24,657,D,0,1,GH7811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to revise the care plan for 2 residents (#45, #68) of 19 residents reviewed for care plans. The findings included: Medical record review revealed Resident #45 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of the [MEDICAL TREATMENT] Communication Record dated 8/1/17 revealed .Shunt Site: Location: R (right) arm . Medical record review of the Care Plan, with problem onset dated 10/16/15, and last updated 11/27/17, revealed .requires [MEDICAL TREATMENT] .ACCESS Site: Left Arm . Interview with Licensed Practical Nurse (LPN) #1 on 12/19/17 at 3:25 PM at the South Nurses Station revealed Resident #45's [MEDICAL TREATMENT] shunt was now in his right arm and the location was changed several months ago. Interview with Minimum Data Set Coordinator on 12/19/17 at 3:40 PM in his office revealed the care plan does say left. Continued interview confirmed the facility failed to revise the Care Plan to reflect the correct positioning of the [MEDICAL TREATMENT] shunt for Resident #45. Medical record review revealed Resident #68 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Care Plan updated on 11/1/17 revealed .readmit 11/1/17 resident at risk for altered integument (skin) due to impaired mobility . Further review revealed the Care Plan was not revised to reflect the [MEDICATION NAME] Lumbar Spinal brace until 11/14/17 when pressure ulcer on armpit was found. Medical record review of the Care Plan Conference Summary dated 11/15/17 revealed .Nursing discussed the wounds from the brace (back brace) Resident is taking the brace off himself, son reports to take brace off Resident and leave him in bed . Interview with LPN #3 on 12/20/17 at 10:41 AM on the 200 Hall Nurse's Station revealed .He came back from the hospital with the brace on and on bed rest. He had a big decline after the last fall . Further interview with LPN #3 confirmed the facility failed to revise the Care Plan dated 11/1/17 to reflect the [MEDICATION NAME] Lumbar Spine Brace.",2020-09-01
630,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2018-01-24,684,G,0,1,GH7811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide timely treatment after a fall for 1 resident (#2), a fall resulting in [MEDICATION NAME] and Lumbar fractures for 1 resident (#68) and failed to utilize interventions to achieve maximum function of a [DIAGNOSES REDACTED] limb for 1 resident (#74) of 16 residents reviewed. The facility's failure to prevent falls resulted in HARM for Resident #2 and #68. The findings included: Medical record review revealed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Discharge with return anticipated Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 had severe cognitive impairment with short term memory problems and required extensive assistance with bed mobility, transfers, Activities of Daily Living, eating, toileting and was always incontinent of bowel and bladder. Medical record review of a Facility Investigative report dated 8/30/17 for Resident #2 revealed .Resident leaning over in her chair and rolled out of chair into the floor, did not hit her head .Assisted resident out of the floor, vital signs obtained, total body assessment, doctor notified . Medical record review of General Notes dated 8/30/17 revealed .Resident sitting in day room this morning at 10:18 AM and was leaned over into her lap with her eyes closed. Nurse observed resident slide into the floor and not hit her head. Resident assessed and no injuries found. Denies pain . Medical record review of General Notes dated 8/31/17 revealed .Staff observed resident noted to have bruise on right hip, reddened area on right knee, and scratch to right upper thigh. Resident had a fall yesterday and did land on right side of her body when she fell . Staff reported that resident was grimacing holding her right hip and that when she transferred that she appeared to have more pain when using right leg. Nurse practitioner notified with no new orders received .Resident will continue to be monitored due to fall yesterday . Medical record review of General Notes dated 9/1/17 revealed .Signs of pain with transfers and bed mobility .Resident using wheelchair instead of walking since fall . Medical record review of General Notes dated 9/4/17 revealed .Resident with a new order .X-ray to right knee and right hip 2 views due to pain . Resident radiology report received showing results of fracture involving the right femoral neck with modest displacement .Nurse practitioner notified and ordered her to be sent out to emergency room for further evaluation . Medical record review of a Radiology Data entered on 9/5/17 revealed .Acute transcervical fracture through the right femoral neck with mild superior migration and varus deformity of the distal fracture fragment. No dislocation . Medical record review revealed Resident #68 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 6/26/17 revealed no new intervention for the fall dated 8/6/17. Medical record review of a Facility Investigative Report dated 8/6/17 at 11:01 AM revealed, .resident stated he was trying to move from the bed to floor . Resident had a non-witnessed fall with complaint of hip pain. Further review of the Facility Investigative Report revealed the facility failed to complete a post fall investigation after the fall as evidenced by multiple sections left blank. Medical review of the MDS dated [DATE] revealed Resident #68 had a Brief Mental Interview for Status score of 0, indicating severe cognitive impairment. Medical record review of Facility Investigative Report dated 10/31/17 2:50 PM revealed .Resident observed lying on floor on his stomach in front of his bed. Resident stated he was trying to get in his bed and fell . Continued review revealed Resident #68 was sent to the Emergency Department and was diagnosed with [REDACTED].fractures of the T1, T2, T12, ([MEDICATION NAME] fractures of the mid spine, at levels 1, 2, and 12) and fracture at L1, (Lumbar [MEDICAL CONDITION] back) fractures of the right anterior fourth through the seventh ribs near the costochondral junction (near the sternum) .which correlating clinically for point tenderness . Interview with the DON (Director of Nursing) on 12/20/17 at 4:30PM in her office confirmed, Resident #68 was sent to the hospital after the fall dated 10/31/17 and returned on 11/1/17 with a [DIAGNOSES REDACTED]. Resident #68 returned on 11/1/17 with a [MEDICATION NAME] Lumbar Spinal Brace in place. Medical record review revealed Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #74 was severely impaired cognitively. Continued review of the MDS revealed Resident #74 was dependent on 1 person for transfers and bathing; required extensive assistance of 1 person for dressing, grooming, and eating; had impairment of 1 upper extremity and both lower extremities for range of motion. Further review revealed Resident #74 was always incontinent of bowel and had an indwelling catheter. Medical record review of physician's orders [REDACTED].Put on left elbow splint and left hand splint at beginning of 7-3 (7 AM - 3 PM) shift. Take off left elbow splint and left hand splint at end of shift 7-3 (7 AM - 3 PM). Wear time no more than 8 hours . Observation on 12/18/17 at 9:15 AM revealed Resident #74 was lying in bed. Observation of the resident's left arm revealed no splint in place on the hand or elbow. Observation on 12/19/17 at 10:00 AM revealed Resident #74 lying in bed with no splint on the left hand or left elbow. Interview with Licensed Practical Nurse #2 on 12/19/17 at 10:07 AM at the 200 Hall Nurse's Station confirmed Resident #74 was ordered to have a left hand and elbow splint on during the 7:00 AM - 3:00 PM shift and the facility failed to apply the splint as ordered.",2020-09-01
631,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2018-01-24,686,G,0,1,GH7811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to prevent a pressure ulcer for 1 resident (#68) of 7 residents reviewed. The facility's failure to prevent a pressure ulcer for Resident #68 resulted in HARM. The findings included: Review of facility policy, Skin Care Guideline, dated 6/2017 revealed .the plan of care will address problems, goals and interventions directed toward prevention of pressure ulcers in those at risk and for any skin integrity concerns identified . Medical record review revealed Resident #68 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 6/12/17, revealed the problem of .altered integument (skin) .fragile and poorly perfused skin . with approaches including .weekly skin assessment to be performed/documented by nursing . Further review of the Care Plan revealed Resident #68 was readmitted on [DATE] with intact, but fragile and poorly perfused skin. Care Plan updated on 11/1/17 revealed .readmit 11/1/17 resident at risk for altered integument due to impaired mobility, altered judgment, altered perfusion, incontinence, as well as natural age-related physiological changes. This is evident by need for staff to provide peri-care/hygiene and extensive assist with bed mobility and transfers. Weekly skin assessment to be performed/documented by Nursing . Medical review of the Minimum (MDS) data set [DATE] revealed Resident #68 had a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment. Observation of Resident #68 on 12/20/17 at 10:00AM in his room revealed the resident lying in bed with a dressing intact to the right axilla area (armpit) and upper inner arm. Interview with Licensed Practical Nurse (LPN) #3 on 12/20/17 at 10:41 AM on the 200 Hall Nurses Station revealed .Resident #68 is scheduled to have weekly skin assessments . Further interview with LPN #3 confirmed the facility failed to follow the care plan to complete weekly skin assessments. A total of 26 skin assessments were missed during 11/1/17 through 11/14/17 when pressure ulcer under armpit was found. Medical record review of a Facility Investigative Report dated 10/31/17 at 2:50 PM revealed .Resident observed lying on floor on his stomach in front of his bed. Resident stated he was trying to get in his bed and fell . Continued review revealed Resident #68 was sent to the Emergency Department and returned on 11/1/17 with [DIAGNOSES REDACTED]. Continued review revealed the resident returned with a [MEDICATION NAME] Lumbar Spinal Orthopedic (TLSO) brace. Medical record review revealed Physicians Orders with no instructions for the TLSO brace. Continued review revealed .Occupational Evaluation and Plan of Treatment dated 11/3/17 [MEDICATION NAME] Lumbar Spinal brace . Medical record review revealed a Nursing Note dated 11/5/17 at 7:00 AM .[MEDICATION NAME] brace and right hand brace intact . Continued review revealed a Nurse's note dated 11/9/17 at 4:59 AM .No episodes of trying to .remove brace . Continued review revealed a Nurse's note dated 11/10/17 at 3:18 AM .no episodes of trying to crawl out of bed or attempts to remove brace . Further review of a Nurse's note dated 11/11/17 at 4:18 AM revealed .[MEDICATION NAME] brace and right hand (brace) removed reapplied . Further review revealed a Nursing Note dated 11/14/17 at 4:25 AM revealed .Resident heard calling for help at 11:45 PM. Resident has removed his [MEDICATION NAME] brace . Medical record review of the Dietary Note dated 11/14/17 at 11:32 AM revealed .follow up new wound areas per Wound Treatment Nurse . Medical record review of the Departmental Notes dated 11/14/17 at 2:52PM .Pressure Ulcer/Right Upper Quadrant .Therapist reported that patient had skin breakdown underneath brace. Up on assessment patient was noted to have 2 areas on right lateral chest wall under armpit. Smaller area measures 2.0 cm x 2.8 cm x 0.25cm. Noted to have bluish green drainage with foul odor noted. Center tissue with necrotic black tissue with whiteish gray slough at outer edges of wound . Medical record review of the Care Plan Conference Summary dated 11/15/17 revealed .Nursing spoke about the possibility of hospice from the last care plan. Nursing reports that Resident is declining. Nursing discussed the wounds from the brace (back brace) Resident is taking the brace off himself, son reports to take brace off Resident and leave him in bed . Interview with the Wound Care Nurse on 12/20/17 at 7:55 AM in the 200 Hall Nurses Station revealed .It was the brace that caused his wound, it was not properly fitting and rubbed him . Interview with Physical Therapy Assistant and Speech Language Pathologist (SLP) on 12/20/17 at 10:19 AM in the dining room revealed, .we were treating him after he returned from the Emergency Department and we were trying to get clarification about his brace SLP stated when she observed him it was usually early in the morning and she would get assistance from another staff member to positions him in the bed. Further interview revealed on 11/2/17, SLP observed Resident #68 wearing the brace while in bed. Interview with Licensed Practical Nurse (LPN) #3 on 12/20/17 at 10:41 AM on the 200 Hall Nurses Station revealed .He came back from the hospital with the brace on and on bed rest, he had a big decline after the last fall . Further interview revealed Resident #68 is scheduled to have weekly skin assessments. LPN #3 confirmed the last documented skin assessment was on 9/27/17. Interview with the Director of Nursing (DON) on 12/20/17 at 4:30 PM revealed Resident #68 .came back with the brace on . Further interview confirmed .we were trying to get his orders clarified . When asked what is a reasonable time period to get Physicians orders clarified the DON responded, .as quick as possible . The DON confirmed the facility failed to obtain clear orders with instructions for the [MEDICATION NAME] Lumbar Spinal Orthopedic brace and continued use of the brace resulted in pressure ulcer and HARM to Resident #68.",2020-09-01
632,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2018-01-24,688,D,0,1,GH7811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to utilize devices to improve range of motion for 1 resident (#74) of 16 residents reviewed. The findings included: Medical record review revealed Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #74 was severely impaired cognitively. Continued review of the MDS revealed Resident #74 was dependent on 1 person for transfers and bathing; required extensive assistance of 1 person for dressing, grooming, and eating; had impairment of 1 upper extremity and both lower extremities for range of motion. Further review revealed Resident #74 was always incontinent of bowel and had an indwelling catheter. Medical record review of physician's orders [REDACTED].Put on left elbow splint and left hand splint at beginning of 7-3 (7 AM - 3 PM) shift. Take off left elbow splint and left hand splint at end of shift 7-3 (7 AM - 3 PM). Wear time no more than 8 hours . Observation on 12/18/17 at 9:15 AM revealed Resident #74 was lying in bed. Observation of the resident's left arm revealed no splint in place on the hand or elbow. Observation on 12/19/17 at 10:00 AM revealed Resident #74 lying in bed with no splint on the left hand or left elbow. Interview with Licensed Practical Nurse #2 on 12/19/17 at 10:07 AM at the 200 Hall Nurses Station confirmed Resident #74 was ordered to have a left hand and elbow splint on during the 7:00 AM - 3:00 PM shift and the facility failed to apply the splint as ordered.",2020-09-01
633,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2018-01-24,689,G,0,1,GH7811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to update the Care Plan with interventions for Resident #68 after first fall on 8/6/17, which resulted in a second fall on 10/31/17 with multiple fractures. The failure to develop interventions to prevent falls for Resident #68 resulted in HARM from a fall. Medical record review revealed Resident #68 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical review of the Minimum (MDS) data set [DATE] revealed Resident #68 had a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment. Medical record review of a Facility Investigative Report dated 10/31/17 at 2:50 PM revealed .Resident observed lying on floor on his stomach in front of his bed. Resident stated he was trying to get in his bed and fell . Continued review revealed Resident #68 was sent to the Emergency Department and returned on 11/1/17 with [DIAGNOSES REDACTED]. Continued review revealed the resident returned with a [MEDICATION NAME] Lumbar Spinal Orthopedic (TLSO) brace. Observation of Resident #68 on 12/20/17 at 10:00AM in his room revealed the resident lying in bed with a dressing intact to the right axilla area (armpit) and upper inner arm. Interview with the Director of Nursing (DON) on 12/20/17 at 4:30 PM confirmed Resident #68 fell on [DATE] and went to the hospital. This was the second documented fall for Resident #68. Failure of the facility to update the Care Plan with additional interventions after first fall on 8/6/17 resulted in HARM when Resident #68 fell again on 10/31/17.",2020-09-01
634,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2018-01-24,732,D,0,1,GH7811,"Based on observation and interview, the facility failed to post the current staffing for 1 of 3 days. The findings included: Observation of the posted staffing on 12/20/17 at 11:45 AM revealed the posting was dated 12/18/17. Interview with the Administrator on 12/20/17 at 11:55 AM in the Administrator's office confirmed the posted staffing was the incorrect date.",2020-09-01
635,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2018-01-24,758,D,0,1,GH7811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to complete behavior monitoring for 1 resident (#81) of 5 residents reviewed for [MEDICAL CONDITION] medications. The findings included: Medical record review revealed Resident #81 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #81 received antipsychotic medication during the assessment look-back period. Medical record review of a physician's orders [REDACTED].[MEDICATION NAME] (antipsychotic) 5MG (milligrams) BY MOUTH TWICE DAILY . Continued review revealed a Physician order [REDACTED].Discontinue [MEDICATION NAME] 5mg in AM (morning) Continue [MEDICATION NAME] 5mg at HS (bedtime). [MEDICATION NAME] 2.5mg 1 by mouth daily in AM . Further review revealed a Physician order [REDACTED].Decrease [MEDICATION NAME] to 2.5mg qhs (at bedtime) . Medical record review of the (MONTH) (YEAR)-December (YEAR) Medication Administration Record [REDACTED]. Further review of the (MONTH) (YEAR) through (MONTH) (YEAR) MAR indicated [REDACTED]. Interview with the Director of Nursing on 12/20/17 at 9:30 AM in her office confirmed the facility failed to complete behavior monitoring for Resident #81 who was administered antipsychotic medication.",2020-09-01
636,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2018-01-24,761,D,0,1,GH7811,"Based on facility policy review, observation, and interview the facility failed to lock 1 of 5 medication carts. The findings included: Review of facility policy, Medication Storage in the Facility, undated, revealed .Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access . Observation on 12/20/17 from 11:45 AM to 11:50 AM in the secure unit common area revealed the 500 hall medication cart was not locked and no nurse was in view of the cart. There were no medications or residents in sight at time of occurrence. Observation and interview with the Director of Nursing on 12/20/17 at 11:51 AM in the secure unit common area at the 500 Medication Cart confirmed there was no nurse in sight of the cart and the facility failed to keep the 500 hall medication cart locked when not attended by the nurse in charge.",2020-09-01
637,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2018-01-24,812,F,0,1,GH7811,"Based on observation and interview, the facility failed to maintain dietary equipment in a clean and sanitary manner in 1 of 3 kitchen observations affecting 92 of 93 residents. The findings included: Observation on 12/18/17 at 3:00 PM in the dietary department with the Dietary Manager present, revealed the following: 3 of 14 steam table pans on the drying rack and ready for use with dried tan and brown debris on the inside perimeter of the pans; 2 of 8 serving scoops stored and ready for use with dried yellow and tan debris; 4 of 12 full sheet cake pans stored and ready for use with dried tan and brown debris on the inside perimeter of the pans; and 2 of 7 half sheet cake pans stored and ready for use with dried tan and brown debris on the inside perimeter of the pans. Interview with the Dietary Manager on 12/18/17 at 3:00 PM in the dietary department confirmed the facility failed to maintain the dietary equipment in a clean and sanitary manner.",2020-09-01
638,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2018-01-24,919,D,0,1,GH7811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, observation, and interview, the facility failed to ensure call lights were functioning properly in 7 of 55 resident rooms and in 6 of 55 resident bathrooms on 2 of 5 halls. The findings included: Review of the facility policy, Nurse Call System, dated 9/1/14, revealed .Monthly the Nurse Call system should be checked for proper function for the following .Each call cord should be exercised to ensure that it activates the light in the corridor and the annunciation panel at the nurse's station .Any component that does not function should be repaired as soon as practically feasible . Observation of the 300 hall rooms revealed the following: Observation on 12/18/17 at 9:40 AM in room [ROOM NUMBER] revealed a resident was sitting in bed and holding the call light in her left hand. The call light was plugged into the wall however, the cord was severed near the plug and therefore was not functioning. Interview with Licensed Practical Nurse (LPN) #1 on 12/18/17 at 10:20 AM on the 300 Hall confirmed the facility failed to maintain a functioning call light for the resident in room [ROOM NUMBER]. Observation of the 500 hall revealed the following: Observation on 12/18/17 from 10:20 AM to 10:25 AM revealed the call lights in rooms 504, 508, 509, 511, 512, and 513 were not functioning. Interview with CNA #1 on 12/18/17 at 10:27 PM on the 500 hall, this surveyor asked CNA #1 .How do you know if a resident needs help? . CNA stated .We have somebody on the floor walking up and down the hall . Interview and observation with LPN #2 on 12/18/17 between 12:40 PM and 12:52 PM confirmed the bathroom call lights in rooms 502, 504, 509, 510, 512, and 513 were not functioning and the call lights in rooms 504, 508, 509, 511, 512, and 513 were not functioning. Interview with the Maintenance Director on 12/18/17 at 3:15 PM at the south nurse station confirmed the facility failed to maintain functioning call lights for rooms 504, 508, 509, 511, 512, and 513 and for the bathrooms in rooms 504, 508, 509, 511, 512, and 513. Interview with the Maintenance Director on 12/20/17 at 3:00 PM in the Nurse Educator Office confirmed the Maintenance Director worked only a couple of months at the facility and did not know how to operate the work order system. Maintenace Director stated . he checks the call lights monthly but did not document the rooms he checked .",2020-09-01
639,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2020-02-26,550,D,0,1,T07H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to treat 1 of 5 residents (Resident #391) who required an indwelling urinary catheter with dignity related to not covering the resident's indwelling urinary catheter drainage bag with a privacy cover, and failed to treat 4 of 17 residents with dignity who were referred to as feeders during the breakfast tray pass on 2/25/2020. The findings include: Review of the medical record, showed Resident #391 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED].#391, dated 2/24/2020, showed .16F (size of catheter) 10 ml (milliliter) catheter . Review of Resident #391's Care Plan dated 2/24/2020, showed .Cover drain bag with privacy bag/cover . Observation of the resident's room on 2/24/2020 at 9:22 AM, and 12:25 PM, showed Resident #391's indwelling urinary catheter bag was placed on the right side of the bed facing the door without a privacy cover. During an observation and interview conducted on 2/24/2020 at 1:22 PM, in the resident's room, Licensed Practical Nurse (LPN) #1 confirmed Resident #391's indwelling urinary catheter bag was not placed in a privacy cover. During an interview conducted on 2/24/2020 at 4:14 PM, the Director of Nursing (DON) stated that her expectations were for the urinary catheter bags to be placed in a privacy cover at all times. Review of the medical record, showed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment for Resident #14 dated 12/5/2019, showed the resident required extensive assistance of 1 person with eating. Review of the medical record, showed Resident #62 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment for Resident #62 dated 1/31/2020, showed the resident required extensive assistance of 1 person with eating. Review of the medical record, showed Resident #64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS for Resident #64 dated 1/31/2020, showed the resident required extensive assistance of 1 person with eating. Review of the medical record, showed Resident #85 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE], showed the resident required extensive assistance of 1 person with eating. Observation of staff passing the breakfast meal trays on the 300 hallway on 2/25/2020 at 7:53 AM LPN #2 stated, The only trays left on the cart are for the feeders. During an interview conducted on 2/25/2020 at 7:55 AM, LPN #2 confirmed she referred to the residents who required assistance with dining as feeders. During an interview conducted on 2/25/2020 at 8:01 AM, the DON confirmed any resident who required assistance with meals were to be referred to as assisted diners not feeders.",2020-09-01
640,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2020-02-26,558,D,0,1,T07H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility documentation review, medical record review, observation, and interview the facility failed to have a call light in reach for 1 of 41 residents (Resident #27) reviewed for call light placement. The findings include: Review of the facility documentation, Call Light, Use Of, showed, .When providing care to residents be sure to position the call light conveniently for the resident to use. Tell the resident where the call light is and show him/her how to use the call light .Be sure all call lights are placed on the bed at all times, never on the floor or bedside stand . Review of the medical record, showed Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data (MDS) assessment dated [DATE], showed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. Observation in the resident's room on 2/25/2020 at 9:12 AM, showed the call light was behind the chest of drawers located on the right side of the resident. During an observation and interview conducted on 2/25/2020 at 9:25 AM, with Licensed Practical Nurse (LPN) confirmed the call light was behind the chest of drawers and not in reach for Resident #27. During an interview conducted on 2/25/2020 at 2:40 PM, with the Director of Nursing (DON) confirmed the call was to be in reach for Resident #27 on the right side at all times.",2020-09-01
641,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2020-02-26,600,D,1,1,T07H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, facility documentation review, medical record review, and interview, the facility failed to prevent abuse for 1 of 2 residents (Resident #42) involved in a resident to resident altercation. The findings include: Review of the facility policy, Abuse, dated June 2018, showed, .It is the policy of the center to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown origin and misappropriation of resident/patient property and to ensure that all alleged violations of Federal or State laws which involve mistreatment, neglect, abuse, injuries of unknown origin and misappropriation of resident/patient property are reported immediately to the Administrator/Director of Nursing of the center. Review of the medical record, showed Resident #4 was admitted to the facility on [DATE], with readmission on 6/7/2019 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #4 had a Brief Interview for Mental Status (BI[CONDITION]) score of 11 indicating moderate cognitive impairment. Further review showed Resident #4 had verbal behavior symptoms directed toward others. Review of the medical record, showed Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE], showed Resident #42 was rarely/never understood. Further review showed the resident had no mood or behavioral symptoms. Review of the facility investigation dated 2/18/2020, showed a witnessed physical altercation between Resident #4 and Resident #42 in the Activity room while waiting for the activity to begin. Further review showed Resident #4 grabbed Resident #42's wrist, slapped and kicked her. During an interview conducted on 2/25/2020 at 7:30 AM, the Activity Director confirmed Resident #4 and Resident #42 had a physical altercation. Further interview she stated, When I walked into the Activity room I saw (named Resident #4) holding (named Resident #42's) wrist. I asked (named Resident #4) to let go of (named Resident #42) and before I could separate them (named Resident #4) slapped and kicked (named Resident #42). During an interview conducted on 2/26/2020 at 2:10 PM, the Administrator confirmed Resident #4 and Resident #42 had a physical altercation on 2/18/2020.",2020-09-01
642,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2020-02-26,641,D,0,1,T07H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to capture Hospice Services on the Quarterly Minimum Data Set (MDS) assessment for 1 of 4 residents (Resident #19) who received hospice services. The findings include: Review of the medical record, showed Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].Under the services of (named Hospice) . Review of the Quarterly MDS assessment dated [DATE], showed Hospices were not captured for Resident #19. During an interview conducted on 2/26/2020 at 3:25 PM, the MDS Coordinator confirmed Resident #19's Quarterly MDS dated [DATE] did not reflect hospice services.",2020-09-01
643,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2020-02-26,677,D,0,1,T07H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure 1 of 41 residents (Resident #31) had clean and groomed fingernails. The findings include: Review of the medical record, showed Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE], showed Resident #31 was dependent on staff for bathing and required extensive assistance of 2 staff for personal hygiene. Review of the comprehensive care plan dated 10/15/2018, showed Resident #31 required assistance with bathing. Observations of the resident's room on 2/24/2020 at 9:17 AM and 11:13 AM, showed Resident #31 had brown debris under his fingernails on both hands. Observation of the resident's room on 2/24/2020 at 12:22 PM, showed Resident #31 lying in bed eating his lunch. Continued observation showed the resident had brown debris under his fingernails on both hands. During an observation and interview conducted on 2/24/2020 at 12:43 PM, Certified Nursing Assistant (CNA) #1 confirmed she was assigned to care for the resident on that day; she stated I gave him a bath this morning and cleaned his fingernails. During continued interview CNA #1 looked at the resident's hands and confirmed the resident had brown debris underneath his fingernails on both hands, she stated, I guess I didn't clean them as well as I should have. During an observation and Interview conducted on 2/24/2020 at 1:07 PM Licensed Practical Nurse #1 confirmed the resident had brown debris underneath his fingernails on both hands. During an interview conducted on 2/24/2020 at 5:14 PM, the Director of Nursing confirmed her expectation was for the residents' nails to be cleaned with bathing and when they were visibly dirty.",2020-09-01
644,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2020-02-26,684,D,0,1,T07H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to implement physician's orders for 1 of 41 residents (Resident #88) reviewed for physician orders. The findings include: Review of the medical record, showed Resident #88 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician Order Report dated 2/26/2020, showed, .CBC (Complete Blood Count), BMP (Basic Metabolic Panel), Free T4 (Free [MEDICATION NAME]) with TSH ([MEDICAL CONDITION] Stimulating Hormone), Hepatic Panel, Lipid Panel and HgbA1C (Glycated Hemoglobin) every 6 months, (MARCH and SEPTEMBER) . Review of the medical record, showed there was no CBC, BMP, T4 with TSH or HgbA1C obtained for the month of (MONTH) 2019 or (MONTH) 2019. During an interview conducted on 2/26/2020 at 10:40 AM, the Director of Nursing confirmed Resident #88 did not have a CBC, BMP, Free T4 with TSH, or HgbA1C obtained in (MONTH) or (MONTH) 2019.",2020-09-01
645,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2020-02-26,695,D,0,1,T07H11,"**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 label and date oxygen tubing and store nebulizer tubing in a safe and sanitary manner for 2 of 18 residents (Residents #27 and #390) receiving respiratory treatments. The findings include: Review of the facility policy titled, Departmental (Respiratory Therapy) - Prevention of Infection, dated (MONTH) 2011, showed, .The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff .change the oxygen cannula and tubing every seven (7) days, or as needed .Infection Control Considerations related to Medication Nebulizers/Continuous Aerosol: Store the circuit in plastic bag, marked with date and resident's name, between uses . Review of the medical record, showed Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data (MDS) assessment dated [DATE], showed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. Review of the physician order dated 2/26/2020, showed, .Oxygen at bedtime at 2 LPM (litters per minute) to use when in bed . Review of the medical record, showed Resident #390 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician Orders dated 2/24/2020, showed .change oxygen tubing and clean 02 concentrator every Sunday night 11-7 shift .[MEDICATION NAME] (a medication to treat wheezing and shortness of breath) Nebulization Solution (2.5 MG/3ML (milligram/milliliter)) 0.083% 1 inhalation orally via nebulizer every 4 hours as needed for wheezing . Observation in the resident's room on 2/24/2020 at 9:41 AM, showed Resident #27's oxygen tubing was not dated. Observation in the resident's room on 2/24/2020 at 9:46 AM and 12:38 PM, showed Resident #390's oxygen and nebulizer tubing was not dated. Continued observation showed the nebulizer tubing and mouthpiece was placed on the nebulizer machine not stored in a bag. During an observation and interview conducted on 2/24/2020 at 1:12 PM, Licensed Practical Nurse #1 confirmed Resident #390's oxygen tubing and nebulizer mouthpiece was not dated or stored in a bag. During an interview conducted on 2/26/2020 at 4:50 PM, the Assistant Director of Nursing (ADON) confirmed the oxygen tubing and equipment was to be changed and dated every Sunday night. During an interview conducted on 2/24/2020 at 5:14 PM, the Director of Nursing confirmed her expectations were for the oxygen tubing, nebulizer tubing and mouthpiece to be dated and stored in a bag when not in use.",2020-09-01
646,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2020-02-26,732,F,0,1,T07H11,"Based on facility documentation review and interview the facility failed to post complete daily staffing sheets of nursing hours for 18 months. The findings include: Observation of the posted daily staffing sheet on 2/24/2020 and 2/25/2020 at 9:30 AM, showed no hours posted for the nursing staff. Review of the POS [REDACTED]. During an interview conducted on 2/25/2020 at 2:08 PM the Director of Nursing (DON) confirmed there was no nursing hours posted for 18 months.",2020-09-01
647,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2020-02-26,880,F,0,1,T07H11,"**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 post signage for 1 of 1 resident (Resident #85) on contact isolation. The facility failed to transport and store laundry in a safe and sanitary manner to 1 of 3 clean linen storage rooms. The facility failed to apply proper PPE (Personal Protective Equipment) before entering 1 of 1 contact isolation room. The findings include: Review of facility policy, Infection Control, dated (MONTH) 1, (YEAR), showed, .The center's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections .Gowns required if clothing may come into contact with the patient/resident or environmental surfaces or if the patient/resident has diarrhea . Review of facility policy, Linen Handling Guidelines, dated (MONTH) 1, (YEAR), showed, .Keep soiled and clean linen, and their respective hampers and laundry carts, separate at all times . Review of the medical record showed, Resident #85 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Order Summary Report dated (MONTH) 2020, showed an order for [REDACTED]. Review of the physician progress notes [REDACTED].Due to ongoing issues with loose stools, will need to continue with isolation . Observation of the resident's room on 2/24/2020 at 9:39 AM, 10:20 AM, and 11:07 AM, showed no signage for contact isolation. During an interview conducted on 2/24/2020 at 11:15 AM, the Infection Control Nurse confirmed there was no sign on the door for contact isolation. Observation on 2/24/2020 at 11:53 AM and 11:54 AM, showed, the Laundry Supervisor brought a stack of towels out of the 300/400 Hall soiled utility room and walked across the hall and went into the 300/400 Hall clean linen room and put the towels on the shelf. During an interview conducted on 2/24/2020 at 11:55 AM, the Laundry Supervisor stated, I brought them in a bag from out there and pointed to the soiled utility room. Observation of the 300/400 Hall soiled utility room on 2/24/2020 at 11:56 AM, showed the clean laundry/linen cart was in the soiled utility room. During an interview conducted on 2/25/2020 at 11:56 AM, the Laundry Supervisor confirmed he pushed the clean laundry cart with clean linen into the soiled utility room on the 300/400 hall on 2/24/2020. During further interview he stated, The clean linen cart was not to be stored or transported through the soiled utility room because it would contaminate the clean linen. Observation of Certified Nurse Assistant (CNA) #2 on 2/24/2020 at 3:10 PM, showed, she went into the isolation room without proper PPE. During an interview conducted on 2/24/2020 at 3:11 PM, CNA #2, who was assigned to Resident #85, confirmed she did not apply appropriate PPE prior to entering the room. During further interview she stated, she did not know if the resident was on isolation precautions. She stated, I just go by my gut feeling. I only picked up the linens out of the bathroom floor and I should have put on a gown, gloves and shoe covers. During an interview conducted on 2/24/2020 at 5:48 PM, Licensed Practical Nurse (LPN) #3 stated Resident #85 continued to have loose stools and continued to be on isolation for [MEDICAL CONDITION]. Further interview confirmed staff were to wear gloves, gowns, shoe covers and were to wash their hands with soap and water to prevent the spread of infection. During an interview conducted on 2/26/2020 at 2:25 PM, the Administrator confirmed clean linen were not to be stored in or transported through the soiled utility room. During an interview conducted on 2/26/2020 at 3:08 PM, the Director of Nursing confirmed signage was to be on the door for residents on isolation. During further interview she confirmed the staff were to wear appropriate PPE when entering an isolation room.",2020-09-01
648,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2019-03-06,550,D,0,1,T35K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to provide 1 (#16) of 5 residents with dignity during the noon meal on 3/4/19 related to Certified Nurse Aide (CNA) standing while assisting Resident #16 with the meal. The findings include: Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 3/4/19 at 12:04 PM in the 300 hallway revealed CNA #1 was standing while assisting Resident #16 with the meal. Interview with CNA #1 on 3/4/19 at 12:05 PM in the 300 hallway confirmed she was standing while assisting Resident #16 with the noon meal. Interview with the Director of Nursing on 3/6/19 at 9:26 AM in the Conference Room confirmed staff were to sit while assisting residents with meals.",2020-09-01
649,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2019-03-06,644,D,0,1,T35K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to perform a level 2 Preadmission Screening and Resident Review (PASARR) for 1 resident (#27) of 11 residents receiving antipsychotics. The findings include: Medical record review revealed Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed Resident #27 was diagnosed with [REDACTED]. Medical record review revealed Resident #27 did not have a level 2 PASARR. Medical record review of Resident #27's Annual Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview of Mental Status score of 15 indicating the resident was cognitively intact. Continued review revealed the resident had a [DIAGNOSES REDACTED]. Interview with the Regional Nurse Consultant (RNC) on 3/5/19 at 12:45 PM in the Director of Nurse's (DON) office confirmed Resident #27 was not screened for a level 2 PASARR after being diagnosed with [REDACTED]. Interview with the DON on 3/6/19 at 7:45 AM in her office confirmed when a resident was diagnosed with [REDACTED]. Interview with the RNC on 3/6/19 at 8:25 AM in the conference room confirmed Resident #27 did not have a level 2 PASARR screening. Continued interview confirmed I agree the [DIAGNOSES REDACTED].#27) and I don't have one to show you.",2020-09-01
650,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2019-03-06,695,D,0,1,T35K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, facility's performance skill checklist oxygen delivery form review, medical record review, observation and interview, the facility failed to properly store oxygen tubing, nebulizer mask and tubing for 1 resident (#62) of 14 residents reviewed receiving respiratory treatments. The findings include: Review of the undated facility policy, Using Small Volume Nebulizers, revealed .reassemble the clean nebulizer parts and store them in a small bag between treatments . Review of facility's performance skill checklist oxygen delivery form revealed .attach oxygen delivery device to oxygen tubing .place in a bag .Keep off floor when not in use . Medical record review revealed Resident #62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #62's Annual Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview of Mental Status score of 12 indicating the resident was moderately cognitively impaired. Continued review revealed the resident received oxygen therapy. Medical record review of Resident #62's Order Review Report revealed .[MEDICATION NAME]/[MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME]-medication used to prevent the worsening of [MEDICAL CONDITION]) Neb (nebulizer) 1 vial inhale orally every 6 hours as needed for wheezing related to shortness of breath (8/1/18) . Observation on 3/4/19 at 9:27 AM and at 3:39 PM revealed Resident #62 in her room in bed with oxygen in place by nasal cannula. Continued observation revealed the resident had a nebulizer treatment machine with an uncovered mask not stored in a bag sitting on the machine. Continued observation revealed a portable oxygen tank on the resident's wheelchair with the tubing exposed and not stored in a bag. Observation and interview on 3/4/19 at 3:44 PM, with Licensed Practical Nurse #1 present, confirmed Resident #62's nebulizer mask and tubing and the resident's oxygen tubing were not stored properly in a plastic bag. Continued interview revealed .when the resident finishes the treatment the masks are washed and dried and then placed in a plastic bag on the nebulizer machine and the oxygen tubing is also stored in a bag or thrown away if not in use . Interview with the Director of Nursing on 3/6/19 at 7:45 AM in her office confirmed nebulizer tubing, masks and oxygen tubing were to be stored in a bag when not in use.",2020-09-01
651,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2019-03-06,755,D,0,1,T35K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Pharmacy contract review, observation and interview, the pharmacy services failed to ensure medications and biologicals were stored and labeled according to current professional standards of practice for 3 of 5 medication carts. The findings include: Review of the Pharmacy contract titled Pharmacy Services Agreement, dated (MONTH) 21, (YEAR), revealed .Services include disposing of outdated and disposing of or restocking of discontinued non-controlled medications provided by the pharmacy . Observation of the 100 Hall medication cart on 3/5/19 with Licensed Practical Nurse (LPN) #1 at 1:11 PM revealed [MEDICATION NAME] 1% (percent) cream (medicated cream used to treat fungal infections) opened and not dated; Iron Supplement [MEDICATION NAME] (liquid medication for low hemoglobin/decreased red blood cells) 220 mg/tsp (milligram per teaspoon) multiple dose 16 oz. (ounce) bottle opened and expired 2/2019. Observation of the 200 Hall medication cart on 3/5/19 with LPN #5 at 4:22 PM revealed 1 vial of [MEDICATION NAME] R Insulin (injectable medication for Diabetes Mellitus), the vial was opened on 2/1/19 and expired on 2/28/19; 2 [MEDICATION NAME] opened, not dated and not stored inside the protective foil package (special packaging to protect the medication from light and moisture); [MEDICATION NAME] (medication for bloating) 80 mg multiple dose bottle (100 tabs) opened and not dated; Geri kot (laxative medication) 8.6 mg multiple dose bottle (100 tabs) opened and not dated; Calcium [MEDICATION NAME] (medication for bone loss) 500 mg multiple dose bottle (150 tabs) opened and not dated; Fish oil 1000 mg multiple dose bottle (120 soft gels) opened and not dated; and Geri [MEDICATION NAME] (medication for cough) 1000 milliliters (ml) multiple dose bottle expired 12/2018. Observation of the 400 Hall medication cart on 3/5/19 with LPN #4 at 4:44 PM revealed 2 [MEDICATION NAME] protective foil packages opened and not dated; 10 [MEDICATION NAME] not dated and not stored in the protective foil package; 1 [MEDICATION NAME] (nasal spray for allergies [REDACTED].#22 gauge expired on 3/18; 2 tubes of [MEDICATION NAME] Ointment (topical ointment applied for pain relief) opened, unlabeled and not dated; Multi Dex powder tube (powder used to absorb wound drainage) opened, not dated and unlabeled; Derma Med Ointment tube (skin protectant ointment), opened, unlabeled and not dated; Sodium [MEDICATION NAME] (medication used as an antacid and also to reduce the acidity of the blood and urine) 650 mg multiple dose bottle (1000 tabs) opened and not dated; Mineral oil (oil laxative) multiple dose 16 ounce bottle expired 11/2018; [MEDICATION NAME] 160 mg/5 ml, a 16 ounce multiple dose bottle expired 2/2019; Iron Supplement [MEDICATION NAME] 220 mg/5 ml, a 16 ounce multiple dose bottle, unopened and expired 1/2019; and Geri-Mucil (liquid laxative medication) 10 ounce bottle expired 7/2018. Telephone interview with the Pharmacy Consultant on 3/7/19 at 8:25 AM revealed .The [MEDICATION NAME] R Insulin was definitely expired and should not have been on the medication cart, and the creams should not be with the oral medications . Further interview revealed .I do not check any over the counter multi dose bottles or intravenous equipment .The nurses restock the carts with over the counter medications from their central supply and the intravenous catheters should not even be on the cart .I check all the facility carts and give the Director of Nursing a detailed print out each month, and in (MONTH) I pulled all the expired medications off their carts .",2020-09-01
652,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2019-03-06,761,E,0,1,T35K11,"**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 store medications and biologicals in accordance with currently accepted professional standards of Practice for 1 resident (#62) of 85 residents observed and in 5 of 7 medication storage areas. The findings include: Review of the facility policy, 5.3 Storage and Expiration of Medications, Biologicals, Syringes and Needles, dated 5/10/10, and revised on 10/31/16 revealed .Facility should ensure that medications and biologicals that have an expired date on the label are stored separate from other medications until destroyed or returned to the pharmacy .Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened .Store all medications and biologicals requiring special containers for stability in accordance with manufacturer/supplier specifications .Topical medications are stored separately from oral medications .Facility should destroy and reorder medications and biologicals with soiled, illegible, worn, makeshift, incomplete, damaged or missing labels .Facility should ensure that infusion therapy products and supplies are stored separately from other medications and biologicals, under appropriate temperatures and sterility conditions .Facility personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis .and Facility should ensure that all medications and biologicals, including treatment items, are securely stored in locked cabinet/cart or locked medication room that is inaccessible by residents and visitors . Medical record review revealed Resident #62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #62's Order Review Report revealed .[MEDICATION NAME] (powder used to treat fungal skin infections) 100MU(micro units)/1GM (gram) powder apply to perineal area topically two times a day for rash and bilateral folds (8/1/18) . Medical record review of Resident #62's Annual Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview of Mental Status score of 12 indicating the resident was moderately cognitively impaired. Continued review revealed the resident used topical medications. Observation on 3/4/19 at 3:39 PM in Resident #62's room revealed a bottle of [MEDICATION NAME] powder 100,000 units/gram and Derma Med (skin protectant) on Resident #62's bedside table. Interview with Licensed Practical Nurse (LPN) #1 on 3/4/19 at 3:44 PM in Resident #62's room confirmed the resident had [MEDICATION NAME] powder and Derma Med skin protectant on her bedside table. Continued interview with LPN #1 confirmed medications were to be kept in the medication cart. Interview with the Director of Nursing (DON) on 3/6/19 at 7:45 AM in her office confirmed medications were to be stored on the medication cart or in the medication room. Observation of the 100 Hall medication cart on 3/5/19 with LPN #1 at 1:11 PM revealed [MEDICATION NAME] 1% (percent) cream (medicated cream used to treat fungal infections) opened and not dated; Iron Supplement [MEDICATION NAME] (liquid medication for low hemoglobin/decreased red blood cells) 220 mg / tsp (milligram per teaspoon) multiple dose 16 oz. (ounce) bottle opened and expired 2/2019. Observation of the 500 Hall medication cart on 3/5/19 with LPN #3 at 1:41 PM revealed 2 bottles of [MEDICATION NAME] Powder (medicated powder used to treat fungal infection) opened and not dated; Antifungal cream (medicated cream used to treat fungal infection) opened, not dated, or labeled; sterile water 100 ml (milliliter) container with approximately 25 ml remaining in the container, opened and not dated; Muscle and joint cream (topical cream for muscle pain) opened, unlabeled and not dated; [MEDICATION NAME] cream (cream used to treat fungal infections) opened, unlabeled and not dated; [MEDICATION NAME] Syrup (medication for cough) 120 ml bottle, opened and not dated; Senna tabs (stool softener) multiple dose bottle (100 tabs) opened and not dated; Vitamin C (vitamin supplement) 500 mg multiple dose bottle (1000 tabs) opened and not dated; and 3 #24 gauge intravenous (IV) catheter needles expired 7/2017. Antifungal cream, Muscle and joint cream, and [MEDICATION NAME] cream were found in a drawer with oral medications; 2 [MEDICATION NAME] (inhaled medication to treat [MEDICATION NAME] spasms) [MEDICATION NAME] (plastic single unit dose dispensers) not dated and not inside protective foil package (special medication packaging to protect the medicine from light and moisture). Observation of the 200 Hall medication cart on 3/5/19 with LPN #5 at 4:22 PM revealed 1 vial of [MEDICATION NAME] R Insulin (injectable medication for Diabetes Mellitus) the vial was opened on 2/1/19 and expired on 2/28/19; 2 [MEDICATION NAME] opened, not dated and not stored inside the protective foil package; [MEDICATION NAME] (medication for bloating) 80 mg multiple dose bottle (100 tabs) opened and not dated; Geri kot (laxative medication) 8.6 mg multiple dose bottle (100 tabs) opened and not dated; Calcium [MEDICATION NAME] (medication for bone loss) 500 mg multiple dose bottle (150 tabs) opened and not dated; Fish oil 1000 mg multiple dose bottle (120 soft gels) opened and not dated, and Geri [MEDICATION NAME] (medication for cough) 1000 ml multiple dose bottle expired 12/18. Observation of the 400 Hall medication cart on 3/5/19 with LPN #4 at 4:44 PM revealed 2 [MEDICATION NAME] protective foil packages opened and not dated; 10 [MEDICATION NAME] not dated and not stored in the protective foil package; 1 [MEDICATION NAME] (nasal spray for allergies [REDACTED].#22 gauge expired 3/18; 2 tubes of [MEDICATION NAME] Ointment (topical ointment applied for pain relief) opened, unlabeled and not dated; Multi Dex powder tube (powder used to absorb wound drainage) opened, not dated and unlabeled; Derma Med Ointment tube (skin protectant ointment), opened, unlabeled and not dated; Sodium [MEDICATION NAME] (medication used as an antacid and also to reduce the acidity of the blood and urine) 650 mg multiple dose bottle (1000 tabs) opened and not dated; Mineral oil (oil laxative) multiple dose 16 ounce bottle expired 11/2018; [MEDICATION NAME] 160 mg/5 ml, a 16 ounce multiple dose bottle expired on 2/2019; Iron Supplement [MEDICATION NAME] 220 mg/5 ml, a 16 ounce multiple dose bottle, unopened and expired 1/2019; and Geri-Mucil (liquid laxative medication) 10 ounce bottle expired 7/2018. Observation of the 300 Hall medication cart on 3/6/19 with LPN #6 at 11:30 AM revealed 2 [MEDICATION NAME] of [MEDICATION NAME] opened, not dated and not stored inside the protective foil package; 1 multiple dose bottle of extra strength Tylenol opened and not dated; 1 multiple dose bottle of Aspirin 81 mg opened and not dated; 1 multiple dose bottle of Aspirin 325 mg opened and not dated; 1 multiple dose bottle of vitamin C (Vitamin supplement) opened and not dated; and 1 multiple dose bottle emergency use glucose tabs (dissolvable wafers used to treat low blood sugar) opened and not dated. Interview with the Director of Nursing on 3/6/19 in the 100/200 Hall medication room at 12:00 PM confirmed .I would not expect to find any expired medications, multiple dose medications opened and not dated, or medications improperly stored on any of the medication carts or in any of the medication rooms . Further interview confirmed .I would not expect to find any medication left in any resident room .",2020-09-01
653,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2019-03-06,800,F,0,1,T35K11,"Based on observation and interview, the facility failed to sanitize a thermometer while obtaining food temperatures in 1 of 5 observations of the dietary department. The findings include: Observation on 3/4/19 at 11:12 AM in the dietary department revealed the resident trayline was in progress and 1 cart had been delivered to a unit. Further observation revealed the dietary cook was obtaining food temperatures on the trayline. Further observation revealed the cook wiped the thermometer in a cloth towel between each food item. Further observation revealed the cook did not sanitize the thermometer between each of the 7 hot food items and 1 cold food item served to the residents. Interview with the dietary cook on 3/4/19 at 11:15 AM at the dietary trayline confirmed she did not sanitize the thermometer because we ran out of wipes. Interview with the Certified Dietary Manager on 3/4/19 at 1:15 PM in the hallway outside the dining room confirmed the thermometer was to be wiped with an alcohol wipe between each food item.",2020-09-01
654,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2019-03-06,812,F,0,1,T35K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to serve food in a safe and sanitary manner for 1 (#56) of 14 residents during the noon meal on [DATE]; the facility dietary department failed to label and date leftovers stored in the walk-in refrigerator, and failed to dispose of expired food items stored in the walk-in refrigerator in 1 of 5 observations of the dietary department. The findings include: Medical record review revealed Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on [DATE] at 12:20 PM in Resident #56's room revealed Certified Nurse Aide (CNA) #2 took a slice of bread out of a sandwich bag with her bare hand and laid it on the resident's tray. Interview with CNA #2 on [DATE] at 12:22 PM in Resident #56's room confirmed, I was suppose to shake the bread out of the bag or use gloves when handling the resident's food. Interview with the Director of Nursing on [DATE] at 9:28 AM in the Conference Room confirmed staff were never to touch a resident's food with their bare hands. Observation on [DATE] at 8:45 AM in the dietary department walk-in refrigerator revealed the following: 1. Two containers were not labeled or dated to identify the food contents; 2. A 5 pound container of cottage cheese, was half full, and had an expiration date of [DATE]; 3. A container labeled Cream Chicken had a Use By date of [DATE]; 4. A container labeled B. Pudding had a Use By date of [DATE]. 5. A container labeled Grits had a Prepared Date of [DATE]. Interview with the dietary cook on [DATE] at 8:55 AM in the dietary department walk-in refrigerator confirmed 2 containers were not labeled and dated. Further interview revealed the department was to dispose of food no later than 3 days after the prepared date. Further interview confirmed 4 food items were past the Use By date and should have been thrown out. Interview with the Certified Dietary Manager on [DATE] at 1:15 PM in the hallway outside the dining room revealed left overs were to be labeled and dated and food thrown out at least 3 days after it was made or by the expiration date.",2020-09-01
655,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2017-09-14,225,D,1,0,TNU911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility investigations, and interview, the facility failed to complete a thorough investigation following an allegation of abuse for one resident (#8) of eight residents reviewed for abuse. The findings included: Review of the facility Abuse Policy dated (MONTH) (YEAR), revealed .Investigation .the investigation shall include interviews of team members, visitors, residents/patients, volunteers .who may have knowledge of the alleged event . Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the resident's Care Plan dated 6/14/17 revealed .requires staff assistance for all ADL's (activity of daily living) .[DIAGNOSES REDACTED]. Medical record review revealed Resident #8 was unable to complete the Brief Interview for Mental Status due to a Dementia diagnosis. Review of a facility abuse investigation beginning 6/18/17, revealed Resident #8's daughter reported an allegation a staff member was mean as a snake to Resident #8 and squeezed his sore arm. The daughter alleged it occurred when the staff member positioned Resident #8 in bed on 6/17/17 on the third shift. Interview with the accused staff member on 9/12/17 at 10:40 AM, by phone, revealed she denied harming the resident and stated she no longer worked for the facility. Continued interview revealed she was not questioned about the alleged abuse and was not asked to provide a statement regarding the alleged abuse. Interview and review of the facility investigation with the Administrator and Social Worker on 9/12/17 at 10:45 AM, in the Administrator's office, confirmed the alleged perpetrator was not interviewed regarding the alleged abuse. Continued interview confirmed the facility failed to follow the facility abuse policy for investigating allegations of abuse.",2020-09-01
656,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2017-09-14,280,E,1,0,TNU911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to revise the care plan to include fall interventions for three residents (#6, #9, and #1), and failed to notify the responsible parties of annual care plan conferences for five residents (#6, #7, #2, #3, and #1) of six residents reviewed for care plans. The findings included: Review of the facility policy Comprehensive Care Plan dated 5/1/12, revealed .2. Social Services staff and/or designee notifies resident and responsible party prior to each care plan meeting . Review of the facility's Clinical Care System Guidelines for falls, dated (MONTH) (YEAR), revealed, Post fall, fall event and intervention is recorded on 24 hour report, patient's care plan and caregiver guide. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan with a start date of 10/14/15 revealed .at risk for impaired mobility related to [MEDICAL CONDITION] diagnosis, history of falls . Review of facility fall investigations revealed the resident had falls on 3/28/17, 4/30/17, and 8/15/17 with interventions to prevent further falls implemented after each fall. Medical record review of the current Care Plan revealed the Care Plan was not revised to reflect the newly implemented falls interventions after the falls on 3/28/17, 4/30/17, and 8/15/17. Interview with the Director of Nursing (DON) on 9/13/17 at 8:05 AM, in the conference room, confirmed the Care Plan was not revised to reflect the fall interventions. Interview and review of the Care Plan meeting book with the Social Services Director (SSD) on 9/13/17 at 9:02 AM, in the conference room, confirmed Resident #6's responsible party was not notified of the annual care plan conference held on 8/4/17, in order for the responsible party to have an opportunity to participate in care planning for Resident #6. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview and review of the Care Plan meeting book with the SSD on 9/13/17 at 9:02 AM, in the conference room, confirmed Resident #7's responsible party was not notified of the annual care plan conference held on 5/11/17, in order for the responsible party to have an opportunity to participate in care planning for Resident #7. Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan with a start date of 4/23/12 revealed .is at risk for falls due to [MEDICAL CONDITION] .history of falls . Review of facility fall investigations revealed Resident #9 had falls on 6/25/17, 7/7/17, 8/5/17, and 8/26/17 with falls interventions implemented after each fall. Medical record review of the current Care Plan revealed the Care Plan was not revised to reflect the interventions implemented after the falls. Interview with the DON on 9/13/17 at 9:58 AM, in the conference room, confirmed the Care Plan was not revised to reflect the fall interventions. Medical record review revealed Resident #2 was admitted to the facility on [DATE]. Review of Resident #2's Care Conference Summary form revealed the 5/10/17 Status Review form had been signed by various facility interdisciplinary team members but not the responsible party for the resident. Review of the Care Conference Meeting Schedule for the month of (MONTH) (YEAR), revealed Resident #2 was scheduled for an annual care conference meeting on 5/3/17 and the responsible party had not been notified. Interview with the SSD on 9/12/17 at 8:30 AM, in the conference room, confirmed Resident #2's responsible party had not been notified of the annual[NAME](YEAR) care conference meeting. Medical record review revealed Resident #3 was admitted to the facility on [DATE]. Medical record review of the resident's Care Plan Conference Summary Form: dated 4/25/17 revealed the care plan had been updated with no changes. The document had been signed by the facility's Dietary Manager, activity staff and SSD as attendees of the care plan conference. There was no indication the resident's responsible party attended the meeting. Review of the Care Conference Meeting Schedule for the month of (MONTH) (YEAR) revealed Resident #3 was scheduled for an annual care conference meeting on 4/25/17 and the responsible party had not been notified. Interview with the SSD on 9/12/17 at 8:30 AM, in the conference room, confirmed the resident's responsible party had not been notified of the annual (MONTH) (YEAR) care conference meeting. Medical record review revealed Resident #1 was admitted to the facility on [DATE]. Medical record review of Resident #1's care plan dated 10/27/15 revealed the resident was at risk for falls related to a history of falls, poor safety awareness and impaired judgment. Further review revealed the last revision to the falls interventions was on 1/24/17. Medical record review of the Nursing Note dated 4/5/47 at 4:30 PM, revealed Resident #1 was sitting on floor on buttocks with knees bent .resident unable to say how she fell . Assisted resident to wheelchair with assist of two. Medical record review of a nursing note dated 4/25/17 at 9:45 AM revealed, Technician called for help after resident had fallen in her room. Medical record review of the resident's care plan revealed the care plan was not revised to reflect new interventions implemented after the fall. Interview with the Minimum Data Set (MDS) Nurse #1 and #2 on 9/11/17 at 3:00 PM, they stated a monthly calendar was generated to indicate which residents were due for annual and quarterly conference meetings for that month. The calendar was then submitted to the Social Services Department for notification to the responsible party for the upcoming meeting. Interview with the SSD on 9/11/17 at 3:10 PM, confirmed she received the monthly care conference calendars from the MDS office. The SSD stated she then sent a letter out to the responsible party to notify them of the care conference meeting. The responsible party then called the SSD to set up the date and time of the meeting depending on their schedules. Review of the monthly calendar for the months of (MONTH) through (MONTH) (YEAR) revealed resident names had been highlighted with the letter Q next to the name. Further review revealed resident names with the letter A next to the names which had not been highlighted. Interview with the SSD on 9/11/17 at 3:10 PM, revealed the Q indicated a quarterly care conference meeting and the A indicated an annual care conference meeting. The SSD stated she had been instructed to only notify responsible parties of Quarterly meetings, and not annual care conference meetings. The SSD indicated if the name on the calendar had not been highlighted, it meant the resident was scheduled for an annual care conference meeting and the responsible party would not have been notified. Review of the Care Conference Meeting Schedule for the month of (MONTH) (YEAR), revealed Resident #1 was scheduled for an annual care conference meeting on 3/2/17 and there was no documentation the responsible party had been notified of the annual meeting. Interview with the SSD on 9/12/17 at 8:30 AM, in the conference room, confirmed the care plan for Resident #1 had not been revised to include newly implemented interventions after the falls on 4/5/17 and 4/25/17, and the responsible party had not been notified of the annual care conference meeting held on 3/2/17.",2020-09-01
657,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2017-09-14,309,D,1,0,TNU911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to monitor and evaluate the effectiveness of interventions for identified behaviors in order to attain and maintain the highest practicable psychosocial well-being for 1 (Resident# 3) of 9 sampled residents. The findings included: Medical record review revealed Resident#3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 7/4/17, revealed Resident# 3 had a BIMS (Brief Interview for Mental Status) score of 14, indicative of intact cognitive status. Resident #3's Behavior Section of the MDS indicated [MEDICAL CONDITION] and other behavior not directed towards others. Medical record review of the plan of care developed on 3/24/08, revealed an established problem, Episodes of socially inappropriate behaviors AEB (as evidenced by) places washcloths down the front of his pants, urinates on floor and causes odor in his room, refuses care, may refuse showers at times due to his being embarrassed about his incontinence. Keeps urinal on bedside table. Interventions included: Explain the need for care trying to be provided; psych (psychiatric) eval (evaluation) and tx (treatment) as indicated; be calm in manner and approach. If resident is resistant try reproaching; encourage and then praise resident for using call light when assistance is needed; social services to visit prn (as needed); remind the resident of the need for good hygiene and odor control; Male tech if available and remove soiled linens from resident closet and bedside stand, dresser daily to eliminate odors. Medical record review of Nursing Notes, from (MONTH) and (MONTH) (YEAR) revealed on 7/18/17 at 9:07 PM Resident# 3 was noted with a history of poor hygiene habits such as pours urine at bedside. Hiding dirty laundry in closet. Medical record review of Nursing Notes dated 7/25/17 at 2:56 PM, revealed, When staff ask resident to change his clothes and to get shaved resident started yelling at staff. I'm not wet! Medical record review of Nursing Notes dated 7/31/17 at 6:32 AM, revealed, Refused x (times) 2 this morning to have brief changed which was wet, started yelling and cursing at nurse. Medical record review of Nursing Notes dated 8/8/17 at 11:15 PM, revealed, (Resident #3) was noted to like to pour urine on bedroom floor and hiding dirty laundry in closet, causing a strong smell in room and making his roommate very uncomfortable. Medical record review of the Nursing Note dated 8/16/17 at 1:13 AM, revealed, Has behavior issue such as pour urine on the floor often, hiding dirty laundry in places. Medical record review of Social Service documentation revealed no Social Services involvement regarding the identified behaviors. Interview with the Social Services Director (SSD) #1 on 9/12/17 at 8:30 AM, confirmed she had not been involved with Resident #3 and was not aware of Resident #3's inappropriate behaviors. Interview with the Director of Nursing (DON) on 9/12/17 at 10:00 AM, revealed monitoring of behaviors was documented by the nurses on the Medication Administration Record [REDACTED]. Further interview with the DON at 3:05 PM, after a review of Resident #3's MAR, confirmed the implementation of care plan approaches were not being monitored to evaluate effectiveness of interventions to further develop a systematic approach in care and services in order for Resident#3 to attain his highest practicable psychosocial well-being.",2020-09-01
658,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2017-09-14,514,D,1,0,TNU911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to ensure an accurate medical record for one resident (#6) of nine residents reviewed. The findings included: Medical record review revealed Resident #6 was admitted to the facility on [DATE]. Medical record review of the resident [DIAGNOSES REDACTED]. Medical record review of the resident current Medication Administration Record [REDACTED]. Interview and review of resident [DIAGNOSES REDACTED].#6 received the [DIAGNOSES REDACTED]. Further interview confirmed the resident was not hospitalized around the time of the 11/15/16, and was not being treated for [REDACTED]. Continued interview confirmed the resident's medical record was inaccurate.",2020-09-01
659,"AGAPE NURSING AND REHABILIATION CENTER, LLC",445162,505 N ROAN STREET,JOHNSON CITY,TN,37604,2018-03-14,565,E,1,0,2X2811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the Resident Council Meeting Minutes, medical record review, observations, and interviews the facility failed to ensure the residents' concerns/grievances related to staffing and call light response time were promptly acted upon for residents who attended resident council meetings, and for two (Resident #5 and #13) of six residents (Residents #1, #3, #5, #9, #12, and #13) sampled for quality of care. The findings included: Review of the resident Council Meeting Minutes for the past six months (October (YEAR) - (MONTH) (YEAR)) revealed the following: On 10/4/17 one resident stated he was not being changed at night on the second to third shift. He stated the facility needed more nurses and aides. On 11/1/17 one resident stated he was not being changed at night on the third shift. The minutes indicated, Multiple residents at the meeting complained of late night/early morning staff not answering call lights. On 12/6/17 one resident stated he was still not being changed on the second and third shift. The minutes indicated, Residents stated some staff just walks in the room and turns call light off and walks out without asking what they need. On 1/3/18 the minutes indicated, Residents stated call lights were still being turned off at times without finding out what the problem is. They also stated that if the call lights were answered it took a while to be answered. One resident stated if the call light was answered, some staff said they would be back, but did not come back or came back 1 to 2 hours later. On 2/7/18 the residents stated they felt the call lights could be answered timelier on the first and third shifts. On 3/7/18 one resident stated her call light was not being answered timely and one resident stated he was not being changed. Continued review revealed none of the Resident Council Meeting minutes included documentation of previous concerns raised by the group and what action had been taken to resolve them. Observation on 3/13/18 at 5:45 AM of the available staffing revealed the facility had a census of 76 residents; had a total of two certified nurse aides (CNA) #1 and CNA #2; and two licensed practical nurses (LPN) #1 and LPN #6 in the facility. Continued observation and interview with CNA #2 on 3/13/18 at 6:10 AM in the hallway revealed, they were supposed to have three CNAs working; however, one called in and that left just she and another CNA to care for 76 residents. She stated the LPNs helped when they could; however, they were still unable to meet the needs of the residents timely when they only had two aides on duty. CNA #2 was asked if any of the residents experienced falls or were not able to make it to the bathroom on time due to not having the third CNA to help. CNA #2 stated Resident #13 was not assisted to the bathroom timely and had a bowel movement in her incontinence brief when she normally made it to the bathroom on time and voided on the toilet. Medical record review for Resident #13 revealed she had [DIAGNOSES REDACTED]. Review of the admission nursing assessment, dated 3/3/18 revealed she did not show signs of cognitive loss or communication limitations; she required assistance with all her activities of daily living (ADLs). Her plan of care with an effective date of 3/5/18 stated she had an ADL self-care problem because she required assistance with some ADLs. Interview with Resident #13 her room on 3/13/18 at 8:15 AM, confirmed she had been in the facility for a little over a week and she felt she could, get better care at home. She stated when she put her call light on it, takes forever to get help. She stated she put her call light on last night because she needed to have a bowel movement (BM) and waited 10 minutes in her bed and when no one came and she could not hold it any longer she got up by herself with her walker to go to the bathroom. She stated her doctor told her not to get up without help because of her blood pressure, but she had no choice. She stated, just as she stood up she had an accident and got (BM) on the floor and in her brief. She stated once she got into the bathroom, she put the call light on because she had BM up her back and she needed help to get cleaned up. She stated she had to wait 20 more minutes while sitting on the toilet in the bathroom before staff arrived. The resident stated she found it frustrating to have to wait. Observation and interview on 3/12/18 at 3:44 PM with Resident #5 in his room revealed the facility needed more staff on the third shift. He stated, It just seems like there were no staff in the building on night shift. When asked if his call light was answered timely, he stated it took a while for it to get answered, but did not state how long. Review of Resident #5's Admission MDS assessment revealed he had a BIMs score of 14 (indicating he was cognitively intact). Interview on 3/14/18 at 9:48 AM the Director of Nursing and the Administrator in the activity room revealed the Administrator was asked about how complaints from the resident council were handled. The Administrator stated after the resident council meeting, the department heads were given the complaints about their areas and they were supposed to address them. The Administrator was asked for documentation related to the ongoing complaints about staffing and call light response from the resident council. The Administrator did not provide any documentation to demonstrate any efforts had been made by the facility to resolve the residents' grievances. The Administrator stated the staff were inserviced (educated) about answering call lights timely; however, she did not provide documentation of the inservice.",2020-09-01
660,"AGAPE NURSING AND REHABILIATION CENTER, LLC",445162,505 N ROAN STREET,JOHNSON CITY,TN,37604,2018-03-14,600,D,1,0,2X2811,"**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 ensure two residents (#2, #3) were free from abuse of 10 residents reviewed for abuse. The findings included: Review of the facility policy, Abuse Protocol, dated 11/2016, revealed .Each resident has the right to be free from abuse .2. Abuse means the willful infliction of injury . Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 14 day Minimum Data Set ((MDS) dated [DATE] revealed resident Brief Interview for Mental Status (BIMS) score of 10 indicating resident with moderately impaired cognition. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed resident Brief Interview for Mental Status (BIMS) score of 6 of 15 indicating resident with severe cognitive impairment. Review of a facility investigation dated 12/19/17 revealed .nurse notified of an altercation .upon entering room this nurse was told by CNA on staff that she had witnessed resident in bed #2 being hit by her mother. CNA on staff had separated the altercation .resident in bed #2 stated that resident in bed #1 had hit her in the face with a closed fist more than once .Resident in bed #1 stated resident in bed #2 mother stated to daughter be good, you need to stay here and proceeded to slap daughter. Resident in bed #2 proceeded to hit her mother. Resident in bed #2 stated she couldn't stand to see resident in bed #2 slap her mother, so she went over there and slapped resident in bed #2. Resident in bed #1 stated she got me, pulled my hair and bit my hand and when she did that I slapped the hell out of her . Review of facility investigation statements and interview with the Assistant Director of Nursing (ADON) on 3/13/18 at 9:51 AM, in the activity room, confirmed resident #2 had been smacked by her mother. Continued interview revealed resident #3's hair was pulled and her hand had been bitten by resident #2.",2020-09-01
661,"AGAPE NURSING AND REHABILIATION CENTER, LLC",445162,505 N ROAN STREET,JOHNSON CITY,TN,37604,2018-03-14,725,E,1,0,2X2811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview, the facility failed to provide adequate nursing staff to meet the needs of 2 residents ( #5, #13) of 6 residents ( #1, 3, 5, 9, 12, and 13) sampled for quality of care and residents who attended the resident council meetings. The findings included: Medical record review of Resident #13 revealed she had [DIAGNOSES REDACTED]. Review of the admission nursing assessment, dated 3/3/18 revealed she did not show signs of cognitive loss or communication limitations; she required assistance with all her activities of daily living (ADLs). Her plan of care with an effective date of 3/5/18 stated she had an ADL self-care problem because she required assistance with ADLs. Observation on 3/13/18 at 5:45 AM revealed the facility had a census of 76 residents, and there were a total of two certified nurse aides, (CNA) #1 and CNA #2, and two licensed practical nurses, (LPN) #1 and LPN #6 in the facility. On 3/13/18 at 6:10 AM CNA #2 was interviewed in the hallway. She stated they were supposed to have three CNAs working; however, one called in and that left just her and another CNA to care for 76 residents. She stated the LPNs helped when they could; however, they were still unable to meet the needs of the residents timely when they only had two aides working. CNA #2 was asked if any of the residents experienced falls or were not able to make it to the bathroom on time due to not having the third CNA to help. CNA #2 stated Resident #13 was not assisted to the bathroom timely and had a bowel movement in her incontinence brief when she normally made it to the bathroom and voided on the toilet. Interview with Resident #13 in her room on 3/13/18 at 8:15 AM, revealed she had been in the facility for a little over a week, and she felt she could, get better care at home. She stated when she put her call light on it, takes forever to get help. She stated she put her call light on last night because she needed to have a bowel movement (BM) and waited 10 minutes in her bed and when no one came and she could not hold it any longer she got up by herself with her walker to go to the bathroom. She stated her doctor told her not to get up without help because of her blood pressure, but she had no choice. She stated, just as she stood up she had an accident and got (BM) on the floor and in her brief. She stated once she got into the bathroom, she put the call light on because she had BM up her back and she needed help to get cleaned up. She stated she had to wait 20 more minutes while sitting on the toilet in the bathroom before staff arrived. The resident stated she found it frustrating to have to wait. Medical record review of Resident #5's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed he had a Brief Interview for Mental Status score of 14/15 (indicating he was cognitively intact). Continued review revealed Resident #5 required extensive assistance of 2 staff for bed mobility and transfers. Interview with Resident on 3/12/18 at 3:44 PM, in his room, revealed the facility needed more staff on the third shift. He stated, It just seems like there were no staff in the building on night shift. When asked if his call light was answered timely, he stated it took a while for it to get answered, but did not state how long. Review of the Resident Council Meeting Minutes for (MONTH) (YEAR) through (MONTH) (YEAR) revealed residents voiced concerns every month related to the facility not having adequate staff to meet their needs and/or not having care needs met timely. Cross reference F565. Interviews were conducted on 3/14/18 at 9:48 AM with the Director of Nursing (DON) and the Administrator in the activity room. The DON stated the goal was to have 3 to 4 CNAs and 2 nurses on the 11:00 PM to 7:00 AM shift. She stated a CNA called in prior to the beginning of the 3/12/18, 11:00 PM to 7:00 AM shift and she attempted to get a replacement without any luck. She stated the 11:00 PM to 7:00 AM staff called her at home after the shift started and informed her that the CNA had not come to work. Continued interview confirmed she informed them of the call off and again attempted to call in a replacement without any success. The Administrator was informed of what Resident #13 had stated about taking 30 minutes to get her light answered, and CNA #2 confirmed the resident had bowel incontinence because she (CNA #2) was unable to answer her call light in a timely manner, the Administrator stated if the resident stated it took 30 minutes then it took 30 minutes. The Administrator stated, Then we can do better. She stated they experienced high turnover and were having a hard time recruiting staff, despite advertising on the radio and on social media sources. She stated they also had a difficult time getting employees to fill in for staff who called off, despite offering pay incentives to work overtime and pick up additional shifts.",2020-09-01
662,"AGAPE NURSING AND REHABILIATION CENTER, LLC",445162,505 N ROAN STREET,JOHNSON CITY,TN,37604,2019-03-26,550,D,0,1,GERH11,"**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 promote resident rights to respect and dignity, and ensure privacy for 1 resident (#8) of 1 resident reviewed of 19 sampled residents. The findings include: Review of the facility policy Dignity and Respect, dated 7/91, revealed .Residents' individual preferences .clothing .are elicited and respected by the facility .Residents shall be examined and treated in a manner that maintains the privacy of their bodies. A closed door or drawn curtain shields the Resident from passers-by . Review of the facility policy Activities of Daily Living, dated 3/17, revealed .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 7, indicating the resident was severely cognitively impaired. Further review revealed dressing required extensive assistance of 2 staff members. Medical record review of Resident #8's care plan, dated 12/26/18, revealed .Assist me with bed mobility, transfers, toileting, grooming, dressing, and locomotion . Observation and family interview with Resident #8's family on 3/24/19 at 12:45 PM, in the resident's room, revealed the resident was .left in hospital clothes, and never has pants on . The resident was dressed in a hospital gown, without pants, at the time of the interview. Observation and family interview with Resident #8's family on 3/25/19 at 4:57 PM, in the resident's room, revealed the resident remains in bed dressed in a hospital gown, and no pants.I wish they would put clothes on him every day .it would make him feel better, and stay warmer . Observation of Resident #8 on 3/26/19 at 8:31 AM, from the 100 hallway, revealed resident lying disheveled, and uncovered with his legs and brief exposed. Interview with the Director of Nursing (DON) on 3/26/19 at 8:54 AM, in the 100 hallway, revealed it would depend on the resident's preferences and needs as to what clothing she would expect them to have on. Continued interview confirmed, .honestly, it is easier to provide care to some of them in a gown .if people are up and going to therapy, they need shirt and pants on . Interview with the DON on 3/26/19 at 9:10 AM, in the conference room, confirmed the facility failed to promote resident rights to respect and dignity, and to ensure privacy for Resident #8.",2020-09-01
663,"AGAPE NURSING AND REHABILIATION CENTER, LLC",445162,505 N ROAN STREET,JOHNSON CITY,TN,37604,2019-03-26,812,F,0,1,GERH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, and interview, the facility failed to discard expired and damaged food items and failed to ensure food items were not open to air in 2 of 3 coolers, 1 of 1 bread racks, and 1 of 1 freezers. The findings include: Review of the facility policy Food Storage dated [DATE], revealed .Food is stored and prepared in clean safe sanitary manner that will comply with state and federal guidelines . Observation of the kitchen with Dietary Aide #1 on [DATE] at 9:43 AM, revealed the following: In the upright cooler: (5) cartons of 2% (percent) milk with a use by date of [DATE] In the milk cooler: (13) cartons of 2% (percent) milk with a use by date of [DATE] On the bread rack: (3) packages of 12 count hotdog buns with a use by date [DATE] (6) 1lb (pound) loaves of whole wheat bread with a use by date of [DATE] (2) 1lb loaves of sandwich bread with a use by date of [DATE] (1) 1lb sandwich bread with the bread damaged and open to air with a hole in the bottom of the bag (5) slices left in a 1lb bag of wheat bread with a use by date of [DATE] In the walk-in freezer: (2) frozen burger patties in a box open to air (1) 20 lb box of frozen peas open to air (20) frozen biscuits in a box open to air Interview with the Dietary Director on [DATE] at 10:30 AM, in the kitchen, confirmed the facility failed to ensure expired food items were not available for resident use, failed to ensure damaged foods were not available for resident use, and failed to ensure foods were not stored open to air.",2020-09-01
664,"AGAPE NURSING AND REHABILIATION CENTER, LLC",445162,505 N ROAN STREET,JOHNSON CITY,TN,37604,2018-05-02,657,D,0,1,Y2B811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to revise the care plan for 1 resident (#71) of 18 sampled residents. The findings included: Medical record review revealed Resident # 71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility policy Fall Prevention Program, revised 3/17 revealed, .When a fall occurs .These interventions will be documented in the medical record as well as the Kardex (medical information system used to communicate information about patients) /CNA (certified nursing assistant) Communication Sheet Review of facility's Incident Case Report dated 4/10/18 with completion date of 5/1/18 revealed, . new action is to use the bedpan opposed to bedside commode . Medical record review of the care plan dated 4/10/18 revealed no intervention for use of a bed pan. Medical record review of Post Incident Documentation, dated 4/14/18, revealed, . new interventions put in place? Yes .New intervention added to Care Plan / Kardex? Yes . Review of Resident #71's current KARDEX revealed, no intervention for use of bedpan , further review revealed, .Fall interventions: Non-skid socks. Interview with CNA # 1 on 5/02/18 at 7:44 AM, in the station 3 hallway, confirmed Resident #71 used bedside commode (BSC) for toileting. Interview with the Director of Nursing (DON) on 5/02/18 at 10:52 AM, in the DON's office, confirmed the facility failed to revise the care plan for Resident #71 following a fall.",2020-09-01
665,"AGAPE NURSING AND REHABILIATION CENTER, LLC",445162,505 N ROAN STREET,JOHNSON CITY,TN,37604,2018-05-02,689,D,0,1,Y2B811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, review of facility investigation, medical record review, observation, and interview, the facility failed to implement a new intervention and monitor effectiveness of interventions after a fall for 1 resident (#71) of 4 residents reviewed for falls of 18 sampled residents. The findings included: Review of the facility policy Fall Prevention Program, revised 3/17 revealed, .When a fall occurs .These interventions will be documented in the medical record as well as the Kardex (medical information system used to communicate information about patients) /CNA (certified nursing assistant) Communication Sheet For 72 hours following the fall, staff will document .The resident's reaction/response to the new fall intervention placed . Medical record review revealed Resident # 71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical Record Review of Admission Minimum Data Set (MDS), dated [DATE], revealed Resident #71 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Further review revealed the resident required staff assistance for transfers and toileting. Medical Record Review of progress notes dated 4/14/18 revealed, This nurse was approached by CNA and told that resident had fallen in the floor . Review of facility's Incident Case Report dated 4/10/18 (correct date 4/14/18) revealed, . new action is to use the bedpan opposed to bedside commode . Medical record review of Post Incident Documentation, dated 4/14/18, revealed, . new interventions put in place? Yes .New intervention added to Care Plan / Kardex? Yes . Medical record review of the care plan dated 4/10/18 revealed no intervention for use of a bedpan. Review of Resident #71's current KARDEX (not dated) revealed no intervention for the use of a bedpan. Further review revealed, .Fall interventions: Non-skid socks . Observation of Resident # 71 on 5/01/18 at 7:56 AM, in the resident's room, revealed the resident lying in bed with a bedside commode (BSC) and safety mat at the bedside. Observation of Resident #71 on 5/02/18 at 7:33 AM, in the resident's room, revealed a BSC and safety mat in place at the bedside. Interview with CNA #1 on 5/02/18 at 7:44 AM, in the station 3 hallway, confirmed Resident #71 uses a BSC for toileting. Interview with the Director of Nursing (DON) on 5/02/18 at 8:27 AM, in the DON's office, confirmed Resident #71's fall occurred on 4/14/18 and the Incident Case Report date of 4/10/18 was incorrect. Further interview confirmed after falls occur, the resident would be assessed, the DON would be called to assist with new interventions and staff would complete a report. Continued interview confirmed the Interdisciplinary Team would review the interventions the following day to ensure the new intervention was appropriate. Further interview confirmed the facility would monitor the effectiveness and resident's response of the new intervention for 3 days after a fall, and review/revise as needed. Continued interview confirmed the new interventions would be added to the Kardex and the care plan would be updated. Interview with Resident #71 on 5/02/18 at 9:38 AM, in the resident's room, confirmed Resident #71 used BSC or bathroom for toileting and stated, .I hate a bedpan . Interview with the DON on 5/02/18 at 10:52 AM, in the DON's office, confirmed the facility failed to implement the new intervention and monitor effectiveness following Resident #71's fall.",2020-09-01
666,"AGAPE NURSING AND REHABILIATION CENTER, LLC",445162,505 N ROAN STREET,JOHNSON CITY,TN,37604,2018-05-02,791,D,0,1,Y2B811,"**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 ensure dental services were provided for 1 resident (#17) of 18 sampled residents. The findings included: Review of the facility policy Dental Services - Professional, revised 3/17 revealed, .routine and emergency dental services are available to meet the resident's oral health .nursing services is responsible for notifying Social Services of a resident's need for dental services .Social Services personnel will be responsible for assisting the resident/family in making dental appointments . Medical record review revealed Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed .Obvious or likely cavity or broken natural teeth . Observation of Resident #17 on 4/30/18 at 10:34 AM, in the resident's room revealed the resident with tooth decay. Interview with the Director of Social Services on 5/2/18 at 8:20 AM, in the Social Services Office, confirmed Resident #17 had tooth decay and was scheduled to be seen by dental services on 4/20/18. Further interview confirmed Resident #17 was not seen by dental services on 4/20/18 despite being scheduled. Continued interview confirmed the facility failed to provide dental services for Resident #17 since admission to the facility on [DATE].",2020-09-01
667,"AGAPE NURSING AND REHABILIATION CENTER, LLC",445162,505 N ROAN STREET,JOHNSON CITY,TN,37604,2018-05-02,880,D,0,1,Y2B811,"**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 post an isolation precaution sign on the door of 1 Resident (#328) of 3 residents on isolation precautions of 18 residents sampled of 73 total residents. The findings included: Review of the facility policy Reverse Isolation revised 11/17 revealed, .Place 'Please see nurse before entering room' sign on the outer door . Medical record review revealed Resident #328 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician order dated 4/25/18 revealed, .reverse isolation (isolation procedures designed to protect a patient from infectious organisms that might be carried by the staff, other patients, or visitors) for [DIAGNOSES REDACTED] (an abnormally low count of a type of white blood cell) . Medical record review of the care plan dated 4/25/18 revealed, .I am in reverse isolation because my immune system is low and I am susceptible to bacteria/viruses .Post signs at my door informing visitors to check in with licensed staff prior to entering room . Observation during initial tour of Resident #328's room, on 4/30/18 at 9:45 AM, in the station 3 hallway, revealed no isolation precaution sign on the door. Interview with Certified Nurses Aid (CNA) #2, on 4/30/18 at 9:45 AM, in the station 3 hallway, revealed Resident #328 was on reverse isolation precautions and a mask needed to be worn when entering the resident's room for his protection. Interview with the Registered Nurse Consultant, on 4/30/18 at 10:06 AM, in the Station 3 hallway, confirmed Resident #328 was on reverse isolation precautions and the facilty failed to post a sign on the resident's door to notify staff and visitors of the reverse isolation.",2020-09-01
668,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2018-01-25,641,D,0,1,UGFX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record and interview, the facility failed to accurately assess residents for hospice and medications for 2 of 31 (Resident #88 and 99) sampled residents reviewed. The findings included: 1. Medical Record review revealed Resident #88 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Physicians orders dated 3/21/17 documented, .Admit to (Named Hospice) .for Abnormal Weight Loss . The care plan dated 3/20/17 and updated 10/2/17 documented, .Problem/Need .Resident has chosen to receive Hospice Care with (Named Hospice) . The quarterly Minimum Data Set ((MDS) dated [DATE] documented Resident #88 was receiving Hospice Care. The quarterly MDS dated [DATE] did not document Resident #88 was receiving hospice care. Interview with MDS Coordinator #1 on 1/24/18 at 3:50 PM, in MDS office, MDS Coordinator #1 was asked if hospice services was on the MDS dated [DATE]. She stated,No it is not there. She was asked if this would be an error. She stated, Yes. 2. Medical record review revealed Resident #99 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 5-day MDS assessment dated [DATE] documented opioid was given 6 days of the 7 day look back period. The October, (YEAR) Medication Administration Record [REDACTED]. The admission MDS assessment dated [DATE] documented Resident #99 received opioids 3 days of the 7 day look back period. The November, (YEAR) MAR indicated [REDACTED]. Interview with the Administrator and the Director of Nursing (DON) on 01/25/18 at 7:48 PM, in the conference room, they confirmed this MDS information was inaccurate.",2020-09-01
669,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2018-01-25,692,D,0,1,UGFX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to follow physician diet orders for 1 of 5 (Resident #121) sampled residents reviewed. The findings included: 1. Medical record review revealed Resident #121 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].DIET .NAS (no added salt) pureed diet .fortified foods at all meals .fortified milkshakes w/ (with) lunch & dinner .double portions at all meals . The care plan dated 1/9/17 reviewed 1/8/18 documented, .Requires NAS/Pureed/Double Entree/Fortified Food tid (three times a day) Milk shake with lunch and dinner . 2. Observations on the second floor dining room on 1/24/18 at 11:50 PM, revealed Resident #121's meal tray with a meal ticket that documented, .Diet: Pureed, NAS, Fortified Foods . A milk shake was not observed on Resident #121's meal tray. Observations on the second floor dining room on 1/24/18 at 6:10 PM, revealed Resident #121's meal tray consisted of pureed broccoli, pureed corn, pureed chicken, pureed bread, and a carton of milk. A milk shake was not observed on Resident #121's tray. Observations on the second floor dining room on 1/25/18 at 8:30 AM, revealed Resident #121 being assisted with her breakfast. Her breakfast consisted of pureed eggs, sausage, toast, milk. 3. Interview with Certified Nursing Assistant (CNA)#1 on 1/25/18 at 8:32 AM, in the dining room, CNA #1 was asked if Resident #121's breakfast tray contained double portions. CNA #1 stated, No. Interview with the Dietary Tech and Kitchen Manager on 1/25/18 at 9:54 AM, in the main dining room, the Dietary Tech was asked what her job responsibilities were. The Dietary Tech stated, .I take care of the clinical part for the facility and charting . The Dietary Tech and Kitchen Manager were asked what Resident #121 was supposed to receive on her meal tray. The Dietary Tech stated, .Puree, NAS, Fortified Foods, milk shakes on lunch and dinner tray, double portions on lunch and dinner tray, and med pass tid . The Kitchen Manager stated, .she gets fortified oatmeal on her breakfast tray .double portion with fortified food and milk shake on her lunch tray, and double portions with fortified foods and milk shake on her dinner tray . The Kitchen Manager was shown Resident #121's meal ticket and asked (looking at the meal ticket), would the CNA know that the resident was supposed to receive double portions and milk shakes. The Kitchen Manager stated, .absolutely not .",2020-09-01
670,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2018-01-25,842,D,0,1,UGFX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to have a complete and accurate medical record for Activities of Daily Living (ADLs) and medications for 2 of 31 (Resident #33 and #99) sampled residents reviewed. The findings included: 1. Medical record review revealed Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] and quarterly MDS assessment dated [DATE] documented Resident #33 was cognitively intact, required extensive assistance with activities of daily living, had functional limitations in range of motion with impairment in both lower extremities. The care plan dated 8/23/16 documented Resident #33 had a self-care deficit with interventions to provide a shower or bath according to the schedule. The ADL Flow Record did not document Resident #33 had a shower or bath on 10/1/17, 10/2/17, 10/3/17, 10/4/17, 10/5/17, 10/6/17, 10/7/17, 10/8/17, 10/23/17, 10/24/17, 10/25/17, 10/26/17, 10/27/17, and 10/28/17. The ADL Flow Record did not document Resident #33 had a shower or bath on 11/8/17, 11/9/17, 11/10/17, 11/11/17, and 11/12/17. The ADL Flow Record did not document Resident #33 had a shower or bath on 12/23/17, 12/24/17, 12/25/17, 11/26/17, and 11/27/17. The ADL Flow Record did not document Resident #33 had a shower or 1/1/18, 1/2/18, 1/3/18, 1/4/18, 1/16/18, 1/17/18, 1/18/18, 1/19/18, 1/20/18, 1/21/18, and 1/22/18. Interview with Licensed Practical Nurse (LPN) #1 and 2nd floor Unit Manager on 1/25/18 at 8:20 AM, at the 2nd floor nurses station, the Unit Manager stated, .if it's not documented, it's (shower) not been done . LPN #1 continued to state, she gets her showers even though we don't have the documentation to back that statement up .otherwise she would be calling ya'll (state) to file a complaint . Interview with Resident #33 on 1/23/18 at 8:45 AM, in Resident #33's room, Resident #33 stated, .I got a shower last week and thank God for that .It's the first shower I've gotten in 2 months .they are not very regular with the showers . 2. Medical record review revealed Resident #99 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The CONTROLLED SUBSTANCES form documented [MEDICATION NAME] ([MEDICATION NAME]) was signed out for Resident #99 on 10/28/17 at 10:00 AM, 10/29/17 at 11:00 AM, 10/30/17 at 11:00 AM and at 5:00 PM, and 10/31/17 at 10:00 AM. The October, (YEAR) Medication Administration Record [REDACTED]. The CONTROLLED SUBSTANCES form documented [MEDICATION NAME] ([MEDICATION NAME]) was signed out for Resident #99 on 11/4/17 at 2:00 PM, 11/5/17 at 11:00 AM, 11/10/17 at 8:00 AM, 11/12/17 at 6:00 AM, 11/15/17 at 10:00 AM, 11/16/17 at 10:00 AM, 11/17/17 at 10:00 AM, 11/18/17 at 10:00 AM, 11/20/17 at 10:00 AM, and at 5:00 PM, 11/21/17 at 2:00 AM, and at 11:00 AM, 11/22/17 at 10:00 AM, 11/23/17 at 10:00 AM, 11/24/17 at 10:00 AM, 11/25/17 at 10:00 AM, 11/27/17 at 8:30 AM, 11/28/17 at 10:00 AM, and 11/30/17 at 10:00 AM. The November, (YEAR) MAR indicated [REDACTED]. Interview with the Administrator and the Director of Nursing on 1/25/18 at 7:48 PM, in the conference room, they confirmed this medical record was inaccurate.",2020-09-01
671,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2019-03-10,580,D,1,0,TO3W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review and interview, the facility failed to ensure the physician and resident representative were notified of the use of oxygen, antibiotic therapy, breathing treatments and a recent [DIAGNOSES REDACTED].#5 and #6) sampled residents. The findings include: 1. The facility's Change in a Resident's Condition or Status policy documented, .Our facility shall notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and /or status .The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: .e. A need to alter the resident's medical treatment significantly .Except in medical emergencies, notifications of a change occurring in the resident's medical/mental condition or status will be made . 2. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an interview with Respiratory Therapist (RT) #1 on 2/27/19 at 3:25 PM in the respiratory therapy office, RT #1 stated, .Monday he was wheezing .Nurse put O2 (oxygen) on him because he was winded .the RT (RT #2) on Sunday night had put O2 on him as precaution . During an interview with RT #2 on 2/28/19 at 11:38 AM in the conference room, RT #2 stated, .went and got a concentrator for O2 . RT #2 was asked if the physician or family was notified of the need for oxygen. RT #2 stated, I didn't. I guess not. Medical record review revealed there was no documentation the physician or the family had been notified of the changes in Resident #5's condition or the need for the use of oxygen. 3. Medical record review revealed Resident #6 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Telephone Orders dated 2/5/19 documented, .CXR (chest x-ray) due to congestion, cough, rales . Review of the Telephone Orders dated 2/6/19 documented, .[MEDICATION NAME] (an antibiotic used to treat a bacterial infection) 250 mg PO (by mouth) tab (tablet) BID (twice daily) for pneumonia For 7 days .[MEDICATION NAME] sulfate (a [MEDICATION NAME][MEDICATION NAME]) 0.083% (percent) 2-5-3 mg (milligram) INH (inhalation) Q (every) 8 hrs (hours) for 7 days . Review of a Progress Note dated 2/6/19 documented, .CHEST X-RAY RESULTS RECEIVED; LEFT LOWER LOBE PNEUMONIA FOUND . Medical record review revealed there was no documentation Resident #6's family/representative had been notified of the change in condition, the results of the chest x-ray,the new [DIAGNOSES REDACTED].",2020-09-01
672,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2019-03-10,677,E,1,0,TO3W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview, the facility failed to ensure Activities for Daily Living (ADL) assistance related to incontinence care was provided for 2 of 6 (Resident #4 and #11) sampled residents reviewed of the 12 residents included in the sample. The findings include: 1. Medical record review revealed Resident #4 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date of 12/12/18 revealed Resident #4 scored 14 on the Brief Interview of Mental Status (BIMS) which indicated the resident was cognitively capable for decision making. Section G of the MDS documented the resident was dependent for hygiene/bathing, dressing, and eating. Review of the Comprehensive Care Plan documented, .The resident has an ADL self-care performance deficit r/t (related to) Disease Process (Stiff ma[DIAGNOSES REDACTED]) .PERSONAL HYGIENE/ORAL CARE: The resident is totally dependent on staff for personal hygiene .TOILET USE: The resident is totally dependent on staff for toilet use .The resident has potential for impairment to skin integrity r/t immobility, and disease process .Keep skin clean and dry . Observations on 2/27/19 at 1:40 PM in Resident #4's room revealed the resident wearing a urine soaked incontinence brief. There was a foul urine odor in the room. Interview with Resident #4 on 2/27/19 at 12:50 PM in her room, the resident stated, Nobody has been in here .I have not been changed since 5 AM .fed me breakfast and that's all . Interview with Licensed Practical Nurse (LPN) #1 on 2/27/19 at 3:47 PM at the 200 Hall nurses' Station, the LPN was asked who was responsible for providing care for Resident #4 from 7:00 AM until 3:00 PM. LPN #1 stated, I can't say that anyone did. 2. Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an assessment reference date of 1/30/19 revealed Resident #11 scored 12 on the Brief Interview of Mental Status (BIMS) which indicated the resident was cognitively capable for decision making. Section G of the MDS documented the resident required extensive assistance for hygiene/bathing and dressing. Review of the Comprehensive Care Plan documented, .The resident has an ADL self-care performance deficit r/t Disease Process .TOILET USE: The resident is totally dependent on staff for toilet use .The resident has potential for impairment to skin integrity r/t impaired mobility and incontinence .Keep skin clean and dry .The resident has bowel and bladder incontinence .Clean peri-area with each incontinence episode . Interview with Resident #11's wife on 3/10/19 at 1:32 PM in the 100 Hall chart room, the wife stated, .I have to change him because I can't find an aide to do it. They work with only 2 or 3 aides on this hall. They don't have enough help to take care of these people. I've had to call my son to come in and help me change my husband .He has not been checked or changed since he got up for breakfast. He is wet now . Resident #11 confirmed he was wet with urine and needed incontinence care. The facility failed to provide ADL care related to incontinence care.",2020-09-01
673,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2019-03-10,684,D,1,0,TO3W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility protocol, medical record review, and interview, the facility failed to ensure physician orders [REDACTED].#5) sampled residents. The findings include: 1. The facility's Clinical Pathways protocol documented, .[MEDICAL CONDITION]: (Chest pain) Begin oxygen 2L (liters) by nasal cannula and notify Provider .Dyspnea: Oxygen 2L by nasal cannula .Heartburn: [MEDICATION NAME] suspension (or house equivalent) 30 cc (cubic centimeters) po (by mouth) . 2. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During interview with Respiratory Therapist (RT) #1 on 2/27/19 at 3:25 PM in the respiratory therapy office, RT #1 stated, .the RT on Sunday night had put O2 on him as precaution . During an interview with RT #2 on 2/28/19 at 11:38 AM in the conference room, RT #2 stated, .went and got a concentrator for O2 . RT #2 was asked why the O2 was administered to the resident. She stated, Because I'm an RT and he rubbed his stomach without description. It's just what I do . RT #2 was asked if Resident #5 had chest pain or shortness of breath. RT #2 stated, No. During a telephone interview with LPN #2 on 2/28/19 at 2:18 PM, LPN #2 stated, .He was in his room, rubbing his stomach, wanted something for stomach. I gave him TUMS . LPN #2 was asked if there was a physician order [REDACTED]. During an interview with the Director of Nursing (DON) ) on 2/28/19 at 2:02 PM in the conference room, the DON was asked if there was an order for [REDACTED]. TUMS is what we have as house stock . During a telephone interview with the Physician on 3/1/19 at 7:33 AM, the Physician was asked if TUMS was included in the facility's standing orders protocol. The Physician stated, There are protocols for them to give [MEDICATION NAME] . The Physician was asked if [MEDICATION NAME] and TUMS were the same drugs. The Physician stated, No. They are different drugs.",2020-09-01
674,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2019-03-10,697,D,1,0,TO3W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to follow physician orders [REDACTED].#12) sampled residents reviewed of the 12 residents included in the sample. The findings include: 1. Medical record review revealed Resident #12 was admitted to the facility with Hospice services on 2/12/19 at 2:00 PM with [DIAGNOSES REDACTED]. Review of the admission orders [REDACTED].[MEDICATION NAME] ER (extended release) 60 mg (milligram) tablet take one tablet po (by mouth) q (every) 12 hrs (hours) . Review of the ADMINISTRATION RECORD dated 2/12/19 revealed the [MEDICATION NAME] ER 60 mg po was not administered as ordered on [DATE] or 2/13/19. Review of the Comprehensive Care Plan documented, .has potential for pain related to [MEDICAL CONDITION] .Administer medication for pain as ordered and document effectiveness . 2. During an interview with Registered Nurse (RN) #1 on 3/5/19 at 10:45 AM in the conference room, RN #1 was asked what time Resident #12 received the [MEDICATION NAME] ER as ordered. RN #1 stated, On the 13th at 9:00 AM a prn (as needed) dose .Didn't get it ([MEDICATION NAME] ER 60 mg) on the 12th. During an interview with Licensed Practical Nurse (LPN) #3 on 3/10/19 at 3:55 PM at the 200 Hall nurses' desk, LPN #3 was asked if Resident #12 was given his pain medication as ordered when he was admitted on [DATE]. LPN #3 stated, If Hospice is bringing them we would use from Hospice. He did not come with his meds. We should have gotten a hard script for the [MEDICATION NAME] and sent to pharmacy. We would get the next day in the evening. During review of Resident #12's Administration Record with LPN #3, she was asked if the first dose of the scheduled [MEDICATION NAME] ER 60 mg was given on 2/13/19 at 6:00 PM. LPN #3 stated, Correct. During an interview with the Director of Nursing (DON) on 3/10/19 at 4:05 PM in the DON office, the DON was asked when Resident #12 received the [MEDICATION NAME] ER 60 mg tablet that was ordered every 12 hours. The DON stated, On new admits (admissions) we don't get their meds (medications) till the evening run the next day. Evening run is at 5:00 PM or later. Nurse says between 9:00 PM and 9:30 PM the next evening. We didn't have it since Hospice didn't bring it . The DON confirmed Resident #12 did not receive the scheduled [MEDICATION NAME] ER 60 mg every 12 hours as ordered on admission on 2/12/19 and 2/13/19.",2020-09-01
675,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2019-03-10,725,E,1,0,TO3W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the Daily Staffing Sheet, medical record review, and interview, the facility failed to ensure adequate certified staff to provide care for the residents for 3 of 3 (January, February, and (MONTH) 2019) months reviewed. The findings include: 1. Review of the (MONTH) 2019 Daily Staffing Sheet revealed the facility did not have adequate staff to meet the needs of the residents 6 of 31 days: a. 1/1/19 - For a census of 146 there were 9 Certified Nursing Assistants (CNA), each providing care for 16 residents from 7:00 AM-3:00 PM. b. 1/3/19 - For a census of 144 there were 9 CNAs, each providing care for 16 residents from 7:00 AM-3:00 PM c. 1/5/19 - For a census of 148 there were 8 CNAs, each providing care for /18 residents from 3:00 PM-11:00 PM. d. 1/6/19 - For a census of 148 there were 9 CNAs, each providing care for 16 residents from 3:00 PM-11:00 PM. e. 1/13/19 - For a census of 148 there were 9 CNAs, each providing care for 16 residents from 7:00 AM-3:00 PM and 3:00 PM-11:00 PM. f. 1/14/19 - For a census of 146 there were 9 CNAs, each providing care for 16 residents from 7:00 AM-3:00 PM. Review of the (MONTH) 2019 Daily Staffing Sheet revealed the facility did not have adequate staff to meet the needs of the residents 10 of 28 days: a. 2/3/19 - For a census of 148 there were 9 CNAs, each providing care for 16 residents from 7:00 AM-3:00 PM. b. 2/6/19 - For a census of 150 there were 10 CNAs, each providing care for 15 residents from 7:00 AM-3:00 PM. c. 2/10/19 - For a census of 152 there were 9 CNAs, each providing care for 16-17 residents from 7:00 AM-3:00 PM. d. 2/14/19 - For a census of 157 there were 9 CNAs, each providing care for 17 residents from 7:00 AM-3:00 PM and 8 CNAs each providing care for 19-20 residents from 3:00 PM-11:00 PM. e. 2/16/19 - For a census of 153 there were 10 CNAs, each providing care for 15 residents from 7:00 AM-3:00 PM. f. 2/17/19 - For a census of 153 there were 10 CNAs, each providing care for 15 residents from 7:00 AM-3:00 PM. g. 2/19/19 - For a census of 155 there were 10 CNAs, each providing care for 15-16 residents from 7:00 AM-3:00 PM h. 2/24/19 - For a census of 151 there were 10 CNAs, each providing care for 15 residents from 7:00 AM-3:00 PM and 9 CNAs each providing care for 16-17 residents from 3:00 PM-11:00 PM. i. 2/25/19 - For a census of 158 there were 10 CNAs, each providing care for 15-16 residents from 7:00 AM-3:00 PM. j. 2/27/19 - For a census of 151 there were 9 CNAs, each providing care for 16-17 residents from 7:00 AM-3:00 PM. Review of the (MONTH) Daily Staffing Sheet revealed the facility did not have adequate staff to meet the needs of the residents 6 of 31 days: a. 3/1/19 - For a census of 151 there were 9 CNAs, each providing care for 16-17 residents to provide care from 7:00 AM-3:00 PM. b. 3/4/19 - For a census of 153 there were 9 CNAs, each providing care for 17 residents from 7:00 AM-3:00 PM. c. 3/5/19 - For a census of 153 there were 9 CNAs, each providing care for 17 residents from 7:00 AM-3:00 PM. d. 3/7/19 - For a census of 157 there were 10 CNAs, each providing care for 15-16 residents from 7:00 AM-3:00 PM. e. 3/9/19 - For a census of 157 there were 9 CNAs, each providing care for 17 residents from 7:00 AM-3:00 PM. f. 3/10/19 - For a census of 157 there were 8 CNAs, each providing care for 19-20 residents from 7:00 AM-3:00 PM and 10 CNAs each providing care for 15-16 residents from 3:00 PM-11:00 PM. This review revealed a total of 19 day shifts (7:00 AM-3:00 PM) and 7 evening shifts (3:00 PM-11:00 PM) that did not have sufficient staffing to meet the needs of the residents. 2. Medical record review revealed Resident #4 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date of 12/12/18 revealed Resident #4 scored 14 on the Brief Interview of Mental Status (BIMS) which indicated the resident was cognitively capable of making decisions. Section G of the MDS documented the resident was dependent for hygiene/bathing, dressing, and eating. Review of the Comprehensive Care Plan documented, .The resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) Disease Process (Stiff ma[DIAGNOSES REDACTED]) .PERSONAL HYGIENE/ORAL CARE: The resident is totally dependent on staff for personal hygiene .TOILET USE: The resident is totally dependent on staff for toilet use .The resident has potential for impairment to skin integrity r/t immobility, and disease process .Keep skin clean and dry . Interview with Resident #4 on 2/27/19 at 12:50 PM in her room, the resident stated, Nobody has been in here .I have not been changed since 5 AM .fed me breakfast and that's all . Interview with Licensed Practical Nurse (LPN) #1 on 2/27/19 at 1:20 PM at the 200 Hall nurses' station, LPN #1 was asked what CNA was assigned to provide care to Resident #4. LPN #1 stated, Not sure. I've been too busy on the medication pass. I didn't know she hadn't been helped. 3. Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an assessment reference date of 1/30/19 revealed Resident #11 scored 12 on the Brief Interview of Mental Status (BIMS) which indicated the resident was cognitively capable of making decisions. Section G of the MDS documented the resident required extensive assistance for hygiene/bathing and dressing. Review of the Comprehensive Care Plan documented, .The resident has an ADL self-care performance deficit r/t Disease Process .TOILET USE: The resident is totally dependent on staff for toilet use .The resident has potential for impairment to skin integrity r/t impaired mobility and incontinence .Keep skin clean and dry .The resident has bowel and bladder incontinence .Clean peri-area with each incontinence episode . Interview with Resident #11's wife on 3/10/19 at 1:32 PM in the 100 Hall chart room, the wife stated, .I have to change him because I can't find an aide to do it. They work with only 2 or 3 aides on this hall. They don't have enough help to take care of these people. I've had to call my son to come in and help me change my husband .He has not been checked or changed since he got up for breakfast. He is wet now . Interview with CNA #1 on 3/10/19 at 1:47 PM on the 100 Hall, CNA #1 was asked how many residents was assigned for her to provide care. CNA #1 stated, 19. CNA #1 was asked if she could provide care and meet the needs of each of the 19 residents. CNA #1 stated, No, I can't provide it all. Can't get all the ones up and out of bed today. Some will have to stay in bed. Interview with CNA #2 on 3/10/19 at 1:50 PM on the 100 Hall, CNA #2 was asked if she could provide care and meet the needs of each of the residents on her assignment. CNA #2 stated, With lunches and breakfast and get people up, I can't get to all of them. Interview with the Director of Nursing (DON) on 3/4/19 at 2:15 PM in the conference room, the DON was asked what CNA staffing was required for the day shift and evening shift to meet the care needs of the residents. The DON stated, I schedule 4 on 1st floor and usually 8 to 9 on 2nd floor. The DON was asked if that was the number that had been working recently. The DON stated, No. We had some quit and some went prn (as needed). We work with what we have . Interview with the Administrator on 3/5/19 at 4:30 PM in the Administrator's office, the Administrator stated, Staffing is a problem. We don't use agency. We work with what we have it goes up and down on staffing .",2020-09-01
676,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2019-03-10,760,E,1,0,TO3W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the Institute for Safe Medication Practices, medical record review, and interview, the facility failed to ensure residents were free of significant medication errors when 2 of 2 (Nurse #1 and #4) nurses crushed the [MEDICATION NAME] ER (extended release) tablets and administered the crushed medications to Resident #12. The findings include: 1. Review of the Institute for Safe Medication Practices list of Oral Dosage Forms That Should Not Be Crushed list documented, .[MEDICATION NAME] Tablet Slow-release NOTE: crushing, chewing, or dissolving tablets can cause rapid release and absorption of a potentially fatal dose . Medical record review for Resident #12 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #12 was admitted with Hospice Services. A physician's telephone order for Resident #12 dated 2/15/19 documented, .[MEDICATION NAME] ER 60 mg tablet to be one tablet po (by mouth) q (every) 8 hrs (hours) . Review of the Medication Administration Record [REDACTED]. Review of the Nurses' Note for Resident #12 dated 3/9/19 at 10:31 PM documented, .9pm .Administered medication including [MEDICATION NAME] crushed and mixed in pudding. Resident (Resident #12) took medication followed by cup of supplement w/o (without) spitting anything out. Swallowed without difficulty . Review of a Nurses' Note for Resident #12 dated 3/10/19 at 6:31 AM documented, .MEDICATIONS CRUSHED AND GIVEN RESIDENT (Resident #12) TOOK MEDS WITH NO COMPLAINTS AND WENT BACK TO SLEEP . During an interview with the Director of Nursing (DON) on 3/10/19 at 4:05 PM in the conference room, the DON was asked if [MEDICATION NAME] ER tablet should be crushed and administered. The DON stated, No. It's not to be crushed. During an interview with Nurse #1 on 3/10/19 at 4:15 PM in the conference room, Nurse #1 was asked if she crushed the [MEDICATION NAME] ER 60 mg tablet and administered the crushed medication to Resident #12. Nurse #1 confirmed she administered the crushed [MEDICATION NAME] ER 60 mg to Resident #12.",2020-09-01
677,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2019-03-10,842,D,1,0,TO3W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, and interview, the facility failed to provide and maintain accurate, complete medical records for 2 of 12 (Resident # 5 and 7) sampled residents. The findings include: 1. The facility's Charting and Documentation policy documented, .All observations, medications administered, services provided, etc., must be documented in the resident's clinical records .All incidents, accidents, or changes in the resident's condition must be recorded . The facility's Change in a Resident's Condition or Status policy documented, .The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . The facility's Clinical Pathways (standing orders) protocol documented, .[MEDICAL CONDITION]: (Chest pain) Begin oxygen 2L (liters) by nasal cannula and notify Provider .Dyspnea: Oxygen 2L by nasal cannula .Heartburn: [MEDICATION NAME] suspension (or house equivalent) 30 cc (cubic centimeters) po (by mouth) . 2. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed there was no documentation of an assessment of Resident #5 on 2/16/19 or 2/17/19 and no documentation of the administration of oxygen or TUMS to the resident. During an interview with Respiratory Therapist (RT) #1 on 2/27/19 at 3:25 PM in the respiratory therapy office, RT #1 stated, .Monday he was wheezing .Nurse put O2 (oxygen) on him because he was winded .the RT on Sunday night had put O2 on him as precaution . During an interview with RT #2 on 2/28/19 at 11:38 AM in the conference room, RT #2 stated, .went and got a concentrator for O2 . RT #2 was asked why the O2 was administered to the resident. She stated, Because I'm an RT and he rubbed his stomach without description. It's just what I do .I didn't document it. I should have put it in a general note . RT #2 was asked if the resident had chest pain or shortness of breath. RT #2 stated, No. During an interview with Licensed Practical Nurse (LPN) #2 on 2/28/19 at 2:18 PM at the 200 Hall nurses' station, LPN #2 stated, .He was in his room, rubbing his stomach, wanted something for stomach. I gave him TUMS . LPN #2 was asked if she documented the administration of TUMS and she stated, I wrote it on a piece of paper. I didn't document in the computer. I didn't document in his record. LPN #2 was asked if there was a physician's orders [REDACTED]. LPN #2 stated, I thought it was on standing orders. I know [MEDICATION NAME] is on it . During an interview with the Director of Nursing (DON) on 3/5/19 at 3:10 PM in the conference room, the DON was asked how staff would know the oxygen and TUMS were administered if there was no documentation. The DON stated, We don't. Should be documented. The DON was asked what the expectation was for documentation of assessments and changes in a resident's condition. The DON stated, Chart skilled assessments daily and chart every shift at times . During a telephone interview with the Physician on 3/1/19 at 7:33 AM, the Physician was asked if TUMS was on the facility's standing orders. The Physician stated, There are protocols for them to give [MEDICATION NAME] . The Physician was asked if [MEDICATION NAME] and TUMS were the same drugs. The Physician stated, No. They are different drugs. 3. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a [MEDICAL CONDITION] Note dated 2/26/19 documented, .Resident complain of SOB (shortness of breath) and requested to be on a little o2 (oxygen). RT checked his o2 sats (oxygen saturation) they were 92%, HR (heart rate) 88, rr (respiratory rate) 20. RT placed resident on 2L (liter) bnc (by nasal cannula). SPo2 (peripheral capillary oxygen saturation) came up to 98%, HR 38, rr 20. No distress noted . During a telephone interview with RT #3 on 3/5/19 at 4:22 PM, RT #3 stated, I charted that wrong. That's an error. Heart Rate was 83 . During an interview with the DON on 3/5/19 at 11:10 AM in the Administrator's office, the DON was asked if the heart rate of 38 was correct as documented. The DON looked at the [MEDICAL CONDITION] note and stated, That can't be correct .",2020-09-01
678,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2018-07-12,690,D,1,0,MQID11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, and interview, the facility failed to ensure laboratory services were provided as ordered by the physician for 1 of 3 (Resident #5) residents reviewed for urinary tract infection. The findings included: Medical record review revealed Resident #5 was admitted to the facility on [DATE] with a readmission date of [DATE] with the [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 04, which indicated severe cognitive impairment and the presence of an indwelling urinary catheter. The physician's orders [REDACTED].UA (urinalysis) & (and) Culture . Interview with the Director of Nursing (DON) on 7/5/18 at 11:37 AM, in the administrator's office, the DON was asked if the urinalysis was collected for Resident #5. The DON stated, No .we were unable to find the labs (laboratory test results) ordered by the physician on 1/31/18 . The DON was asked if it was acceptable to not follow doctor orders for labs. The DON stated, No.",2020-09-01
679,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2018-07-12,695,D,1,0,MQID11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation, and interview, the facility failed to provide proper [MEDICAL CONDITION] care for 1 of 3 (Resident #3) residents observed with a [MEDICAL CONDITION]. The findings included: 1. The facility's [MEDICAL CONDITION] Care policy documented, .[MEDICAL CONDITION] should be changed as ordered and as needed . 2. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with a readmission date of [DATE] with the [DIAGNOSES REDACTED]. The physician's orders [REDACTED].TRACH ([MEDICAL CONDITION]) CARE Q SHIFT (every shift) . The admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 was assessed with [REDACTED]. Review of Medication Administration Record [REDACTED]. Review of the MARs dated (MONTH) and (MONTH) (YEAR) revealed no documentation of [MEDICAL CONDITION] care provided on either shift. Observations in Resident #3's room on 7/3/18 at 10:00 AM, revealed a large amount of thick, creamy secretions flowed from the end of the resident's [MEDICAL CONDITION] and pooled on her upper chest. Observations in Resident #3's room on 7/3/18 at 1:19 PM, revealed a small amount of thick, creamy secretions flowed from the end of the residents [MEDICAL CONDITION]. Interview with Licensed Practical Nurse (LPN) #1 on 7/3/18 at 10:00 AM, in Resident #3's room, LPN #1 was asked how often [MEDICAL CONDITION] care is performed on the resident. LPN #1 stated, .It's not due .the night shift nurse told me she did it . Interview with the Director of Nursing (DON) on 7/3/18 at 1:38 PM, in the administrator's office, the DON was asked how often [MEDICAL CONDITION] care should be performed. The DON stated, Every shift .and as needed. The DON was asked if she could tell me where the [MEDICAL CONDITION] care was documented. The DON stated, .On the MAR's . The DON was asked if it was acceptable to not perform or document [MEDICAL CONDITION] care. The DON stated, .No .it should be documented .",2020-09-01
680,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2019-07-30,686,D,1,0,MKNB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview the facility failed to follow physician orders [REDACTED].#2 and #3) sampled residents reviewed with pressure ulcers. The findings include: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Clean sacral wound c (with) NS (normal saline). Pat dry. Apply Santyl oint. (ointment) to slough. Apply collagen & (and) calcium alginate to wound bed. Cover c protective dressing. (symbol for change) QD (everyday) & PRN (as needed) Observations in Resident #2's room on 7/30/19 at 11:22 AM, revealed Treatment Nurse #1 did not apply the Collagen dressing to the wound bed during wound care. Interview with Treatment Nurse #1 on 7/30/19 at 4:40 PM, at the First Floor Nursing desk, the Treatment Nurse #1 was asked were the physician orders [REDACTED]. Treatment Nurse #1 stated, .I didn't put the Collagen, I forgot . Medical record review revealed Resident #3 was admitted to facility 3/20/19 with [DIAGNOSES REDACTED]. The physicians's order dated 7/13/19 documented, .Cleanse area to sacrum, R (right) hip c NS, pat dry, apply santyl + (and) cover drsg (dressing) (symbol for change) QD + PRN . Observations in Resident #3's room on 7/30/19 at 1:36 PM, revealed Treatment Nurse #2 applied Santyl ointment to a Calcium Alginate dressing and applied to the wound bed, and then applied the a cover dressing during wound care. Interview with Director of Nursing (DON) on 7/30/19 at 4:15 PM, at the First Floor Nursing desk, the DON was shown the physician order [REDACTED].#2 have applied Calcium Alginate to this wound. The DON stated, No .",2020-09-01
681,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2019-10-22,580,D,1,1,IWI711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to immediately notify the physician of [DIAGNOSES REDACTED] (low blood glucose level results) for 1 of 3 (Resident #36) sampled residents reviewed for significant change in condition. The findings include: Medical record review revealed Resident #36 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A progress notes dated 9/8/19 at 10:31 PM, documented, .at the beginning of the tour pt's (patient's) blood sugar was 115, No insulin was given. one hour later pt's blood sugar had dropped 48. pt (Patient) was given PEPSI cola, 1 amp ([MEDICATION NAME]) of [MEDICATION NAME] ([MEDICATION NAME]), 1 carton of milk with 2 packs of sugar, 1 small can of sprite. 20 minutes later pt's blood sugar was 101. pt was not given any insulin this tour. pt will continue to be monitored. The facility was unable to provide documentation that the physician was immediately notified on 9/8/19 of the low blood glucose level of 48. A progress note dated 9/18/19 at 2:52 AM, documented, [MEDICATION NAME] 1 MG (milligram) HYPOKIT Inject 1 mg subcutaneously as needed for BLOOD SUGAR BELOW 50 AND UNCONSCIOUS OR UNABLE TO SWALLOW .BLOOD SUGAR 40, resident unable to swallowing (swallow) just letting juice run down face. The facility was unable to provide documentation that the physician was immediately notified on 9/18/19 of the low blood glucose level of 40. Interview with the Director of Nursing (DON) on 10/21/19 at 1:30 PM, in the Conference room, the DON confirmed the facility was unable to provide documentation the physician was immediately notified of Resident #36's change in condition of [DIAGNOSES REDACTED] and that the physician should have been notified of these [DIAGNOSES REDACTED] episodes.",2020-09-01
682,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2019-10-22,761,D,0,1,IWI711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview the facility failed to ensure medications were stored properly when expired medications were found in 1 of 11(First Floor Medication Room) medication storage areas. The findings include: The undated Storage of Medications policy documented, .The nursing staff shall be responsible for maintaining medication storage .The facility shall not use discontinued, outdated or deteriorated drugs or biologicals . Observations in the First Floor Medication Room on 10/22/19 at 2:35 PM, revealed the following medications were stored past the expiration date: a. Three boxes of Influenza Vaccine vials with an expiration date of 7/30/19. b. One 1000 milliliter bag of 5% (percent) [MEDICATION NAME] with 1/2 normal saline with an expiration date of (MONTH) 2019. c. [MEDICATION NAME] Sodium premixed in 100 milliliters normal saline with an expiration date of 8/26/19. Interview with the Director of Nursing (DON) on 10/22/19 at 2:40 PM, in the First Floor Medication Room, the DON was asked should expired medications be in this storage area. The DON stated, No, they should not.",2020-09-01
683,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2019-10-22,880,D,1,1,IWI711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, observation and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 1 of 3 (Registered Nurse (RN) #1) nurses failed to properly disinfect a glucometer (glucose testing machine) after use and when 1 of 1 (Respiratory Therapist (RT) #1) staff failed to perform proper hand hygiene during [MEDICAL CONDITION] care. The findings include: 1. The undated policy Cleaning and Disinfecting Your Even-Care G2 Meter documented, .Purpose: Cleaning and disinfecting your meter and lancing device is very important in the prevention of infectious diseases .Cleaning also allows for subsequent disinfection to ensure germs and disease causing agents are destroyed on the meter and lancing device surface . 4. To disinfect your meter clean the meter with one of the validated disinfecting wipes listed below .Micro-Kill Bleach Germicidal Bleach Wipes . Observations in Resident #36's room on 10/16/19 at 4:23 PM, revealed RN #1 preformed a blood glucose check and then cleaned the glucometer with an alcohol pad. RN #1 did not use the Micro-Kill Bleach Germicidal Bleach Wipe to disinfect the glucometer. Interview with the Director of Nursing (DON) on 10/21/19 at 1:25 PM, in the Conference Room, the DON confirmed the glucometers should be disinfected with Micro-Kill Bleach Germicidal Bleach Wipes. 2. The [MEDICAL CONDITION] Care policy with a revision date of (MONTH) 2014 documented, Remove old dressings .Wash hands .Put on sterile gloves .remove the inner cannula .Remove and discard gloves .Wash hands and put on fresh gloves .Replace the cannula . Observations of [MEDICAL CONDITION] care in Resident #10's room on 10/22/19 at 8:07 AM, revealed RT #1 removed the [MEDICAL CONDITION] dressing and inner cannula with sterile gloves and then performed [MEDICAL CONDITION] care and replaced the sterile inner cannula without performing hand hygiene or applying new sterile gloves. Interview with the Director of Nursing (DON) on 10/22/19 at 10:09 AM, in the Administrator Office, the DON was asked should the Respiratory Therapist change gloves and perform hand hygiene after removing a dirty inner cannula and cleaning the [MEDICAL CONDITION] site. The DON stated, Yes.",2020-09-01
684,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2017-11-15,281,G,1,0,JVWH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of The Lippincott Manual of Nursing Practice, 10th Edition, page 746, facility policy, medical record review, observation, and interview, the facility failed to ensure the implementation of professional standards of practice for 2 of 3 (Resident #1 and #2) sampled residents reviewed who were receiving Percutaneous Endoscopic Gastrostomy (PEG) Tube feedings. The failure to ensure staff provided appropriate care and services for the PEG tube feeding resulted in actual harm to Resident #1 when staff failed to ensure that PEG tube feedings were appropriately administered through the PEG tube to Resident #1 who had Nepro Carb Steady (carbohydrate nutritional product for residents with kidney disease) administered through his peritoneal [MEDICAL TREATMENT] catheter. The findings included: 1. The Lippincott Manual of Nursing Practice, 10th Edition page 746 documented, .For continuous tube feeding .flush tubing, attach to volume control infuser according to manufacturer's instructions, attach distal end to feeding tube . 2. The facility's Enteral Tube Feeding Continuous Pump policy, documented .The purpose of this procedure is to provide nourishment to the resident who is unable to obtain nourishment orally .Preparation .3. Ensure that the equipment and devices are working properly .General Guidelines .3 .Check the following information: .e. Access site (PEG insertion site) .Steps in the Procedure .Verify placement of tube: .7. Auscultate: (listening for internal sounds with a stethescope) a. Do not rely on this as the singular method to differentiate between respiratory, gastric, [MEDICAL CONDITION] and bowel placement. b. Attach 60 mL (milliliters) syringe containing approximately 10 mL air. c. Auscultate the abdomen (approximately 3 inches below the sternum) while injecting the air from the syringe into the tubing .8. When correct tube placement has been verified, flush tubing with at least 30 mL warm water (or prescribed amount) .Check gastric residual (stomach contents amount) volume (GRV): 1. Aspirate stomach contents .Reporting .1. Report complications .2. Report negative consequences of tube use .4. Report other information in accordance with facility policy and professional standards of practice . 2. Medical record review for Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Physicians Orders received by Registered Nurse (RN) #1 on 10/31/17 and signed by the physician on 11/3/17 documented .TUBE FEEDING FORMULA Nepro Carb Steady RATE 45 mL/hr (milliliters per hour) .H2O (water) FLUSH 60 cc (cubic centimeters) 1 (one) HOURS .ENSURE PEG DISK ROTATES EVERY SHIFT .CHECK PEG TUBE PLACEMENT FOR AUSCULTATION .CHECK RESIDUAL . Review of the Initial Care Plan dated 10/27/17 revealed .FEEDING TUBES .Observe peg tube/[DEVICE] (gastrostomy tube) site for S/S (signs and symptoms) of infection/irritation .Peg care every shift & prn (as needed) .*check Peg tube placement By auscultation .* Check residual .Renal/[MEDICAL TREATMENT] .[MEDICAL TREATMENT] as ordered .Shunt care .*Peritoneal catheter (Not in use) (Lower Lt (left) Q (quadrant)) .*[MEDICAL TREATMENT] 3 x (times) wk (week) . Review of the Admission Evaluation and Interim Care Plan Skin Condition Body Diagram dated 10/27/17 revealed, .PEG site .Peritoneal Catheter (plastic flexible tube inserted into the abdomen to allow [MEDICAL TREATMENT] fluid to enter abdominal cavity, dwell inside for a prescribed amount of time and then drain back out again) .LA (left arm) AV fistula Review of the initial Admission/Readmission Nurses Notes dated 10/27/17 at 8:20 PM revealed .Resident is currently non verbal @ (at) this time but is alert & awake .Abd. (abdomen) soft nontender/nondistended c (with) bowel sounds in all 4 quads (quadrants) Noted peritoneal [MEDICAL TREATMENT] cath. (catheter) to LL (left lower) quad of Abd. Has a PEG which is patent & intact. Receives [MEDICAL TREATMENT] x (times) 3 days wkly (weekly). AV fistula to Lt. (left) upper arm c no problems . Review of a facility incident report revealed .(Resident #1) is alert but he is nonverbal. Resident was admitted to facility on 10/27/17 at 8:20 pm for skilled services under the care of (named Medical Director) .Resident admitted with a peg tube located in his left upper abd. quadrant and a peritoneal catheter in lower left abdominal catheter (quadrant). On the evening of 10/31/2017 (named RN #1) entered resident's room. (RN #1) was unaware that resident had a peritoneal catheter. (RN #1) connected the peg tube feeding to the peritoneal catheter. (RN #1) started the tube feeding at 8:45 pm. The error was discovered by the 11-7 (11:00 pm-7:00 am) nurse (Licensed Practical Nurse (LPN #1) at 5:45 am. (LPN #1) stopped the feeding immediately .called (RN #1) and she immediately came to the facility and notified The DON (Director of Nursing). I the DON notified (Medical Director) and orders were given to transfer resident to the hospital .(RN #1) called the family and spoke with the responsible party .resident was transported via 911 ambulance . Interview with the Administrator on 11/12/17 at 6:50 PM in the conference room, the Administrator was asked about Resident #1. She stated, .he was on a continuous feed (PEG tube infusion) until he went out to [MEDICAL TREATMENT] .then it was stopped .his peritoneal tube was not in use .he had a shunt for [MEDICAL TREATMENT] (indicated her left arm) .went to (named hospital) on the 1st (11/1/17) .was in ICU (Intensive Care Unit) for 3 days, then on the 4th day he went back on the vent (ventilator) . Interview with the DON on 11/12/17 at 6:50 PM in the conference room, the DON stated RN #1 .was not aware he had 2 tubes .she checked placement .checked residual .tubing had a flap on it, said she (RN #1) wondered why they did that .took the flap off and put an adapter on it . When the DON was asked if nurses undergo a skills check-off (nursing competency skills validation) the DON stated that they do a skills check-off upon hire and annually. Telephone interview with RN #1 on 11/15/17 at 11:34 AM, RN #1 was asked about the incident with Resident #1 on 10/31/17. She stated .I went in to prepare to give him (Resident #1) his feeding .I aspirated and hooked up his feeding and that's all . When she was asked if there were any problems with his feeding, she stated, .no .a cap was on it and I had to go get a connection for it .I took the cap off and put a connection on it . She was asked if she was aware that Resident #1 had a peritoneal catheter and she stated No. She further stated that she had taken care of him one other time in the past. Telephone interview with LPN #1 on 11/15/17 at 9:50 AM, LPN #1 stated, .I can't remember his (Resident #1) name .only had him one time .I remember the Unit Manager (RN #1) was on duty that night .she was on a cart .in report she (RN #1) said, '(named LPN #1) .I had to alter his (Resident #1) feeding tube because someone took the end off .I (RN #1) spent two hours trying to get that end on' .I (LPN #1) went down there (Resident #1's room) and checked to see what she (RN #1) was talking about and everything was running okay .end looked like a PEG tube .I thought she (RN #1) said the end was off .didn't check the site .he (Resident #1) don't get no midnight meds (medications), he (Resident #1) got 6:00 meds .I went down there with the aide and I told her to change his sheets and get him ready while I was giving him his meds .as soon as she turned him over and uncovered him, I saw he was hooked up to the wrong tube .peritoneal catheter .I unhooked it immediately .went and got the night supervisor (RN #2) .she (RN #2) came down there and checked him (Resident #1) .we knew it was a peritoneal catheter, but we checked the chart just to make sure .called the Unit Manager (RN #1) .she (RN #1) said call the doctor and get a KUB (kidney, ureter, and bladder study is an X-ray study) .we called (named Medical Director and Resident #1's provider), but he said don't get a KUB send him to the ER (emergency room ) .called the family and let them know what happened .I (LPN #1) stayed with him until he left . She was then asked if she had checked on him during the night, and she stated .yes .even at the time his stomach wasn't distended .didn't grimace or anything when I pressed on it .was fine through the night . When she was asked if she was aware, prior to that night, that he had two abdominal tubes, she stated, .I knew the first night he was admitted .I had him that night .another nurse admitted him .was told in report .was also written in his chart in the nurse's notes . Review of the hospital records revealed the following: .Operative Report dated 11/1/17 at 8:35 PM- .FINDINGS: The patient had copious white fluid within the abdominal cavity .There was copious white fluid that was suctioned out. We then retrieved the peritoneal [MEDICAL TREATMENT] catheter from the abdominal cavity .After suctioning all the fluid possible, we then irrigated the abdominal cavity in all 4 quadrants in the [MEDICAL CONDITION] (area under the diaphragm) space and subhepatic (area under the liver) spaces as well as the pelvis with 7 liters of warm saline. At the end of the irrigation, the effluent (outflowing fluid) was clear .He did have some changes of [MEDICAL CONDITION] (low blood pressure) during the operation. He was taken to the intensive care unit in guarded condition (a prognosis given by the physician when the outcome of a patient's illness is in doubt) . c) Progress Note dated 11/6/17 - .Back on vent (ventilator) for stridor (high pitched breath sound) . The failure of the facility to ensure nursing staff provided professional care according to resident's care plan, facility policy, Physician order [REDACTED].#1 when the nursing staff connected a PEG tube feeding of Nepro Carb Steady and administered the feeding through his peritoneal [MEDICAL TREATMENT] catheter for approximately 9 hours. Resident #1 was sent to the hospital, had emergent surgery and remained in the hospital on mechanical ventilation at the conclusion of this survey. 3. Medical record review for Resident #2, documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. A Physician order [REDACTED].Give Glucerna 1.2 1 (one) can ppt (per PEG Tube) tid (three times a day) . Physician's recertification orders signed 11/3/17, documented .H2O MED FLUSH 60 cc BEFORE & AFTER EACH MED PASS . Observations in Resident #2's room on 11/13/17 at 10:50 AM, revealed LPN #5 checked the tubing for the proper label as his PEG tube, checked placement per auscultation and aspiration, and then administered the bolus Glucerna 1.2. LPN #5 did not flush the PEG tube prior to administering the bolus. He stated, .I skipped a step .I'm just going to be honest .supposed to flush with 30 ccs before and after . LPN #5 flushed with 60 cc after administering the bolus of Glucerna 1.2. LPN #5 confirmed he failed to follow Physician order [REDACTED].",2020-09-01
685,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2017-11-15,322,G,1,0,JVWH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility incident report review, hospital record review, observation and interview, it was determined the facility failed to ensure staff provided appropriate care and services for the Percutaneous Endoscopic Gastrostomy (PEG) Tubes for 2 of 3 (Residents #1 and #2) sampled residents reviewed with PEG tubes. The failure to ensure that PEG tube feedings were administered through the PEG tube resulted in actual harm to Resident #1 who had Nepro Carb Steady (carbohydrate nutritional product for residents with kidney disease) administered through his peritoneal [MEDICAL TREATMENT] catheter. The findings included: 1. The facility's Enteral Tube Feeding Continuous Pump policy, documented .The purpose of this procedure is to provide nourishment to the resident who is unable to obtain nourishment orally .Preparation .3. Ensure that the equipment and devices are working properly .General Guidelines .3 .Check the following information: .e. Access site (PEG insertion site) .Steps in the Procedure .Verify placement of tube: .7. Auscultate: (listening for internal sounds with a stethescope) a. Do not rely on this as the singular method to differentiate between respiratory, gastric, [MEDICAL CONDITION] and bowel placement. b. Attach 60 mL (milliliters) syringe containing approximately 10 mL air. c. Auscultate the abdomen (approximately 3 inches below the sternum) while injecting the air from the syringe into the tubing .8. When correct tube placement has been verified, flush tubing with at least 30 mL warm water (or prescribed amount) .Check gastric residual (stomach contents amount) volume (GRV): 1. Aspirate stomach contents .Reporting .1. Report complications .2. Report negative consequences of tube use .4. Report other information in accordance with facility policy and professional standards of practice . 2. Medical record review for Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Physicians Orders received by Registered Nurse (RN) #1 on 10/31/17 and signed by the physician on 11/3/17, documented .TUBE FEEDING FORMULA Nepro Carb Steady RATE 45 mL/hr (milliliters per hour) .H2O (water) FLUSH 60 cc (cubic centimeters) 1 (one) HOURS .ENSURE PEG DISK ROTATES EVERY SHIFT .CHECK PEG TUBE PLACEMENT FOR AUSCULTATION .CHECK RESIDUAL . Review of the Initial Care Plan dated 10/27/17 revealed .FEEDING TUBES .Observe peg tube/[DEVICE] (gastrostomy tube) site for S/S (signs and symptoms) of infection/irritation .Peg care every shift & prn (as needed) .*check Peg tube placement By auscultation .* Check residual .Renal/[MEDICAL TREATMENT] .[MEDICAL TREATMENT] as ordered .Shunt care .*Peritoneal catheter (Not in use) (Lower Lt (left) Q (quadrant)) .*[MEDICAL TREATMENT] 3 x (times) wk (week) . Review of the Admission Evaluation and Interim Care Plan Skin Condition Body Diagram dated 10/27/17 revealed .PEG site .Peritoneal Catheter (plastic flexible tube inserted into the abdomen to allow [MEDICAL TREATMENT] fluid to enter abdominal cavity, dwell inside for a while and then drain back out again) .LA (left arm) AV fistula. Review of the initial Admission/Readmission Nurses Notes dated 10/27/17 at 8:20 PM revealed .Resident is currently non verbal @ (at) this time but is alert & awake .Abd. (abdomen) soft nontender/nondistended c (with) bowel sounds in all 4 quads (quadrants) Noted peritoneal [MEDICAL TREATMENT] cath. (catheter) to LL (left lower) quad of Abd. Has a PEG which is patent & intact. Receives [MEDICAL TREATMENT] x (times) 3 days wkly (weekly). AV fistula to Lt. (left) upper arm c no problems. Has palpable thrill and audible bruit (an indication of a well functioning [MEDICAL TREATMENT] fistula) .Requires total care with all ADLs (activities of daily living) . Review of a facility incident report revealed .(Resident #1) is alert but he is nonverbal. Resident was admitted to facility on 10/27/17 at 8:20 pm for skilled services under the care of (named Medical Director) .Resident admitted with a peg tube located in his left upper abd. quadrant and a peritoneal catheter in lower left abdominal catheter (quadrant). On the evening of 10/31/2017 (named RN #1) entered resident's room. (RN #1) was unaware that resident had a peritoneal catheter. (RN #1) connected the peg tube feeding to the peritoneal catheter. (RN #1) started the tube feeding at 8:45 pm. The error was discovered by the 11-7 (11:00 pm-7:00 am) nurse (LPN #1) at 5:45 am. (LPN #1) stopped the feeding immediately .called (RN #1) and she immediately came to the facility and notified The DON (Director of Nursing). I the DON notified (Medical Director) and orders were given to transfer resident to the hospital .(RN #1) called the family and spoke with the responsible party .resident was transported via 911 ambulance . Interview with the Administrator on 11/12/17 at 6:50 PM in the conference room, the Administrator was asked about Resident #1. She stated, .he was on a continuous feed (PEG tube infusion) until he went out to [MEDICAL TREATMENT] .then it was stopped .his peritoneal tube was not in use .he had a shunt for [MEDICAL TREATMENT] (indicated her left arm) .went to (named hospital) on the 1st (11/1/17) .was in ICU (Intensive Care Unit) for 3 days, then on the 4th day he went back on the vent (ventilator) . Interview with the DON on 11/12/17 at 6:50 PM in the conference room, the DON stated RN #1 .was not aware he had 2 tubes .she checked placement .checked residual .tubing had a flap on it, said she (RN #1) wondered why they did that .took the flap off and put an adapter on it . When the DON was asked if nurses undergo a skills check-off (nursing competency skills validation) prior to working at the facility, the DON stated that they do a skills check-off upon hire and annually. A written statement signed by RN #1 documented, .On the night of Oct (October) 31st at 845/pm I prepared to hang Nepro on (Resident #1). I checked his residual. The residual was zero. I did not know he had a peritoneal cath (catheter) & a peg tube. Resident was comfortable c no s/s (signs & symptoms) of distress. I did not provide any other services. Around 630/am I received a call from (named LPN #1) 11-7 (11:00 pm-7:00am) charge nurse. She informed me Resident (#1) had another tube higher up. I Jumped in my truck immediately & (and) came to the facility. B/P (blood pressure)153/94 (pulse)- 117 (pulse documented in medical record 119) (respirations), - 20 temp (temperature) 100.2 (degrees Fahrenheit). I called the Director (DON). Director informed me she was calling (named Medical Director). DON returned call back to facility & instructed to send out 911. 911 came to the facility immediately. Family notified. Report called to (named hospital) & spoke to a female nurse in the ER (emergency room ). Gave vital signs to nurse and informed her we were sending out due to Resident receiving tube feedings through his peritoneal cath - Informed nurse this is exactly why we are sending the Resident out. Family notified. Resident was being sent to hospital & reason for sending out. On exit Resident was easily aroused c (with) no s/s (signs and symptoms) of distress . Telephone interview with RN #1 on 11/15/17 at 11:34 AM, RN #1 was asked about the incident with Resident #1 on 10/31/17. She confirmed her written statement, and stated .I went in to prepare to give him (Resident #1) his feeding .I aspirated and hooked up his feeding and that's all . When she was asked if there were any problems with his feeding, she stated, .no .a cap was on it and I had to go get a connection for it .I took the cap off and put a connection on it . She was asked if she was aware that Resident #1 had a peritoneal catheter, and she stated No. She further stated that she had taken care of him one other time in the past. A written statement signed by Licensed Practical Nurse (LPN) #1, dated 11/1/17, documented .During shift change off going nurse (RN #1) stated she couldn't find the end of the peg tube and she had replaced it. On going nurse (LPN #1) went to the resident (Resident #1) room to observe the new pegtube. Nepro was running through the line. At 5:45 am nurse (LPN #1) return to resident (Resident #1) room to give 6AM meds. CNA (Certified Nursing Assistant #1) was already inside resident room and ask for assistance in repositioning and turning; during this time CNA (CNA #1) changed resident gown and this is when nurse (LPN #1) notice that the resident was not receiving tube feeding in the right tubing. Resident (Resident #1) was receiving feeding through his peritoneal catheter. Nurse (LPN #1) immediately disconnect the feeding and informed RN supervisor (RN #2). The charge nurse (LPN #1) and RN supervisor (RN #2) assessed the resident. The unit manager (RN #1) which was the nurse who intact (attached) the feeding was notified and she return to the facility @ 6:15am. Unit Manager (RN #1) called the DON who contact the doctor. Charge nurse (LPN #1) was getting vitals signs which was as following B/P (blood pressure) 159/94, Pulse 119 Respiration 20, Blood Glucose 159. Unit Manager (RN #1) receive orders @ (at) 6:30 am to send resident (Resident #1) to the ER (emergency room ) for further evaluation. Nurse (LPN #1) and CNA (CNA #1) stayed with resident until paramedic arrived to transport . Telephone interview with LPN #1 on 11/15/17 at 9:50 AM, LPN #1 confirmed her written statement. She stated, .I can't remember his (Resident #1) name .only had him one time .I remember the Unit Manager (RN #1) was on duty that night .she was on a cart .in report she (RN #1) said, '(named LPN #1) .I had to alter his (Resident #1) feeding tube because someone took the end off .I (RN #1) spent two hours trying to get that end on' .I (LPN #1) went down there (Resident #1's room) and checked to see what she (RN #1) was talking about and everything was running okay .end looked like a PEG tube .I thought she (RN #1) said the end was off .didn't check the site .he (Resident #1) don't get no midnight meds (medications), he (Resident #1) got 6:00 meds .I went down there with the aide and I told her to change his sheets and get him ready while I was giving him his meds (medications) .as soon as she turned him over and uncovered him, I saw he was hooked up to the wrong tube .peritoneal catheter .I unhooked it immediately .went and got the night supervisor (RN #2) .she (RN #2) came down there and checked him (Resident #1) .we knew it was a peritoneal catheter, but we checked the chart just to make sure .called the Unit Manager (RN #1) .she (RN #1) said call the doctor and get a KUB (kidney, ureter, and bladder study is an X-ray study) .we called (named Medical Director and Resident #1's provider), but he said don't get a KUB send him to the ER (emergency room ) .called the family and let them know what happened .I (LPN #1) stayed with him until he left . She was then asked if she had checked on him during the night, and she stated .yes .even at the time his stomach wasn't distended .didn't grimace or anything when I pressed on it .was fine through the night . When she was asked if she was aware, prior to that night, that he had two abdominal tubes, she stated, .I knew the first night he was admitted .I had him that night .another nurse admitted him .was told in report .was also written in his chart in the nurse's notes . Review of the hospital records revealed the following: a) Computerized [NAME]ography (CT) Scan dated 11/1/17 at 2:50 PM - .Numerous nondistended fluid-filled loops of small bowel are noted with associated bowel wall thickening and adjacent fluids .A PEG tube is noted with balloon in the stomach. Fluid is present diffusely throughout the colon with associated air-filled levels .There is a 5.8 x 4.3 cm (centimeter) irregular gas fluid collection superior to the bladder. This is concerning for abscess .A small amount of free fluid is seen within the pelvis .IMPRESSION: .2. Small amount of free intraperitoneal air. Etiology uncertain, however this is concerning for bowel perforation .4. [MEDICATION NAME] (within a tube or tubular organ) fluid throughout nondistended small bowel with associated bowel wall thickening and adjacent free fluid. [MEDICATION NAME] fluid with air- fluid levels throughout a nondistended colon. These findings are concerning for [MEDICATION NAME]. Consider infectious, [MEDICAL CONDITION] ischemic (insufficient blood flow) etiologies. 5. Small amount of free fluid in the abdomen and pelvis . b) Operative Report dated 11/1/17 at 8:35 PM- .FINDINGS: The patient had copious white fluid within the abdominal cavity .There was copious white fluid that was suctioned out. We then retrieved the peritoneal [MEDICAL TREATMENT] catheter from the abdominal cavity .After suctioning all the fluid possible, we then irrigated the abdominal cavity in all 4 quadrants in the [MEDICAL CONDITION] (area under the diaphragm) space and subhepatic (area under the liver) spaces as well as the pelvis with 7 liters of warm saline. At the end of the irrigation, the effluent (outflowing fluid) was clear .He did have some changes of [MEDICAL CONDITION] (low blood pressure) during the operation. He was taken to the intensive care unit in guarded condition . c) Progress Note dated 11/6/17 - .Back on vent (ventilator) for stridor (high pitched breath sound) . The failure of the facility to ensure that PEG tube feedings were administered appropriately through the PEG tube to Resident #1 who had Nepro Carb Steady administered through his peritoneal [MEDICAL TREATMENT] catheter for approximately 9 hours resulted in actual harm. He was sent to the hospital, had emergent surgery and remained in the hospital at the conclusion of this survey. 3. Medical record review for Resident #2, documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. A Physician order [REDACTED].Give Glucerna 1.2 1 (one) can ppt (per PEG Tube) tid (three times a day) . Physician's recertification orders signed 11/3/17, documented .H2O MED FLUSH 60 cc BEFORE & AFTER EACH MED PASS . Observations in Resident #2's room on 11/13/17 at 10:50 AM, revealed LPN #5 checked the tubing for the proper label as his PEG tube, checked placement per auscultation and aspiration, and then administered the bolus of Glucerna 1.2. LPN #5 did not flush the PEG tube prior to administering the bolus. He stated, .I skipped a step .I'm just going to be honest .supposed to flush with 30 ccs before and after . LPN #5 flushed with 60 cc after administering the bolus of Glucerna 1.2. LPN #5 confirmed he failed to follow Physician order [REDACTED].",2020-09-01
686,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2017-11-15,520,G,1,0,JVWH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview, the facility's Quality Assessment and Assurance Committee (QAA) failed to have an effective ongoing quality program that identified, developed, implemented, and monitored appropriate plans of action to correct issues. The failure to ensure staff provided appropriate care and services for the Percutaneous Endoscopic Gastrostomy (PEG) Tube resulted in actual harm to Resident #1 when staff failed to ensure that PEG tube feedings were appropriately administered through the PEG tube to Resident #1 who had Nepro Carb Steady (carbohydrate nutritional product for residents with kidney disease) administered through his peritoneal [MEDICAL TREATMENT] catheter. The findings included: 1. The QAA Committee failed to ensure that care and services were provided appropriately to a resident with a PEG tube. The failure to provide appropriate care and services of a PEG tube feeding to a resident resulted in actual harm when Resident #1 received a feeding of Nepro Carb Steady through his peritoneal [MEDICAL TREATMENT] catheter for 9 hours. Resident #1 was sent to the hospital and had emergent surgery. Refer to F322. The deficient practice of F322 is a repeat deficient practice for failure to provide appropriate care and services to a resident with a PEG tube feeding. The facility was cited F322 on the recertification survey on 12/4/16. Interview with the Director of Nursing (DON) on 11/12/17 at 6:50 PM, in the conference room, the DON stated, Registered Nurse #1 was not aware he had 2 tubes .she checked placement .checked residual .tubing had a flap on it, said she (RN#1) wondered why they did that .took the flap off and put an adapter on it .",2020-09-01
687,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2018-12-06,550,D,0,1,G6WX11,"Based on policy review, observation, and interview, the facility failed to maintain or enhance resident dignity and respect when an indwelling urinary catheter bag was not in a dignity bag for 1 of 6 (Resident #111) sampled residents reviewed with an indwelling urinary catheter. The findings include: The facility's Quality of Life - Dignity policy with a revision date of October, 2009 documented, .Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality .2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth . Observations in Resident #111's room on 12/3/18 at 11:12 AM, 3:54 PM, and on 12/4/18 at 3:13 PM revealed Resident #111 seated in a wheelchair. He had an indwelling urinary catheter and the catheter drainage bag was not in a dignity bag. The urine in the bag could be seen from the hallway when walking by the room. Observations in the 2nd Floor Dining room on 12/3/18 at 12:10 PM revealed Resident #111 seated in a wheelchair. He had an indwelling urinary catheter and the catheter drainage bag was not in a dignity bag. Interview with the Director of Nursing (DON) on 12/5/18 at 11:45 AM in the Conference Room, the DON was asked if an indwelling urinary catheter drainage bag should be in a dignity bag. The DON stated, Yes.",2020-09-01
688,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2018-12-06,641,D,0,1,G6WX11,"**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 nutrition and hospice for 3 of 32 (Resident #36, 96, and 136) sampled residents reviewed. The findings include: 1. Medical record review revealed Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed the following weights: 3/9/18 - 195 pounds (lbs) 4/11/18 - 196.2 lbs 5/10/18 - 196.8 lbs 6/15/18 - 197 lbs 7/12/18 - 195.2 lbs 8/10/18 - 217.4 lbs 9/5/18 - 223 lbs The weight gain of 28 lbs in 6 months resulted in a 14.36 percent (%) significant weight gain. Medical record review did not reveal a physician prescribed weight gain program. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed yes to significant weight gain and the resident was on a physician-prescribed weight gain regimen. Interview with Dietary Technician #1 on 12/6/18 at 11:09 AM in the Administrative Offices, Dietary Technician #1 was asked about the assessment the resident had a significant weight gain and was on a weight gain program. Dietary Technician #1 confirmed this MDS was inaccurate and stated, Oh, I checked the wrong thing. 2. Medical record review revealed Resident #96 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The quarterly MDS assessment dated [DATE] was not coded for hospice. Interview with MDS Coordinator #1 on 11/6/18 at 12:45 pm in the MDS office, MDS coordinator #1 was asked if the MDS dated [DATE] was coded correctly for hospice. MDS coordinator #1 stated, No ma'am. 3. Medical record review revealed Resident #136 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed the following weights: 4/11/18 - 168.6 lbs 5/10/18 -168 lbs 6/15/18 - 165 lbs 7/12/18 - 160 lbs 8/10/18 - 139.6 lbs 8/29/18 - 138 lbs 9/5/18 - 134 lbs 9/12/18 - 134.4 lbs 9/19/18 - 138.5 lbs 9/25/18 - 138.4 lbs 10/10/18 - 137.6 lbs 11/9/18 - 135 lbs 11/28/18 - 131 lbs The weight loss of 20.4 lbs from 7/12/18 to 8/10/18 resulted in a significant weight loss of 12.75 % in one month. Medical record review did not document a physician prescribed weight loss program. The quarterly MDS assessment dated [DATE] revealed a significant weight loss in the last month or 6 months and the resident was on a physician prescribed weight loss program. The weight loss of 31 lbs from 4/11/18 to 10/10/18 resulted in a significant weight loss of 18.39 % in 6 months. The significant change MDS assessment dated [DATE] revealed no significant weight loss in the last month or 6 months. Interview with Dietary Technician #1 on 12/5/18 at 4:19 PM in the Conference Room, Dietary Technician #1 was asked about the MDS assessment dated [DATE] which revealed significant weight loss and a physician prescribed weight loss program. Dietary Technician #1 confirmed this was inaccurate and stated, I hit the wrong button. Dietary Technician #1 was asked about the 11/7/18 MDS with no significant weight loss checked. She confirmed this was inaccurate, and stated I don't think I went back 6 months.",2020-09-01
689,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2018-12-06,690,D,0,1,G6WX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure services were provided as ordered for the care of an indwelling urinary catheter for 2 of 6 (Resident #3 and 42) sampled residents reviewed for indwelling urinary catheters. The findings include: 1. Medical record review revealed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].FOLEY CATH (catheter) CARE Q (every) SHIFT/PRN (as needed) . Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. 2. Medical record review revealed Resident #42 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].FOELY (Foley) CATH CARE QSHIFT/PRN . Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Interview with the Director of Nursing (DON) on 12/5/18 at 4:45 PM in the Conference Room, the DON was asked if it was acceptable to not follow physician's orders [REDACTED]. The DON stated, No its not.",2020-09-01
690,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2018-12-06,761,D,0,1,G6WX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure medications were securely and properly stored when 1 of 5 (Licensed Practical Nurse (LPN) #1) nurses left a medication cart unlocked and insulin was not dated when opened in 1 of 6 (100 Hall Cart 2 medication cart) medication storage areas. The findings include: 1. The facility's Storage of Medications policy with a revision date of April, (YEAR) documented, .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use . Observations in the 200 hall in front of the Nurses' Station beginning on 12/4/18 at 11:32 AM revealed LPN #1 prepared supplies to perform an accucheck, walked down the hall to Resident #125's room to perform the accucheck, and left the unlocked medication cart unattended and out of sight. At 11:40 AM LPN #1 returned to the cart and prepared insulin for Resident #125. LPN #1 walked down the hall to administer the insulin to the resident and left the unlocked medication cart unattended and out of sight. Interview with Registered Nurse (RN) #1 on 12/4/18 at 11:58 AM, RN #1 was asked if she had locked this medication cart. She confirmed the medication had been unlocked and stated, Yes Ma'am, I did. Interview with the Director of Nursing (DON) on 12/5/18 at 11:45 AM in the Conference room, the DON was asked if the medication cart should be left unlocked. The DON stated, Oh my God .No. 2. The facility's Insulin Administration policy revised (MONTH) 2010 documented, If opening a new vial, record expiration date and the date you open the vial .pen . Observations at the 100 Hall Cart 2 medication cart on 12/6/18 at 12:15 PM, revealed 1 vial of Regular [MEDICATION NAME]with no open date, 1 [MEDICATION NAME]pen with no open date, and 2 [MEDICATION NAME] pens with no open date. The multi dose insulins had been opened and in use. Interview with RN #2 on 12/6/18 at 12:15 PM, at the 100 Hall Cart 2 medication cart, RN #2 confirmed the insulin should have been dated when opened. Interview with the DON on 12/6/18 at 2:15 PM, in the Conference room, the DON was asked should insulin be dated when opened. The DON stated, Yes it should.",2020-09-01
691,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2018-12-06,880,E,0,1,G6WX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 6 of 8 (Licensed Practical Nurse (LPN) #1, 2, 3, and 4, Certified Nursing Assistant (CNA) #1, and Respiratory Therapist (RT) #1) staff members failed to perform appropriate infection control practices during medication administration, catheter care, wound care, and [MEDICAL CONDITION] care observations and when an indwelling urinary catheter bag was on the floor for 1 of 6 (Resident #111) sampled residents reviewed with an indwelling urinary catheter. The findings include: 1. The facility's Insulin Administration policy with a revision date of October, 2010 documented, .Steps in the Procedure (Insulin Injections via Syringe) .3. Dispose of glucose strip in the designated container . The facility's Handwashing/Hand Hygiene policy dated April, 2012 documented, .Employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and under water under the following conditions .After removing gloves . The facility's Administering Topical Medications policy with a revision date of October, 2010 documented, .Trans-dermal patches .b. Clean and dry a selected area that is approved for application of the patch . Observations in the 200 hall in front of the Nurses' station on 12/4/18 beginning at 11:32 AM, revealed LPN #1 entered Resident #125's room and performed an accucheck. LPN #1 returned to the medication cart and disposed of the glucometer strip contaminated with blood in the regular trash on the side of the medication cart. Observations at the 1st Floor Nurses' station medication cart on 12/5/18 beginning at 9:44 AM revealed LPN #3 prepared medications. LPN #3 entered Resident #129's room, washed her hands, and applied gloves. LPN #3 administered medications and an inhaler to the resident, removed her gloves, and did not perform hand hygiene. LPN #3 returned to the medication cart and prepared medications for Resident #127. LPN #3 wheeled the resident to his room and administered medications to the resident without performing hand hygiene. Observations in front of Resident #14's room on 12/5/18 beginning at 10:23 AM revealed LPN #4 prepared medications for Resident #14. LPN #4 entered Resident #14's room and applied a topical medication patch to the resident's right upper shoulder without cleansing the skin. Interview with the Director of Nursing (DON) on 12/5/18 at 11:45 AM in the Conference room, the DON was asked how a glucometer strip contaminated with blood should be disposed. The DON stated, In the biohazard. The DON was asked what should be done before and after removing gloves or between glove use. The DON stated, Wash hands. The DON was asked what should be done to the skin prior to applying a medication patch to the skin. The DON stated, Clean the skin. 2. The facility's Catheter Care, Urinary policy dated October, 2010 documented, .Place soiled linen into the designated container . Observations in Resident #42's room on 12/5/18 at 9:19 AM revealed CNA #1 was providing catheter care to Resident #42. CNA #1 placed soiled wash cloths on Resident #42's over bed table, completed catheter care, then placed the soiled wash cloths in a plastic bag. CNA #1 positioned the over bed table across Resident #42 and then placed the residents water pitcher on the over bed table. CNA #1 failed to clean the over bed table before placing personal items on the table. Interview with the DON on 12/6/18 at 12:36 PM in the Conference room, the DON was asked if soiled wash cloths should be placed on the residents over bed table during catheter care and fail to clean the table after use. The DON stated, No. 3. The facility's Handwashing/Hand Hygiene policy dated April, 2012 documented, .Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel . Observations in Resident #53's room on 12/5/18 at 9:47 AM revealed LPN #2 preparing to perform wound care on Resident #53. LPN #2 prepared the wound care supplies, washed her hands, touched the paper towel dispenser to obtain a paper towel, dried her hands, and turned the water off with the same paper towel. LPN #2 donned gloves, removed a dressing from Resident #53's right heel, and cleaned the wound. LPN #2 removed her gloves, washed her hands, touched the paper towel dispenser to obtain paper towels, turned the water off with the paper towels, and dried her hands with the same paper towels. LPN #2 then donned gloves and continued performing wound care on Resident #53. Interview with the DON on 9/6/18 at 12:56 PM in the Conference room, the DON was asked when washing hands should staff turn the faucet off with the paper towel and then dry their hands with the same paper towel. The DON stated, No . 4. The facility's Handwashing/Hand Hygiene policy dated April, 2012 documented, .Employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and under water under the following conditions .After contact with a resident's mucous membranes and body fluids or excretions . The facility's Suctioning the Lower Airway (Endotracheal (ET) of [MEDICAL CONDITION]) policy dated (MONTH) 2010 documented, .Use sterile equipment to avoid widespread [MEDICAL CONDITION] and systemic infection .Apply sterile gloves. The dominant hand will remain sterile . Observations in Resident #79's room on 12/6/18 at 9:43 AM revealed RT #1 preparing to suction Resident #79. RT #1 placed the supplies on the night stand, opened a sterile suction kit, donned a sterile glove on her right hand, and then suctioned Resident #79 placing the thumb of her bare left hand over the suction catheter value during the procedure. Interview with the DON on 12/6/18 at 11:30 AM in the Conference room, the DON was asked if it was acceptable to use a bare hand to cover the suction catheter value during suctioning. The DON stated, No it's not. The facility's [MEDICAL CONDITION] Care revised (MONTH) 2014, policy documented, .Remove old dressing .Pull soiled glove over dressing and discard into appropriate receptacle .Wash hands .open [MEDICAL CONDITION] cleaning kit .set up supplies on sterile field .open four gauze pads and saturate with hydrogen peroxide .put on sterile gloves .unlock the inner cannula with gloved dominate hand .Gently remove the inner cannula .remove and discard gloves .Wash hands and put on fresh gloves .replace the cannula . Observations in Resident #79's room on 12/6/18 at 9:56 AM, RT #1 placed a sterile [MEDICAL CONDITION] tray on the night stand, opened the [MEDICAL CONDITION] tray, removed the gauze and [MEDICAL CONDITION] ties from the sterile tray with bare hands, poured hydrogen peroxide into the sterile tray, donned sterile gloves, picked up the contaminated gauze, saturated the gauze in hydrogen peroxide, cleaned around the [MEDICAL CONDITION] cannula, placing her hands on the old dressing and contaminating the sterile gloves. RT #1 then picked up 2 packs of 4x4 gauze from the over bed table, opened the packs, placed the gauze into hydrogen peroxide, continued to clean the [MEDICAL CONDITION], and removed the inner cannula. 6. The facility's .Emptying a Urinary Drainage Bag policy with a revision date of October, 2010 documented, .General Guidelines .9. Keep the drainage bag and tubing off the floor at all times to prevent contamination and damage . Observations in Resident #111's room on 12/3/18 at 11:12 AM and 3:54 PM revealed Resident #111 seated in a wheelchair. He had an indwelling urinary catheter with cloudy dark urine and the bag was touching the floor. Observations in the 2nd Floor Dining room on 12/3/18 at 12:10 PM revealed Resident #111 seated in a wheelchair. He had an indwelling urinary catheter with cloudy dark urine and the bag was touching the floor. Interview with the DON on 12/05/18 11:45 AM in the Conference room, the DON was asked if a urinary catheter bag should be touching the floor. The DON stated, No.",2020-09-01
692,THE HEALTH CENTER AT RICHLAND PLACE,445166,504 ELMINGTON AVENUE,NASHVILLE,TN,37205,2018-03-01,656,D,1,0,4S6V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to develop a Comprehensive Care Plan to address the resident's issues with oral care for 1 resident (#2) of 5 residents reviewed. Findings include: Review of facility policy, Oral Hygiene, undated, revealed .Designated partners will provide care of mouth and teeth to all patients every morning and evening as needed to prevent mouth infections; prevent dental decay; prevent gum disease; and promote personal hygiene .Gently clean patient's teeth .Inspect oral cavity . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 5 Day Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 Brief Interview for Mental Status (BIMS) scored as 3 and severely impaired cognitively. Continued review of the MDS revealed Resident #3 was dependent on 2 people for transfers; required extensive assistance of 1 person for dressing, eating; extensive assistance of 2 people for grooming; was dependent on 1 person for bathing; had functional limitations in both lower extremities; was frequently incontinent of bladder and always incontinent of bowel. Medical record review of the Activities of Daily Living (ADL) record revealed documentation Resident #3 received personal hygiene twice daily. Continued review revealed out of 40 opportunities for oral care, it was documented he received care on 24 occasions. Medical record review of a Speech Therapy evaluation dated 11/24/17 revealed Resident #3 had his natural teeth. Continued review revealed he had decreased bolus control (problems swallowing solid food). Further assessment revealed medication from earlier administration was noted in the oral cavity. Medical record review of weights revealed Resident #3 weighed 126 pounds on admission to the facility. Continued review revealed weight on 11/22/17 was 125 pounds; on 11/23/17 weight was 125 pounds. Further review revealed on 11/29/17 weight was 122 pounds and on 12/6/17 weight was 120 pounds. Continued review revealed Resident #3 refused to be weighed on 12/13/17. Medical record review of a Nutrition consult dated 12/4/17 revealed Resident #3 had poor intake, consuming Medical record review of the Care Plan dated 11/22/17 revealed Resident #3 was at risk for alteration in nutritional status/weight loss related to swallowing difficulty; age; polypharmacy; and [MEDICAL CONDITION]. Continued review revealed interventions included to adjust diet consistency as needed; mechanical soft with ground meat with gravy and high calorie diet; nutritional supplements of Ensure Clear 3 times daily with meals and House Supplement twice daily; encourage fluids between meals; adaptive equipment as needed; assist with meals; dietician assessment in progress. Medical record review revealed no documentation of any issues with oral care until 12/11/17 when nursing documented .Attempted to provide oral care on resident. Was able to get swab in mouth after coaching. As soon as swab placed in mouth pt. bit down and would not allow nurse to clean mouth. With help of therapist finally got resident to release bite on swab so it could be removed. Oral care not completed because resident refused . Medical record review of the care plan revealed no documentation of issues with oral care such as pocketing food and biting down on swabs. Medical record review of the Provider Progress Note dated 12/12/17 revealed .One of the daughters is very upset because she feels oral care has not been adequate. However, nursing staff have been very diligent to provide oral care and patient will frequently not except oral care by clenching teeth and biting sponges. Speech Therapy has really worked with patient on this and will be teaching family how to perform oral care as well so patient may respond to a more familiar person. Registered dietitian reports he is still only receiving around 20 bites of food an hour. Patient frequently pockets food in this puts him at great risk for aspiration pneumonia. Labs showed he was maintaining renal function okay, no dehydration notes. Failure to thrive - patient's prognosis is poor and not likely to make meaningful recovery . Medical record review of a Provider Progress Note dated 12/19/17 revealed .Diligent oral care has been attempted but patient will frequently clench and bite sponges which make cleaning difficult for nursing staff. Patient also pockets food in this puts him at great risk for aspiration pneumonia. Unfortunately he is experiencing failure to thrive. Patient's daughter is not accepting of this diagnosis . Interview with the Director of Nursing (DON) on 2/14/18 at 11:55 AM in the conference room revealed staff had tried to perform oral care for Resident #2 but he clamped down on the swab or anything placed in his mouth. Continued interview with the DON confirmed the care plan did not include the fact Resident #2 pocketed his food and also he clamped down on the swab. Further interview confirmed there were no interventions for addressing these issues.",2020-09-01
693,THE HEALTH CENTER AT RICHLAND PLACE,445166,504 ELMINGTON AVENUE,NASHVILLE,TN,37205,2018-03-01,689,D,1,0,4S6V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to ensure residents had adequate supervision to prevent falls for 1 resident (#1) of 3 residents reviewed for falls. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 14 Day Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was scored 99 on BIMS ( Brief Interview for Mental score ) of 99 indicating severely impaired cognitively. Continued review of the MDS revealed Resident #1 required extensive assistance of 1 person for transfers, ambulation, dressing, eating, grooming, and bathing; was occasionally incontinent of bowel and bladder; and had functional limitation of 1 upper extremity. Medical record review of the Hospital Discharge summary dated [DATE] revealed Resident #1 was admitted with a [MEDICAL CONDITION], left humerus and ulna fractures. Continued review revealed the injury was non-operative and would be conservatively managed. Further review revealed Resident #1 had a small right convexity subdural hematoma (collection of blood in the brain on the top right side of the head) and a large left superior convexity subdural hematoma. Medical record review of the care plan dated [DATE] revealed a problem of being at risk for complications related to behavior - refuses care, combative, agitated, disorganized thoughts. Continued review of the care plan revealed Resident #1 had a problem of being at risk for orthopedic complications related to fall with fracture, refusal to wear C-collar (cervical collar), non-compliant with weight-bearing status from the humerus and ulna fracture. Further review revealed interventions included assess for signs/symptoms of infection at surgical site; notify physician of signs/symptoms of complications; Occupational Therapy screen; observe for signs/symptoms of [MEDICAL CONDITION]. Medical record review of a Provider Progress Note dated [DATE] revealed .Patient has been very lethargic and vomited x2 today. Patient's medications have been titrated due to agitation from dementia. Patient had recent titration up on [MEDICATION NAME] to 2 times daily. She also had [MEDICATION NAME] 2 times daily. [MEDICATION NAME] as needed. Nausea with vomiting - new problem. Patient did not have any recent falls. Will go ahead and initiate neuro checks as she does have history of recent new subdural hematoma. Medical record review of a Post Fall Initial Note dated [DATE] revealed on [DATE] at 5:15 PM Resident #1 was found lying on the floor in fetal position in the activities room. Continued review revealed she had been walking in the room unassisted. Further review of the note revealed the following questions: 1. Did the patient have pain after the fall? Yes 2. Description of injury: Right fracture femur 3. First aid treatment administered: X-ray sent to ER (emergency room ) for evaluation 4. Right hip range of motion: Unable to perform Review of facility investigation revealed a written statement from Certified Nurse Aide (CNA) #5 dated [DATE] at 5:30 PM, which stated .I was doing rounds and observed patient on the floor. I called for a nurse. The nurse checked her and I ran vitals, and safely assisted resident to wheelchair . Review of facility investigation revealed a statement from Registered Nurse (RN) #1 dated [DATE] which stated .Patient did not appear uncomfortable on [DATE] or [DATE]. When the tech went to get patient OOB (out of bed) patient called out in discomfort. Patient was left in bed and nurse practitioner notified on morning of [DATE] . Review of facility investigation revealed a statement from CNA #1, dated [DATE] which stated .While providing daily care during AM shift (6A - 2P) on 24th and 25th I noted no increased pain in (named resident) when getting her cleaned and up to the chair. On morning of ,[DATE] I went to get her up and saw her frown like she may be in pain so I left her in bed and went to tell nurses who came to check on patient when I told them . Review of facility investigation revealed a statement from Licensed Practical Nurse (LPN) #2 dated [DATE] which stated .At time of fall patient was assessed, no c/o (complaint of ) pain, and no apparent injuries notes. Scheduled Tylenol given as ordered as patient had been getting this prior to fall. Review of facility investigation revealed a statement from RN #3 dated ,[DATE] 18 who stated .I took care of the patient approximately 24 hours post fall on a Saturday evening shift. The patient was not in increased pain and did not otherwise show any signs of change of function during my shift. I decided to put the patient in bed and perform neurological checks per post-fall protocol. The patient was comfortable in bed and all vital signs were stable during the shift . Review of facility investigation of an undated statement from LPN #3, revealed .I worked Saturday 23rd. (named resident #1) was resting in bed most of that double shift. I did not notice any acute distress or discomfort that weekend . Medical record review of a Change in Condition report dated [DATE] revealed .Pt crying with complaints of pain upon getting up, or also lifting her left leg .she did fall on Fridat evening this past week . Medical record review of a Provider Progress Note dated [DATE] revealed .night shift nurse reports patient complains of pain to right LE (lower extremity), cries out with transfers and care, report fell on Friday. Pt very confused with dementia, unable to answer ROS (review of symptoms) question. She does however cry out and grimace in pain with passive ROM (range of motion) of right LE, at hip and knee. X-ray ordered. NWB (non weightbearing) until resulted. Highly suspect fracture d/t (due to) pt response to movement and her overall withdrawn mood today. Pt usually restless and trying to ambulate, mildly agitated and constantly busy; staff frequently engaged in distracting and occupying pt with conversation, folding linens, drawing, etc. Today she is very quiet and withdrawn, no attempts to get out of WC (wheelchair) observed . Medical record review of a Provider Progress Note dated [DATE] revealed .Patient seen for abnormal x-ray. Patient fell over the weekend Patient originally was not found to have any injury. However, she became progressively more in pain when trying x-ray of the hip was done and showed acute fracture. Patient sent to hospital for further evaluation by orthopedics . Review of facility investigation of a statement from Nurse Practitioner (NP) #1, revealed .I was called to see the patient (Resident #1) on [DATE] related to lethargy and vomiting. I ordered abdominal x-ray, blood work, and neuro checks because she did have a recent history of a SDH (subdural hematoma) I felt the most likely rationale for her symptoms was slight oversedation from [MEDICATION NAME] plus [MEDICATION NAME]/[MEDICATION NAME]. The abdominal film and blood work were within normal limits. She then had a fall on [DATE] and was not immediately found to have any injuries from nursing staff. On the night of the 25th/morning of the 26th nursing notes she was having pain and difficulty turning so this prompted an x-ray. This did reveal an assumed acute fracture on the right hip. Her family was notified and agreed to send to the ER for prompt evaluation by orthopedics . Review of facility investigation of an undated statement by NP #2, revealed .(Resident #1) had several falls prior to admission and her dementia was made worse by [MEDICAL CONDITION] related to a pretty severe non-operative cerebral hemorrhage which occurred prior to admission. During her stay she was continually confused and disoriented, frequently agitated and trying to rise from the wheelchair, bed, or chair without any awareness of personal safety and fall risk . On (MONTH) 26th I was notified at the beginning of my work day by the outgoing night shift nurse the patient was crying out in pain with transfers and personal care, especially when the right lower extremity was moved. On examination I found the patient sitting in a wheelchair but not her usual active, agitated self. She denied pain verbally but called out and grimaced with passive ROM exam of her lower extremities, more so on the right side. Because the patient was constitutionally changed with flat affect, withdrawn, refusing offer of drink, my suspicion of a possible [MEDICAL CONDITION] was heightened. The nurse reported she had fallen several days earlier but no visible injury or change in behavior or ROM was noted at the time of the fall. The pain in the right lower extremity seemed, from verbal reports by staff, to be a concern early that morning (26th). I ordered an x-ray of the right hip and knee. The results were give to my colleague who followed up with an exam of the patient and sent her out to the hospital for further evaluation and treatment . Review of facility investigation revealed Resident #1 was transferred from the hospital to Hospice where she expired on [DATE]. Review of the Death Certificate from the Medical Examiner revealed the cause of death was acute right femur fracture; the contributing cause was acute on chronic left subdural hematoma; and the death was accidental. Interview with the Director of Nursing (DON) on [DATE] at 11:55 AM in the conference room revealed Resident #1 had a fall on [DATE]; the nurse assessed her; and Resident #1 was determined to have no injury. Continued interview revealed Resident #1 was assisted to bed without problem. Further interview revealed on [DATE] the night nurse discovered Resident #1 was in increased pain which was reported to the NP and an x-ray was ordered. Continued interview revealed the DON talked to all staff who cared for Resident #1 from [DATE] - [DATE]. Further interview revealed Resident #1 complained of nausea and vomiting on [DATE] and the NP assessed her, concerned the subdural hematoma was extending. Continued interview revealed the NP ordered labs and neuro checks to assess any changes. Further interview revealed Resident #1 received Tylenol Arthritis three times daily and did not required any additional pain medication from [DATE] - [DATE]. Continued interview revealed Resident #1 had [MEDICAL CONDITION] and the NP questioned whether the resident sustained [REDACTED]. Further interview the DON confirmed Resident #1 was not supervised adequately to prevent a fall.",2020-09-01
694,THE HEALTH CENTER AT RICHLAND PLACE,445166,504 ELMINGTON AVENUE,NASHVILLE,TN,37205,2017-06-07,272,D,0,1,O29L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to comprehensively assess 1 resident (#153) of 26 residents reviewed in the stage 2 sample. The findings included: Medical record review revealed Resident #153 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed a physician's orders [REDACTED].condom catheter prn (as needed) for [MEDICAL CONDITION] per patient request; diagnosis-[MEDICAL CONDITION]. Further review revealed this order was discontinued on 3/3/17. Interview with Certified Nurse Aide #1 on 6/7/17 at 10:25 AM on the third floor near the resident's room revealed the resident did use a condom catheter and staff does provide care for the catheter as needed. Interview with the Minimum Data Set (MDS) Coordinator/Registered Nurse #1 on 6/7/17 at 5:00 PM in her office confirmed the MDS dated [DATE] did not reflect the resident's use of a condom catheter and should've been coded . for an external catheter. Interview with Resident #153 on 6/7/17 at 6:00 PM in the resident's room revealed the resident did use a condom catheter. The resident stated he applied the condom catheter himself as needed. Continued interview with Resident #153 revealed when needed the staff will empty the catheter bag and sometimes he will empty it.",2020-09-01
695,THE HEALTH CENTER AT RICHLAND PLACE,445166,504 ELMINGTON AVENUE,NASHVILLE,TN,37205,2017-06-07,280,D,0,1,O29L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to revise the comprehensive care plan to reflect a low bed and fall mat intervention for 1 Resident (#216) of 26 residents reviewed in the stage 2 sample. The findings included: Medical record review revealed Resident #216 was admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a 14 day Minimum (MDS) data set [DATE] revealed the resident was moderately cognitively impaired. Continued review revealed the resident required limited assistance of 1 person for bed mobility, transfers, walking in the room, corridor, locomotion on and off the unit, and toileting. Medical record review of a Falls Risk assessment dated [DATE] indicated the resident was at risk for falls. Medical record review revealed Resident #216 had a fall 3/9/17. Continued review revealed an intervention in place prior to the fall was bed in low position. Medical record review revealed Resident #216 had a fall on 3/18/17. Continued review revealed the immediate intervention put into place after the fall was initiated low bed. Medical record review revealed Resident #216 had a fall on 3/19/17. Continued review revealed, .bed was lowered to lowest and locked .floor mat is in place . Medical record review of a comprehensive care plan dated 3/8/17 and revised 4/7/17 revealed a problem of .Patient is at risk for falls (related to) dementia with [MEDICAL CONDITION] and behaviors/agitation, use of (medications) that can increase risk, (End Stage [MEDICAL TREATMENT]) with recent (Mental Status) change .and (history) of fall since admission . Continued review revealed there was no intervention for a low bed or a fall mat on the care plan. Interview with the Director of Nursing on 6/7/17 at 3:50 PM in the Fine Dining Room confirmed the facility failed to update the care plan to reflect a low bed and fall mat intervention for Resident #216.",2020-09-01
696,THE HEALTH CENTER AT RICHLAND PLACE,445166,504 ELMINGTON AVENUE,NASHVILLE,TN,37205,2017-06-07,281,D,0,1,O29L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure an order was obtained for the use of a condom catheter for 1 resident (#153) of 26 residents reviewed in the stage 2 sample. The findings included: Medical record review revealed Resident #153 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed a physician's orders [REDACTED]. Further review revealed this order was discontinued on 3/3/17. Interview with Unit Manager/Registered Nurse (RN) #1 on 6/7/17 at 1:42 PM on the third floor at the nurses station confirmed there was no order for a condom catheter for the resident. RN #1 stated the resident did use a condom catheter and had it on this morning . Interview with Resident #153 on 6/7/17 at 6:00 PM in the resident's room revealed the resident did use a condom catheter. The resident stated he applies the condom catheter himself as needed. Resident #153 said when needed the staff will empty the catheter bag and sometime he will empty it.",2020-09-01
697,THE HEALTH CENTER AT RICHLAND PLACE,445166,504 ELMINGTON AVENUE,NASHVILLE,TN,37205,2017-06-07,318,D,0,1,O29L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical reocrd review, observation, and interview, the facility failed to provide services to prevent further decrease in range of motion for 1 Resident (#105) of 26 residents sampled. The findings included: Medical record review revealed Resident #105 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a notation of discharge from a restorative dining form dated 7/27/10 revealed the resident could feed self with staff set up. Medical record review of the admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief interview for Mental Status was not completed related to the resident was rarely/never understood. Medical record review of a progress note dated 2/14/17 revealed the resident was .contracted . (a fixed condition preventing stretching of a muscle) in both arms with the left wrist .worst than other areas. Medical record review of a significant change MDS dated [DATE] revealed Resident #105 required extensive asistance of two people for bed mobility, dressing, toileting, and personal hygiene. Continued review revealed the resident had limited range of motion to both arms. Medical record review of a case conference summary dated 4/12/17 revealed .changes in functioning ability are patient is nonverbal, contracted, bedbound . Medical record review of a care plan revised on 4/25/17 revealed .Patient requires assistance with ADLs (Activities of Daily Living) and/or functional mobility . an intervention for active and passive range of motion to extremities during care as tolerated. Medical record review of a progress note dated 6/6/17 revealed .extremities contracted Observation on 6/6/17 at 9:17 AM in the resident's room revealed Resident #105 in bed, the resident's left arm was bent at the elbow and the left wrist was curled toward Resident #105's chest. There was no supportive device for the resident's arm. Observation on 6/7/17 at 8:11 AM in the resident's room revealed the resident was in bed, the left arm was bent at the elbow and the left wrist was curled toward the resident's chest. There was no supportive device for the resident's arm. Interview with Licensed Practical Nurse (LPN) #2 on 6/7/17 at 9:17 AM in the hallway near the resident's room confirmed the resident had contractures to the left arm. Continued interview confirmed the resident did not currently receive physical therapy or restorative therapy and did not use supportive devices. Interview with Certified Nursing Assistant (CNA) #1 on 6/7/17 at 10:02 AM in the hallway revealed the CNA had a permanent assignment to care for the resident. Continued interview revealed the CNA had cared for the resident for aproximately 6 months. Further interview revealed the CNA was aware the resident had limited movement of both arms. Continued interview revealed the CNA had not received instructions on range of motion and did not provide range of motion to the resident. Interview with LPN #1 on 6/7/17 at 10:20 AM at the 3rd floor nurse's station revealed the nurse was familiar with Resident #105. Continued interview confirmed the resident was not receiving physical therapy or restorative services. Further interview revealed in the past the facility used towels or stuffed animals to support the arms or legs of a resident having limited mobility however this was not currently being done for Resident #105. Interview with Nurse Practitioner #1 on 6/7/17 at 12:30 PM in the Assistant Director of Nursing's (ADON) office revealed the resident was receiving palliative care. Continued interview revealed the Nurse Practitioner did not know when the resident had declined. Further interview confirmed range of motion was appropriate for Resident #105. Interview with the ADON on 6/7/17 at 12:30 PM in the ADON's office revealed range of motion was an appropriate intervention for Resident #105. Further interview revealed staff were expected to provide range of motion during care. Continued interview revealed no evidence the staff provided range of motion to the resident. Further interview confirmed the facility failed to provide range of motion to Resident #105's arms to prevent further decrease in motion.",2020-09-01
698,THE HEALTH CENTER AT RICHLAND PLACE,445166,504 ELMINGTON AVENUE,NASHVILLE,TN,37205,2019-06-13,600,G,0,1,TUZL11,"**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 communicate and document two pressure ulcers causing a delay in care for 6 days. The facility deficient practice resulted in the worsening of 2 pressure ulcers assessed and staged at a 2 on 6/4/19 then again on 6/10/19 at a Stage 4 for 1 of 16 (#55) residents with pressure ulcers resulting in Neglect. The findings include: Review of the facility policy, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, revised 12/11/17 revealed .Medical and emotional support will be made immediately available to any individual suffering either alleged abuse, neglect, misappropriation of patient property or expolitation Neglect: the failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness . Medical record review revealed Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Braden Scale for Predicting Pressure Sore Risk, dated 5/7/19, revealed a total Braden Score of 13 indicating Resident #55 was at a moderate risk for developing a pressure ulcer. Medical record review of the Admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating Resident #55 was cognitively intact, understood others with clear comprehension, had adequate vision-saw fine detail, wore glasses, and had no behaviors. Resident required extensive assistance with bed mobility using 1 person, limited assistance with transfers using 2 persons, had a urinary catheter and a [MEDICAL CONDITION], and had no Pressure Ulcer's on admission to the facility. Medical record review of the Nursing Care Plan, revised 5/27/19, revealed .Pt (patient) at risk for bed sores (pressure ulcers) and increased pain due to immobility from metastatic/[MEDICAL CONDITION] .Decrease pt pain and maintain bed mobility .Implement exercise program that targets strength, ROM (range of motion) .Pt is likely to have pain and pressure areas develop without AROM (active range of motion)/strength maintenance. Pt has [MEDICAL CONDITION] . Medical record review of the Weekly Skin Assessment, undated, posted at the 3rd floor nurses station, revealed Resident #55 was scheduled to have a skin assessment every Saturday by the resident's nurse. Medical record review of the Hospice Communication Form admission note, dated 6/4/19, at 5:08 PM revealed .met with pt nurse (Licensed Practical Nurse (LPN) #1) .collaborated P[NAME] (plan of care) with pt, facility nurse (LPN #1) et (and) this RN (Registered Nurse) .wound stage 2 coccyx . Medical record review of the Hospice Communication Form, dated 6/5/19, revealed .stage II (Pressure Ulcer) (partial thickness skin loss involving eprdermis, dermis, or both .superficial and presents as an abrasion or blister) to bilateral (both) buttocks .care collaborated .continue with current P[NAME] . Medical record review of the Certified Nursing Assistant (CNA) skin assessments, dated 6/1/19 to 6/10/19, revealed no documentation of PU's for Resident #55. Medical record review of Wound Care notes, dated 6/10/19, revealed .While competing weekly assessment of patient (resident), (resident) c/o (complained of) 'butt hurting'. Had patient turn to right and two pressure ulcers were noted; one to coccyx and one to the right gluteal. Medical record review of the Wound Management note, dated 6/10/19, revealed Pressure Ulcer on coccyx assessed to be 2 centimeters (cm) long x 1 cm wide x 0.3 cm deep with light exudate (drainage) that was serous (clear, amber, thin and watery), with no odor, unstageable with slough and/or eschar (dead tissue) 95%, granulation tissue (healthy tissue) 5%. PU on right buttock assessed to be 1.2 cm long x 1.8 cm wide x 0.2 cm deep with light exudate that was serous, without odor, unstageable with slough and/or eschar 100%. Review of the Nursing Care Plan dated 6/10/19 revealed .Resident has a pressure ulcer R/T (related to) decreased mobility .unstageable pressure ulcers (ulcer covered with slough or eschar) to coccyx and right gluteal .Start Date: 6/12/2019 Apply dressings per MD (medical doctor) order .See wound care orders .Assess resident for pain related to pressure ulcer or its treatment .Prevent or treat pain by repositioning, redirection, medication .Assess the pressure ulcer for stage, size (length, width, and depth), presence/absence of granulation tissue and epithelization, and condition of surrounding skin weekly and PRN .Conduct a systematic skin inspection weekly .Report any signs of any further skin breakdown (sore, tender, red, or broken areas) .Instruct resident to reposition self every 1-2 hours when resident is in bed .Keep clean and dry as possible .Minimize skin exposure to moisture .Keep linens clean, dry, and wrinkle free .Keep resident off coccyx and right gluteal .Reduce friction injuries by using lubricants, protective films, protective dressings, protective padding, etc .Supplements: see Dietary orders .Use moisture barrier product to perineal area .Use support surface when resident in bed: pressure reducing mattress . Interview with Hospice Registered Nurse (RN) #3, on 6/12/19 at 10:15 AM in the 3rd floor hallway revealed she assessed Resident #55 on 6/5/19 with 2 Stage 2 Pressure Ulcers. Continued interview confirmed a Hospice Care Plan was not available to the facility at this time. Interview with RN #1, identified as the Wound Care nurse, on 6/12/19 at 10:20 AM in the 3rd floor hallway revealed she was not informed of the PU's on Resident #55 and was unaware of them until her assessment on 6/10/19. Continued interview revealed she depended on the weekly skin assessments by the nurses and daily skin assessments by the CNAs (Certified Nursing Asssitants) done with resident care each shift to inform her of developing Pressure Ulcers. Continued interview also revealed she expected the hospice nurse to inform her of developing Pressure Ulcers. Interview with RN #2, identified as the 3rd floor Unit Manager and Assistant Director of Nursing (ADON), on 6/12/19 at 2:50 PM at the 3rd floor nurses station revealed the Hospital Report Sheet (transfer form with information about the resident) was initiated on admission and kept at the nurses station for the CNAs and nurses to use for report. Continued interview revealed .it (Hospital Report Sheet) is updated daily by the Unit Clerk or the nurse . CNA Skin assessment forms are filled out each shift and left in the Wound Care Nurses' office. Continued interview confirmed .I expect the CNAs to do a skin assessment with all care .bedbaths .diaper changes .and notify the nurse . Continued interview confirmed there was no documentation of Pressure Ulcer's on Resident #55's Hospital Report Sheet. Interview with CNA #3 on 6/12/19 at 3:10 PM in the 3rd floor dining room revealed the CNAs .do skin assessments every time we do care like a bedbath or a diaper change (adult briefs) .we have sheets we fill out and give to the wound care nurse .or we tell the nurse if we need to . Interview with the DON on 6/12/19 at 5:45 PM at the 3rd floor nurses station confirmed she expected the nurses to do skin assessments with all care, document them, and let the Wound Care Nurse know about changes. Continued interview revealed the facility failed to prevent the worsening of pressure ulcers by failing to treat 2 pressure ulcers which was assessed and staged at a 2 on 6/4/19 by hospice, and rediscovered by the facility on 6/10/19 at a Stage 4 (full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer, slough or eschar may be visible) for 1 of 16 (#55) residents with pressure ulcers resulting in HARM",2020-09-01
699,THE HEALTH CENTER AT RICHLAND PLACE,445166,504 ELMINGTON AVENUE,NASHVILLE,TN,37205,2019-06-13,623,F,0,1,TUZL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to send notification of discharge/transfer to the Ombudsman for 3 of 3 (#23, #62, #91) residents reviewed. The findings include: Medical record review revealed Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Matrix Care resident census revealed Resident #23 was discharged /transferred to the hospital on [DATE]. Medical record review revealed Resident #62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Matrix Care resident census revealed Resident #62 was discharged /transferred to the hospital on [DATE]. Medical record review revealed Resident #91 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Matrix Care resident census revealed Resident #91 was discharged /transferred to the hospital on [DATE]. Interview with the Director of Health Information on 6/12/19 at 4:12 PM in her office confirmed the Ombudsman notifications of discharge/transfers had not been sent since the facility started using Matrix Care in late (MONTH) (YEAR). Interview with the Director of Nursing on 6/13/19 at 5:15 PM in her office confirmed the Ombudsman notifications of discharge and transfer were expected to be sent to the Ombudsman by the 20 day of the month after the current month.",2020-09-01
700,THE HEALTH CENTER AT RICHLAND PLACE,445166,504 ELMINGTON AVENUE,NASHVILLE,TN,37205,2019-06-13,686,G,0,1,TUZL11,"**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 communicate, document and treat the presence of 2 pressure pressure ulcers assessed and staged at a 2 on 6/4/19 by a Hospice Nurse and later by the facility on 6/10/19 at a Stage 4 for 1 of 16 (#55) residents with pressure ulcers resulting in HARM. The findings include: Review of facility policy, Skin Integrity Prevention and Management Assessment, dated 1/1/03 revealed .skin assessments are completed on all patients by the licensed nurse and documented using the Weekly Skin Assessment Record . Review of facility policy, Skin Monitoring Assessment Guidelines, dated 1/1/03, revealed .daily monitoring will enable staff to remain alert to potential changes in the skin condition . Medical record review revealed Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Braden Scale for Predicting Pressure Sore Risk, dated 5/7/19, revealed a total Braden Score of 13 indicating Resident #55 was at a moderate risk for developing a pressure ulcer. Medical record review of the Admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating Resident #55 was cognitively intact, understood others with clear comprehension, had adequate vision-saw fine detail, wore glasses, and had no behaviors. Resident required extensive assistance with bed mobility using 1 person, limited assistance with transfers using 2 persons, had a urinary catheter and a [MEDICAL CONDITION], and had no Pressure Ulcer's on admission to the facility. Medical record review of the Nursing Care Plan, revised 5/27/19, revealed .Pt (patient) at risk for bed sores (pressure ulcers) and increased pain due to immobility from metastatic/[MEDICAL CONDITION] .Decrease pt pain and maintain bed mobility .Implement exercise program that targets strength, ROM (range of motion) .Pt is likely to have pain and pressure areas develop without AROM (active range of motion)/strength maintenance. Pt has [MEDICAL CONDITION] . Medical record review of the Weekly Skin Assessment, undated, posted at the 3rd floor nurses station, revealed Resident #55 was scheduled to have a skin assessment every Saturday by the resident's nurse. Medical record review of the Hospice Communication Form admission note, dated 6/4/19, at 5:08 PM revealed .met with pt nurse (Licensed Practical Nurse (LPN) #1) .collaborated P[NAME] (plan of care) with pt, facility nurse (LPN #1) et (and) this RN (Registered Nurse) .wound stage 2 coccyx . Medical record review of the Hospice Communication Form, dated 6/5/19, revealed .stage II (Pressure Ulcer) (partial thickness skin loss involving eprdermis, dermis, or both .superficial and presents as an abrasion or blister) to bilateral (both) buttocks .care collaborated .continue with current P[NAME] . Medical record review of the Certified Nursing Assistant (CNA) skin assessments, dated 6/1/19 to 6/10/19, revealed no documentation of PU's for Resident #55. Medical record review of the Wound Management note, dated 6/10/19, revealed Pressure Ulcer on coccyx assessed to be 2 centimeters (cm) long x 1 cm wide x 0.3 cm deep with light exudate (drainage) that was serous (clear, amber, thin and watery), with no odor, unstageable with slough and/or eschar (dead tissue) 95%, granulation tissue (healthy tissue) 5%. PU on right buttock assessed to be 1.2 cm long x 1.8 cm wide x 0.2 cm deep with light exudate that was serous, without odor, unstageable with slough and/or eschar 100%. Review of the Nursing Care Plan dated 6/10/19 revealed .Resident has a pressure ulcer R/T (related to) decreased mobility .unstageable pressure ulcers (ulcer covered with slough or eschar) to coccyx and right gluteal .Start Date: 6/12/2019 Apply dressings per MD (medical doctor) order .See wound care orders .Assess resident for pain related to pressure ulcer or its treatment .Prevent or treat pain by repositioning, redirection, medication .Assess the pressure ulcer for stage, size (length, width, and depth), presence/absence of granulation tissue and epithelization, and condition of surrounding skin weekly and PRN .Conduct a systematic skin inspection weekly .Report any signs of any further skin breakdown (sore, tender, red, or broken areas) .Instruct resident to reposition self every 1-2 hours when resident is in bed .Keep clean and dry as possible .Minimize skin exposure to moisture .Keep linens clean, dry, and wrinkle free .Keep resident off coccyx and right gluteal .Reduce friction injuries by using lubricants, protective films, protective dressings, protective padding, etc .Supplements: see Dietary orders .Use moisture barrier product to perineal area .Use support surface when resident in bed: pressure reducing mattress . Medical record review of the Skilled Nursing Notes, dated 6/1/19-6/12/19, revealed no Pressure Ulcer's were documented for Resident #55. Observation and interview with Resident #55 on 6/11/19 at 10:45 AM in the resident's room revealed the resident was sitting in the wheelchair and stated, .it's my own fault because I refuse to get up in my chair and off my back .I like to watch TV in bed all day . Interview with RN #1, identified as the Wound Care nurse, on 6/12/19 at 10:20 AM in the 3rd floor hallway revealed she was not informed of the PU's on Resident #55 and was unaware of them until her assessment on 6/10/19. Continued interview revealed she depended on the weekly skin assessments by the nurses and daily skin assessments by the CNAs done with resident care each shift to inform her of developing Pressure Ulcers. Continued interview also revealed she expected the hospice nurse to inform her of developing Pressure Ulcers. Observation of Resident #55 on 6/12/19 at 10:30 AM in the resident's room revealed resident able to assist turning herself to the side by using upper body strength and the side rails during wound care. Interview with RN #2, identified as the 3rd floor Unit Manager and Assistant Director of Nursing (ADON), on 6/12/19 at 2:50 PM at the 3rd floor nurses station revealed the Hospital Report Sheet (transfer form with information about the resident) was initiated on admission and kept at the nurses station for the CNAs and nurses to use for report. Continued interview revealed .it (Hospital Report Sheet) is updated daily by the Unit Clerk or the nurse . CNA Skin assessment forms are filled out each shift and left in the Wound Care Nurses' office. Continued interview confirmed .I expect the CNAs to do a skin assessment with all care .bedbaths .diaper changes .and notify the nurse . Continued interview confirmed there was no documentation of Pressure Ulcer's on Resident #55's Hospital Report Sheet. Interview with CNA #3 on 6/12/19 at 3:10 PM in the 3rd floor dining room revealed the CNAs .do skin assessments every time we do care like a bedbath or a diaper change (adult briefs) .we have sheets we fill out and give to the wound care nurse .or we tell the nurse if we need to . Interview with the DON on 6/12/19 at 5:45 PM at the 3rd floor nurses station confirmed she expected the nurses to do skin assessments with all care, document them, and let the Wound Care Nurse know about changes. Continued interview revealed the facility failed to prevent the worsening of pressure ulcers by failing to treat 2 pressure ulcers which was assessed and staged at a 2 on 6/4/19 by hospice, and rediscovered by the facility on 6/10/19 at a Stage 4 (full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer, slough or eschar may be visible) for 1 of 16 (#55) residents with pressure ulcers resulting in Harm. Interview with LPN #1 on 6/13/19 at 8:15 AM on the 3rd floor hallway revealed .I remember the hospice nurse talking to me about (Resident #55) on 6/4/19 but she didn't tell me about Pressure Ulcer's .I would have put a dressing on them and called the wound care nurse .",2020-09-01
701,THE HEALTH CENTER AT RICHLAND PLACE,445166,504 ELMINGTON AVENUE,NASHVILLE,TN,37205,2019-06-13,689,G,0,1,TUZL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, review of the facility investigation, review of hospital data, observation and interview, the facility failed to provide supervision to prevent a fall; and failed to provide a complete investigation of the fall for 1 of 20 residents (#36) with falls. The findings include: Review of the facility policy, Accidents and Incidents-Investigation and Reporting, revised 7/2017, revealed .All accidents and incidents involving residents .occurring on our premises shall be investigated . Further review revealed .The following data, as applicable, shall be included on the Report of Incident/Accident form .The circumstances surrounding the accident or incident .The disposition of the injury (i.e. transferred to hospital .) .Any corrective action taken .Follow-up information .Other pertinent data as necessary or required . Review of the facility policy, Administering Medications through a Small Volume (handheld) Nebulizer, revised 10/2010, revealed .remain with the resident for the treatment unless determined to be safe for self-administration . Medical record review revealed Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Fall Risk Assessment Tool dated 3/27/19 revealed the score of 17, indicating Resident #36 was at High Risk for falls, (score over 13 is high risk). Medical record review of the baseline Care Plan dated 3/27/19 revealed Resident #36 was .at risk for falls related to .Fall Risk Assessment Tool .history of falls . with approaches including .medication review by nurse, pharmacy, MD/NP (Medical Doctor/Nurse Practitioner) as needed .OT (Occupational Therapy) .PT (Physical Therapy) referral and treat as needed . Medical record review of the admission orders [REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #36 had short and long term memory impairment; required extensive 2 person assistance for bed mobility; required extensive 1 person assistance for transferring, locomotion on the unit, dressing, and toileting; required limited 1 person assistance for locomotion off the unit and personal hygiene; was frequently incontinent of bowel and bladder; and on 1 or 2 occasions walked in room or corridor with 1 person assistance. Further review revealed the resident had a fall 2-6 months prior to the admission to the facility and had had no falls after admission to the facility. Medical record review of the 14 day MDS dated [DATE] revealed Resident #36 had a Brief Interview for Mental Status (BIMS) of 15/15, indicating the resident was cognitively intact. Resident #36 exhibited no [MEDICAL CONDITION], moods, [MEDICAL CONDITION], or behaviors; required extensive 2 person assistance for bed mobility; required extensive 1 person assistance for transferring, locomotion on and off the unit, dressing, toileting and bathing; required limited 1 person assistance for walking in the room; and walking in the corridor did not occur. Resident #36 was frequently incontinent of bladder, occasionally incontinent of bowel; and had no falls since admission. Medical record review of the Occupational Therapy (OT) Daily Treatment Note revealed the following: On 4/22/19 and 4/23/19 Resident #36 .required supervision from therapist to ensure safe body mechanics to target specific muscle groups to avoid injury . Further review of the 4/23/19 note revealed .Cont'd (Continued) edu (education)/retraining utilizing rollator (mobility device) within facility/room environment . On 4/24/19 Resident #36 .requiring supervision with 35% verbal and visual cues for sequencing through safe rollator placement, for locking/unlocking brakes appropriately, and overall safety awareness .pt hopes to return to (home) Friday, (MONTH) 26 . Medical record review of the Physical Therapy (PT) Daily Treatment Note revealed the following: On 4/22/19 Resident #36 .ambulated over 400 feet with RW (rolling walker/rollator) at Moderate (Mod) 1 level demonstrating safety awareness with ascending/descending to rollator seat . Medical record review of the Resident Progress Note dated 4/25/19 revealed .Pt (Patient) found on floor in doorway of bathroom. Pt states .was trying to use bathroom. Pt hit head; knot noted to back of head . Medical record review of the Event Report dated 4/25/19 revealed Resident #36 was resting in the bed prior to the fall, was found on the bathroom floor, and had pain to the back of the head at an intensity of 4 out of 10 indicating moderate pain. Further review revealed the .Location of Injury .Knot noted to back of head .Note any injury to the head .Bump/Hematoma .Range of Motion (ROM) x (times) 4 (extremities) Without Pain/Limitation .Position of Extremities .No Rotation/Deformity/Shortening Noted .Mental Status .No Changes .Vitals (Vital Signs) Blood Pressure 170/76 .Notes .Pt found on floor in doorway of bathroom. Pt states .trying to use the bathroom. Pt hit head; Knot noted to back of head. Neurochecks initiated . Review of the Event form of the Neuro Checks revealed they were within normal limits. Further review revealed the .Intervention immediate measure taken .rest .education . Further review revealed the .Orders .Fall with Suspected Head Trauma: Initiate Neurochecks per facility protocol; Fall: Initiate Fall Prevention Program; and Fall: Monitor status for 72 hours for bruising, change in mental status, pain, or other injuries related to fall . Review of the facility investigation revealed Resident #36 had an unwitnessed fall on 4/25/19 at 6:30 AM, and was found .laying on floor in doorway of bathroom ., the fall was related to toileting, had no falls in last 3 months, no new medication or significant increase within 1 week, required no medical attention, and fell while walking in the resident's bathroom. The Root Cause determination revealed .getting out of bed without assistance, weakness, pt needing to use restroom, and did not use call light . The Root Cause revealed .getting out of bed without assistance . The intervention based on root cause revealed .Educate pt to call for assistance . Further review revealed when the family was notified of the fall, the family .requesting a MRI (Magnetic Resonance Imaging- strong magnetic field and radio waves to create detailed images of organs and tissues within the body), NP notified . Further review of the investigation revealed no identification of staff assigned to the resident, no staff interviews or statements of the fall scene or observation/interaction with resident on 4/25/19; no description of the environment of the fall scene; no data regarding right shoulder issue; no data of the hospitalization or the results from the hospitalization ; and no review of medication or laboratory data. Medical record review of the (MONTH) 2019 Treatment Administration Record revealed on every shift, the neurochecks were completed for 2 days, the resident was monitored for 72 hours, and the fall prevention program was initiated and monitored for 5 days. Review of the Fall Risk Assessment Tool dated 4/25/19 revealed a score of 9, Moderate Fall Risk (moderate range was 6-13). Medical record review of the NP Progress Note dated 4/25/19 revealed .Pt seen at request of staff due to fall at approx (approximately) 630 this AM in which pt struck .head on the tile and bathroom. Pt has large hematoma to occipital lobe. Pt has no alteration in mental status .is alert and oriented and states .was going to the bathroom and .'does not know what happened' but .'fell backwards striking .head.' Pt states (name NP), this is terrible because I am supposed to discharge tomorrow.' I explained that we would contact .daughter .but due to the size of the hematoma on back of .head, we would be sending .to the emergency room for additional evaluation. I have a concern for subdural hematoma. Pt verbalizes understanding .Assessment Plan 1. Fall with head injury-new onset-pt states .was ambulating in bathroom and fell backwards striking .head on floor. Pt had large hematoma noted to occipital lobe. Pt is alert and oriented with no change in mental status .Pt will be transported .emergency room for further evaluation and treatment due to concern for subdural hematoma . Continued review revealed .Follow-Up: Pt was returning early afternoon- Per .Hospital CT (Computed tomography-combination of x-rays and computer to create pictures of organs, bones, and other tissue) head was negative. Pt did return with right upper extremity in sling. Per hospital records pt has evidence of possible fracture noted to right forearm. Recommendation is that pt follow-up with orthopedic service for additional examination. Instructed staff to please obtain appointment for pt with orthopedic service as soon as possible. Pt will be kept at nonweight bearing status to right upper extremity until follow up with orthopedic. Right upper extremity will be kept in sling until follow up with orthopedic. Therapy notified of change in pt's status and that pt will not be able to discharge as planned tomorrow . Medical record review of the Nursing Home to Hospital Transfer Form dated 4/25/19 revealed the transfer was related to Fall-Hit head, knot on back of head. Review of the hospital Final Report dated 4/25/19 revealed .pt presents after a fall .going to bathroom with (resident's) walker .let go of the walker to reach for the bar, missed, and fell backwards .hit .head, but not lose consciousness . Review of the Medical Decision Making: revealed .CT scan of head demonstrated scalp hematoma, but no intracranial abnormality. Xrays right shoulder and humerus demonstrated possible nondisplaced fracture distally. I have low clinical suspicion of fracture as pt had no swelling or deformity on examination, but a sling was ordered as precaution .pt given Tylenol for headache . Medical record review of Resident #36's Care Plan initiated on 3/27/19 was at risk for falls approaches, updated on 4/25/19, revealed .educate patient on need to call for assistance . Medical record review of the Orthopedic Surgeon report dated 4/29/19 at 2:20 PM revealed .Chief Complaint: Follow up on right shoulder pain and new complaint right arm pain . Further review revealed Resident #36 .returns to the clinic today .fell recently .stated .fell backwards and landed on .head .performed x-rays of .shoulder and arm at that time. (Resident) was told .could have a crack in .arm . Continued review of the .Physical Exam demonstrates supple motion of .elbow .has no tenderness along .elbow .is neurovascularly intact. In regard to .shoulder .continues to have pain with passive and active motion . Further review of the .Imaging from 4/25/19 of .humerus is normal. The shoulder demonstrates severe arthritis again .Assessment: Shoulder arthritis .Plan: has significant shoulder arthritis .discussed options .wants to try another injection .steroid injected right shoulder 1 ml (milliter) Depo-[MEDICATION NAME] and 4 ml of 1% (percent) [MEDICATION NAME] .procedure tolerated well as needed . Medical record review of the Fall Risk Assessment Tool dated 4/29/19 at 2:21 AM revealed a score of 18 indicating Resident #36 was a high risk for fall. Medical record review of the Event Report dated 4/29/19 revealed Resident #36 was receiving a nebulizer treatment prior to the unwitnessed fall. The resident was found on the floor in the resident's room and the .Pt heard yelling 'HELP' shortly after nebulizer tx (treatment) was administered and found lying on floor next to .wheelchair . Further review revealed the .Pain Observation .Does resident exhibit or complain of pain related to the fall? .Yes, right shoulder . with the intensity of .6/10 . in the moderate/severe range; the range of Motion was .painful/limited upper extremity Neurological Check .was the same as the 4/25/19 neurological check except the left and right lower extremity movement was weak. The vital signs dated 4/29/19 at 8:51 PM revealed 96% O2 Sat (oxygen saturation) while resting with O2 in use at 2 lpm (liters per minute) and blood pressure of 126/86. Review of the POS [REDACTED]. Further review revealed .Additional Information .X ray shows fracture to right shoulder . and the .Interventions Immediate measures taken .[MEDICATION NAME], cold, and rest . Review of the facility fall investigation revealed Resident #36 fell while standing or attempting to stand in the resident's room on 4/29/19, Monday, at approximately 8:30 PM and required .medical attention, no hospitalization .was on restorative caseload . received .purposeful rounding . had .2 falls in last 3 months . and .no new medication or increases within 1 week . Review revealed the root cause determination included .Pt got up from wheelchair without assistance and did not use call light, pt tripped over footrest on wheelchair, and didn't move foot rest . with the root cause of .pt attempted ambulation without assistance . Further review revealed the intervention based on root cause was .reinforce using call light to ask for assistance-Pt demonstrates understanding verbally and agrees to comply . Further review revealed the investigation failed to include the identification of staff assigned to the resident, had no staff interview or statements of the fall scene or observation/interaction with resident on 4/29/19; no description of the environment of the fall scene; had no reference regarding second issue with right shoulder, had no data of the hospitalization or the results from the hospitalization ; and had no review of medication or laboratory data. Medical record review of the Radiology Report dated 4/30/19 of the right shoulder revealed .Results .There is a fracture involving humeral neck with displacement . Observation on 6/10/19 at 10:00 AM of Resident #36 in the resident's room revealed the right arm in a sling. When asked why the arm was in a sling the resident stated .fell in facility once and hurt my right arm . Observation at 9:14 AM revealed the resident was in the room in the wheelchair with a sling for the right arm and had non-skid socks on. When asked why the resident was wearing a sling the resident stated .was trying to stand up and went to fast and fell on my face .no staff there but were there right away .told me to stick to my wheelchair and not to walk without staff and to call for help . Telephone interview with Licensed Practical Nurse (LPN) #2 on 6/13/19 at 8:57 AM regarding the 4/29/19 fall involving Resident #36 confirmed the LPN was the assigned nurse to the resident and responded to the fall. LPN #2 stated he had administered a nebulizer treatment to the resident in the resident's room and the resident was in a wheelchair. The LPN stated under .ideal circumstances the nurse stays with the resident during the administration but he had to step out of the room to the medication cart about 10 feet away . The LPN stated the .resident was behind a privacy curtain and not in direct site . The LPN stated a Certified Nurse Aide (CNA) was doing rounds and entered the room no more than 5 minutes from when he left the room. The CNA yelled out the resident was on the floor and the LPN went in to see the resident on the floor. The LPN stated the .resident said (the resident) stood up and was turning off the nebulizer and tripped . Telephone interview with CNA #2 on 6/13/19 at 9:02 AM and 9:05 AM revealed she was not on duty on 4/29/19 and .was not there .I didn't find it (resident on floor) . When informed she was on duty, was providing care to the resident per the time sheet and ADL (Activities of Daily Living) report, the CNA stated she did not recall assisting the nurse getting resident off the floor. Further interview at 10:28 AM revealed the CNA .wanted to clarify what was said earlier and did not mean to indicate .I was not working that night but that I did not recall the incident . Interview with the Director of Nursing (DON) on 6/13/19 starting at 9:12 AM in the conference room confirmed the investigation .had no statements from staff regarding the fall, the investigation failed to identify staff on duty, and the investigation was not complete . When asked how the root cause was determined, the DON stated the Charge Nurse on duty at the time of the fall determined the root cause and then it was reviewed the next day by the team for additional thoughts. The DON suggested and obtained medication review by the psychiatric nurse and orthopedic services who agreed to trial decrease/discontinue medications. Since then the resident had become more alert and the resident's daughter took the resident to a personal psychiatrist who did change the medication and would monitor also. Further interview confirmed all the issues discussed were not included in the investigation information. Further interview revealed .Our FOLLOW-UP addressed what the circumstances of the fall was, the intervention, how the intervention worked, the resident fell involving the same shoulder on both falls; (orthopedic) interventions as well as medication reviews decreased in antipsychotic use, resident has a long history of antipsychotic use. We thought the cause of the first fall was due to training/knowledge of the resident .in that we know (resident was told to use call light and at times (resident) would and other times not. Resident knew was going home Friday (April 26, 2019) and thought .could walk to bathroom on .own so we felt reminding (resident) after fall would emphasize why to call us and (resident) was compliant most of time . The cause of the second fall, 4/29/19, was miscommunication or failure to communicate .resident not calling to get us to help . Interview with the DON and Registered Nurse (RN) #6 on 6/13/19 at 2:40 PM and 3:00 PM in the conference room revealed the RN was the unit clerk on 4/25/19 and wrote the Event Report. Further interview with the RN and DON revealed at the time of the 4/25/19 fall .we felt (Resident #36) was excited regarding leaving on Friday and was trying to do more for self so we felt reminding the resident to use the call light for help was enough at the time. Initially the resident was compliant but not 100% and staff reminded the resident to call so not fall. The resident remained alert and oriented and did what the resident thinks the resident could or can do for self . When asked regarding the follow-up to intervention process the DON stated .We would have followed up in a meeting a week after the fall. From what I was told on 4/29/19 the resident was going to turn off the nebulizer, got up from the wheelchair to do that unassisted . When asked do you feel the facility failed to provide adequate supervision to prevent the fall, the DON stated .If the nurse would have stayed in the room during the treatment as stated in the policy the fall may not have happened . When asked if would agree the investigation did not include who responded to the fall, statements or interviews by staff responding and other staff on duty to determine what staff was aware of on the days of the falls, failed to identify the same shoulder was involved in both falls, the hospital data 4/25/19, the orthopedic results, and the failure of LPN #2 not remaining with the resident while a nebulizer treatment was administered in order to have a complete investigation to determine the root cause, the DON confirmed .I agree the investigation lacked information . The facility failed to provide a thorough investigation to determine the root cause of both falls to place interventions in place to prevent the second fall that resulted in a fracture. On 4/25/19 the resident got out of bed by self and ambulated to the bathroom where resident fell backwards hitting back of head resulting in a scalp hematoma. The facility determined the root cause to be the resident getting out of bed without assistance and educate pt to call for assistance. On 4/29/19 the resident was receiving a nebulizer treatment prior to the fall. Facility policy revealed the Nurse set up the nebulizer while resident in wheelchair with foot pedals and left the resident even though facility policy was to stay during administration of medication with a nebulizer. The Nurse left the resident and went back to the medication cart with curtain pulled and Resident stood up from wheelchair without assistance and tripped over the foot pedals and fell resulting a fracture to the right shoulder and HARM.",2020-09-01
702,THE HEALTH CENTER AT RICHLAND PLACE,445166,504 ELMINGTON AVENUE,NASHVILLE,TN,37205,2019-06-13,732,C,0,1,TUZL11,"Based on observation and interview, the facility failed to update the daily posted staffing and census on 6/8/19 and 6/9/19. The findings include: Observation on 6/10/19 at 8:39 AM on the main hallway wall revealed the posted staffing and census was dated 6/7/19. Interview with the Director Of Nursing on 6/13/19 at 5:29 PM in the conference room confirmed .we usually have the weekend Admission Nurse to post the daily staffing and census. She took the weekend off and we got somebody to cover the admission part but forgot to update them on that part (posting the daily staffing and census sheet daily) .",2020-09-01
703,THE HEALTH CENTER AT RICHLAND PLACE,445166,504 ELMINGTON AVENUE,NASHVILLE,TN,37205,2019-06-13,773,D,0,1,TUZL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to identify 1 of 33 residents (#55) prior to obtaining laboratory services. The findings include: Review of facility policy, Laboratory and Diagnostic Test Results-Clinical Protocol, dated 9/2012, revealed .The staff will process requisitions and arrange for tests . Medical record review revealed Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating resident was cognitively intact, understood others with clear comprehension, had adequate vision-saw fine detail, wore glasses, and had no behaviors. Medical record review of the physician's orders [REDACTED]. Medical record review of an Event Report dated 5/31/19 with a completion date of 6/11/19, revealed .Lab drawn in error x 2 . on Resident #55 on 5/31/19 and 6/3/19. Interview with Resident #55 on 6/11/19 at 10:45 AM in the resident's room revealed serum lab tests were drawn twice from her left arm in the last 1-2 weeks without a physician's orders [REDACTED].it bothers me . and the phlebotomist did not ask for her name. Continued interview revealed she questioned her nurse on 6/3/19 .after the 2nd time and that's when they (facility) found out I didn't have any labs ordered . Resident #55 denied bruising or pain at the venipuncture site. Interview with Licensed Practical Nurse (LPN) #1 on 6/11/19 at 5:00 PM at the 3rd floor nurses station revealed the Director of Nursing (DON) was notified that lab tests were drawn on Resident #55 on 5/31/19 and 6/3/19. Continued interview revealed when lab tests were ordered, the nurse entered the order into the facility electronic documentation system which generated a computerized requisition through the clinical laboratories and placed in a notebook at the nurses station for the phlebotomist. Continued interview with LPN #1 revealed the computerized Daily Log was initialed by the phlebotomist after the lab specimens were obtained. Interview with Registered Nurse (RN) #2, identified as the 3rd floor Unit Manager and Assistant Director of Nursing (ADON), on 6/12/19 at 3:15 PM at the 3rd floor nurses station revealed once lab orders were placed in the computer system by the nurse there were electronic lab reminders at 12:15 AM, were printed by the nurse working at th time and placed in the identified lab notebook at the nurses station with the computerized requisition. Interview with the phlebotomist on 6/13/19 at 7:30 AM in the hallway on the 3rd floor revealed .the names on the door said the resident (#35) was in 'A' bed .I asked the resident (in the 'A' bed/actually Resident #55) if .name was (Resident #35) and (resident in the 'A' bed/actually Resident #55) said yes .I asked .where .armband was and .said it was in the cup .I should have found the nurse to help identify .(the resident) . Telephone interview with the Account Manager for the Clinical Laboratories on 6/12/19 at 5:35 PM confirmed a phlebotomist should check the resident's name on the door, ask for a resident's name and date of birth, or ask the resident's nurse to identify a resident before obtaining a specimen for laboratory tests. Interview with the DON on 6/13/19 at 11:15 AM in the conference room revealed it was up to the nurse entering the lab order into the computer system to change the room and bed number so the computerized Daily Log was accurate for the phlebotomist. Continued interview with the DON revealed the computer automatically generated the information for the requisition from the admission data on the resident and must be checked by the nurse with each lab order before printing the requisition for the phlebotomist. Resident #35 was admitted to room [ROOM NUMBER]-A and later moved to 320-B prior to 5/31/19 lab order. Continued interview with the DON confirmed the nurse entered lab orders on Resident #35 on 5/31/19 and 6/3/19 and failed to change the bed from 320-A to 320-B when the order was entered resulting in Resident #55 having 2 unnecessary venipunctures for unordered lab tests.",2020-09-01
704,THE HEALTH CENTER AT RICHLAND PLACE,445166,504 ELMINGTON AVENUE,NASHVILLE,TN,37205,2019-06-13,849,D,0,1,TUZL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility contract review, medical record review, and interview, the facility failed to have an interdisciplinary care plan between the hospice services provider and the facility for 1 of 8 residents (#55) receiving hospice services. The findings include: Review of a facility contract, Agreement between Hospice and Facility, dated 6/12/08, revealed .Hospice will prepare a care plan for that patient within two (2) working days and deliver a copy of it to the Facility . Medical record review revealed Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED]. Medical record review of the Nursing Care Plan, revised 6/11/19, revealed Resident has recently elected hospice services for comfort care--please notify hospice nurse of changes in condition/comfort .Nursing staff and hospice will collaborate care of resident/services needed for resident . Medical record review of the Hospice Care Plan, dated 6/12/19, revealed .skilled nursing to assess and evaluate 6/3/19 through 6/17/19 . Interview with Hospice Registered Nurse (RN) #3, on 6/12/19 at 10:15 AM in the 3rd floor hallway revealed she assessed Resident #55 on 6/5/19 with 2 Stage 2 Pressure Ulcers. Continued interview confirmed a Hospice Care Plan was not available to the facility at this time. Telephone interview with Hospice RN #7, identified as the Clinical Director of the Hospice provider, on 6/12/19 at 5:00 PM confirmed .we communicate our assessments verbally to the facility .we always talk to the nurse in the facility .written assessments are available to be sent over on request .we place the (handwritten) note (Communication Form) in a box in the charting room to be scanned into the chart .yes our policy says 48 hours after admission we try to give the (Hospice) care plan to the facility . Interview with the Director of Nursing (DON) on 6/13/19 at 3:00 PM in the conference room confirmed the Hospice Plan of Care was signed by the Hospice Medical Director on 6/12/19, sent to the facility 8 days after the resident was admitted to the Hospice provider instead of the 2 days required by the contract agreement between hospice and the facility.",2020-09-01
705,THE HEALTH CENTER AT RICHLAND PLACE,445166,504 ELMINGTON AVENUE,NASHVILLE,TN,37205,2018-06-27,693,D,0,1,ITMM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, medical record review, observation, and interview, the facility failed to administer a tube feeding formula as ordered by the physician for 1 resident (Resident #133) of 5 residents with tube feeding. Findings include: Review of the undated policy, Enteral Tube Feeding (Continuous Pump), revealed the .Procedure .Verify the physician's order .Check the label on the enteral formula against the physician order . Medical record review revealed Resident #133 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician order dated 6/15/18 revealed Glucerna (enteral/tube feeding for artificial nutrition) 1.2 calories at 60 milliliters per hour (ml/hr) continuous. Further review revealed the order was discontinued on 6/21/18. Further review of the physician orders dated 6/21/18 revealed Glucerna 1.2 calories at 75 ml/hr continuous. Observations on 6/25/18 at 8:37 AM and at 12:55 PM in Resident #133's room revealed a bottle of Glucerna 1.5 was available to be or was being administered. Observation on 6/26/18 at 7:43 AM revealed Resident #133 in the room and the tube feeding, Glucerna 1.5, was being administered with approximately 925 ml of the 1000 ml remaining available for administration. Observation in the resident's room on 6/26/18 at 10:27 AM, with Registered Nurse (RN) #3 present, and at 10:35 AM, with the Assistant Director of Nursing (ADON) #1 and RN #3 present, revealed the bottle of Glucerna 1.5 with 800 ml remaining in the bottle. Interview with RN #3 on 06/26/18 at 10:25 AM on the 200 hall confirmed RN #3 was assigned to Resident #133. Further interview confirmed the current physician order for [REDACTED].#133's room confirmed the tube feeding hung to be administered and had been administered to the resident was Glucerna 1.5. Further interview confirmed the facility failed to administer the ordered tube feeding. Interview with ADON #1 on 6/26/18 at 10:32 AM at the 200 nursing station confirmed the current tube feeding ordered for Resident #133 was Glucerna 1.2 at 75 ml/hr continuous. Further interview in Resident #133's room, with RN #1 present, confirmed the available tube feeding was Glucerna 1.5. Further interview confirmed the facility failed to follow the physician's order for the tube feeding.",2020-09-01
706,THE HEALTH CENTER AT RICHLAND PLACE,445166,504 ELMINGTON AVENUE,NASHVILLE,TN,37205,2018-06-27,732,C,0,1,ITMM11,"Based on observation and interview, the facility failed to update the posted staffing and census on 6/23/18 and 6/24/18. Findings included: Observation on 6/25/18 at 8:08 AM on the main hallway wall revealed the posted staffing and census was dated 6/22/18. Interview with the Administrator on 6/25/18 at 1:30 PM in the private dining room confirmed the facility failed to update the posted staffing and census for 6/23/18 and 6/24/18.",2020-09-01
707,THE HEALTH CENTER AT RICHLAND PLACE,445166,504 ELMINGTON AVENUE,NASHVILLE,TN,37205,2018-06-27,800,D,0,1,ITMM11,"Based on observation and interview, the facility dietary department failed to serve the cold food at or below 41 degrees Fahrenheit (F). Findings include: Observation on 6/25/18 at 11:22 AM revealed the resident main dining room mid-day meal trayline was in process and residents were eating. Further observation revealed banana pudding with whipped topping stored on ice on the trayline. Further observation revealed Registered Dietitian (RD) #1 obtaining 52 degrees F for the banana pudding. Observation on 6/25/18 at 11:32 AM in the dietary department revealed the resident mid-day meal trayline was in progress and 1 cart with 8 trays had been delivered to a unit. Further observation revealed RD #1 obtaining temperatures of individual servings of chicken salad at 50 degrees F, cottage cheese at 47 degrees F, potato salad at 48 degrees F, and banana pudding with whip topping at 42 degrees F. Observation on 6/25/18 at 11:42 AM in the dietary department revealed RD #1 tested the thermometer used to obtain all the food temperatures calibration and obtained the appropriate 32 degrees F. Interview with RD #1 on 6/25/18 at 11:22 AM in the resident main dining room and at 11:32 AM in the dietary department confirmed the facility failed to maintain the cold food at or less than 41 degrees F.",2020-09-01
708,THE HEALTH CENTER AT RICHLAND PLACE,445166,504 ELMINGTON AVENUE,NASHVILLE,TN,37205,2018-06-27,880,D,0,1,ITMM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, revealed the facility failed to store and date the nebulizer equipment for 2 of 6 residents (Resident #20 and Resident #13) with nebulizer equipment. Findings include: Review of the facility policy Respiratory Manual revised 7/14 revealed .Be sure nebulizer and tubing are labeled with date and initials . Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician orders dated 6/18/18 revealed .[MEDICATION NAME]-[MEDICATION NAME] 0.5 mg-3(2.5mg (milligram) base)/3 ml (milliter) Neb (nebulizer) Solution ([MEDICATION NAME]/[MEDICATION NAME] SULFATE) 1 ampul ([MEDICATION NAME]) Inhalation 4 times per day 7 days NEBULIZATION Dx (diagnosis): PNEUMONIA . Medical record review of the physician orders dated 4/27/18 revealed .[MEDICATION NAME]-[MEDICATION NAME] 0.5 mg-3 (2.5mg base)/3 ml Neb Solution ([MEDICATION NAME]/[MEDICATION NAME] SULFATE) 1 ampul Inhalation 4 times per day as needed CONGESTION NEBULIZER Dx: [MEDICAL CONDITIONS] . Observation on 6/25/18 at 9:08 AM in Resident #20's room revealed a nebulizer mask on top of the bedside dresser undated and not bagged. Observation on 6/25/18 at 11:25 AM in Resident #20's room, with Register Nurse (RN) #1 present, revealed the undated nebulizer mask and tubing was connected to the nebulizer machine. Further observation revealed the mask and tubing were found in the trash can. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician orders dated 6/8/18 revealed .[MEDICATION NAME]-[MEDICATION NAME] 0.5 mg -2.5 mg /2.5 mL Neb Solution ([MEDICATION NAME]/[MEDICATION NAME] SULFATE) 1 ampul Inhalation 4 times per day NEBULIZATION DX: RESPIRATORY SYMPTOMS . Observation on 6/25/18 at 9:13 AM in Resident #13's room revealed an undated and unbagged nebulizer mask attached to the nebulizer machine stored on top of the bedside dresser. Interview with RN #1 on 6/25/18 at 11:27 AM at the 3rd floor nurse station confirmed Resident #13 and, Resident #20, had undated and unbagged nebulizer masks stored on top of their bedside dressers. Interview with RN #2 on 6/27/18 at 10:32 AM at the 3rd floor nurse station confirmed the nebulizer masks were to be changed out every other day and were to be stored in a clear bag. Further interview confirmed the facility failed to date and appropriately store the nebulizer tubing and masks.",2020-09-01
709,LIFE CARE CENTER OF CROSSVILLE,445167,80 JUSTICE ST,CROSSVILLE,TN,38555,2019-06-19,695,D,0,1,S4TK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to administer oxygen (O2) as ordered for 2 residents (#65, #234) of 10 residents reviewed for O2 use of 19 residents sampled. The findings include: Medical record review revealed Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 14 Day Minimum Data Set ((MDS) dated [DATE] revealed the resident scored a 10 on the Brief Interview for Mental Status (BIMS) indicating the resident had moderate cognitive impairment. Continued review revealed the resident required extensive assistance of 2 staff for bed mobility, transfers, dressing, toileting, and hygiene. Further review revealed Resident #65 received supplemental O2. Medical record review of the Comprehensive Care Plan dated 6/5/19 revealed the resident had O2 therapy related to [MEDICAL CONDITION] with the intervention of O2 via (by) nasal cannula (bnc) at 6 liters per minute (l/m) continuous. Medical record review of the physician's orders [REDACTED]. Observation of Resident #65 on 6/17/19 at 1:35 PM, in the resident's room, revealed the resident was seated in a wheelchair with O2 tubing in place. Continued observation revealed the O2 tubing was attached to a portable O2 tank affixed to the resident's wheelchair. Further observation revealed the O2 tank was empty. Observation of Resident #65 and interview with Licensed Practical Nurse (LPN) #3 on 6/17/19 at 1:37 PM, in the resident's room, confirmed the resident's O2 tank was empty. Continued observation and interview revealed LPN #3 removed the O2 tubing from the portable tank and applied the O2 tubing to the concentrator. Continued observation revealed Resident #65's O2 saturation level was 92% (percent) after the resident was placed back on the O2 concentrator. Further interview with LPN #3 confirmed Resident #65 had not received the O2 as ordered by the Physician. Observation of Resident #65 on 6/18/19 at 8:13 AM, in the resident's room, revealed the resident was lying in bed with eyes closed. Continued observation revealed the O2 concentrator at the bedside was turned on, and the O2 tubing was in the O2 cover bag attached to the concentrator. Further observation revealed the O2 was not being administered to the resident. Continued observation revealed the resident was not in acute respiratory distress. Observation of Resident #65 and interview with Registered Nurse (RN) #1 on 6/18/19 at 8:18 AM, in the resident's room, confirmed the O2 tubing was in the plastic cover bag attached to the concentrator and not on the resident. Further interview confirmed Resident #65 had not received the O2 as ordered. Interview with the Director of Nursing (DON) on 6/19/19 at 8:10 AM in the DON's office, confirmed the facility failed to administer O2 to Resident #65 as ordered by the Physician. Medical record review revealed Resident #234 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED]. Observation of Resident #234 on 6/17/19 at 2:00 PM, in the resident's room, revealed the resident seated in a wheelchair eating lunch. Continued observation revealed the resident had O2 tubing in place and the tubing was connected to a portable O2 tank affixed to the wheelchair. Further observation revealed the O2 tank was empty. Continued observation revealed the resident was not in respiratory distress. Observation of Resident #234 and interview with Licensed Practical Nurse (LPN) #4 on 6/17/19 at 2:05 PM, in the resident's room, confirmed the resident's oxygen tank was empty. Continued observation and interview confirmed the resident had not received the O2 as ordered by the Physician. Further observation revealed the resident's O2 saturation level was 98% after the O2 was reapplied to the resident. Observation of Resident #234 on 6/18/19 at 3:10 PM, in the resident's room, revealed the resident was lying in bed without oxygen in use. Continued observation revealed the O2 tubing was lying on top of the O2 concentrator and was not within reach of the resident. Observation of Resident #234 and interview with LPN #1 on 6/18/19 at 3:20 PM, in the resident's room, confirmed the resident's O2 tubing was not in place and Resident #234 did not receive the O2 as ordered by the Physician. Continued observation revealed the resident's O2 saturation level was 92%. Observation of Resident #234 and interview with LPN #5 on 6/19/19 at 8:00 AM, in the resident's room, revealed the resident's O2 tubing was connected to a humidifier bottle (water bottle to help moisten the air) on the O2 concentrator. Continued observation of Resident #234 and interview with LPN #5 confirmed the humidifier bottle was not connected to the O2 concentrator. Further interview confirmed the O2 tubing and the humidifier bottle were not properly connected to the concentrator and the resident was not administered the O2 as ordered by the Physician. Interview with the Director of Nursing (DON) on 6/19/19 at 8:10 AM, in the DON's office, confirmed the facility failed to administer O2 as ordered to Resident #234.",2020-09-01
710,LIFE CARE CENTER OF CROSSVILLE,445167,80 JUSTICE ST,CROSSVILLE,TN,38555,2019-06-19,759,D,0,1,S4TK11,"**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 administer the correct dosage and correct medication for 1 resident (#39). The facility had a total of 2 medication errors in 35 opportunities resulting in a medication error rate of 5.71% (percent). The findings include: Review of facility policy, Administration of Medications, with an effective date of 4/24/19, revealed .All medications are administered safely and appropriately per physician order [REDACTED].>Medical record review revealed Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED]. Medical record review of a physician's orders [REDACTED]. Observation of medication administration with Licensed Practical Nurse (LPN) #6 on 6/18/19 at 7:40 AM, revealed LPN #6 administered Senna 8.6 mg 1 tablet; the physician's orders [REDACTED]. Continued observation revealed LPN #6 administered [MEDICATION NAME] (medication to treat seasonal allergies [REDACTED]. Interview with LPN #6 on 6/18/19 at 9:45 AM, at the East Wing nurse's station, confirmed Resident #39 received 1 tablet of the Senna and 1 tablet of [MEDICATION NAME] 10 mg. Continued interview confirmed the resident was not administered the [MEDICATION NAME] HCL 10 mg as ordered.we don't have any ([MEDICATION NAME]) to give, we are out .I gave her the [MEDICATION NAME] ([MEDICATION NAME]) in place of it so she would at least get something . Continued interview confirmed the Senna and the [MEDICATION NAME] were not administered as ordered and the [MEDICATION NAME] was administered without a physician's orders [REDACTED].>Interview with the Director of Nursing (DON) on 6/19/19 at 11:25 AM, in the DON's office, confirmed the facility failed to follow the physician's orders [REDACTED].#39 and failed to follow the facility's policy regarding medication administration.",2020-09-01
711,LIFE CARE CENTER OF CROSSVILLE,445167,80 JUSTICE ST,CROSSVILLE,TN,38555,2019-06-19,812,F,0,1,S4TK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility policy review, observation, and interview the facility failed to ensure expired food items were discarded and not available for resident use in 1 of 1 dry storage room, 1 of 1 kitchen, and 1 of 2 ice cream coolers observed. The findings include: Review of the facility policy, Food Safety, with a revised date of [DATE] revealed a Policy Statement .'Use by Date' is noted on the label or product when applicable. The 'use by date' guide is easily accessible to all associates involved with resident food storage .Food not safe for consumption or the safety of the food is in question will be removed from storage . Observation on [DATE] at 9:21 AM, during tour of the kitchen with the Dietary Manager revealed the following available for resident use: 1. ,[DATE] count box of banana frozen treats with a use by date of [DATE] 2. 43 mozzarella cheese sticks with a use by date of [DATE] 3. ,[DATE] count boxes of banana frozen treats with a use by date of [DATE] 4. ,[DATE] count boxes of banana frozen treats with a use by date of [DATE] 5. ,[DATE] count packages of hamburger buns with a use by date of [DATE] 6. 1 large package spaghetti noodles with a use by date of [DATE] 7. ,[DATE] count packages of hamburger buns with a use by date of [DATE] 8. ,[DATE] count packages of hotdog buns with a use by date of [DATE] Interview with the Dietary Manager on [DATE] at 9:55 AM, in the kitchen, confirmed the food items were past the use by dates and available for resident use in 1 of 1 dry storage room, 1 of 1 kitchen, and 1 of 2 ice cream coolers.",2020-09-01
712,LIFE CARE CENTER OF CROSSVILLE,445167,80 JUSTICE ST,CROSSVILLE,TN,38555,2019-06-19,880,D,0,1,S4TK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, and interview, the facility failed to follow contact isolation precautions for 1 resident (#46) of 1 resident reviewed for isolation precautions of 19 residents sampled. The findings include: Review of the facility policy, Transmission-based Precautions and Isolation Procedures, with an effective date of 1/30/19 revealed .Purpose .Transmission-based precautions are implemented based upon the means of transmission of an infection (contact, droplet, or airborne .in addition to standard precautions in order to prevent or control infection .Clearly identify the type of precautions and the appropriate PPE (Personal Protective Equipment) to be used .Place signage .outside the resident's room such as the door or on the wall next to the doorway identifying .precautions .instructions for use of PPE, and/or instructions to see the nurse before entering . Review of the facility policy, ,[MEDICAL CONDITION]. (Clostridioides) Difficile (infection in the colon causing diarrhea), with an effective date of 2/27/19 revealed .Alcohol-based hand rubs do not kill spore-forming organisms therefore hand washing must be done with soap and water . Medical record review revealed Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Resident #46's current Comprehensive Care Plan, revised 5/23/19, revealed .The resident has C. (,[MEDICAL CONDITION].) Difficile .CONTACT ISOLATION . Medical record review of current active Physician Orders revealed .contact isolation for [MEDICAL CONDITIONS]. every shift .order date 5/21/19 . Observation on 6/17/19 at 11:50 AM, revealed no sign outside the resident's room on the door or on the wall next to the doorway identifying precautions or instructions for use of PPE, and/or instructions to see the nurse before entering. Further observation revealed a PPE holder hanging on the resident's door with PPE (gown, gloves, masks, and shoe covers) available for use. Interview with Certified Nursing Assistant (CNA) #1 on 6/17/19 at 11:53 AM, in the A hallway, revealed the resident was on contact isolation for [MEDICAL CONDITION]. Continued interview revealed the facility does not place a sign on the resident's door regarding isolation. Interview with Licensed Practical Nurse (LPN) #1 on 6/17/19 at 11:59 AM, in the A hallway, revealed Resident #46 had a [DIAGNOSES REDACTED]. Further interview revealed if a visitor visits the resident she attempts to catch them before entering the room to let them know what PPE is needed prior to entering the resident's room. Continued interview revealed sometimes when visitors see the caddy on the door they question what it is for. Interview with LPN #1 on 6/17/19 at 12:46 PM, at the nurse's station, confirmed there was no contact isolation sign indicating isolation or see the nurse before entering the resident's room to alert visitors or staff regarding contact isolation. Observation on 6/17/19 at 1:15 PM, in the Resident #46's room, revealed a Blue Care Choices Coordinator standing at the bedside talking with the resident and no PPE had been donned (put on). Observation of LPN #2 on 6/17/19 at 1:17 PM, in the hallway at the resident's room, revealed LPN #2 entered Resident #46's room and delivered the meal tray without donning PPE. Interview with LPN #2 on 6/17/19 at 1:22 PM, in the A hallway, revealed if staff enter the resident's room and deliver a meal tray and are not touching the resident or anything soiled in the room, staff do not have to don PPE. Observation on 6/17/19 at 1:25 PM, in the hallway at Resident #46's room, revealed CNA #2 entered the resident's room to answer his call light. Further observation revealed the CNA donned gown, gloves, and mask prior to entering the room. Continued observation revealed she removed the PPE and placed it in biohazard containers in the room, exited the room, and used hand sanitizer to sanitize the hands. Observation on 6/17/19 at 1:35 PM, in the hallway at the resident's room, revealed CNA #2 re-entered Resident #46's room and the CNA donned gown, gloves, and mask prior to entering the room. Further observation revealed the CNA reached in her pocket, retrieved packets of butter and sour cream and gave them to the resident. Continued observation revealed the CNA removed the PPE and placed it in biohazard containers in the room, exited the room, and used hand sanitizer to sanitize the hands. Interview with CNA #2 on 6/17/19 at 1:50 PM, in the A hallway, revealed she was unaware that she should wash the hands with soap and water and was not aware she should not use hand sanitizer to sanitize the hands when a resident had [MEDICAL CONDITION]. Observation on 6/18/19 at 7:55 AM, in the resident's room, revealed the Minimum Data Set (MDS) LPN standing at the resident's bedside assisting with meal set up with gloved hands, and no gown in place. Observation of CNA #2 on 6/18/19 at 7:55 AM, in the resident's room, revealed the CNA assisting the resident with denture care. Further observation revealed the CNA had gloved hands and no gown in place. Interview with the MDS LPN on 6/18/19 at 8:08 AM, in the A hallway, revealed a gown had to be donned if touching anything contaminated in the room, otherwise only gloves had to be donned prior to entering Resident #46's room. Further interview revealed the resident should have a sign on his door that informs staff and visitors to see the nurse before entering the room due to contact isolation precautions. Interview with CNA #2 on 6/18/19 at 8:20 AM, in the A hallway, revealed she had been informed staff only had to wear gloves in the resident's room unless they were providing care for the resident and their clothes would likely come in contact with the resident. Interview with the Director of Nursing (DON) on 6/19/19 at 8:00 AM, in the Administrators office, confirmed staff should don gown and gloves prior to entering a contact isolation room. Further interview confirmed the facility failed to follow the contact isolation and [MEDICAL CONDITION] policy when providing care for Resident #46.",2020-09-01
713,LIFE CARE CENTER OF CROSSVILLE,445167,80 JUSTICE ST,CROSSVILLE,TN,38555,2017-06-21,282,G,1,1,VPY311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, facility investigation review, and interview the facility failed to provide supervision and assistance based on the resident's individualized care plan for toileting and personal care needs for 1 resident (#66) of 33 residents reviewed. Failure of the facility to provide care directed by the care plan resulted in HARM for Resident #66. The findings included: Review of the facility policy, Fall Management, dated 6/2016, 11/2016, revealed .promote patient safety and reduce patient falls by proactively identifying, care planning .avoidable accident: means that an accident occurred because the facility failed to .implement interventions, including supervision, consistent with a patient's needs, goals, plan of care .in order to reduce the risk of an accident . Medical record review revealed Resident #66 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record of the Care Plan dated 1/12/13 and confirmed with the Director of Nursing (DON) on 6/21/17 at 10:35 AM, in the DON office to be correct for both the MDS assessment and the care plan, revealed Activities of Daily Living (ADLs) requires extensive staff assistance with all ADLs due to impaired mobility and cognitive impairment. Further review of the Falls Care Plan revealed, assist x (times) 2 with bed mobility. Medical record review of the Care Directive Certified Nurse Aide (CNA) guide for care plans dated 1/18/17, revealed, Bed Mobility assist x 2 and Toileting total. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #66 scored 6 out of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. Further review revealed Bed Mobility and Toilet use had been assessed as Extensive Assistance requiring 2 plus persons for physical assistance. Medical record review of the facility's investigation dated 3/6/17 revealed .CNA was providing pericare (incontinence care) to resident in bed and had resident turned on her left side when CNA turned around to reach for a washcloth and resident slid off the edge of bed . Continued review of the Witness Statement Form revealed CNA #1 .I .was changing (Resident #66) when she had a large BM (bowel movement) .on her left side when I turned away to get another washcloth she had slide off the bed onto the floor . Medical record review of the Progress Notes dated 3/6/17 revealed .staff was providing resident with pericare .slid off the bed and into the floor .observed to be sitting on her bottom .abrasion noted to middle right finger .left leg also noted to be bent behind resident with hard protrusion noted below left knee with laceration .admitted .with [DIAGNOSES REDACTED].'' Medical record review of the Skin Integrity Data Collection dated 3/6/17 revealed .right forearm and hand .skin tear to middle finger right hand .skin tear to left knee below left knee . Medical record review of the hospital's Left Leg X-Ray Two Views findings, dated 3/6/17 revealed .comminuted impacted fractures of proximal left tibia and fibula . Review of facility's inservice training, Providing Care to a Resident While in Bed, dated 3/10/16 revealed .resident should never be rolled away .never turn from resident while providing care .turn attention away .if providing care and needs to reach for an item or look away, the resident should be returned to a safe position .ensure you have appropriate amount of assistance . Interview with Licensed Practical Nurse (LPN) #3 on 6/19/17 at 9:00 AM, at the 100 nursing station confirmed she had been assigned to the care of Resident #66 on 3/6/17 .slipped off the side of the bed . she (CNA #1) rolled her over .legs must have been too close to the edge .(CNA #1) called me into the room .one leg was behind her .(Resident #66) said she had fallen . Continued interview revealed Resident #66 was totally dependent on care. Interview with the Assistant Director of Nursing (ADON) on 6/20/17 at 10:00 AM, in the 100 nursing station confirmed she assisted with Resident #66 after the fall on 3/6/17. Continued interview confirmed .(CNA #1) was on (Resident #66) right side .there was no other staff in the room .the resident was on the floor, her left leg curled behind her, her knee was discolored, a skin tear on her hand and knee .(Resident #66) said she was hurting . Further interview confirmed they called an ambulance and the resident was transported to the hospital. Telephone interview with the Medical Director on 6/21/17 at 10:00 AM, revealed .somebody changed her by herself .she was dependent on care .not sure if she could have held onto a side rail .it sounds reasonable to have 2 persons to assist her . Interview with the Director of Nursing (DON) on 6/21/17 at 10:35 AM in the DON office confirmed Resident #66 was care planned correctly as a 2 person assist for bed mobility and toileting needs. Continued interview confirmed the facility's failure to ensure the care plan for Resident #66 was followed utilizing the amount of assistance required for safe administration of care when working with Resident #66 resulted in a fall with a fracture and HARM to the resident.",2020-09-01
714,LIFE CARE CENTER OF CROSSVILLE,445167,80 JUSTICE ST,CROSSVILLE,TN,38555,2017-06-21,323,G,1,1,VPY311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the facility's policy, review of the medical record, review of the facility's investigation, and interview, the facility failed to ensure supervision and assistance in toileting and personal care to prevent accidents for 1 resident (#66) of 3 residents reviewed for accidents resulting in HARM to Resident #66. The findings included: Review of the facility policy, Fall Management, dated 6/2016, 11/2016, revealed .promote patient safety and reduce patient falls by proactively identifying, care planning .avoidable accident: means that an accident occurred because the facility failed to .implement interventions, including supervision, consistent with a patient's needs, goals, plan of care .in order to reduce the risk of an accident . Medical record review revealed Resident #66 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record of the Care Plan dated 1/12/13 and confirmed with the Director of Nursing (DON) on 6/21/17 at 10:35 AM, in the DON office to be correct for both the MDS assessment and the care plan, revealed Activities of Daily Living (ADLs) requires extensive staff assistance with all ADLs due to impaired mobility and cognitive impairment. Further review of the Falls Care Plan revealed, assist x (times) 2 with bed mobility. Medical record review of the Care Directive Certified Nurse Aide (CNA) guide for care plans dated 1/18/17, revealed, Bed Mobility assist x 2 and Toileting total. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #66 scored 6 out of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. Further review revealed Bed Mobility and Toilet use had been assessed as Extensive Assistance requiring 2 plus persons for physical assistance. Medical record review of the facility's investigation dated 3/6/17 revealed .CNA was providing pericare (incontinence care) to resident in bed and had resident turned on her left side when CNA turned around to reach for a washcloth and resident slid off the edge of bed . Continued review of the Witness Statement Form revealed Certified Nursing Aide (CNA) #1 .I .was changing (Resident #66) when she had a large BM (bowel movement) .on her left side when I turned away to get another washcloth she had slide off the bed onto the floor . Medical record review of the Progress Notes dated 3/6/17 revealed .staff was providing resident with pericare .slid off the bed and into the floor .observed to be sitting on her bottom .abrasion noted to middle right finger .left leg also noted to be bent behind resident with hard protrusion noted below left knee with laceration .admitted .with [DIAGNOSES REDACTED].'' Medical record review of the Skin Integrity Data Collection dated 3/6/17 revealed .right forearm and hand .skin tear to middle finger right hand .skin tear to left knee below left knee . Medical record review of the hospital's Left Leg X-Ray Two Views findings, dated 3/6/17 revealed .comminuted impacted fractures of proximal left tibia and fibula . Review of facility's inservice training, Providing Care to a Resident While in Bed, dated 3/10/16 revealed .resident should never be rolled away .never turn from resident while providing care .turn attention away .if providing care and needs to reach for an item or look away, the resident should be returned to a safe position .ensure you have appropriate amount of assistance . Interview with Licensed Practical Nurse (LPN) #3 on 6/19/17 at 9:00 AM, at the 100 nursing station confirmed she had been assigned to the care of Resident #66 on 3/6/17 .slipped off the side of the bed . she (CNA #1) rolled her over .legs must have been too close to the edge .(CNA #1) called me into the room .one leg was behind her .(Resident #66) said she had fallen . Continued interview revealed Resident #66 was totally dependent on care. Interview with the Assistant Director of Nursing (ADON) on 6/20/17 at 10:00 AM, in the 100 nursing station confirmed she assisted with Resident #66 after the fall on 3/6/17. Continued interview confirmed .(CNA #1) was on (Resident #66) right side .there was no other staff in the room .the resident was on the floor, her left leg curled behind her, her knee was discolored, a skin tear on her hand and knee .(Resident #66) said she was hurting . Further interview confirmed they called an ambulance and the resident was transported to the hospital. Telephone interview with the Medical Director on 6/21/17 at 10:00 AM, revealed .somebody changed her by herself .she was dependent on care .not sure if she could have held onto a side rail .it sounds reasonable to have 2 persons to assist her . Interview with the Director of Nursing (DON) on 6/21/17 at 10:35 AM, in the DON office confirmed Resident #66 was correctly assessed for both the MDS assessment and the care plan. Further interview confirmed the facility failed to prevent the fall which resulted in injury and HARM to Resident #66.",2020-09-01
715,LIFE CARE CENTER OF CROSSVILLE,445167,80 JUSTICE ST,CROSSVILLE,TN,38555,2017-06-21,431,F,0,1,VPY311,"Based on observations, staff interview and review of the policy on medication storage, the facility failed to ensure medications were stored according to manufacturer's guidelines, failed to label medications with resident names, and failed to discard expired medications. This affected medication stored in 2 of 2 medication storage rooms observed. The findings included: On 6/19/17 at 10:30 AM, observations were made of the West Hall medication storage room and the B Hall medication cart with Licensed Practical Nurse (LPN) #1. One 8 ounce bottle of Tussin liquid (cough syrup) approximately half full had an expiration date of 8/15. The Tussin liquid had a manufacturer's expiration date of 8/15. The expiration date was verified by LPN #1. The bottle of Tussin liquid had been opened and was dated 6/15/17. On 6/19/17 at 11:20 AM, observations were made of the East Hall medication storage room with Registered Nurse (RN) #1. One bottle of 1 fluid ounce Systane Lubricating Eye Drops was observed in the refrigerator with no resident name. The Systane Lubricating Eye Drops manufacturer's instructions on the bottle indicated the eye drops were to be stored at room temperature. The medication refrigerator in the East Hall medication storage room also had two, 5 milliliter (ml) bottles of influenza vaccine with an expiration date of 6/7/17. RN #1 was interviewed in the medication room on the East Hall and stated she didn't know why the eye drops were stored in the refrigerator. She also verified the 2 bottles of influenza vaccination expired on 6/7/17. RN #1 stated it was the nurses' responsibility who worked on the floor to check the medications for proper storage. On 6/19/17 at 11:36 AM in the East Hall, RN #1 provided the policy, Medication Storage & Security in the Facility with a revision date of 6/21/06. RN #1 was interviewed at the time the policy was provided in the East Hall. She stated she was not sure why the Systane Lubricating Eye Drops were not labeled correctly with a resident's name or why they were stored in the refrigerator when the manufacturer's instructions were to store at room temperature. Review of the Medication Storage & Security in the Facility policy, with a revision date of 6/21/06 included the following: The medications for each resident shall be stored in containers in which they were received and must not be transferred to other containers for storage. Medication containers that are damaged or poorly labeled must be returned to the pharmacy for relabeling or disposal, if permitted by state law. medications are stored safely, securely and properly following manufacturer's recommendations or those of the supplier. The policy also indicated medications requiring storage at room temperature are kept at temperatures ranging from 15 degrees Celsius (C) or 59 degrees Fahrenheit (F) to 30 degrees (C) or 86 degrees (F). On 6/21/17 at 9:55 AM, the Director of Nursing (DON) was interviewed in the conference room. The DON stated a pharmacy technician comes in monthly and looks at the facility's drug storage. The DON thought the Tussin cough syrup was purchased at a local drugstore and was outdated. The DON did not know why the eye drops were stored with no resident name in the refrigerator. She thought the influenza vaccine bottles must have been left over when their influenza season ended at the end of (MONTH) (YEAR).",2020-09-01
716,LIFE CARE CENTER OF CROSSVILLE,445167,80 JUSTICE ST,CROSSVILLE,TN,38555,2018-07-11,658,D,1,1,QYTP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility documentation, and interview, the facility failed to follow professional standards of practice for 1 resident (#49) of 30 residents reviewed for medication administration. The findings include: Review of the facility policy Administration of Medication, undated, revealed .Standard .All medications are administered safely and appropriately .Responsibility of the nursing professional: be aware of the classification, action, correct dosage, and side effects of a medication before administration .Read each order entirely . Medical record review revealed Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status score of 12, indicating moderate cognitive impairment. Further review revealed Resident #49 required extensive 2 person physical assistance for all activities of daily living except eating, which required supervision and set up and personal hygiene which only required extensive assistance by 1 staff member. Further review revealed the resident experienced behaviors not directed towards others 4-6 days per week and rejected care 1-3 days a week. Continued review revealed the resident received an antipsychotic, antianxiety, and antidepressant medication for 7 of 7 days. Medical record review of a Physician's Recapitulation Order dated 10/23/17 revealed .Quetiapine (antipsychotic medication) 150 MG (milligrams) PO (by mouth) daily at bedtime [MEDICAL CONDITION] Disorder . Review of facility documentation dated 11/7/17 revealed .Resident had an order for [REDACTED]. (approximately) 2:30 PM prior to MD (physician) being called to obtain a new order to separate the dose . Telephone interview with Registered Nurse (RN) #1 on 7/10/18 at 10:16 AM confirmed .(on 11/4/17) took it upon myself to give (Resident #49) a part of her bedtime dose of (antipsychotic medication) .I gave her 50 (mg) of that (150 MG dose) around 4pm .it was too early .doctor was later contacted . Interview with the Director of Nursing (DON) on 7/11/18 at 4:10 PM, in the DON's office, confirmed the facility failed to follow professional standards of practice for medication administration for Resident #49.",2020-09-01
717,LIFE CARE CENTER OF CROSSVILLE,445167,80 JUSTICE ST,CROSSVILLE,TN,38555,2018-07-11,698,E,0,1,QYTP11,"**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 post [MEDICAL TREATMENT] assessments were completed for 1 resident (#58) of 1 resident reviewed for [MEDICAL TREATMENT] for 17 days of 18 scheduled [MEDICAL TREATMENT] days of 30 sampled residents. The findings include: Review of facility policy [MEDICAL TREATMENT] dated 11/28/16 revealed .Procedure .The [MEDICAL TREATMENT] patient shall receive consistent care pre and post-[MEDICAL TREATMENT] .Post [MEDICAL TREATMENT] .1. Obtain Vital signs of patient upon return from [MEDICAL TREATMENT] .2. Follow routine [MEDICAL TREATMENT] instructions on [MEDICAL TREATMENT] transfer form .6. Internal vascular access (vascath/permcath): dressing should be reinforced with tape as needed to assure that catheter is kept clean and dry .If dressing becomes wet/soiled or if the patient removes it, please use the sterile technique to replace it .7. Maintain [MEDICAL TREATMENT] transfer form in the patient's medical record .General Guidelines .3. Assess for any signs/symptoms of infection .4. Monitor for any complaints or observations at vascular access site .6. Document in the clinical nursing record: [MEDICAL TREATMENT] treatment completed . Medical record review revealed Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating Resident #58 was cognitively intact. Continued review revealed the resident had special treatments with [MEDICAL TREATMENT] and required extensive assistance of 2 person with bed mobility, transfer, and dressing. Medical record review of the Pre/Post [MEDICAL TREATMENT] Communication form for Resident #58 dated 6/1/18 - 7/10/18 revealed the following: *6/1/18 missing vital signs, condition of [MEDICAL TREATMENT] access/site, and signs/symptoms (S/S) of infection *6/2/18 missing condition of [MEDICAL TREATMENT] access/site, S/S of infection *6/5/18 missing condition of [MEDICAL TREATMENT] access/site, S/S of infection *6/7/18 missing vital signs, condition of [MEDICAL TREATMENT] access/site, S/S of infection *6/9/18 no Pre/Post [MEDICAL TREATMENT] assessment was done *6/12/18 no Pre/Post [MEDICAL TREATMENT] assessment was done *6/13/18 missing condition of [MEDICAL TREATMENT] access/site, S/S of infection *6/16/18 missing condition of [MEDICAL TREATMENT] access/site, S/S of infection *6/19/18 missing vital signs, condition of [MEDICAL TREATMENT] access/site, S/S of infection *6/21/18 missing condition of [MEDICAL TREATMENT] access/site, S/S of infection *6/23/18 missing condition of [MEDICAL TREATMENT] access/site, S/S of infection *6/26/18 missing vital signs, condition of [MEDICAL TREATMENT] access/site, S/S of infection *6/28/18 No Pre/Post [MEDICAL TREATMENT] assessment was done *6/30/18 missing condition of [MEDICAL TREATMENT] access/site, S/S of infection *7/5/18 missing vital signs, condition of [MEDICAL TREATMENT] access/site, S/S of infection *7/7/18 missing condition of [MEDICAL TREATMENT] access/site, S/S of infection *7/10/18 missing vital signs, condition of [MEDICAL TREATMENT] access/site, S/S of infection Medical record review of Nursing Notes dated 6/1/18 - 7/11/18 revealed no documentation of the Post [MEDICAL TREATMENT] assessment. Interview with Licensed Practical Nurse (LPN) #1 on 7/11/18 at 9:40 AM, in the East Nursing station, confirmed the [MEDICAL TREATMENT] form should be completed pre and post [MEDICAL TREATMENT]. Interview with LPN #2 Unit/Care Coordinator on 7/11/18 at 10:12 AM, in the East Nursing station, revealed .we take the vitals and assess the site .the nurse should fill out the [MEDICAL TREATMENT] form before they go and when they come back (from the [MEDICAL TREATMENT] clinic) .they should make a note when the resident comes back and the condition of their [MEDICAL TREATMENT] site and take vitals . Interview with the Director of Nursing (DON) on 7/11/18 at 10:18 AM, in the DON's office, confirmed .the expectation for a [MEDICAL TREATMENT] resident is (the nurse) to fill out the [MEDICAL TREATMENT] form on the chart, take vital signs .when the resident comes back to the facility the nurses are to fill out the Post [MEDICAL TREATMENT] part on the form . Continued interview confirmed the Post [MEDICAL TREATMENT] assessment was not complete for Resident #58 on 6/1/18, 6/2/18, 6/5/18, 6/7/18, 6/9/18, 6/12/18, 6/13/18, 6/16/18, 6/19/18, 6/21/18, 6/23/18, 6/26/18, 6/28/18, 6/30/18, 7/5/18, 7/7/18 and 7/10/18.",2020-09-01
718,LIFE CARE CENTER OF CROSSVILLE,445167,80 JUSTICE ST,CROSSVILLE,TN,38555,2018-07-11,812,F,0,1,QYTP11,"Based on facility policy, observation, and interview, the facility failed to maintain a sanitary environment in 1 of 1 dry storage rooms, 1 of 1 walk in coolers, and during 1 of 1 meal services observed potentially affecting 86 of the 87 residents residing in the facility. The findings include: Review of an undated facility policy, Food Safety revealed .Scoops will be stored in a manner that does not have the potential to contaminate the food ingredients. For example, scoops will be stored outside of bins or placed in a holder on the side of a bin . Review of the facility Use by Date Guide last revised 1/13/17 revealed .Item/Category .Milk, opened/unopened .Use by .Manufacturer's use by date . Observation and interview with the Dietary Manager (DM) on 7/9/18 at 9:30 AM, in the dry storage room, revealed a scoop stored inside the sugar, flour, and cornmeal bins. Interview with the DM confirmed the scoops should not have been stored inside the bins. Observation and interview with the DM on 7/9/18 at 9:40 AM, in the walk in cooler, revealed 1 gallon of 2% milk, half empty, with a best by date of 7/2/18. Interview with the DM confirmed milk was good for 3 days after opening and should be labeled with the date opened. Continued interview confirmed the milk was not labeled with the open date and should have been discarded. Observation and interview with Dietary Aid (DA) #1 on 7/9/18 at 11:30 AM, in the kitchen, revealed the DA was wearing gloves and blew her nose into a napkin. Further observation revealed DA #1 failed to remove gloves, wash the hands, or throw away the napkin prior to handling a plate warmer. Interview with DA #1 confirmed she failed to perform proper hand hygiene before handling food service equipment.",2020-09-01
719,GOOD SAMARITAN HEALTH AND REHAB CENTER,445170,500 HICKORY HOLLOW TERRACE,ANTIOCH,TN,37013,2019-01-08,842,D,1,0,KGXD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview, the facility failed to maintain complete and accurate medical record for 1 resident (#1) of 3 records reviewed. The findings include: Review of the facility policy, Medication Administration, dated 1/15/12, revealed .Medications shall be administered .as prescribed .The individual administering the medication must initial the resident's Medication Administration Record (MAR) on the appropriate line after giving the medication . Medical record review revealed Resident #1 was admitted to the facility on [DATE]. Resident #1's [DIAGNOSES REDACTED]. The resident was discharged to an acute hospital on [DATE]. Medical record review of Resident #1's Pain Tool form dated 12/6/18 revealed the location of pain in right and left knees (front), pain was relieved by Tylenol 650 milligrams, effected the resident's sleep, social and physical activities/mobility, and emotions; and pain was made worse with movement and weather change. Medical record review of Physician Orders dated 12/6/18 revealed .Aspirin 81 milligrams (mg) 1 time daily for pain related to fracture, Monitor pain every shift, and Tylenol 325 mg Give 2 tablets every 8 hours as needed (PRN) for pain/fever . Medical record review of the Pain Interview form dated 12/13/18 revealed Resident #1 had occasional pain in last 5 days; pain did not make it hard to sleep; pain did limit day-to-day activities in past 5 days; intensity of pain 5 out of 10; indicators of pain/possible pain-vocal complaints; frequency with which resident complains or shows evidence of pain or possible pain-3 to 4 days; .Treatment .Received PRN pain medication-[MEDICATION NAME] 325 mg (milligrams) give 2 tablets po (by mouth) every 8 hr (hours) as needed-effective .Receive non-pharmaceutical intervention-Repositioning, Dim Light/Quiet environment, sometimes not effective (12/9, 12/10); Comments - resident has moderately cognitive impairment which can affect his perception of pain . Medical record review of the Admission Minimum (MDS) data set [DATE] revealed Resident #1 had experienced occasional pain within the past 5 days of the review period which limited his day-to-day activity with an intensity of 5 out of 10. Medical record review of the 12/2018 Daily Skilled Charting forms regarding Resident #1's complaints of pain revealed the following: 12/8 at 1:48 PM D (Days) .Describe pain .Bilateral legs and lower back; Received PRN pain medication or was offered and declined; and Comments- Has order for Tylenol 650mg, no relief noted, placed on MD (Medical Doctor) communication book for 12/9/18 . Review of the MD communication book on 12/8/18 revealed no documentation regarding pain for Resident #1. 12/8 at 6:14 PM [NAME] (Evening) . Describe pain .BLE/Back (Bilateral Lower Extremities/Back); Received PRN pain medication or was offered and declined . 12/9 at 11:19 AM D .Describe pain .Bilateral Lower Extremities, greater to knees, low back; Received PRN pain medication or was offered and declined; Comments-MD aware . 12/10 6:34 PM [NAME] .Describe pain .in BLE, back; Received PRN pain medication or was offered and declined . 12/11 at 7:50 PM [NAME] .Describe pain .BLE; Received PRN pain medication or was offered and declined . 12/12 at 6:18 PM [NAME] .Describe pain .BLE, lower back; Received PRN pain medication or was offered and declined . Medical record review of the 12/2018 MAR revealed the Aspirin was administered daily as ordered and the pain was monitored every shift. The pain level was zero except for 12/8/18 at 9:00 AM when it was 5 out of 10. The PRN Tylenol was administered on 12/6/18 at 11:06 PM and on 12/12/18 at 12:38 PM. The level of pain monitored every shift revealed on 12/6/18 at 11:06 PM was 7; on 12/8/18 was 5 for day shift, 6 for evening shift, 2 for night shift; on 12/9/18 was 4 for day shift, was 5 for evening shift; and on 12/11/18 was 4 on evening shift. Interview with Licensed Practical Nurse (LPN) #2/Nurse Supervisor on 1/8/19 at 9:55 AM by the nursing station when asked if the Daily Skilled Charting form had the resident complaining of pain and PRN pain medication was administered what was the LPN's expectation of documentation in the MAR. The LPN stated she would .expect the MAR to indicate the PRN pain medication was administered . Further interview at 10:25 AM in the conference room confirmed the MAR failed to address the administration of the PRN medication when compared to the Daily Skilled Charting forms dated 12/8/18 to 12/12/18. Interview with the Director of Nursing (DON) on 1/8/19 at 10:10 AM in the conference room stated her expectation of .staff was to initial the MAR when a medication was administered . When asked if the Daily Skilled Charting form stated the resident was complaining of pain and the PRN pain medication was administered would she expect the MAR to reflect the administration, the DON stated Yes.",2020-09-01
720,GOOD SAMARITAN HEALTH AND REHAB CENTER,445170,500 HICKORY HOLLOW TERRACE,ANTIOCH,TN,37013,2017-02-16,157,D,0,1,BNS411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and interview, the facility failed to obtain a discharge to hospital order for 1 resident (#4) of 30 residents reviewed and failed to obtain a physician order for [REDACTED]. The findings included: Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a nursing note dated 1/16/17 revealed Resident #4 was transferred to the hospital for pain. Medical record review revealed no physician order to transfer the resident to the hospital. Further review revealed a physician order dated 1/18/17 .Return from hospital . Interview with Licensed Practical Nurse (LPN) #4 on 2/14/17 at 9:04 AM in the conference room confirmed the facility failed to obtain a physician order for [REDACTED]. Medical record review revealed Resident #14 was admitted to the facility on [DATE], and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Observation on 2/13/17 at 11:00 AM and on 2/14/17 at 11:12 AM revealed a C-Pap mask stored on the bed side table in Resident #14's room. Medical record review of the physician orders revealed no order for the C-Pap setting. Interview with LPN #3 on 2/15/17 at 8:12 AM at the nursing station revealed the staff turned the machine on and off per the direction of the resident and gave him the mask to put on. Further interview confirmed the facility failed to obtain the C-Pap setting order.",2020-09-01
721,GOOD SAMARITAN HEALTH AND REHAB CENTER,445170,500 HICKORY HOLLOW TERRACE,ANTIOCH,TN,37013,2017-02-16,225,D,0,1,BNS411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility investigation review, and interview the facility failed to report allegations of abuse in a timely manner for 3 residents (#20, #31, #102) of 5 residents reviewed for abuse and failed to complete a thorough investigation for an injury of unknown origin for 1 resident (#20) of 5 residents reviewed for abuse. The findings included: Review of facility policy, Accidents/Incidents Investigations, revised 6/1/12 revealed, .The facility will investigate and report all accidents/incidents in accordance with State and Federal Regulations . Review of facility policy, Abuse Investigations, revised 6/1/12 revealed, .All reports of .injuries of an unknown source shall be promptly and thoroughly investigated by facility management .the investigation should, at a minimum .determine events leading up to the incident; Interview the person (s) reporting the incident .interview the resident .interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .A facility incident report should be filled out and all supporting documentation filed with the incident report . Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Significant Change Minimum Data Set ((MDS) dated [DATE] revealed the resident was cognitively intact and exhibited no signs or symptoms of [MEDICAL CONDITION] or behaviors. The resident was totally dependent requiring assistance of 2 or more people for bed mobility and transfers. Continued review revealed the resident had no falls since the prior assessment on 11/21/16. Review of a facility investigation dated 12/15/16 for Resident #20 revealed the resident was sitting at the nurse station complaining of left knee pain. An X-ray was ordered and revealed a [MEDICAL CONDITION] distal femur. Continued review revealed the investigation did not contain any statements from the resident or staff providing care to the resident. Further review revealed there was no determination as to the cause of the fracture. Further review revealed the facility reported the injury of unknown origin to the State Agency on 12/21/16. Interview with the Administrator on 2/16/17 at 8:10 AM in the Conference Room confirmed she was notified of a fracture to Resident #20's left leg on 12/15/16. Continued interview confirmed the facility reported the injury to the State Agency on 12/21/16. The Administrator confirmed the facility failed to report an injury of unknown origin in a timely manner. Medical record review of a DXA Bone Density Axial Radiological Scan dated 8/15/16 revealed, .Hip data indicate [MEDICAL CONDITION] . Medical record review revealed Resident #20 received Aqua Therapy through a research program at a University, and Restorative Nurse Aide (RNA) range of motion services in 11/2016 and 12/2016 prior to obtaining the distal femur fracture. Medical record review of a Nursing Progress Note dated 12/15/16 at 5:31 PM revealed, .X-ray of left knee . No other documentation was present as to why the X-ray was ordered, or the symptoms of Resident #20. Medical record review of a Radiology Report dated 12/15/16 at 9:20 PM revealed, .Conclusion: Impacted distal femur fracture . Interview with Resident #20 on 2/16/17 at 9:50 AM in the fine dining room revealed he attended Aqua Therapy at a university on Mondays and Wednesdays. The resident stated on a Tuesday (12/13/16) RNA #1 was doing stretching exercises on his legs and he heard a pop when his left leg was raised. The resident denied pain at that point. The resident told RNA #1 his leg was dead, and he couldn't raise it at all anymore. The next day (12/14/16) he went to Aqua Therapy and wasn't able to do any therapy. Resident #20 reported his leg began to swell and have pain later that evening and the next day. The next day (12/15/16) the resident received an X-ray and found out he had a fracture. Continued interview confirmed the only people who asked him about the fracture were the Nurse Practitioner (NP), the MD ( Medical Doctor), the Physical Therapist (PT) and the Occupational Therapist (OT). Resident #20 denied any interview with facility administration following the fracture. Medical record review of a Follow Up Question Report dated 12/1/16-12/31/16 regarding how well Resident #20 tolerated the exercise activity provided by the RNA revealed the resident tolerated the exercises well on 12/11/16, 12/12/16, and 12/13/16. Telephone interview with the NP on 2/16/17 at 11:39 AM revealed she found out about the research study for Resident #20 based on his request. The NP confirmed the MD was aware of the research program based on the information she provided and was aware of the results of the bone density scan with a [DIAGNOSES REDACTED]. Telephone interview with the MD on 2/16/17 at 12:15 PM confirmed he was in agreement with Aqua Therapy research therapy and was aware of the potential risks to the resident related to the bone density results. The MD stated, We treated him with [MEDICATION NAME] (medication used to prevent and treat bone loss) for a year first. In hindsight, it probably wasn't the best thing to do but I would do it again. The MD confirmed he had frequent conversations with the NP regarding the therapy and did see improvement with the resident's function prior to the fracture. When asked what the cause of the femur fracture was, the MD stated, Really, really severe [MEDICAL CONDITION] and he was functionally not capable of weight bearing activity. Interview with the Administrator on 2/16/17 at 12:15 PM in the Administrator's office confirmed the facility investigation report was incomplete. Continued interview confirmed the facility did not interview the resident, other staff members who had contact with the resident between 12/13/16 and 12/15/16 or obtain statements from them. The Administrator confirmed there was no determination of the cause of the fracture and confirmed the facility failed to complete a thorough investigation for an injury of unknown origin for Resident #20. Medical record review revealed Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility investigation revealed Resident #31 was observed with a pink, swollen .left hand pinky finger . on 1/2/17 at 11:30 AM in the main dining room. Further review revealed the cause of the swelling and discoloration was unknown and the facility initiated an investigation. Review of a facility investigation revealed the facility reported the injury of unknown origin to the State Agency on 1/9/17, 8 days after the incident occurred. Interview with the Administrator on 2/16/17 at 8:10 AM in the conference room confirmed the facility failed to report the injury of unknown origin to the State Agency in a timely manner. Medical record review revealed Resident #102 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Annual Minimum (MDS) data set [DATE] revealed the resident was severely impaired cognitively. Review of a facility investigation dated 1/21/16 revealed at 11:20 AM Housekeeper #1 witnessed CNA #5, .Allegedly .pulled covers off resident and cursed at him Continued review of the facility investigation revealed a written statement by Housekeeper #1 dated 1/26/17. Interview with Housekeeper #1 on 2/15/17 at 1:50 PM in the housekeeping room on the 300 Hall revealed she was cleaning in Resident #102's room on 1/21/17. She stated CNA #5 entered the room, talking trash, calling Resident #102 names, using profanity, and .jerked the cover off him . She further stated the resident appeared to look scared and hurt. She stated she reported the incident to her immediate supervisor, the Director of Housekeeping on 1/21/17. She also stated she was scheduled off work until 1/25/17. She stated on 1/26/17 she was called to Administration and asked to complete a written report of the incident. Interview with the Administrator/Abuse Coordinator on 2/15/17 at 5:00 PM in her office revealed she was made aware of the alleged abuse to Resident #102 on 1/26/17 by the Director of Housekeeping, after he returned to work following an illness. Continured interview revealed the facility failed to report an allegation of abuse in a timely manner to appropriate agencies.",2020-09-01
722,GOOD SAMARITAN HEALTH AND REHAB CENTER,445170,500 HICKORY HOLLOW TERRACE,ANTIOCH,TN,37013,2017-02-16,226,D,0,1,BNS411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility investigation review and interview the facility failed to follow it's own policy for investigating allegations of abuse for 1 resident (#20) of 5 residents reviewed for abuse. The findings included: Review of facility policy, Accidents/Incidents Investigations, revised 6/1/12 revealed, .The facility will investigate and report all accidents/incidents in accordance with State and Federal Regulations . Review of facility policy, Abuse Investigations, revised 6/1/12 revealed, .All reports of .injuries of an unknown source shall be promptly and thoroughly investigated by facility management .the investigation should, at a minimum .determine events leading up to the incident; Interview the person (s) reporting the incident .interview the resident .interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .A facility incident report should be filled out and all supporting documentation filed with the incident report . Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Significant Change Minimum Data Set ((MDS) dated [DATE] revealed the resident was cognitively intact and exhibited no signs or symptoms of [MEDICAL CONDITION] or behaviors. The resident was totally dependent requiring assistance of 2 or more people for bed mobility and transfers. Continued review revealed the resident had no falls since the prior assessment. Review of facility investigation dated 12/15/16 revealed Resident #20 was sitting at the nurse station complaining of left knee pain. Continued review revealed an X-ray was ordered and revealed a [MEDICAL CONDITION] distal femur. Continued review revealed the investigation did not contain any statements from the resident or staff providing care to the resident. Further review revealed there was no determination as to the cause of the fracture. Interview with the Administrator on 2/16/17 at 12:15 PM in the Administrator's office confirmed the facility investigation was incomplete. Continued interview confirmed the facility did not interview the resident, other staff members who had contact with the resident between 12/13/16 and 12/15/16, or obtain statements from them. The Administrator confirmed there was no determination of the cause of the fracture and confirmed the facility failed to follow their policy regarding investigating allegations of abuse for Resident #20.",2020-09-01
723,GOOD SAMARITAN HEALTH AND REHAB CENTER,445170,500 HICKORY HOLLOW TERRACE,ANTIOCH,TN,37013,2017-02-16,363,F,0,1,BNS411,"Based on observation, review of the meal spread sheet identifying the portion control for food served, and interview, the facility failed to serve resident food according to the spread sheet for 1 of 2 meals served. The findings included: Observation of the resident mid-day meal trayline in progress in the dietary department on 2/13/17 at 11:43 AM, revealed a dietary staff member serving food from the steam table. Further observation revealed one resident tray delivery cart had left the dietary department. Further observation revealed dietary staff member #1 serving pureed textured meat and pureed vegetables with #12 (1/3/cup) scoops and mashed potatoes with a #10 (2/5 cup) scoop. Review of the spread sheet for the mid-day meal revealed the serving (portion) sizes of pureed meat was to be a #8 (1/2 cup) scoop, pureed vegetables a #10 (2/5 cup) scoop and mashed potatoes was a #8 (1/2 cup) scoop. Interview with the Registered Dietitian and the cook on 2/13/17 at 11:43 AM by the trayline confirmed the portions for pureed meat and vegetables and the portion for mashed potatoes served to the residents were less than the portion size documented on the spread sheet.",2020-09-01
724,GOOD SAMARITAN HEALTH AND REHAB CENTER,445170,500 HICKORY HOLLOW TERRACE,ANTIOCH,TN,37013,2017-02-16,371,F,0,1,BNS411,"Based on observation and interview, the facility failed to ensure dietary staff facial hair was covered in the food production and food service areas; failed to serve food in a sanitary manner for 1 of 2 meals observed; failed to maintain food production equipment in a sanitary manner; and failed to ensure the dish racks were not stacked in the dish machine, the trays were dry and free of debris prior to storage, and the staff did not cross contaminate from the dirty to clean side of the dish machine. The findings included: Observation on 2/13/17 at 11:43 AM in the dietary department of the resident mid-day meal tray line in progress, revealed bearded male dietary staff server #1 serving food from the steam table without wearing a facial cover. Further observation revealed one resident tray delivery cart had left the dietary department and the dietary member continued serving food on the resident trayline. Interview with the Registered Dietitian and the cook on 2/13/17 at 11:43 AM by the trayline confirmed the bearded male dietary server #1 failed to cover the facial hair in the food service area while serving the residents mid-day meal. Observation on 2/13/17 at 12:15 PM in the dietary department, with the Registered Dietitian and cook present, revealed the following: 1. 6 of 12 hood filters had an accumulation of brown colored debris on the grill and convection oven side of the hood. 2. The interior of the hood had numerous streaks from the top to the bottom of the hood and an accumulation of debris. 3. The grill spill pan had an accumulation of food debris and liquid. Interview with the cook on 2/13/17 at 12:15 PM by the grill revealed the grill was .last used sometime last week . Further interview confirmed the facility failed to clean the grill spill pan after use. Observation on 2/13/17 at 5:00 PM in the dietary department, with the Registered Dietitian and cook present, of the evening resident meal service, revealed the server on the trayline wearing gloves on both hands. Further observation revealed the server removed a round bun from a bag, opened each half of the bun and placed each half on the plate with both gloved hands, picked up a piece of fried fish with one gloved hand, positioned the fish onto the bun with both gloved hands, put the top of the bun over the fish with one gloved hand without changing gloves between each process. Further observation revealed the server touched the bag the round buns were stored in, open a drawer, remove a serving utensil, shut the drawer and proceed to touch numerous buns and fish without changing gloves. Interview with the Registered Dietitian and the cook on 2/13/17 at 5:00 PM by the trayline confirmed the server touched buns, fish, every utensil on the trayline and the drawer without changing gloves or washing hands. Observation on 2/14/17 at 9:22 AM in the dietary department, with the Registered Dietitian present, revealed the following: 1. 6 of 12 hood filters had an accumulation of brown colored debris on the grill and convection oven side of the hood 2. The interior of the hood had numerous streaks from the top to the bottom of the hood and an accumulation of debris. 3. The plastic covered floor mixer had dried white and tan colored splatters on the underside of the beater arm. 4. The plastic covered slicer had dried debris on the food securing device with prongs, had dried dark brown debris on the base against the side of the slicer arm, and the food securing device with prongs sliding arm was rusted. 5. A bearded and mustached male dietary employee #2 was slicing roast beef without wearing a facial covering. Interview with the Registered Dietitian on 2/14/17 at 9:45 AM in the dietary department, by the mixer and slicer revealed the plastic cover indicated the equipment was clean and ready to use. Further interview confirmed the facility failed to maintain the mixer and slicer in a sanitary manner. Further interview confirmed the facility failed to ensure the bearded and mustached dietary staff member #2 wore a facial covering while in the food production area. Observation on 2/14/17 at 9:22 AM, in the dietary department, of the dish machine in operation revealed a dietary staff member with gloved hands working the dirty side of the dish machine positioning dirty glasses on a rack. This dietary staff member went to the clean side of the dish machine, opened the dish machine door, pulled out the clean rack with the soiled gloved hand, go back to the dirty side of the dish machine and continued to position dirty glasses on the rack. The dietary staff member placed the rack of dirty glasses on top of a rack containing dirty side dish bowls. The dietary staff member pushed the stacked racks into the dish machine. Further observation revealed the stacked racks were removed from the dish machine and the glasses and the side dishes were placed in storage. Observation on 2/15/17 at 9:10 AM in the dietary department of the dish machine in operation, with the cook and Registered Dietitian present, revealed 3 racks, of 5 trays per rack, processed through the dish machine. The trays came out of the dish machine wet, and the trays were transported, stacked and stored wet on the trayline. Further observation revealed 6 of the 15 trays had debris present. Interview with the Registered Dietitian and cook on 2/15/17 at 9:15 AM in the dietary department, by the tray storage on the trayline, confirmed the facility failed to ensure the trays were clean and dry prior to storage.",2020-09-01
725,GOOD SAMARITAN HEALTH AND REHAB CENTER,445170,500 HICKORY HOLLOW TERRACE,ANTIOCH,TN,37013,2017-02-16,372,F,0,1,BNS411,"Based on observation and interview, the facility failed to contain the facility waste in 1 dumpster of 2 dumpsters observed. The findings included: Observation on 12/13/17 at 8:00 AM and at 1:30 PM revealed 2 sealed plastic bags and 2 cardboard boxes on the top lid of the dumpster on the right side of the 2 exterior dumpsters. Interview with the Administrator on 2/13/17 at 8:10 AM in the dietary hallway confirmed the facility failed to contain the facility waste appropriately.",2020-09-01
726,GOOD SAMARITAN HEALTH AND REHAB CENTER,445170,500 HICKORY HOLLOW TERRACE,ANTIOCH,TN,37013,2017-02-16,412,D,0,1,BNS411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide dental care for 1 resident (#71) of 30 residents reviewed. The findings included: Medical record review revealed Resident #71 was admitted to the facility 6/1/15 with [DIAGNOSES REDACTED]. Observation and interview with the resident on 2/14/17 at 2:52 PM, in the resident's room revealed the resident had no natural lower teeth and an upper denture plate. Interview with Resident #71 revealed she lost her lower denture plate and had told the staff she wanted to see a dentist but had not seen one. Continued interview with Resident #71 revealed her roommate had seen a dentist but she had not. Interview with the Social Worker (SW) on 2/15/17 at 9:50 AM in the Social Services office confirmed the resident had been scheduled to see the dentist on 10/27/16, however, the appointment was canceled by the Dentist's office due to incomplete paperwork. Continued interview revealed the SW confirmed the facility failed to provide dental care for Resident #71.",2020-09-01
727,GOOD SAMARITAN HEALTH AND REHAB CENTER,445170,500 HICKORY HOLLOW TERRACE,ANTIOCH,TN,37013,2017-02-16,441,F,0,1,BNS411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, interview, and employee record review, the facility failed to maintain a Continuous Positive Airway Pressure (C-Pap) mask in a sanitary manner for 1 resident (#14) of 1 resident reviewed for use of a C-Pap machine and failed to have documentation facility staff were offered the Hepatitis B+ vaccine for 8 of 8 employee records reviewed. The findings included: Review of facility policy, Ventilator Equipment Storage: Bi-Pap (Bilevel Positive Airway Pressure), C-Pap, Nebulizer dated 10/1/10 revealed .The purpose of this procedure is to ensure the resident's equipment is cleaned, disinfected and stored properly between usage .The mask will be stored in a zip lock bag. The zip lock bag will be dated . Medical record review revealed Resident #14 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of the resident's room on 2/13/17 at 11:00 AM revealed a C-Pap mask in contact with a urinal stored on the bed side table. Observation of the resident's room on 2/14/17 at 11:12 AM, with the Director of Nursing present, revealed the C-Pap mask in contact with the urinal stored on the bed side table. Interview with the Director of Nursing on 2/14/17 at 11:12 AM in Resident #14's room confirmed the facility failed to store the C-Pap mask in a sanitary manner and per facility policy. Interview with Resident #14 on 2/15/17 at 7:45 AM in his room revealed he had used the C-Pap on Sunday night, 2/12/17, only. Further interview revealed the staff handed him the mask, he positioned the mask on his face and the staff turned on the machine. Further interview revealed the resident could remove the mask and the staff took the mask and turned the machine off. Interview with Licensed Practical Nurse #3 on 2/15/17 at 12:00 PM at the nursing station revealed Resident #14 required assistance with the C-Pap. Further interview revealed the staff turned the machine on and off per the direction of the resident and gave him the mask to put on. Review of 8 of 8 personnel files, revealed no documentation the facility staff had been offered, received, or declined the Hepatitis B+ vaccine upon employment. Interview with the Administrator on 2/16/17 at 9:48 AM in the conference room, confirmed the facility failed to offer the Hepatitis B+ vaccine to facility staff. Further interview revealed the Administrator was unaware the facility was required to offer the Hepatitis B+ vaccine to employees.",2020-09-01
728,GOOD SAMARITAN HEALTH AND REHAB CENTER,445170,500 HICKORY HOLLOW TERRACE,ANTIOCH,TN,37013,2018-04-18,578,D,0,1,24XE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to maintain accurate advanced directives (code status) in the electronic medical record for 1 of 42 sampled residents (Resident #86) reviewed. Findings include: Medical record review revealed Resident #86 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the electronic medical record for Resident #86 on [DATE] at 4:10 PM and [DATE] at 9:50 AM revealed the resident's advanced directive (codes status) was Cardiopulmonary Resuscitation (CPR) indicating she preferred life saving interventions if she has no pulse and is not breathing. Medical record review of Resident #86's hard chart revealed a POST (Physician order [REDACTED]. Interview with the charge nurse, Licensed Practical Nurse (LPN) #5 on [DATE] at 9:50 AM at the nurses station after viewing Resident #86's, home page on the electronic medical record and the hard chart copy of the POST form confirmed the electronic medical record and hard copy POST form were not the same. Further interview confirmed the hard copy POST form was the correct document to follow. The LPN (#5)confirmed the facility failed to maintain accurate code status for Resident #86 in the electronic medical record.",2020-09-01
729,GOOD SAMARITAN HEALTH AND REHAB CENTER,445170,500 HICKORY HOLLOW TERRACE,ANTIOCH,TN,37013,2018-04-18,580,G,0,1,24XE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility investigation review, Physician Order, Nurse's Notes, Radiology Report and interview, the facility failed to notify the Medical Director/Attending Physician immediately after 1 fall by 12 residents (Resident #239) sampled/reviewed for falls. The facility's failure to notify the Physician in a timely manner resulted in prolonged pain to the Resident and HARM (a situation in which the provider's noncompliance resulted in a negative outcome that had compromised the resident's ability to maintain and/or reach his/her hightest practical physical, mental and psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care and provision of services). Findings include: Review of facility policy Notification of Physician & Family - Change in Resident's Condition or Status revised 11/28/16 revealed, .Our facility shall promptly notify the .Attending Physician .of changes in the resident's medical/mental condition and/or status .The nurse will notify the resident's Attending Physician .when there has been a(an) .accident or incident involving the resident . Medical record review revealed Resident #239 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Discharge Minimum (MDS) data set [DATE] revealed Resident #239 had a Brief Interview for Mental Status score of 11, indicating mild cognitive impairment and required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene and required total dependence for bathing. Continued review revealed the resident was not steady and only able to stabilize with staff assistance for moving from a seated to standing position. Further review revealed Resident #239 was at risk for falls and had a fall with major injury since admission (3/23/18). Review of a facility investigation dated 3/26/18 revealed Resident #239 had a fall resulting in fracture at 5:00 AM and the Medical Director/Attending Physician was notified at 7:30 AM and 8:30AM with no response documented. Review of a physician's orders [REDACTED]. Review of a Radiology Report dated 3/26/18 at 8:02 PM revealed, .acute fracture involving the right subcapital hip . There is a right subcapital fracture with slight displacement . Review of a Nurse's Note dated 3/26/18 at 2100 (9:00 PM) revealed, .mobile xray resultes called to MD. Order obtained to send resident to (hospital named) ER for Eval. and Tx. as ordered. AMR ambulance service to transport . Medical record review revealed Resident #239 had a fall on 3/26/18 which resulted in a fracture (HARM). Further review revealed the resident was admitted to the hospital and received surgery on 3/28/18 to repair the fracture. Interview with the Medical Director/Attending Physician on 4/18/18 at 5:00 PM by telephone revealed he expected to be called immediately for all falls. Interview with the DON on 4/18/18 at 5:45 PM in the conference room confirmed all falls should be reported immediately to the Medical Director/Attending Physician. Continued interview revealed the survey team reviewed the above referenced fall and the DON confirmed the facility failed to notify the Medical Director/Attending Physician immediately for 1 fall for 12 residents (Resident #239).",2020-09-01
730,GOOD SAMARITAN HEALTH AND REHAB CENTER,445170,500 HICKORY HOLLOW TERRACE,ANTIOCH,TN,37013,2018-04-18,600,G,0,1,24XE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, Nurse's Notes, Physician's Orders, review of facility investigation and interview, the facility failed to provide goods and services necessary to treat pain and provide prompt medical attention which resulted in a fracture for 1 of 27 sampled residents (Resident #239) resulting in HARM (a situation in which the provider's noncompliance resulted in a negative outcome that had compromised the resident's ability to maintain and/or reach his/her hightest practical physical, mental and psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care and provision of services). Medical record review revealed Resident #239 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Discharge Minimum (MDS) data set [DATE] revealed Resident #239 had a Brief Interview for Mental Status score of 11, indicating moderate cognitive impairment; required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene and required total dependence for bathing. Continued review revealed the resident was not steady and only able to stabilize with staff assistance. Further review revealed Resident #239 was at risk for falls and had a fall with major injury since admission. Medical record review of a facility investigation revealed on 3/26/18 at 5:00 AM Resident #239 was found in a room across from her room, sitting on the floor behind a couch. Continued review revealed at 6:30 AM the resident complained of pain to the right thigh. Medical record review of a statement dated 3/26/18 written by Licensed Practical Nurse #6 revealed .(at) approximately 7AM patient was in dining room and complained of pain to right leg (upper) to the therapist when she tried to stand her up. Pain was reported to this writer by the therapist. Endorsed the c/o (complaint of) pain to right leg to incoming nursing supervisor to f/u (follow-up) (with) MD . Medical record review of a statement dated 3/26/18 written by Physical Therapist #1 revealed .Brought patient to P.T. (physical therapy) gym to stand in parallel bars. Patient unable to secondary to pain. Patient then told therapist she had fallen. Therapist took patient back to nurse and told nurse of patient's pain . Review of a facility investigation dated 3/26/18 revealed Resident #239 had a fall resulting in fracture at 5:00 AM and the Medical Director/Attending Physician was notified at 7:30 AM and 8:30 AM with no response documented. Review of a Physician's Order dated 3/26/18 at 1449 (2:49PM) revealed a phone order received by the Attending Physician for, x ray right femur, pelvis, pelvis (sic), and right hip r/t pain. Review of a Radiology Report dated 3/26/18 at 8:02 PM revealed, .acute fracture involving the right subcapital hip . There is a right subcapital fracture with slight displacement . Review of a Nurse's Note dated 3/26/18 at 2100 (9:00 PM) revealed, .mobile xray resultes called to MD. Order obtained to send resident to (hospital named) ER for Eval. and Tx. as ordered. AMR ambulance service to transport . Medical record review of the Medication Administration Report for (MONTH) (YEAR) revealed no documentation of pain management interventions after the fall with injury occurred. Further review revealed Resident #239 was not provided with any pain interventions or medications from the first complaint of pain (6:30 AM) until arrival at hospital (2305 or 11:05 PM), approximately 11 hours after the fall with injury occurred. Medical record review of a hospital Emergency Provider Report revealed, Initial Greet Date/Time 3/26/18 2243 (10:43PM). Medical record review of a hospital note dated 3/27/18 revealed Resident #239 was administered [MEDICATION NAME] (opioid pain medication) 2 milligrams on 3/26/18 at 11:05 PM for pain. Further review revealed 16 hours had passed since Resident #239 received treatment or pain interventions for a fracture which occurred on 3/26/18 at 5:00 AM. Interview with the Director of Nursing (DON) on 4/18/18 at 8:30 AM in her office revealed she was made aware of Resident #239's fall on the morning it occurred. The DON said she was notified by the second shift nurse of the X-ray results. The DON confirmed the facility failed to implement measures to prevent an accident which resulted in a fracture for Resident #239 (HARM).",2020-09-01
731,GOOD SAMARITAN HEALTH AND REHAB CENTER,445170,500 HICKORY HOLLOW TERRACE,ANTIOCH,TN,37013,2018-04-18,641,D,0,1,24XE11,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to accurately assess the use of insulin on the Minimum Data Set (MDS) for 1 of 42 sampled residents (Resident # 50) reviewed. Findings include: Medical record review revealed Resident #50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly MDS dated [DATE] for Resident #50 revealed the resident did not receive any insulin during the 7 day review period. Interview with Resident #50 on 4/16/18 at 11:27 AM in her room stated she received insulin injections daily. Medical record review of physician's orders [REDACTED]. Medical record review of the Blood Sugar Administration Record for (MONTH) (YEAR) revealed Resident #50 was administered regular and [MEDICATION NAME] as ordered from 2/1/18 - 2/28/18. Interview with Registered Nurse #2 (MDS Coordinator) on 4/18/18 at 9:40 AM in the conference room confirmed the facility failed to accurately assess Resident #50's use of insulin on the Quarterly MDS dated [DATE].,2020-09-01
732,GOOD SAMARITAN HEALTH AND REHAB CENTER,445170,500 HICKORY HOLLOW TERRACE,ANTIOCH,TN,37013,2018-04-18,655,G,0,1,24XE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview, the facility failed to identify interventions on a baseline Care Plan for 1 of 27 sampled residents (Resident #239) reviewed which resulted in a HARM (a situation in which the provider's noncompliance resulted in a negative outcome that had compromised the resident's ability to maintain and/or reach his/her hightest practical physical, mental and psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care and provision of services) for the facility's failure to provide fall interventions to keep the Resident safe after identification as 'high' falls risk. Findings include: Review of facility policy Baseline Care Plans dated 11/28/17 revealed .To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission .The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan . Medical record review revealed Resident #239 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Discharge Minimum (MDS) data set [DATE] revealed Resident #239 had a Brief Interview for Mental Status score of 11, indicating mild cognitive impairment; required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene and required total dependence for bathing. Continued review revealed the resident was not steady and only able to stabilize with staff assistance for moving from a seated to standing position. Further review revealed Resident #239 was at risk for falls and had a fall with major injury since admission. Medical record review of a Morse Fall Scale (an evidence based tool used to provide a quick and simple assessment of a patient's likelihood of falling) dated 3/23/18 at 2349 (11:49 PM) revealed Resident #239 had a score of 90 (Scoring: Low Risk 0-24, Moderate Risk 25-44, High Risk 45 or higher) indicating High Risk. Continued review revealed the following risk factors were documented: 1. Yes, the Resident has fallen before. (History) 2. Yes, the Resident has more than one [DIAGNOSES REDACTED]. 3. Yes, the Resident uses crutches, cane or walker. (Ambulatory Aid) 4. No, the Resident does not have an intravenous apparatus or [MEDICATION NAME] lock inserted. (IV or IV Access) 5. Resident is Impaired: 5a. difficulty rising from chair, uses chair arms to get up, bounces to rise. 5b. keeps head down when walking, watches the ground. 5c. grasps furniture, person or aid when ambulating. Cannot walk unassisted. 6. Yes, the Resident overestimates or forgets limits. RESULTS: High Risk for Falling SCORE: 90 Medical record review of Resident #239's Baseline Care Plan dated 3/23/18 revealed the facility had identified falls as a safety concern. Further review revealed no identified interventions documented throughout Resident record regarding falls. Medical record review revealed Resident #239 had a fall on 3/26/18 which resulted in a femur fracture (HARM). Further review revealed the resident was admitted to the hospital on [DATE] and received surgery on 3/28/18 to repair the right [MEDICAL CONDITION]. Interview with the Director of Nursing (DON) on 4/18/18 at 8:30 AM in her office revealed Resident #239 had been identified as a high fall risk. The DON confirmed the facility failed to identify fall interventions on the Baseline Care Plan for Resident #239.",2020-09-01
733,GOOD SAMARITAN HEALTH AND REHAB CENTER,445170,500 HICKORY HOLLOW TERRACE,ANTIOCH,TN,37013,2018-04-18,689,G,0,1,24XE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, Physician's Orders, Radiology Report, Nurse's Notes, facility investigation and interview, the facility failed to prevent an accident which resulted in a fracture for 1 of 27 sampled residents (Resident #239) resulting in a HARM. Findings include: Review of facility policy Fall Prevention and Investigation dated 11/28/16 revealed .Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls . Medical record review revealed Resident #239 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Discharge Minimum (MDS) data set [DATE] revealed Resident #239 had a Brief Interview for Mental Status score of 11, indicating moderate cognitive impairment; required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene and required total dependence for bathing. Continued review revealed the resident was not steady and only able to stabilize with staff assistance. Further review revealed Resident #239 was at risk for falls and had a fall with major injury since admission. Medical record review of a facility investigation revealed on 3/26/18 at 5:00 AM Resident #239 was found in a room across from her room, sitting on the floor behind a couch. Continued review revealed at 6:30 AM the resident complained of pain to the right thigh. Review of a facility investigation dated 3/26/18 revealed Resident #239 had a fall resulting in fracture at 5:00 AM and the Medical Director/Attending Physician was notified at 7:30 AM and 8:30AM with no response documented. Review of a Physician's Order dated 3/26/18 at 1449 (2:49PM) revealed a phone order received by the Attending Physician for, x ray right femur, pelvis, pelvis (sic), and right hip r/t pain. Review of a Radiology Report dated 3/26/18 at 8:02 PM revealed, .acute fracture involving the right subcapital hip . There is a right subcapital fracture with slight displacement . Review of a Nurse's Note dated 3/26/18 at 2100 (9:00 PM) revealed, .mobile xray resultes called to MD. Order obtained to send resident to (hospital named) ER for Eval. and Tx. as ordered. AMR ambulance service to transport . Interview with the Director of Nursing (DON) on 4/18/18 at 8:30 AM in her office revealed she was made aware of Resident #239's fall on the morning it occurred. The DON said she was notified by the second shift nurse of the X-ray results. The DON confirmed the facility failed to implement measures to prevent an accident which resulted in a fracture for Resident #239 (HARM).",2020-09-01
734,GOOD SAMARITAN HEALTH AND REHAB CENTER,445170,500 HICKORY HOLLOW TERRACE,ANTIOCH,TN,37013,2018-04-18,697,G,0,1,24XE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide pain management post-fall with a fracture (HARM) after verbal complaints of pain for 1 of 27 sampled residents (Resident #239) reviewed. Findings include: Medical record review revealed Resident #239 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Discharge Minimum (MDS) data set [DATE] revealed Resident #239 had a Brief Interview for Mental Status score of 11, indicating moderate cognitive impairment. Continued review revealed the resident had vocal complaints of pain during the assessment review period. Further review revealed Resident #239 had a fall with major injury since admission. Medical record review of facility investigation dated 3/26/18 revealed at 5:00 AM Resident #239 was found sitting on the floor behind a couch in a room across the hall from her room. Continued review revealed at 6:30 AM the resident complained of pain to the right thigh to the Physical Therapist (PT). Medical record review of a statement dated 3/26/18 written by Physical Therapist #1 revealed .Brought patient to P.T. (physical therapy) gym to stand in parallel bars. Patient unable to secondary to pain. Patient then told therapist she had fallen. Therapist took patient back to nurse and told nurse of patient's pain . Medical record review of a statement dated 3/26/18 written by Licensed Practical Nurse #6 revealed .(at) approximately 7AM patient was in dining room and complained of pain to right leg (upper) to the therapist when she tried to stand her up. Pain was reported to this writer by the therapist. Endorsed the c/o (complaint of) pain to right leg to incoming nursing supervisor to f/u (follow-up) (with) MD . Review of a facility investigation dated 3/26/18 revealed Resident #239 had a fall resulting in fracture at 5:00 AM and the Medical Director/Attending Physician was notified at 7:30 AM and 8:30 AM with no response documented. Review of a physician's orders [REDACTED]. Review of a Radiology Report dated 3/26/18 at 8:02 PM revealed, .acute fracture involving the right subcapital hip . There is a right subcapital fracture with slight displacement . Review of a Nurse's Note dated 3/26/18 at 2100 (9:00 PM) revealed, .mobile xray resultes called to MD. Order obtained to send resident to (hospital named) ER for Eval. and Tx. as ordered. AMR ambulance service to transport . Medical record review of the Medication Administration Report for (MONTH) (YEAR) revealed an order dated 3/23/18 for pain to be assessed every shift. Continued review revealed a pain level of .4 . documented on the evening shift of 3/26/18. Continued review revealed no documentation of pain management interventions. Further review revealed Resident #239 was not provided with any pain interventions or medications from the first complaint of pain (6:30 AM) until arrival at hospital (2305 or 11:05 PM). Medical record review of a hospital Emergency Provider Report revealed, Initial Greet Date/Time 3/26/18 2243 (10:43PM). Medical record review of a hospital note dated 3/27/18 revealed Resident #239 was administered [MEDICATION NAME] (opioid pain medication) 2 milligrams on 3/26/18 at 11:05 PM for pain. Interview with the Director of Nursing (DON) on 4/18/18 at 8:30 AM in her office revealed she was made aware of Resident #239's fall on morning it occurred. The DON said she was also notified of the resident's complaint of pain. The DON confirmed the facility failed to provide pain management after verbal complaints of pain after a fall which resulted fracture for Resident #239. Refer to F-580, F-655, and F-689",2020-09-01
735,GOOD SAMARITAN HEALTH AND REHAB CENTER,445170,500 HICKORY HOLLOW TERRACE,ANTIOCH,TN,37013,2018-04-18,758,D,0,1,24XE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure as needed (PRN) [MEDICAL CONDITION] medications had a 14 day limitation or prescriber documentation with medical rationale for continuation for 2 of 7 sampled residents (Resident #238 and Resident #239) reviewed. Findings include: Medical record review revealed Resident #238 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Continued review revealed no stop date. Medical record review of (MONTH) (YEAR) - (MONTH) (YEAR) Medication Administration Record [REDACTED]. Medical record review revealed Resident #239 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Continued review revealed no stop date. Medical record review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Interview with the Director of Nursing on 4/18/18 at 6:10 PM in the conference room confirmed the facility failed to ensure PRN [MEDICAL CONDITION] medication had a 14 day limitation or documented rationale for continuation for Resident #238 and Resident #239.",2020-09-01
736,GOOD SAMARITAN HEALTH AND REHAB CENTER,445170,500 HICKORY HOLLOW TERRACE,ANTIOCH,TN,37013,2018-04-18,800,F,0,1,24XE11,"Based on facility policy review, observation and interview the facility failed to serve milk and protein shakes at the appropriate temperature for consumption for 87 residents. Findings include: Review of facility policy Food Temperature and Preparation Service revised 11/28/17 revealed .The danger zone for food temperature is between 41 F (Fahrenheit) and 135 F (Fahrenheit). This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. Potentially hazardous foods include meats, poultry, seafood, cut melon, eggs, milk, yogurt, and cottage cheese . Observation on 4/16/18 at 12:36 PM in the dietary department revealed milk and protein shakes (which contained milk products) were individually wrapped in plastic glasses placed on metal trays on racks during plating of the food. Continued observation revealed the milk temperature was 42 degrees Fahrenheit and the protein shakes were 44 degrees Fahrenheit. These temperatures were not within the safe range for consumption or distribution. Interview with the Food Service Supervisor on 4/16/18 at 12:40 PM in the dietary department confirmed that the milk and protein shake were not within the appropriate and safe range for consumption. Interview Food Service Supervisor on 4/18/18 at 8:47 AM in his office confirmed the facility failed to serve milk and protein shakes at the appropriate temperature for 87 residents.",2020-09-01
737,GOOD SAMARITAN HEALTH AND REHAB CENTER,445170,500 HICKORY HOLLOW TERRACE,ANTIOCH,TN,37013,2019-05-02,803,F,0,1,SHOF11,"Based on review of the resident council minutes, review of the 4 week cycle menu, Review of the POS [REDACTED]. The findings include: Review of the Resident Council Minutes dated 2/27/19 revealed 2 residents stating would like something other than chicken and goulash, meal ticket stated resident did not like pork and that was not true, would like more variety on the menu. Review of the facility 4 week menu cycle revealed the following: On Week 2 a chicken entree was listed for the Sunday evening meal, the Monday mid-day meal, the Tuesday evening meal and for the Saturday evening meal. On Week 3 a chicken entree was listed for the Sunday mid-day and evening meals, therefore chicken was served for 3 consecutive meals, excluding the breakfast meal. A pork entree was listed for the Monday mid-day meal and both the Tuesday mid-day and evening meals. On Week 4 a pasta entree was listed for the Sunday and Monday mid-day meals. A chicken entree was listed for the Tuesday evening meal and the Wednesday mid-day meal. Chicken Fried Steak was listed on the Thursday evening and the Saturday mid-day meals. Review of the POS [REDACTED]. Further observation revealed no therapeutic diet menu and no specific portion identified for each food item served on the menu. Review of the cooks menu for 4/29/19 revealed the mid-day meal matched the mid-day meal on the posted menu. Further observation of the evening meal revealed Pot Roast, Mashed Potatoes, Peas and Carrots were to be served. The cooks menu for the evening meal did not match the posted menu. Observation on 4/29/19 at 11:43 AM in the dietary department of the resident mid-day meal trayline, with the Dietary Supervisor present, revealed Pork in Gravy, Lima Beans, Mashed Potatoes and Carrots were to be served. Further observation revealed pureed foods on the trayline. Continued observation revealed regular textured diets were receiving the pork in gravy, mashed potatoes with gravy and carrots. Continued observation revealed the pureed textured diets received pureed meat with gravy, mashed potatoes with gravy, and pureed carrots. Interview with the cook/server on 4/29/19 at 11:57 AM at the dietary department trayline, with the Dietary Supervisor present, when asked what the meat was in the pureed meat stated .breaded chicken tenders with bread added . When the cook/server was asked why the pureed meat was not pork like the posted and cook menus listed, the cook/server stated .a lot of them (residents) don't like pork . When the cook/server was asked why are all the diets were receiving mashed potatoes when the posted and cooks menus listed lima beans, the cook/server stated .a lot of them don't like lima beans . Interview with the Dietary Supervisor on 4/29/19 at 11:59 AM at the dietary department trayline when asked if he was aware of the mashed potatoes being served in place of the lima beans, he stated he did know. When asked why the posted and cooks menu were not followed the Dietary Supervisor did not respond. Interview with the Dietary Supervisor on 4/29/19 at 4:12 PM in the dietary department revealed the Dietary Supervisor wrote the menu and obtained the Registered Dietitian's approval and signature. When asked for the therapeutic menu for the diets the Dietary Supervisor confirmed there was no therapeutic diet menu. When asked how the staff knew what portion to serve per menu item the Dietary Supervisor stated the meat and vegetable portions were 4 ounces each. Further interview confirmed the portion to be served per menu item was not specified on the menu. Further interview revealed any menu changes were documented on the cook's menu and filed. Further interview confirmed the cooks menu had not be changed to omit lima beans and adding mashed potatoes. Telephone interview with the part-time Registered Dietitian (RD) on 4/30/19 at 11:30 AM revealed the RD had worked full time at the facility until 6 weeks ago. The RD stated the Dietary Supervisor had written the menus and she had approved and signed the menus. When the consecutive and repetitive food items were discussed the RD stated she was not aware of that and felt the menu she approved may have been altered after she left the facility. The RD confirmed it sounded as if the menu lacked variety. The RD was not aware the menu failed to include therapeutic diet and portion specification. The RD's expectation was for at least 2 ounces meat/protein and 4 ounces of vegetables to be served.",2020-09-01
738,GOOD SAMARITAN HEALTH AND REHAB CENTER,445170,500 HICKORY HOLLOW TERRACE,ANTIOCH,TN,37013,2019-05-02,804,D,0,1,SHOF11,"Based on review of the resident council minutes, review of the resident posted menu, observation and interview, the facility dietary department failed to serve palatable pureed textured meat for 1 of 3 meals observed. The findings include: Review of the Resident Council Minutes dated 2/27/19 revealed 2 residents stating would like something other than chicken and goulash, meal ticket stated resident did not like pork and that was not true, would like more variety on the menu, more salads like potato salad and macaroni salad. Review of the 4/29/19 resident mid-day meal posted menu revealed Marinated Pork Chops and Gravy, Lima Beans, and Coin Carrots. Further observation revealed no therapeutic diet menu and no portion per food item specified on the menu. Observation on 4/29/19 at 11:43 AM in the dietary department, with the Dietary Supervisor present, revealed the resident mid-day meal trayline was in operation. Further observation revealed the trayline included Pork in Gravy, Lima Beans, Mashed Potatoes and Carrots. Further observation revealed pureed foods on the trayline. Continued observation revealed the pureed textured diets received pureed meat with gravy, mashed potatoes with gravy, and pureed carrots. Further observation revealed the 2 surveyors and the Dietary Supervisor tasted all foods on the tray line including the pureed textured foods. The pureed meat tasted like bread and the meat was not able to be determined. Interview with the cook/server on 4/29/19 at 11:57 AM at the dietary department trayline when asked what the meat was in the pureed meat stated .breaded chicken tenders with bread added . When the cook/server was asked why the pureed meat was not pork as listed on the posted and cooks menus, the cook/server stated .a lot of them (residents) don't like pork . Interview with the Dietary Supervisor on 4/29/19 at 11:59 AM in the dietary department when asked how he would describe the taste of the pureed meat confirmed it .tastes like bread .",2020-09-01
739,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2018-02-28,600,D,1,0,VR3611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of the facility investigation, and interview the facility failed to intervene and protect from abuse 1 (#2) of 4 sampled residents. The findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 1/19/18 Quarterly Minimum Data Set (MDS) revealed Resident #1 was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 8 of 15. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #2 was cognitively intact with a BIMS score of 15 of 15. Review of the facility investigation revealed on 1/28/18 Resident #1 and Resident #2 were together outside of the Bedford Corner dining room. Continued review revealed staff heard Resident #2 state loudly Resident #1 was going to hit (Resident #2). Continued review revealed three staff, including Certified Nurse Assistant (CNA) #1 rushed to reach Resident #1 and Resident #2 to separate them. Further review revealed Resident #1 struck Resident #2 in the chest/upper arm area 3 times before the staff reached Resident #1 and #2. Continued review revealed Resident #1 and Resident #2 were examined for injury and Resident #2 was found to have a hand print mark on her right breast. Interview with CNA #1 on 2/27/18 at 5:05 PM at Nurse Station 1 revealed she had witnessed the altercation between Resident #1 and Resident #2 on 1/28/18. Continued interview revealed CNA #1, just prior to the altercation, had walked through the Bedford Corner dining room and observed and heard Resident #1 and Resident #2 bickering. Continued interview revealed CNA #1 had told Resident #1 and Resident #2 to stop bickering and to separate from one another. Continued interview revealed she left Resident #1 and Resident #2 before ensuring they had separated and she continued down the hallway. Continued interview revealed she heard Resident #2 state Resident #1 was trying to hit (Resident #2). Continued interview revealed she turned and saw Resident #1 strike Resident #2 three times before staff could separate the two residents. Interview with the Director of Nursing (DON) on 2/28/18 at 8:45 AM in the conference room revealed the staff was expected to immediately separate residents who were engaged in any type of altercation. Continued interview confirmed CNA #1 failed to separate Resident #1 and Resident #2 when she witnessed the two residents arguing. Continued interview revealed the facility's failure to separate Resident #1 and Resident #2 resulted in failure to protect Resident #2 from physical abuse from Resident #1.",2020-09-01
740,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2019-06-26,726,D,1,0,UMZP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, narcotic log review, and interview the facility failed to show nursing competency in medication administration documentation for 2 residents (#1 and #2) of 7 residents reviewed. The findings include: Medical record review revealed Resident #1 was admitted [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Medication Administration Record [REDACTED]. Review of the narcotic log sheets dated 2/2019 and 5/14/19 revealed [MEDICATION NAME] (an orally administered narcotic controlled substance for severe pain) was signed out 41 times. Continued review revealed 32 narcotic log sign-outs for [MEDICATION NAME] were not reflected on the MAR indicated [REDACTED] Medical record review revealed Resident #2 was admitted [DATE] and discharged [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Medication Administration Record [REDACTED]. Review of the narcotic log sheets dated 4/2019 and 5/15/19 revealed [MEDICATION NAME] was signed out 17 times. Continued review revealed 10 narcotic log sign-outs for [MEDICATION NAME] were not reflected on the MAR indicated [REDACTED] Interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 6/26/19 at 2:30 PM in the chapel confirmed the narcotics logs and MARs dated 2/2019 to 5/15/19 for Resident #1 and Resident #2 had inconsistencies. Continued interview revealed the DON confirmed the MARs for Resident #1 and Resident #2 had omissions on the MARs dated 2/2019 to 5/15/19.",2020-09-01
741,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2019-06-26,755,D,1,0,UMZP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, narcotic log review, and interview the facility failed to provide a system of medication records that enables periodic accurate reconciliation and accounting for controlled substances for 2 residents (#1 and #2) of 7 residents reviewed. The findings include: Medical record review revealed Resident #1 was admitted [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Medication Administration Record [REDACTED]. Review of the narcotic log sheets dated 2/2019 and 5/14/19 revealed [MEDICATION NAME] (an orally administered narcotic controlled substance for severe pain) was signed out 41 times. Continued review revealed 32 narcotic log sign-outs for [MEDICATION NAME] were not reflected on the MAR indicated [REDACTED] Medical record review revealed Resident #2 was admitted [DATE] and discharged [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Medication Administration Record [REDACTED]. Review of the narcotic log sheets dated 4/2019 and 5/15/19 revealed [MEDICATION NAME] was signed out 17 times. Continued review revealed 10 narcotic log sign-outs for [MEDICATION NAME] were not reflected on the MAR indicated [REDACTED] Telephone interview with the Pharmacist on 6/25/19 at 10:23 AM confirmed an audit done by the Pharmacist, the DON, and the ADON revealed some nurses were sporadic in making entries appropriately and timely to the MAR. Interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 6/26/19 at 2:30 PM in the chapel confirmed the narcotics logs and MARs dated 2/2019 to 5/15/19 for Resident #1 and Resident #2 had inconsistencies. Continued interview revealed the DON confirmed the MARs for Resident #1 and Resident #2 had omissions on the MARs dated 2/2019 to 5/15/19.",2020-09-01
742,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2018-09-25,609,D,1,0,YCKB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility documentation and interview, the facility staff failed to report a suspicion/allegation of abuse to the administrator for 1 of 3 residents (Resident #1) reviewed for abuse. The findings include: Review of the facility policy, Abuse Prevention Program, updated 1/19/17, revealed .It is the policy of this facility to prevent abuse .The following Procedures shall be implemented when an employee or agent becomes aware of abuse .or of an allegation of suspected abuse .Procedure .Abuse Reporting .This facility will not tolerate abuse .by anyone, including staff members .All alleged violations involving .abuse .MUST be reported to the Administrator and Director of Nursing. The Administrator is the Abuse Coordinator .the person(s) observing the incident of resident abuse or suspected resident abuse must IMMEDIATELY report such incidents to the Charge Nurse, regardless of the time lapse since the incident occurred. The Charge Nurse will immediately report the incident to the Administrator .The Charge Nurse must complete an incident report and obtain written, signed and dated statement from the person reporting the incident. A completed copy of the incident report and written statements from witnesses, if any, will be provided to the Administrator .within twenty-four (24) hours of the occurrence of such incident .Identification .Employees are required to report any incident, allegation or suspicion of potential abuse .to the Administrator or an immediate supervisor who will immediately report the allegation to the Administrator .All residents, visitors, volunteers, family members or others are encouraged to report their concerns or suspected incidents of potential abuse .to the Administrator or an immediate supervisor who will immediately report the allegation to the Administrator .Supervisors will immediately inform the Administrator or in absence of the Administrator, the person in charge of the facility of all reports of incidents, allegations or suspicion of potential mistreatment. Upon learning of the report, the Administrator or .the person in charge of the facility shall initiate an incident investigation Investigation .For any incident involving suspicion of abuse .the Administrator or person appointed .will gather further facts prior to making a determination conduct an abuse investigation .Once the Administrator or designee determines there is a reasonable cause for suspected abuse, the Administrator or designee will investigate the allegation The final report shall include facts determined during the process of the investigation, review of the medical records, personnel files and interview of witnesses. The final investigation shall also include a conclusion of the investigation based on known facts . Medical record review revealed Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum (MDS) data set [DATE] revealed Resident #1 had minimal difficulty hearing, had clear speech, could make herself understood, could understand others; scored 9 out of 15 on the Brief Interview for Mental Status, indicating moderate cognitive impairment; exhibited no [MEDICAL CONDITIONS], or behaviors; exhibited feeling down/depressed 2-6 days of the review period; exhibited little interest/pleasure, sleep issue, and concentration issue for 7-11 days of the review period; exhibited change in energy for 12-14 days of the review period; required extensive 2+ person assistance for bed mobility, dressing, toileting; total dependence with 2+ person assistance for transfers, hygiene and bathing; was always incontinent bowel and bladder; and received antianxiety, antidepressant and diuretic medication for 7 days of the review period. Review of the staffing assignments for 9/15/18 for the 7:00 PM to 7:00 AM shift revealed Certified Nurse Aide (CNA) #1, #2, #3, #4, #6; Registered Nurse (RN) #2, and Licensed Practical Nurse (LPN) #1 were on duty. Review of the facility documentation revealed staff had written statements or responses to questionnaires regarding the 9/16/18 allegation of abuse. Review of the facility Abuse Questionnaire completed by Resident #1 dated 9/17/18 revealed .Has staff, a resident or anyone else here abused you, this includes verbal, physical, financial or sexual abuse? .Yes. If Yes, ask who the abuser was, what happened, when it occurred, where it happened, and how often .'I got hit several times. Big hands, big fists.' Further review revealed the person had 'Short hair (blonde) large in posture. Hit her in her head, hit face. Chest hit her with a big hand & fist hit her hand several times happened-several months ago. did not happen Sat. (Saturday) or Friday-happened 6 mo (months) ago happened at night.' When asked Did you tell staff? Yes. Who did you tell? Told friends-Told nurses. Also included in the Questionnaire was a diagram of a person with No new bruises anywhere else. Review of the facility documentation included the statement written by CNA #1 revealed .When I entered the room the tech (CNA #2) was turning patient (Resident #1) trying to clean her, the patient was yelling at tech to get away from her. The patient told me the tech was being rough with her and hurting her. The tech begin to argue with patient saying she didn't do anything to her. The patient became more agitated and told the tech if she hits her again she will get out of bed and whoop her . Review of the facility documentation included the statement written by RN #2 revealed .CNA (#2) came to desk to ask other CNA (#1) for assist (with) pt (patient/Resident #1) because she was agitated. After CNA's provided care this nurse went in to (check) on pt. Pt agitated .Asked pt what was wrong pt stated 'I don't want her in here ever again' (described CNA #2). Asked pt why she didn't want her in there. Pt stated ' .she (CNA #2) just starts bossing me around-saying do this, do that, roll over .and if she ever hits me I'm gong to knock her block-off .' Asked pt has she ever hurt her. Pt stated 'No, but she doesn't have to be so bossy, I'm not going to put up with that, I don't want her in here anymore, she is just rough and rude' . Review of the facility documentation included thestatement written by RN #1 dated 9/17/18 revealed .(Resident #1's) daughter approached me in the hallway with a concern. Her mother had told her Saturday night there was a tech (CNA) smacking on her. She said it was a fat tech and that she kept smacking her. I did report immediately to ADON (Assistant Director of Nursing) /Abuse Coordinator (Administrator) @ (at) which time immediate actions were taken . Telephone interview with CNA #1 on 9/24/18 at 11:47 AM revealed .I was charting at the nursing station when (CNA #2) came up to me and said (Resident #1) was agitated and she needed help .I walked down with her .and resident said 'You're rough with me, you hurt me' and (CNA #2) stepped back. Resident talk with me calm like and said (CNA #2) 'rough, hurt me' and 'I'll get out of bed if she hurts me again' and 'If you ever hit me again I'll whoop your ass.' (CNA #2) said 'I never hit you, just took care of you and cleaned you up.' They argued back and forth 'You hit me, no I didn't hit you' .I went to the nursing station and (CNA #2) there and said she already told the nurse what happened . Telephone interview with CNA #2 on 9/24/18 at 12:16 PM revealed .(Resident #1) was agitated .she was cursing, aggressive, combative, and not cooperative .so I went to the Charge Nurse (RN #2) and tell her what was going on and ask if another tech (CNA #1) to help me. The resident could be heard hollering .Both (CNA #1) and I went into the room .the resident turned over the bedside table onto herself in bed and all the stuff on it went everywhere, on her, on the floor, in the bed. It was a mess and resident agitated made it worse .She was hollering about being abused and I told her no one doing that or anything like that to her . Resident kept saying she was being abused .I went straight to nurse and told her resident said I was hitting her . Telephone interview with RN #2 on 9/24/18 at 4:38 PM and 5:28 PM revealed .around 2:00-3:00 AM, I think, (CNA #2) was doing rounds and came up to the desk and asked (CNA #1) to help her because (Resident #1) being agitated .After care (to Resident #1) both (CNAs) came out and told me about resident's statement .to (CNA #1) that (CNA #2) slapped her .I said I would go and talk with (Resident #1) myself. She was agitated. She never told me (CNA #2) hit her. I asked her if (CNA #2) had been hurt her and she 'no, just hateful, comes in here looking like a bulldog.' (Resident #1) said 'if she (CNA #2) does I'll knock her block off.' (Resident #1) did not tell me (CNA #2) hurt her in any way .(Resident #1) described (CNA #2) as 'blonde, bigger older lady.' She never said (CNA #2) hit her . Further interview revealed when asked why she did not report the allegation to the Administrator or the Director of Nursing the RN stated .She (Resident #1) never said (CNA #2) hit her to me. Said she was rough and rude and I took that to mean bossy. I personally felt no harm came out of it. I did full body check and no marks except her usual stuff, nothing new . Interview with the Administrator on 9/25/8 at 11:15 AM in the conference room when asked if (RN #2) was to report the allegation/suspicion of abuse alleged involving Resident #1 on 9/16/18 to the Administrator or designee, the Administrator stated .should have been reported to me the morning of 9/16/18 .",2020-09-01
743,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2018-09-25,610,D,1,0,YCKB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility documentation and interview, the facility staff failed to thoroughly investigate a suspicion/allegation of abuse to the Administrator or designee for 1 of 3 residents (Resident #1) reviewed for abuse. The findings include: Review of the facility policy, Abuse Prevention Program, updated 1/19/17, revealed .It is the policy of this facility to prevent abuse .The following Procedures shall be implemented when an employee or agent becomes aware of abuse .or of an allegation of suspected abuse .Procedure .The Charge Nurse must complete an incident report and obtain written, signed and dated statement from the person reporting the incident. A completed copy of the incident report and written statements from witnesses, if any, will be provided to the Administrator .within twenty-four (24) hours of the occurrence of such incident .Upon learning of the report, the Administrator or .the person in charge of the facility shall initiate an incident investigation Investigation .For any incident involving suspicion of abuse .the Administrator or person appointed .will gather further facts prior to making a determination conduct an abuse investigation .Once the Administrator or designee determines there is a reasonable cause for suspected abuse, the Administrator or designee will investigate the allegation The final report shall include facts determined during the process of the investigation, review of the medical records, personnel files and interview of witnesses. The final investigation shall also include a conclusion of the investigation based on known facts . Medical record review revealed Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum (MDS) data set [DATE] revealed Resident #1 had minimal difficulty hearing, had clear speech, could make herself understood, could understand others; scored 9 out of 15 on the Brief Interview for Mental Status, indicating moderate cognitive impairment; exhibited no [MEDICAL CONDITIONS], or behaviors; exhibited feeling down/depressed 2-6 days of the review period; exhibited little interest/pleasure, sleep issue, and concentration issue for 7-11 days of the review period; exhibited change in energy for 12-14 days of the review period; required extensive 2+ person assistance for bed mobility, dressing, toileting; total dependence with 2+ person assistance for transfers, hygiene and bathing; was always incontinent bowel and bladder; and received antianxiety, antidepressant and diuretic medication for 7 days of the review period. Medical record review of the Physician Orders revealed the following: From 6/23/18 to the present [MEDICATION NAME] HCL ER ([MEDICATION NAME]-antidepressant) 150 milligrams by mouth 1 time a day for depression. On 8/13/18 [MEDICATION NAME] ([MEDICATION NAME]-antianxiety) 0.5 milligrams by mouth 3 times a day for anxiety. On 8/19/18 Discontinue [MEDICATION NAME] 0.5 milligrams by mouth 3 times a day for anxiety. On 8/19/18 Restore [MEDICATION NAME] back to 1 milligram by mouth three times daily, note in chart GDR (Gradual Dose Reduction) failure. On 8/20/18 [MEDICATION NAME] 1 milligram by mouth three times a day related to anxiety disorder. Medical record review of the (MONTH) and (MONTH) (YEAR) Medication Administration Records revealed the medications noted above were administered as ordered. Behavior monitoring for the antianxiety mediation was done every shift with no documentation of a behavior during (MONTH) and (MONTH) (YEAR). Medical record review of the physician orders dated 9/12/18 revealed .Check UA (urinalysis) . Medical record review of the Urinalysis, Culture and Sensitivity laboratory results dated [DATE] the UA revealed .SL (slightly) cloudy .Many Bacteria . indicating possible urinary tract infection. Further review revealed on 9/15/18 the Culture and Sensitively result .Escherichia Coli (EColi) and Extended Spectrum B-Lactamase (ESBL) . indication the resident had a urinary tract infection requiring contact isolation. Medical record review of the physician orders dated 9/13/18 revealed .Contact Isolation for ESBL until antibiotics complete . Further review of the physician orders dated 9/16/18 revealed [MEDICATION NAME] (antibiotic) 100 milligrams by mouth two times daily times 10 days for Urinary Tract Infection. Medical record review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The facility reported an allegation of abuse occurring on 9/15/18 at 1:00 AM involving Resident #1 and a staff member. Review of the staffing assignments for 9/15/18 for the 7:00 PM to 7:00 AM shift revealed Certified Nurse Aide (CNA) #1, #2, #3, #4, #6; Registered Nurse (RN) #2, and Licensed Practical Nurse (LPN) #1 were on duty. Review of the facility documentation revealed Resident #1 had responded to a questionnaire regarding the 9/16/18 allegation of abuse. Review of the facility Abuse Questionnaire completed by Resident #1 dated 9/17/18 revealed .Has staff, a resident or anyone else here abused you, this includes verbal, physical, financial or sexual abuse? .Yes. If Yes, ask who the abuser was, what happened, when it occurred, where it happened, and how often .'I got hit several times. Big hands, big fists.' Further review revealed the person had 'Short hair (blonde) large in posture. Hit her in her head, hit face. Chest hit her with a big hand & fist hit her hand several times happened-several months ago. did not happen Sat. (Saturday) or Friday-happened 6 mo (months) ago happened at night.' When asked Did you tell staff? Yes. Who did you tell? Told friends-Told nurses. Also included in the Questionnaire was a diagram of a person with No new bruises anywhere else. Review of facility documentation of the statement written by CNA #1 revealed .When I entered the room the tech (CNA #2) was turning patient (Resident #1) trying to clean her, the patient was yelling at tech to get away from her. The patient told me the tech was being rough with her and hurting her. The tech begin to argue with patient saying she didn't do anything to her. The patient became more agitated and told the tech if she hits her again she will get out of bed and whoop her . Review of the undated staff questionnaire completed by CNA #1 after the 9/16/18 event asking Do you know of any abuse? had NO. Review of facility documentation included the email dated 9/18/18 from CNA #2 to the facility revealed On Saturday the 15th of (MONTH) as I was giving care to (Resident #1) she was very agitated and aggressive, cursing and smaking (sic) at me refusing care and knocking her bedside table over all on table stuff was in floor (Resident #1) had been digging and playing in her bm (bowel movement) was trying to get out. Of bed I went immediately to the charge nurse (RN #2) and told her what was going on and ask the other tech (CNA #1) could she help me attend to (Resident #1) she agreed then the nurse asked us to switch patient and I did so. Further review revealed no interview with CNA #2. Review of facility documentation of the statement written by RN #2 revealed .CNA (#2) came to desk to ask other CNA (#1) for assist (with) pt (patient/Resident #1) because she was agitated. After CNA's provided care this nurse went in to (check) on pt. Pt agitated .Asked pt what was wrong pt stated 'I don't want her in here ever again' (described CNA #2). Asked pt why she didn't want her in there. Pt stated ' .she (CNA #2) just starts bossing me around-saying do this, do that, roll over .and if she ever hits me I'm gong to knock her block-off .' Asked pt has she ever hurt her. Pt stated 'No, but she doesn't have to be so bossy, I'm not going to put up with that, I don't want her in here anymore, she is just rough and rude' . Review of the staff questionnaire completed by RN #2 dated 9/18/18 asking Do you know of any abuse? had NO. Review of facility documentation of the statement written by RN #1 dated 9/17/18 revealed .(Resident #1's) daughter approached me in the hallway with a concern. Her mother had told her Saturday night there was a tech (CNA) smacking on her. She said it was a fat tech and that she kept smacking her. I did report immediately to ADON (Assistant Director of Nursing) /Abuse Coordinator (Administrator) @ (at) which time immediate actions were taken . Review of facility documentation of the undated staff questionnaire completed after the 9/16/18 event by CNA #3, #4, #6, and LPN #1 asking Do you know of any abuse? had NO. Telephone interview with CNA #1 on 9/24/18 at 11:47 AM revealed .I was charting at the nursing station when (CNA #2) came up to me and said (Resident #1) was agitated and she needed help .I walked down with her .and resident said 'You're rough with me, you hurt me' and (CNA #2) stepped back. Resident talk with me calm like and said (CNA #2) 'rough, hurt me' and 'I'll get out of bed if she hurts me again' and 'If you ever hit me again I'll whoop your ass.' (CNA #2) said 'I never hit you, just took care of you and cleaned you up.' They argued back and forth 'You hit me, no I didn't hit you' .I went to the nursing station and (CNA #2) there and said she already told the nurse what happened . Telephone interview with CNA #2 on 9/24/18 at 12:16 PM revealed .(Resident #1) was agitated .she was cursing, aggressive, combative, and not cooperative .so I went to the Charge Nurse (RN #2) and tell her what was going on and ask if another tech (CNA #1) to help me. The resident could be heard hollering .Both (CNA #1) and I went into the room .the resident turned over the bedside table onto herself in bed and all the stuff on it went everywhere, on her, on the floor, in the bed. It was a mess and resident agitated made it worse .She was hollering about being abused and I told her no one doing that or anything like that to her . Resident kept saying she was being abused .I went straight to nurse and told her resident said I was hitting her . Telephone interview with RN #2 on 9/24/18 at 4:38 PM and 5:28 PM revealed .around 2:00-3:00 AM, I think, (CNA #2) was doing rounds and came up to the desk and asked (CNA #1) to help her because (Resident #1) being agitated .After care (to Resident #1) both (CNAs) came out and told me about resident's statement .to (CNA #1) that (CNA #2) slapped her .I said I would go and talk with (Resident #1) myself. She was agitated. She never told me (CNA #2) hit her. I asked her if (CNA #2) had been hurt her and she 'no, just hateful, comes in here looking like a bulldog.' (Resident #1) said 'if she (CNA #2) does I'll knock her block off.' (Resident #1) did not tell me (CNA #2) hurt her in any way .(Resident #1) described (CNA #2) as 'blonde, bigger older lady.' She never said (CNA #2) hit her . Further interview revealed when asked why she did not report the allegation to the Administrator or the Director of Nursing the RN stated .She (Resident #1) never said (CNA #2) hit her to me. Said she was rough and rude and I took that to mean bossy. I personally felt no harm came out of it. I did full body check and no marks except her usual stuff, nothing new . Interview with Resident #1's daughter on 9/24/18 at 3:23 PM in the conference room revealed Resident #1 .complained of lady for past couple of weeks. Said 'she (Resident #1) didn't like her (CNA #2), (CNA #2) was rough with me, argues with me, I might have wanted something and press the call light and lady (CNA #2) comes in argues with me and turns call light off and leaves.' (Resident #1) said one night the CNA (#2) stuck her head in the door and said 'I heard you were talking about me, you need to stop talking about me.' I told Mom they don't need to be arguing with you and you not argue with them. She has dementia. This went on for a couple of weeks, then she calmed down for a week. Sunday I was here and she said '(CNA #2) slapped her and was rough with me last night . I told her 'Mom, tell me the truth, are you sure? Why would she slap you?' Mom said 'she was rough with me, I told her to stop and she slapped me. She's rough with me when she changes me and I don't like it.' I told her to tell me the truth and she said the same thing again. I told her it was Sunday and I can't do anything today. I checked her skin and there were no marks on her face. I checked her skin the next day but she bruises all the time anyway. I couldn't go by that .Mom told me was a heavy set red head .I ran into RN #1 up front .When I said a red head to RN #1 she didn't know that person name either. RN #1 said she would take care of it right now. RN #1 went to the Administrator and came back to me and the Administrator and ADON (Assistant Director of Nursing) .talked . Review of the facility documentation regarding the allegation of abuse on 9/16/18 revealed no evidence the UA was considered, the [MEDICAL CONDITION] medications adjusted in 8/2018 were considered, failed to have interview with staff on duty on 9/16/18 at 1:00 AM to 3:00 AM addressing the allegation, failed to have an interview with the alleged perpetrator and residents in the vicinity of the Resident #1, failed to have documentation of Resident #1's multiple interviews with different information, failed to have an interview with the family member reporting the allegation on 9/17/18 and clarifying the details, and failed to clarify why RN #2, CNA #1 and #2 answered No to the employee questionnaire asking Do you know of any abuse? Interview with the Administrator on 9/25/8 at 1:15 PM in the conference room when asked if the facility had the multiple interviews with the resident with different versions of the event, he stated No; if they had the staff interviews of all on duty and clarification of discrepancies, he stated No, but see where should have; if there was an interview with the reporting family member for clarification of information, he stated No; if there were interviews with residents in the vicinity of the event for information, he said No; for there was a medication review considering [MEDICAL CONDITION] medication had recently been changed, he said NO; and if the laboratory results of urinary tract infection was considered to contribute, he said NO.",2020-09-01
744,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2019-11-06,550,D,0,1,TEZO11,"**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 ensure dignity for 1 resident (#54) of 7 residents reviewed with urinary catheters. The findings include: Facility policy review Dignity, undated, revealed .Urinary drainage bags will be covered unless residents are in their rooms, at which time the bag will be placed so as not to be visible from the hall if at all possible . Medical record review revealed Resident #54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #54's Quarterly Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview of Mental Status score of 13 indicating the resident was cognitively intact. Continued review revealed the resident had an indwelling catheter. Medical record review of Resident #54's comprehensive care plan revealed the resident had a suprapubic catheter. Observation on 11/5/19 at 8:06 AM in Resident #54's room revealed the resident lying in bed with a catheter drainage bag not covered and visible from the doorway. Observation on 11/5/19 at 9:44 AM revealed the resident in bed with an uncovered catheter drainage bag on the right side of the bed facing the door. Observation and interview on 11/5/19 at 9:46 AM with Certified Nursing Assistant #1 in Resident #54's door way confirmed the resident's catheter drainage bag was visible from the hall and not covered with a dignity bag. Continued interview when asked the procedure for catheter drainage bag placement she stated, we turn and reposition residents every 2 hours and if they have a catheter then we place the catheter bag to whichever side the resident is turned to; I just turned her and placed her bag on her right side facing the door. Observation and interview on 11/5/19 at 9:50 AM with Registered Nurse #1 in Resident #54's room confirmed the resident's catheter drainage bag was facing the hallway and not covered with a dignity bag. Continued interview when asked what was the procedure for covering a resident's catheter bag she confirmed catheter bags are to be covered with a dignity bag at all times and I don't see one on hers. Observation and interview on 11/5/19 at 9:52 AM with the Director of Nursing in the hallway outside of Resident #54's room confirmed the resident's catheter drainage bag was not covered with a dignity bag. Continued interview she confirmed catheter bags were to be covered with dignity bags at all times; I can see hers through the crack from the door and it's not covered.",2020-09-01
745,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2019-11-06,658,D,0,1,TEZO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview, the facility failed to meet professional standards of practice when the facility failed to obtain a lab that was ordered for 1 resident (#11) of 28 residents reviewed. The findings include: Facility policy review, Physcian Orders-(Following Physican Orders), undated, revealed .It is the policy of the facility to follow the orders of the physician .As assessments are completed, orders will be received from the physician to address significant findings of the assessments . Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician order [REDACTED]. Medical record review of Resident #11's lab report revealed the last HbA1c was obtained on 6/4/19. Medical record review revealed Resident #11 did not have the HbA1c obtained for (MONTH) 2019 per the physicians order. Interview with the Director of Nursing on 11/5/19 at 4:15 PM in her office confirmed the HbA1c lab for Resident #11 was not obtained for (MONTH) 2019.",2020-09-01
746,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2019-11-06,689,J,1,1,TEZO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, facility documentation review, medical record review, observation and interview the facility failed to provide adequate supervision to prevent elopement for 1 resident (#68) of 5 residents reviewed who were wander/elopement (Residents who have a history of leaving or trying to leave the facility, or have wandered or have the potential to wander into unsafe areas) risks resulting 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 was informed of the Immediate Jeopardy (IJ) on 11/5/19 at 6:50 PM in his office. An extended survey was conducted from 11/5/19 to 11/6/19. F-689 was cited at a scope and severity of [NAME] F-689 J is Substandard Quality of Care. The Immediate Jeopardy was effective from 7/27/19 through 8/20/19. The facilities corrective action plan, which removed the IJ, was received and the corrective actions were validated onsite on 11/6/19 F-689 was cited at a scope and severity of J as past noncompliance. The facility is not required to submit a plan of correction for F-689 [NAME] The findings include: Review of the facility policy, Missing Residents and Elopement, dated 8/1/16 revealed .It is the policy of this facility that all residents are provided adequate supervision to meet each resident's personal care needs .All residents will be assessed for behaviors or conditions that put them at risk of elopement .All resident's assessed to be at risk of elopement will have this issue addressed in their plan of care .Residents that are at risk of elopement will be provided at least one of the following safety precautions: staff supervision of facility exits either directly or by video camera .door alarms on facility exits .a personal safety device that notifies facility staff when the resident has left the facility without supervision .all personal safety devices, door alarms and video cameras will be tested and document weekly .at no time will any door alarm or personal safety device be deactivated without direct supervision of the exit .Potential safety hazards on the exterior of the facility shall be identified such as wooded areas, water hazards, and busy roads .Should an alarm on one of the exits to the outside of the facility sound, staff will immediately respond to determine the cause of the alarm . Medical record review revealed Resident #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #68's hospital records dated 7/15/19 revealed approximately 1 week prior to the hospitalization , and susequent admission into the facility the resident had wandered from his home, became lost in the woods and sustained rib fractures. Medical record review of Resident #68's 5 day Minimum Data Set ((MDS) dated [DATE] and Discharge MDS dated [DATE] revealed the resident had a Brief Interview of Mental Status Score of 4 indicating the resident had severe cognitive impairment. Continued review revealed the resident wandered daily. Medical record review of Resident #68's comprehensive care plan dated 7/26/19 revealed the resident was high risk for elopement and wandering. Continued review revealed .roam alert bracelet was applied to resident to reduce risk of elopement .monitor resident location with frequent visual checks .monitor doors when staff and visitors come and go . Continued review revealed the resident was at risk for falls. Medical record review of Resident #68's progress notes dated 7/26/19 through 8/6/19 revealed the resident wandered in and out of resident rooms. Medical record review of Resident #68's Elopement Risk Review dated 7/26/19 revealed .the resident had a history of [REDACTED].hangs around facility exits and/or stairways .responds poorly to staff re-direction when roaming into areas that are 'off limits' or unauthorized .has the physical ability to leave the building .becomes agitated, confused and/or disoriented or displays consistently poor judgement (would not be able to safely care for him/herself outside the facility) .at risk to elope and should be placed on the Elopement Risk Protocol .Resident has a history of trying to elope, he does not do redirection to (too) easily from staff . Medical record review of Resident #68's Wandering Risk assessment dated [DATE] revealed .Resident is cognitively impaired with poor decision making .resident is alert but non-compliant with facility protocols regarding leaving the unit .unauthorized opening doors to the outside without regard to their personal safety .lingering around exit doors, attempting to exit with visitors without authorization .displays behaviors, body language, indicating an elopement may be forthcoming . Medical record review of Resident #68's Fall Risk Review dated 7/26/19 revealed the resident was at risk for falls related to [MEDICAL CONDITION] and Dementia. Review of the facility's investigation for Resident #68 dated 7/27/19 revealed the resident exited the building through the front door of the facility. Interview with Licensed Practical Nurse (LPN) #5 on 11/5/19 at 4:19 PM in the conference room revealed she was working on 7/27/19 when Resident #68 exited the facility out the front entrance door. Continued interview revealed I was on the hallway and a 'tech' (Certified Nursing Assistant (CNA) # 6) came out of room [ROOM NUMBER] and yelled at us that (named resident) was outside. Telephone interview with LPN #6 on 11/5/19 at 4:48 PM revealed I was on the hall at the time he was visiting with family in the dining room. One of the CNA's saw him outside through another resident's window; she came out and told me he was outside so I went out to get him and bring him back inside. I was just concerned about getting the resident to safety. Telephone interview with CNA #6 on 11/5/19 at 5:01 PM confirmed I saw him walking outside in the parking lot out of room [ROOM NUMBER]'s window. I first thought his daughter was with him then when I looked again I realized she wasn't, nobody was; I came out of the room and yelled at other staff that (named resident) was in the parking lot. Observation on 11/5/19 at 5:10 PM from room [ROOM NUMBER]'s window revealed the inability to view the front entrance area of the building. Continued observation revealed the ability to view the side parking lot and the 4 lane highway. Telephone interview with Resident #68's family member on 11/6/19 at 2:42 PM revealed I was there, I had gone to the bathroom and when I came out he (Resident #68) was not where I left him, so I started looking for him. I walked all the hallways even looking in rooms to see if he was there. Continued interview revealed I walked around the building for approximately 10 minutes or so; then when I got to Station 1 (nurses' station 1) the staff started yelling 'he's outside' and then everybody started running toward the front door so I went too. When I got to the front door I saw him. He was already down to the road, fixing to get on the road. Interview with the Director of Nursing (DON) on 11/5/19 at 5:38 PM at the front entrance door revealed the DON confirmed Resident #68 was not safe outside. The facility's corrective action plan included the following: 1. On 7/27/19 Resident #68 was brought back into the facility by staff members without injury. A head to toe assessment was competed on Resident #68. The resident was placed on 1:1 staff monitoring. Education and Elopement Training was administered to staff. Confirmed placement and function of residents with wanderguards (Alarm bands placed on residents at risk for exiting the facility which alarms once the resident nears the exit doors) was completed on 7/27/19. The facility completed 100% of Elopement assessments on all residents on 7/27/19. Maintenance Director immediately reviewed all doors on 7/27/19. 2. Elopement drill was completed on 8/8/19. Elopement plans reviewed at an adhoc Quality Performance Improvement (QAPI) meeting on 8/20/19. 3. All residents facility wide had their assessments for elopement risk reviewed for accuracy. The surveyors verified the facility's corrective action plan as follows: 1. The surveyors interviewed staff to confirm the resident was brought back inside the facility to safety and placed on 1:1 monitoring. The surveyors verified a skin assessment was completed on Resident #68 with no skin issues identified. The surveyors reviewed the maintenance log for the functioning of the door alarm system on 7/27/19. The surveyors interviewed random staff concerning elopement in-services on 7/27/19 and what the procedures were for door alarms sounding and what they would do when an alarm sounds. The surveyors reviewed the facility's investigation dated 7/27/19. The surveyors checked the door alarms and the staff responded to the alarms immediately. 2. The surveyors Varified the facility elopement drill dated 8/8/19 and the adhoc Qapi meeting minutes. 3.The surveyors varified elopement risk assessments on all residents who resided in the facility on 7/27/19.",2020-09-01
747,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2019-11-06,812,E,0,1,TEZO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation and interview, the facility failed to ensure food was served under sanitary conditions when a male dietary employee with visible facial hair was observed working on the tray line without wearing a beard guard on 1 of 4 observations having plated the first 22 trays of the noon meal. The facility also failed to store foods in a safe and sanitary manner as evidenced by expired foods brought in by family in 2 of 2 nourishment rooms observed. The findings include: Facility policy review, Code of Dress and Personal Appearance, dated (YEAR), revealed .Hairnets, hair restraints, and beard guards shall be worn .Personal hygiene guidelines will be followed to ensure safe food production and service . Observation of the noon meal on [DATE] at 11:58 AM in the dietary department revealed 1 male dietary employee working on the resident's tray line with visible facial hair and not wearing a beard guard. Continued observation revealed 22 plated trays had already been served in the dining room. Interview with the Assistant Dietary Manager on [DATE] at 12:00 PM in the dietary department confirmed the male employee failed to wear a beard guard to cover visible facial hair while plating food on the tray line. Facility policy review, Use and Storage of Food Brought in by Family or Visitors, revised ,[DATE], revealed .All food items that are already prepared by the family or visitors brought in must be labeled with content and dated .the prepared food must be consumed by the resident within 3 days .if not consumed in 3 days, food will be thrown away by facility staff . Observation and interview with the Assistant Dietary Manager on [DATE] at 3:40 PM in the station 1 nourishment room confirmed pureed unsweetened orange juice (6) 5.5 fluid ounce cans expired (MONTH) 2019. Continued observation in the station 2 nourishment room confirmed cantaloupe, 16 ounce (OZ) container expired [DATE] and a large bag containing multiple plastic containers of food dated [DATE] were past the 3 day window for use. Interview with Licensed Practical Nurse #6 on [DATE] at 4:00 PM at the station 2 nursing station when asked who is responsible to check for expired foods in the nourishment room she confirmed the nurses and Certified Nursing Assistants check for expiration dates and monitor foods brought in from families. Foods from families are to be labeled and dated and thrown away after 3 days from the date brought in. Interview with the Director of Nursing (DON) on [DATE] at 4:25 PM in the hallway outside of the Bedford Corner conference room, confirmed, she would not expect to find expired foods in the nourishment rooms. The DON also confirmed she expected the nursing staff and the dietary staff to check the nourishment rooms daily for expired food.",2020-09-01
748,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2018-12-05,657,D,0,1,O1CY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, review of facility documents, medical record review and interview, the facility failed to revise care plans for 2 Residents (#26 and #44) of 31 residents reviewed. The findings include: Review of an undated facility policy, Care Plan Review, revealed .all residents receive a review of the Plan of Care by the Interdisciplinary Team at least quarterly . Review of the facility's undated Daily Clinical Control Quality Improvement Meeting form revealed .care plan updates as appropriate . Medical record review revealed Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].Enteral Feed every day and night shift [MEDICATION NAME] 2.0 (enteral formula) @ (at) 40 ml/hr (milliters per hour) x (times) 25 hours turn on at 0000 (12 AM) turn off at 2200 (10 PM) (May use [MEDICATION NAME] 1.5 (enteral formula) until [MEDICATION NAME] 2.0 available) H20 (water) auto flush via (by) percutaneous endoscopic gastrostomy peg tube ([DEVICE])@ 30 ml/hr x 22 hours/day. Turn on @ 0000 Turn off @ 2200, start [DATE] 22:00 . Medical record review of the Care Plan revealed .(resident) is NPO (nothing by mouth) and is receiving tube feedings x 20 hours with auto H2O flush per pump. He has a 16 french [DEVICE] with a 20 ml bulb. He is given [MEDICATION NAME] 2.0 @ 50 ml/hr (hour) x 22 hours turn on at 0000 turn off at 2200 (May use [MEDICATION NAME] 1.5 until [MEDICATION NAME] 2.0 available) H20 auto flush via peg tube ([DEVICE]) @ 30 ml/hr x 22 hours/day. Turn on @ 0000. Turn off @ 2200. He is monitored for residual and placement of [DEVICE] every shift and PRN (as needed) . Interview with Registered Nurse #1 on [DATE] at 5:52 PM at station 1 revealed the update of the resident Care Plans are part of the SWAT (Skin And Weight Assessment Team) team and the different departments are delegated to put in a note or change the order. Further interview confirmed the facility failed to update the Care Plan to reflect a change. Medical record review revealed the facility admitted Resident #44 on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #44's Tennessee Physician order [REDACTED].Do Not Attempt Resuscitation (DNR/no cardiopulmonary resuscitation (CPR)), limited additional interventions no artificial nutrition by tube, no intubation . Review of a physician's orders [REDACTED].DNR with limited interventions. Do not intubate. No mechanical life sustaining measures . Review of the comprehensive care plan dated [DATE] and revised on [DATE] revealed .Full Code/CPR, limited interventions, no artificial nutrition by tube, do not intubate . Interview with the Director of Nursing (DON) on [DATE] at 9:59 AM in her office revealed physician orders [REDACTED]. Further interview with the DON revealed the Minimum Data Set (MDS) Coordinator was responsible for updating the care plans. The DON reviewed the physician order [REDACTED].#44 and stated Yep it's not updated. Interview with the MDS Coordinator on [DATE] at 10:07 AM in her office confirmed physician orders [REDACTED]. Further interview with the MDS Coordinator confirmed Resident #44's care plan was not updated. She stated It should have been updated when the orders were received.",2020-09-01
749,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2018-12-05,693,D,0,1,O1CY11,"**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 administer the rate of a tube feeding as ordered and failed to administer the tube feeding as ordered for 1 Resident (#26) of 5 residents receiving tube feeding. The findings include: Review of an undated facility policy, Enteral Tube Medication Administration revealed, .Verify physician's orders [REDACTED]. Medical record review revealed Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].Enteral Feed every day and night shift [MEDICATION NAME] 2.0 (enteral formula) @ (at) 40 ml/hr (milliters per hour) x (times) 25 hours turn on at 0000 (12 AM) turn off at 2200 (10 PM) (May use [MEDICATION NAME] 1.5 (enteral formula) until [MEDICATION NAME] 2.0 available) H20 (water) auto flush via percutaneous endoscopic gastrostomy (peg tube) @ 30 ml/hr x 22 hours/day Turn on @ 0000 Turn off @ 2200, start 11/21/2018 22:00 . Observation on 12/3/18 at 9:37 AM, and 3:47 PM revealed Resident #26 was administered [MEDICATION NAME] 2.0 tube feeding at 50 ml/hr instead of 40 ml/hr as ordered. Observation on 12/3/18 at 12:08 PM, 3:24 PM and on 12/4/18 at 7:46 AM revealed Resident #26 was not receiving the tube feeding as ordered from 12 AM to 10 PM. Observation and interview with Licensed Practical Nurse (LPN) #4 on 12/4/18 at 4:53 PM on the station 1 hall revealed Resident #26 was receiving the tube feeding at 50 ml/hr. Further interview when asked if the enteral order was changed?, LPN #4 stated .if it had been changed they haven't changed it in the medical record . Further interview confirmed the enteral feeding order had been changed to 40 ml/hr on 11/21/18. Further interview confirmed .sometimes he's sitting out of his room and he would be off the tube feeding .",2020-09-01
750,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2018-12-05,758,D,0,1,O1CY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide monitoring related to performing Abnormal Involuntary Movement Scale (AIMS) assessments in a timely manner for 1 Resident (#4) of 27 residents receiving Anti-Psychotic medications. The findings include: Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].[MEDICATION NAME] 25 milligrams (mg) by mouth twice a day . Medical record review revealed the last AIMS performed for Resident #4 was completed on 10/24/17. Interview with the Director of Nursing on 12/5/18 at 3:48 PM in her office confirmed Resident #4 did not have an AIMS completed since (MONTH) (YEAR). She stated, I know they are to be done quarterly by the nurses, we have a breakdown.",2020-09-01
751,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2017-12-06,550,D,0,1,BDXJ11,"Based on observation and interview, the facility failed to provide feeding assistance in a dignified manner for 1 resident (#66) of 13 residents observed during a dining observation. The findings included: Observation of lunch on 12/4/17 at 12:40 PM in the main dining room revealed Certified Nurse Aide (CNA) #1 provided feeding assistance for Resident #66. Continued observation revealed CNA #1 dropped food from the utensil onto the resident's clothing protector. Further observation revealed CNA #1 picked up the dropped food with the utensil and fed it to Resident #66. Interview with CNA #1 on 12/4/17 at 6:20 PM in the Bedford Corner room revealed CNA #1 confirmed she fed Resident #66 food dropped onto the clothing protector while providing feeding assistance. Interview with the Director of Nursing (DON) on 12/5/17 at 4:53 PM in her office revealed she expected staff to dispose of dropped food and for the food not to be fed to resident's if dropped. The DON confirmed the facility failed to provide feeding assistance in a dignified manner for Resident #66.",2020-09-01
752,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2017-12-06,658,D,1,1,BDXJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > AMENDED: Correction made to date for F658. The dates were: 12/24/17, 12/25/17, and 12/26/17. The correct dates are: 12/24/16, 12/25/16, and 12/26/16. Based on facility policy review, medical record review, and interview, the facility failed to follow physician orders [REDACTED].#439) of 14 residents reviewed. The findings included: Review of facility policy, Drug Administration General Guidelines, dated 11/2016 revealed, .Medications are administrated (administered) as prescribed, in accordance with good nursing principles and practices .At the end of each medication pass, the person administering the medications reviews the MAR (Medication Administration Record) to ascertain that all necessary doses were administered and all administered doses were documented . Medical record review revealed Resident #439 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's orders [REDACTED]. Infuse 100 ml (900 mg) over 60 minutes at 100 ml/hr (per hour) every 24 hours times 2 weeks. Medical record review of the 12/2016 MAR indicated [REDACTED]. Medical record review of Physician's Telephone Orders dated 12/24/16 revealed, .[MEDICATION NAME] (antifungal medication) 150 mg po (by mouth) daily X (times) 3 days for yeast [MEDICAL CONDITION] . Medical record review of the 12/2016 MAR indicated [REDACTED]. Interview with the Director of Nursing (DON) on 12/4/17 at 6:00 PM in the conference room confirmed the facility failed to administer [MEDICATION NAME] and [MEDICATION NAME] as prescribed by the Physician for Resident #439.",2020-09-01
753,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2017-12-06,689,G,1,1,BDXJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of a facility investigation, observation, and interview, the facility failed to prevent an accident resulting in an arm fracture for 1 resident (#66), and failed to prevent elopement for 1 resident (#77) of 14 residents reviewed. The facility's failure resulted in HARM for Resident #66. The findings included: Review of facility policy, Accidents/Incidents, dated 1/1989 revealed, .any accidents/incidents involving Residents .are immediately reported to the charge nurse or immediate supervisor. All accidents/incidents involving Residents are evaluated by the charge nurse who, in consultation with the attending physician, determines the appropriate interventions . Review of facility policy, Gait Belt, dated 7/2007 revealed, .to prevent injury to the resident or staff while ambulating the resident and to provide an additional sense of security for the resident . Medical record review revealed Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #66 was cognitively impaired, rarely understood, required extensive assist of 2 people for transfers, and was mobile in a wheelchair per self. Continued review revealed [DIAGNOSES REDACTED]. Medical record review of Nurses Notes dated 10/27/17 at 8:30 PM revealed LPN #6 was called to the resident's room by the Certified Nurse Aide (CNA) #5 to look at a bruise and swelling of Resident #66's right arm and shoulder. Continued review revealed a Physician's Telephone Order was obtained by the Licensed Practical Nurse (LPN) #6 for an x-ray of the Resident's right arm and shoulder. LPN #6 applied ice to the area and notified Resident #66 responsible party. Medical record review of an x-ray report dated 10/28/17 at 3:40 PM revealed an acute [MEDICATION NAME] humeral metaphysis with slight medial displacement of the distal fracture fragment (fracture occurring at a ninety degree angle in relation to the long bone of the upper arm and near the shoulder joint). Continued review of the x-ray report dated 10/28/17 revealed the humerus and shoulder demonstrated generalized osteopenic (the bone density is more like a honeycomb than solid). Telephone interview with CNA #4 on 12/6/17 at 1:30 PM revealed, I found the bruise on his arm around 11:00 AM on 10/27/17 and told the nurse. Further interview revealed when asked how Resident #66 is transferred the CNA replied, now we use a lift but before we didn't. Further interview revealed when asked if the Nurse Aids used a gait belt to transfer Resident #66 before the injury she replied, No. We just supported his arms. Observation of Resident #66 on 12/4/17 at 1:30 PM in his room revealed the resident was wearing a right arm sling, lying in bed with yellow discoloration to visible aspect of right upper outer arm. Review of the facility Root Cause Analysis worksheet, dated 11/1/17, revealed the root cause of Resident #66's humerus fracture was due to .lack of education and training with system cause of the arm fracture listed as transferring . Interview with the Director of Nursing (DON) in the conference room on 12/6/17 at 4:38 PM revealed she stated, We do not have a transfer policy or written protocol, we just teach them how to use a gait belt and they come to us if they have any questions. Interview with the Assistant Director of Nursing (ADON) on 12/6/17 at 2:00 PM in the conference room, when asked if the fracture was avoidable she stated, Yes I feel the fracture could have been prevented if the staff had been better trained, for instance, if they had been using a gait belt instead of steadying the resident by his arms it could have taken some of the pressure off of his shoulder. Continued interview confirmed .the facility failed to provide adequate transfer training which resulted in the fracture for Resident #66 and actual Harm . Review of facility policy, Resident Elopement Policy, undated revealed .personnel who have residents under their care are responsible for knowing the location of those residents, and in the case of a missing resident ensuring appropriate action is taken. Medical record review revealed Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Admission MDS dated [DATE] revealed Resident #77 had a Brief Interview for Mental Status (BIMS) of 3 indicating severe cognitive impairment and required extensive assistance in transfers, eating, and hygiene and used a wheelchair for locomotion. Medical record review of an Elopement Risk Review dated 11/3/17 revealed the resident was not at risk for elopement. Medical record review of the Nurses Notes dated 11/7/17 at 11:19 PM revealed, .resident exited the garden room door and tipped his wheelchair off the sidewalk .noted by Dietary staff and LPN to be in the grass lying on his right side with the wheelchair tipped over in the grass as well. Small dime sized skin tear noted to back of left hand near his knuckles . Review of a facility investigation and witness statements revealed Resident #77 was last seen inside the facility on 11/7/17 at 6:50 PM after supper. Further review revealed, between 7:15 PM and 7:30 PM the LPN was unable to find the resident and began searching the resident rooms. At 7:45 PM staff began searching outside for the resident, and Resident #77 was found outside the facility lying on the ground at 8:15 PM, .with his wheelchair flipped over on its side . Further review of witness statements revealed, .We found him (Resident #66) outside, flipped over in his chair laying in the grass, wet, he was a little scraped up . Interview with the Maintenance Director on 12/4/17 at 3:45 PM in the garden room revealed, .I was called to the facility after hours and found the garden room exit door not to be functioning properly .I removed the electrical cover and noticed the wiring was corroded and there was moisture on the cover .I cleaned the corrosion and dried up the moisture .The area above the door was caulked and the door began to work properly .sign in sheets were made and the door was checked every fifteen minutes .then weekly .I ordered new mag locks and they were installed .'' Observation on 12/4/17 with the Maintanance Director present revealed all the exit doors functioned correctly. Further review revealed all wandergaurd alarms at exit doors functioned correctly. Interview with the Assistant Director of Nursing (ADON) on 12/6/17 at 2:15 PM in the conference room confirmed, that night the whole door malfunctioned.",2020-09-01
754,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2017-12-06,725,E,0,1,BDXJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, review of a Medication Admin Audit Report, review of the Medication Administration Schedule, and interview, the facility failed to provide sufficient nursing staff as evidenced by untimely medication administration on 3 of 7 days for 1 resident (#39) of 14 residents reviewed. The findings included: Review of facility policy, Drug Administration-General Guidelines, dated 11/16 revealed .Medications are administered within 60 minutes of scheduled time .medications are administered according to the established medication administration schedule for the facility . Medical record review revealed Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] and 10/15/17 revealed the resident was cognitively intact. Medical record review of a Comprehensive Care Plan revised 10/18/17 for Resident #39 revealed interventions including: 1) the [MEDICAL CONDITION] medication administered as ordered 2) observed for behaviors and side effects of the medication every shift. Review of the Medication Admin Audit Report revealed Resident #39 received [MEDICATION NAME] (pain) 50 milligrams (mg),[MEDICATION NAME]([MEDICAL CONDITION]) 10 mg, Polyethylene [MEDICATION NAME] (constipation) 17 grams, [MEDICATION NAME] 10-325 mg (Lumbago pain), [MEDICATION NAME] ([MEDICAL CONDITION]) 50 mg, [MEDICATION NAME] ([MEDICAL CONDITION] depression) 100 mg, [MEDICATION NAME] 25-100 mg ([MEDICAL CONDITION]), [MEDICATION NAME] (Insulin for Diabetes Mellitus) 15 units subcutaneous injection, [MEDICATION NAME] ([MEDICAL CONDITION] depression) 10 mg sublingual (under the tongue), Levetiracetam (tremors with convulsions) 500 mg, and [MEDICATION NAME] (muscle relaxant) 350 mg. These medications were scheduled to be given at 9:00 PM on 11/30/17 but did not receive them until 11:21 PM. Continued review of the Medication Admin Audit Report revealed Resident #39 received [MEDICATION NAME] (pain) 50 milligrams (mg),[MEDICATION NAME]([MEDICAL CONDITION]) 10 mg, Polyethylene [MEDICATION NAME] (constipation) 17 grams, [MEDICATION NAME] 10-325 mg (Lumbago pain), [MEDICATION NAME] ([MEDICAL CONDITION]) 50 mg, [MEDICATION NAME] ([MEDICAL CONDITION] depression) 100 mg, [MEDICATION NAME] 25-100 mg ([MEDICAL CONDITION]), [MEDICATION NAME] (Insulin for Diabetes Mellitus) 15 units subcutaneous injection, [MEDICATION NAME] ([MEDICAL CONDITION] depression) 10 mg sublingual (under the tongue), Levetiracetam (tremors with convulsions) 500 mg, and [MEDICATION NAME] (muscle relaxant) 350 mg. These medications were scheduled to be given at 9:00 PM on 12/1/17 but did not receive them until 11:14 PM. Continued review of the Medication Admin Audit Report revealed Resident #39 received [MEDICATION NAME] (pain) 50 milligrams (mg),[MEDICATION NAME]([MEDICAL CONDITION]) 10 mg, Polyethylene [MEDICATION NAME] (constipation) 17 grams, [MEDICATION NAME] 10-325 mg (Lumbago pain), [MEDICATION NAME] ([MEDICAL CONDITION]) 50 mg, [MEDICATION NAME] ([MEDICAL CONDITION] depression) 100 mg, [MEDICATION NAME] 25-100 mg ([MEDICAL CONDITION]), [MEDICATION NAME] (Insulin for Diabetes Mellitus) 15 units subcutaneous injection, [MEDICATION NAME] ([MEDICAL CONDITION] depression) 10 mg sublingual (under the tongue), Levetiracetam (tremors with convulsions) 500 mg, and [MEDICATION NAME] (muscle relaxant) 350 mg. These medications were scheduled to be given at 9:00 PM on 12/3/17 but did not receive them until 11:28 PM. Review of the facility's Medication Administration Times revealed, .Bid (twice a day) 8:00 AM or 9:00 AM and 5 PM or 8 PM; Tid (three times a day) 9:00 AM, 1:00 PM, 5:00 PM; Qid (four times a day) 12:00 AM, 6:00 AM, 12:00 PM, 6:00 PM or 8:00 AM, 12:00 PM, 4:00 PM, 8:00 PM; Qhs (every hour of sleep) 8:00/9:00 . Interview with Resident #39 on 12/4/17 at 10:25 AM in the resident's room revealed the resident stated the facility was short staffed at night and received his medication, 2 to 3 hours late. Continued interview with the Resident #39 on 12/6/17 at 10:35 AM in the resident's room confirmed the resident did not receive his medication on time for 11/30/17, 12/1/17, and 12/3/17. Interview with Licensed Practical Nurse (LPN) #1 and LPN #2 on 12/4/17 at 5:50 PM at the medication cart on Hall 1 revealed when questioned if the facility had enough staff, they answered the facility could use 1 to 2 more licensed nurses and 1 to 2 more Certified Nurse Aides (CNA's) on the night shift. Interview with LPN #3 on 12/6/17 at 12:15 PM in Hall 2 confirmed medications were late for Resident #39 on 11/30/17, 12/1/17, and 12/3/17. She stated the same residents required the same amount of medications on the night shift, however there are 2 less licensed personnel to administer the medications than there are on the day shift. Interview with the Director of Nursing on 12/6/17 at 12:30 PM in her office confirmed the facility failed to administer medication timely for Resident #39 due to insufficient nursing staff.",2020-09-01
755,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2017-12-06,758,D,0,1,BDXJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, and interview, the facility failed to monitor behaviors for 2 residents (#18, #42) of 6 residents reviewed for unnecessary medications. The findings included: Review of facility policy, Psychopharmacological Medication, dated 7/14 revealed For the purposes of this policy and procedure, the term psychopharmacological medication is defined as anti-anxiety agents, antidepressants, sedative, hypnotics, antipsychotics and other drugs that affect behavior . It is the policy of this facility to document the episodes of behaviors, the interventions attempted to alter the behavior, the impact of the medication on behavior and the presence or absence of side effects on the monthly Behavior Monitoring Form or any other approved form .Nursing will initiate the Behavior Monitoring Form, or any other approved form, for all Psychopharmacological Medications .Complete the appropriate sections every shift . Medical record review revealed Resident #18 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #18 had received antipsychotic medication during the assessment look back period. Medical record review of a Physician order [REDACTED]. Medical record review of the (MONTH) and (MONTH) (YEAR) Medication Administration Record [REDACTED]. Further review revealed no behavior monitoring for [MEDICATION NAME] was documented. Medical record review revealed Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., Dementia, Type 2 Diabetes with Diabetic [MEDICAL CONDITIONS], Heart Failure, [MEDICAL CONDITION] Fibrillation, Heart Failure, [MEDICAL CONDITION], Dysphagia, [MEDICAL CONDITIONS], [MEDICAL CONDITIONS], [DIAGNOSES REDACTED], Gastro-[MEDICAL CONDITION] Reflux Disease, [MEDICAL CONDITIONS], Chronic Pain, Restlessness and Agitation. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #42 had received antipsychotic medication during the assessment look back period. Continued record review of the Quarterly MDS dated [DATE] revealed Resident #42 received antipsychotic medication during the assessment look-back period. Medical record review of a Physician order [REDACTED]. Medical record review of the MAR from (MONTH) (YEAR) - (MONTH) (YEAR) revealed Resident #42 received the medication as prescribed. Further review revealed no behavior monitoring for [MEDICATION NAME]. Interview with Licensed Practical Nurse (LPN) #4 on 12/6/17 at 8:50 AM outside room [ROOM NUMBER] revealed a resident received behavior monitoring if they are prescribed antipsychotic medications. Continued interview revealed the monitoring documentation would be completed on the MAR. Interview with the Director of Nursing (DON) on 12/6/17 at 12:50 PM in the conference room revealed residents who received antipsychotic medications also received behavior monitoring. After review of the medical records, the DON confirmed the facility failed to complete behavior monitoring.",2020-09-01
756,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2017-12-06,804,F,0,1,BDXJ11,"Based on interview and observation, the facility failed to serve palatable food at a safe and appetizing temperature. The findings included: Interview with Resident #29 on 12/4/17 at 10:58 AM in his room revealed the food was always cold and he .might as well have a freezer . Interview with Resident #340 on 12/4/17 at 4:17 PM in his room revealed .The food is always cold 99% of the time and it's not good . Observation on 12/4/17 at 6:21 PM on the station #2 hallway revealed the test tray temperature for baked fish was obtained by Dietary Aide #1. Further observation revealed a temperature of 106 degrees Fahrenheit. Interview with the Registered Dietitian on 12/05/17 at 10:00 AM in her office confirmed the temperature of the baked fish on the test tray was not in parameters for safe consumption for the residents in the facility. Interview with the Resident Council members on 12/6/17 at 2:30 PM in the Bedford Corner room revealed there were continuous complaints of cold food. Residents stated this has been going on for months.",2020-09-01
757,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2020-02-05,580,D,1,0,5CUG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to notify the Resident's Representative of a fall for 1 resident (Resident #3) of 3 residents reviewed for falls. The findings included: Review of the undated policy, Falls Management Program Guides, revealed .the responsible party should be notified . Medical record review revealed Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].FRACTURE OF LUMBOSACRAL SPINE AND PELVIS, REPEATED FALLS, [MEDICAL CONDITIONS] WITHOUT BEHAVIORAL DISTURBANCE, DIFFICULTY IN WALKING, MUSCLE WASTING [MEDICAL CONDITION], GENERALIZED ANXIETY DISORDER, POST-TRAUMATIC STRESS DISORDER, and MAJOR [MEDICAL CONDITION]. Medical record review of the Face Sheet for Resident #3 revealed Family Member #3 was listed as the Contact/Emergency Contact #1. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #3 had adequate hearing; vision was impaired; her speech was unclear, she usually could make herself understood and usually understood others. She scored a 15 on the Brief Interview for Mental Status (BIMS), indicating she was cognitively intact. Medical record review revealed the following: On 1/9/2020 at 3:41 PM, of the Health Status Note, written by Licensed Practical Nurse (LPN) #5, revealed .At around 12:50 PM on Thursday (MONTH) 9, 2020, a pt (patient) yelled down the hallway I need a nurse. This nurse came to room and found pt (patient - (Resident #3) lying face down on the floor. there was a fair amount of blood on floor .pt had blood coming from a small laceration above rt (right) eye, and redness to rt cheek . On 1/10/2020, of the Post Fall Review, written by LPN #5, revealed Resident #3 had an unwitnessed fall on 1/9/2020 at 12:50 PM. Further review revealed the .Family/Responsible Party was notified on 1/9/2020 at 2:00 PM and named the specific family member. Further review revealed the specified family member notified was not Family Member #3. Review of the facility investigation included the Supervisor Investigation of Fall form dated 1/9/2020, written by LPN #5, which revealed Resident #3 fell on [DATE] at 12:50 PM, in her room. The form revealed the resident's family member, specifying the relationship to the resident, was notified on 1/9/2020 at 1:15 PM. Further review revealed the family member notified was not family Member #3. Interview with LPN #5 on 2/5/2020 at 8:34 AM, in the conference room revealed the LPN was working at the medicine cart when Resident #3's roommate rolled out of the room in the wheelchair and told the LPN that (Resident #3) needed help. The LPN entered the room and found Resident #3 face down with a little pool of blood under her head. The LPN stated she went to the nursing station and was checking the resident's chart to initiate the notifications when the nursing station telephone rang. The LPN answered the telephone and Resident #3's relative was asking to speak to the resident. The LPN stated she noticed this family members name was listed as an emergency contact and proceeded to inform the individual of the fall and then took the telephone to the resident for the family member to talk with the resident. The LPN stated she saw the name on the list and did not recall if there was a designation of which to notify first. The LPN stated several hours later, (Named Family Member #3) called the facility and 'was yelling at me why didn't I notify her first.' The LPN stated she tried to apologize and explained what had happened regarding the telephone ringing right when she was ready to call and it was Resident #3's family on the telephone and on the emergency contact list. Interview with the Interim Director of Nursing on 2/4/2020 at 3:05 PM, in the conference room confirmed the facility failed to notify the appropriate Family Member, #3. Further interview revealed the Face Sheet used at the time of the 1/9/2020 fall included the name of the the family member which called the facility but there was no evidence of the information in the current medical record or in the fall investigation documentation.",2020-09-01
758,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2020-02-05,641,D,1,0,5CUG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview, the facility failed to accurately assess the fall on the Minimum Data Set for 1 (Resident #1) resident of 5 residents reviewed. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].NON-ST ELEVATION [MEDICAL CONDITION] INFARCTION; TYPE 2 DIABETES MELLITUS; MAJOR [MEDICAL CONDITION], RECURRENT, SEVERE WITH PSYCHOTIC SYMPTOMS; UNSPECIFIED CONVULSIONS, [MEDICAL CONDITIONS] DISORDER, [MEDICAL CONDITION] TYPE; [MEDICAL CONDITION] DISEASE OF NERVOUS SYSTEM, and AGE-RELATED [MEDICAL CONDITION] since 2014 . Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #1 had clear speech, and usually could make her needs known and usually understood others. The resident scored a 4 on the Brief Interview for Mental Status (BIMS), indicating she was severely cognitively impaired (severely impaired range 0 - 7). She was occasionally incontinent of bowel and bladder. She required limited 1 person assistance for bed mobility, transferring, walking in the room, locomotion on and off the unit, eating and toileting for her activities of daily living (ADL). Resident #1 was assessed as having no falls during the review period. Medical record review of the Nursing Progress Note, written by Licensed Practical Nurse (LPN) #1, dated 12/4/2019 at 7:00 PM, revealed .Resident (#1) was found on the floor of the room across the hall from her own room, (named Certified Nurse Aide (CNA) #1) went down the hall to start her round and saw the resident sitting on her bottom, in the floor, with blood in her hair and on the floor around her, the CNA called for a nurse, this nurse assessed the resident, discovered she had two bleeding wounds, quickly forming lumps, on her head, one on the back, right side, and one on her left side . Review of the facility investigation included the Supervisor Investigation of Fall, written by LPN #1, dated 12/4/2019, revealed Resident #1 had an unwitnessed fall on 12/4/2019 at 7:00 PM, in another resident's room. Further review revealed the resident's head hurt, and she had 2 hematomas to the head and was bleeding. Review of the Resident Event Report Worksheet, written by LPN #1, with the event date and time of 12/4/2019 at 6:55 PM, revealed Resident #1 had an unwitnessed fall with a significant injury while in another resident's room. Further review revealed the resident sustained [REDACTED]. Medical record review of the Quarterly MDS dated [DATE], revealed the MDS did not address the fall with injury which occurred on 12/4/2019. Interview with the Registered Nurse MDS Coordinator on 2/5/2020 at 9:20 AM in the conference room confirmed the MDS dated [DATE] failed to include the fall of 12/4/2019 by Resident #1.",2020-09-01
759,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2020-02-05,689,D,1,0,5CUG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to conduct a thorough investigation of falls for 2 (Resident #1 and #3) residents of 3 residents reviewed with falls. The findings included: Review of the undated policy, Falls Management Program Guides, revealed the corporation strived to maintain a hazard free environment, mitigate fall risk factors and the implementation of preventative measures. The definition of a fall was considered to be .an unintentional coming to rest on the ground, floor, or the lower level, but not as a result of an overwhelming external force .when a resident is found on the floor, a fall is considered to have occurred . The Procedure included the fall risk assessment as part of the admission, quarterly and when a fall occurred, the identified risk factors should have been evaluated for the contribution they may have to the resident's likelihood of falling and the care plan interventions should have been implemented that addressed the resident's risk factors. Further review revealed if the event the resident fell .the attending nurse shall complete a post fall assessment .includes an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce risk of repeat episode and a review by the IDT to evaluate thoroughness of the investigation and the appropriateness of the interventions .nursing staff will observe and document continued resident response and effectiveness of interventions for 72 hours . Medical record review revealed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].NON-ST ELEVATION [MEDICAL CONDITION] INFARCTION; TYPE 2 DIABETES MELLITUS; MAJOR [MEDICAL CONDITION], RECURRENT, SEVERE WITH PSYCHOTIC SYMPTOMS; UNSPECIFIED CONVULSIONS; [MEDICAL CONDITION]; [MEDICAL CONDITION]; [MEDICAL CONDITION] DISORDER, [MEDICAL CONDITION] TYPE; [MEDICAL CONDITION] DISEASE OF NERVOUS SYSTEM, and AGE-RELATED [MEDICAL CONDITION] since 2014 . Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #1 had adequate hearing and vision with no devices; had clear speech, and usually could make her needs known and usually understood others. The resident scored a 4 on the Brief Interview for Mental Status (BIMS), indicating she was severely cognitively impaired (severely impaired range 0 - 7). She did not have a change in mental status and exhibited no [MEDICAL CONDITION] or behaviors during the review period. She did exhibit inattentiveness which did fluctuate. She exhibited alteration in sleep and depression/feeling down for 12 - 14 days of the review period. She exhibited a change in energy for 7 - 12 days of the review period. She exhibited a change in appetite and concentration for 2 - 6 days of the review period. She was occasionally incontinent of bowel and bladder. She required limited 1 person assistance for bed mobility, transferring, walking in the room, locomotion on and off the unit, eating and toileting for her activities of daily living (ADL). Resident #1 was assessed as having no falls during the review period. Medical record review of the care plan updated in 10/28/2019, revealed Resident #1 was at risk for falls related to she required assistance with ADLs at times, received [MEDICAL CONDITION] medication, and had Actual Falls. The interventions included .Encourage resident to request assistance in ambulating, Fall Intervention: Keep personal items within reach, activities that minimize the potential for falls while providing diversion and distraction upon her visitors departure, Make sure shower chair is locked on both sides, Provide non-skid footwear as tolerated, and Therapy to provide resident with a reacher device (long handled device with pinchers on one end to grasp items) . Medical record review of the Morse Fall Scale form dated 10/29/2019, revealed Resident #1 was at a moderate risk for falls with a score of 40. Medical record review of the Nursing Progress Note, written by Licensed Practical Nurse (LPN) #1, dated 12/4/2019 at 7:00 PM, revealed .Resident (#1) was found on the floor of the room across the hall from her own room, (named CNA #1) went down the hall to start her round and saw the resident sitting on her bottom, in the floor, with blood in her hair and on the floor around her, the CNA called for a nurse, this nurse assessed the resident, discovered she had two bleeding wounds, quickly forming lumps, on her head, one on the back, right side, and one on her left side, pressure was applied with a cold towel, the other nurse called for an ambulance, which arrived and transported the resident to (named hospital) . Review of the facility investigation of the undated, Staffs 10 Questions at the Time of a Resident Fall, written by LPN #1, revealed Resident #1's head hurt, .What were you trying to do when you fell ? Walking .Position of resident when they fell ? Near wheelchair. How far from surface where they? Next to surface. What were position of their arms and legs? Arms in lap, legs in front of her .Apparel resident was wearing? Night gown .Shoes, Socks (non-skid) . Review of the facility investigation included the Supervisor Investigation of Fall, written by LPN #1, dated 12/4/2019, revealed Resident #1 had an unwitnessed fall on 12/4/2019 at 7:00 PM, in another resident's room. She possibly fell from the wheelchair, unknown. The resident's head hurt, and she had 2 hematomas to the head and was bleeding. The Immediate Intervention was to apply pressure to the wounds. The resident had not had a previous fall. CNA #1 found the resident. The resident was sent to the emergency room and neurological checks were started after the resident returned from the hospital. The physician and family were notified. Review of the Resident Event Report Worksheet, written by LPN #1, with the event date and time of 12/4/2019 at 6:55 PM, revealed the physician and family were notified. The assigned staff to Resident #1 were CNA #1 and LPN #1. The resident had an unwitnessed fall with a significant injury while in another resident's room and was found on the floor. The circumstances were unknown. The resident sustained [REDACTED]. Review of the POS [REDACTED]. Vital Signs were - Temperature 98.4; Pulse 71; Respiration 16; and Blood Pressure 147/99. The resident was found on the floor of another resident's room and she didn't know what happened, says 'I just fell .' Fall review location: in another resident's room; location prior to fall: wheelchair; Activity at time of the fall? Unknown. Footwear/device at time of fall: shoes. There were no environmental factors identified. The immediate prevention put in place was to encourage resident to ask for assistance with ADL's. Medical record review for the Morse Fall Scale form revealed there was no form for the fall on 12/4/2019 for Resident #1. Review of the undated written statement by CNA # 1 revealed .Went down 300 hall to start my round I saw (named Resident #1) on the floor with blood around her. I immediately called for help. (Named LPN #6) and (named LPN #1) came down and we grabbed towels and applied pressure. (Named LPN #6) went and called 911 and got all the paperwork together. We took her vitals and assessed her. The paramedics showed up and picked her up . Medical record review of the potential resident witnesses to the fall of Resident #1 on 12/4/2019, revealed Resident #4's Quarterly MDS dated [DATE], showed she had a BIMS of 9, indicating she was moderately cognitively impaired (moderately range 8 - 12). She had minimal difficulty hearing, adequate vision, had clear speech and could usually make herself understood and usually understood others. The investigation failed to include an interview of what the resident potentially saw and/or heard during the fall. Medical record review of potential resident witness to the fall of Resident #1 on 12/4/2019, revealed Resident #5's Annual MDS dated [DATE], showed she had a BIMS of 12, indicating she was moderately cognitively impaired. She had adequate hearing and vision, clear speech, and could make herself understood and understood others. Resident #5 had another MDS dated [DATE], which showed her BIMS was 13, indicating she was cognitively intact (intact range 13 - 15) and the other data was the same as the 9/15/2019 MDS. The investigation failed to include an interview of what the resident potentially saw and/or heard during the fall. Further review of the investigation revealed the failure to identify the room where the fall took place, failure to identify the 2 residents in the room of the fall, and failure to obtain an interview from the residents potentially witnessing the fall, if feasible, or have data to show the 2 residents where not capable of providing information. The investigation did not include a diagram of the room layout and the resident's position at the time of the fall. The investigation included 1 witness statement, by CNA #1, who named another staff member, (named LPN #6) was present in the room. There was no statement in the investigation from LPN #6. The investigation did not include a root cause. Interview with the Interim Director of Nursing (IDON) on 2/4/2020 at 8:00 AM, in the conference room stated some areas of the Post Fall Review form addressed the fall risks assessment addressed in the Falls Management Program Guidelines policy. The IDON read the Post Fall Review dated 12/4/2019 and confirmed it did not include the fall risk assessment. Further interview at 9:10 AM confirmed the investigation did not include the statement by the staff named (LPN #6) in CNA #1's statement, did not indicate when Resident #1 was last seen by staff and what she was doing, did not include how Resident #1 got into room of the fall, did not specify the room where the fall occurred, and did not identify the 2 residents who were potential witnesses and if the 2 residents were capable of providing a statement. The IDON confirmed the investigation was not complete. The IDON confirmed the Fall Risk Assessment should have been completed as part of the investigation. Medical record review revealed Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].FRACTURE OF LUMBOSACRAL SPINE AND PELVIS, REPEATED FALLS, HYPERTENSION, CHRONIC PAIN, [MEDICAL CONDITION], TYPE 2 DIABETES MELLITUS, [MEDICAL CONDITIONS] WITHOUT BEHAVIORAL DISTURBANCE, DIFFICULTY IN WALKING, MUSCLE WASTING AND ATROPHY, RETENTION OF URINE, [MEDICAL CONDITIONS], GENERALIZED ANXIETY DISORDER, POST-TRAUMATIC STRESS DISORDER, MAJOR [MEDICAL CONDITION], and ANXIETY DISORDER . Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #3 had adequate hearing; vision was impaired; her speech was unclear, she usually could make herself understood and usually understood others. She scored a 15 on the Brief Interview for Mental Status (BIMS), indicating she was cognitively intact. She had no changes in mental status, no [MEDICAL CONDITION], no [MEDICAL CONDITION] or any behaviors during the review period. The resident exhibited feeling down/depressed and a change in appetite over the past 12-14 days; a change in energy for 7-11 days, and a change in sleep and feeling bad about herself/let others down over the past 2-6 days of the review period. The resident required total 1 person assistance for bathing; extensive 2 plus (+) person assistance with bed mobility; extensive 1 person assistance with transferring, dressing, hygiene, and with toilet use. She required supervision of 1 person with locomotion on and off the unit. She resident was always incontinent of bowel and bladder. The resident had not had falls after the last MDS. Medical record review revealed the following: On 1/8/2020, of the Morse Fall Scale revealed Resident #3 score 55, indicating the resident was at high risk for falls. On 1/9/2020 at 3:41 PM, of the Health Status Note, written by Licensed Practical Nurse (LPN) #5 revealed .At around 12:50 PM on Thursday (MONTH) 9, 2020, a pt (patient) yelled down the hallway I need a nurse. This nurse came to room and found pt (Resident #3) lying face down on the floor. there was a fair amount of blood on floor with pt's glasses on floor in front of her. called another nurse into room, assessed pt then turned her over on her back, pt had blood coming from a small laceration above rt (right) eye, and redness to rt cheek. Pt was A&O x (alert and oriented times) 4, able to tell us what happened, denied any pain at this time. Picked her up and placed her back into her wheelchair. pt stated I was sitting on side of my bed, bent over to plug in my cell phone, and fell over. v/s (vital signs) (Blood Pressure (BP)) 134/78, (Respiration (R)) 18, (Pulse (P)) 80, O2 97% (percent) on room air. at this time bleeding to her head had stopped, contacted wound care nurse to asses for treatment, spoke to (named Nurse Practitioner). Had pt apply ice to right side of face/eye area. Will continue to monitor, continue on neuro checks per protocol. Call light within reach . Review of the facility investigation included the Supervisor Investigation of Fall form dated 1/9/2020, written by LPN #5, which revealed Resident #3 fell on [DATE] at 12:50 PM, in her room while bending forward trying to plug cell phone in. The roommate found the resident. The resident had an injury of a laceration above the right eye, was not sent to the emergency room , neurochecks were initiated and the physician and resident's (family member) were notified. The facility intervention was to attach the phone cord to the bedrail for easy access and the intervention was placed on the care plan. Review of the facility investigation included the undated Staff's 10 Questions at the Time of a Resident Fall form which revealed the resident stated she was 'Okay', that she was face down next to a surface and the environment was clean, dry, had no spills and the area was uncluttered. The resident was wearing pants, shirt, shoes and socks. The assistive device used was a wheelchair and she was wearing her glasses. Review of the facility investigation included the Resident Event Report Worksheet form dated 1/9/2020, written by LPN #5, revealed the date and time of the unwitnessed fall by Resident #3 was 1/9/2020 at 12:50 PM, which had occurred in Resident #3's room. The resident sustained [REDACTED]. The resident had a laceration to the right eyebrow/temple area and a red cheek. The factors related to the fall was she was reaching. The resident had no pain and the physician and family were notified. Medical record review of Resident #3's roommate, at the time of the 1/9/2020 fall, Quarterly MDS dated [DATE], revealed a BIMS score of 11, indicating she was (upper range) moderately cognitively impaired (Moderate range: 8 - 12). She had moderate difficulty with hearing, she had adequate vision and wore lenses. Medical record review of the Neurological Record form dated 1/9/2020 at 1:00 PM through 9:30 PM, and on 1/10/2020 at 1:30 AM through 5:30 AM, revealed Resident #3's results were within normal range. Medical record review of the Health Status Note dated 1/10/2020 at 9:00 AM, revealed .Nurse was called to room by (named Family Member #3). (Named Family Member #3) insisted on resident being sent to hospital for a CT (Computerized [NAME]ography) Scan due to S/P (status [REDACTED]. Noted to have bruise to right shoulder. Skin tear above right eye. No bleeding or swelling noted to site. (Named) NP (Nurse Practitioner) was called, received new orders to transport to (named hospital) for CT scan. Will continue to monitor . Interview with LPN #5 on 2/5/2020 at 8:34 AM, in the conference room revealed the LPN was working at the medicine cart when Resident #3's roommate rolled out of the room in the wheelchair and told the LPN that (Resident #3) needed help. The LPN entered the room and found Resident #3 face down with a little pool of blood under her head. The LPN called for help from other nurse. The LPN could not recall the name of the nurse helping her. The LPN reviewed her written report and confirmed she failed to write the name of the nurse on the report. The LPN stated once the other nurse was available, they assessed the resident. The LPN stated she notified the NP who was in the facility and the LPN recalled the NP went to assess the resident. The NP saw the resident, the vital signs and neurochecks were normal, the resident had complained of a sore head, but not pain, and the NP did not order a discharge to the hospital. Interview with the NP on 2/5/2020 at 9:35 AM, in the conference room revealed the NP had seen Resident #3 earlier in the day, prior to the fall on 1/9/2020. The NP stated she was notified of the fall, went to assess the resident, noted the neurocheck was normal so far, and the resident was not complaining of pain. The NP stated her intent was to continue monitoring the vital signs and neurochecks and to assess the resident for abnormalities. The NP stated the resident returned to the facility on [DATE] and she then wrote her note dated on 1/13/2020. Further review of the investigation revealed no written statements from the staff involved in the response, LPN #5, another unnamed nurse, the assigned CNA, the NP; failed to include what the resident was doing and last known location, prior to the fall; no statement from the resident; no statement from the roommate alerting staff of the fall; no diagram of the resident's room and the of the resident as found at the time of the fall, a complete set of the neurochecks, and no root cause analysis. Medical record review revealed the following: On 1/14/2020 at 10:48 AM, of the Infection Note revealed .Review of (Resident #3's) S/Sx (signs/symptoms) of infection completed using McGeer's Criteria. diagnosed infection: uti (urinary tract infection) Medication Order: [MEDICATION NAME]. Care plan revised as indicated . On 1/20/2020 at 3:20 PM, of the Health Status Note, written by LPN #3, revealed .Nurse was called to resident's room by therapy. Resident was sitting in floor on her bottom at the foot of her bed, with her back leaned up against heater. When asked resident what she was doing she said, I stood up and I was trying to reach my cell phone and I fell over. No complaints of pain voiced. No injuries noted. Intervention: Signage to be used to remind resident to ask for assistance. (Named NP) was notified. (Named Family Member #3) was notified .(Named Director of Nursing) was notified. Will continue to monitor . On 1/21/2020 at 8:53 AM, of the Health Status Note revealed the .IDT met to discuss resident's fall from (1/20/2020). Resident fell while in her room. Intervention is to provide resident with a sign to ask for staff assist . Review of the facility investigation included the Supervisor Investigation of Fall, written by LPN #3, dated 1/20/2020, revealed Resident #3 fell on Monday, 1/20/2020 at 2:30 PM, in her room when she stood up from the wheelchair and was reaching for the cell phone and fell out of the wheelchair. The therapist found the resident on the floor. The resident had no injuries or complaint of pain. The facility's immediate intervention was to assist the resident up from the floor, with 2 staff assisting, back into the wheelchair. The recent had had recent falls and the facility started neurochecks. The physician and (Family Member #3) were notified. The intervention was signage. Review of the facility investigation included the undated, Staff's 10 Questions at the Time of a Resident Fall form, written by LPN #3, revealed Resident #3 stated she was okay, and had stood up to reach for her cell phone. The resident's position after the fall was described as sitting on her bottom with her back against the heater with her legs straight out and her arms in her lap. The environment was described as clean, dry, and uncluttered with good visibility. The resident was wearing shoes and socks with proper fitting clothing. There was no one in the area when the resident fell . Review of the facility investigation included the Resident Event Report Worksheet form, written by LPN #3, dated 1/20/2020, which revealed Resident #3 had a fall in her room while reaching which resulted in no significant injury. Further review revealed LPN #2 and CNA #2 were assigned to the resident. Interview with CNA #2 on 2/4/2020 at 1:07 PM, in the conference room revealed the CNA had been assigned to the resident but she had not witnessed the fall on 1/20/2020. CNA #2 stated she had been informed of the fall by a therapist. The therapist was working with another resident in the hallway and had walked past Resident #3's room when she saw Resident #3 on the floor. The CNA stated when she entered the room the resident was seated on her bottom with her back to the heater/air conditioner, her left side was next to the window wall, her right side was on the bed side, and her legs were straight out in front of her. The CNA asked the resident to wait to get a nurse to check her over. The CNA stated LPN #4 came to the room because LPN #2, assigned to the resident, was not available. LPN #4 assessed the resident and no injury was noted and 'we got the resident into the wheelchair.' Interview with LPN #3 on 2/4/2020 at 1:34 PM, in the conference room revealed the assigned nurse, LPN #2, had gone to lunch and she had responded to CNA #2's request to help with Resident #3. The LPN did not recall a therapist being involved. LPN #3 stated LPN #4 helped her get the resident off the floor. LPN #3 stated she called the NP and Family Member #3 regarding the fall. Interview with LPN #4 on 2/4/2020 at 1:57 PM, in the conference room revealed a therapist had walked down the hall and had said something to LPN #3, then .LPN #3 yelled for me . When LPN #4 got into Resident #3's room the resident was seated on the floor with her back to the heater/air conditioner. LPN #4 stated she and LPN #3 assessed the resident, got her up into her wheelchair, and obtained vital signs. Interview with LPN #2 on 2/4/2020 at 2:55 PM, in the conference room revealed the LPN was assigned to Resident #3 on 1/20/2020. The LPN stated .a therapist got LPN #3 in the hall, then LPN #3 or CNA #2, or someone, got me. The resident was on her buttocks with her back to the heater/air conditioner and her legs were in front of her . when the LPN got into the room. The LPN stated the resident was assessed for pain and injury, while she was on the floor, and she was okay. LPN #2 stated LPN #3 was in the room with LPN #2 but LPN #2 had no recall of LPN #4 being present. LPN #2 stated this LPN notified the NP and Family Member #3 of the fall. Further review of the investigation revealed no written statements by CNA #2, LPN #2, LPN #3, LPN #4, the NP, or the therapist seeing Resident #3 on the floor. The investigation provided failed to identify all the staff involved and failed to identify the therapist. There was no diagram of the resident's room and of the resident as found at the time of the fall, and no root cause analysis. The investigation did not include the potential of the UTI contributing to the fall. Interview with the Interim Director of Nursing on 2/4/2020 at 3:05 PM, in the conference room confirmed the facility failed .to obtain interviews from staff, the therapist, anyone involved with the fall. I understand what you're saying. The information isn't there and the investigation isn't complete .",2020-09-01
760,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2018-03-07,602,D,1,0,V5FH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to protect a resident's right to be free from misappropriation of property for 1 resident (#3) of 10 residents reviewed. The findings included: Review of facility policy, Drug Diversion, POL 602.23, revised 11/28/17, revealed .Oncoming and off-going nurses complete a shift to shift count on medication cards or containers containing controlled substance medication; controlled substance medication sheets; controlled substance medications in Emergency Kits when the kit had been opened .Nurses report any discrepancies in controlled substance medication counts to the Director of Nursing Service immediately .Facility management should investigate and make every reasonable effort to reconcile reported discrepancies .Investigation includes but may not be limited to interviews, medical record review, observation of facility practices related to handling of controlled substances, evaluation if loss is associated or attributed to specific individual(s), time period, unique situation or random, and identify any potential negative impact on resident's condition or safety .If potential criminal activity is suspected notify the Administrator, pharmacy manager, and consultant pharmacist at once .Educate staff on current procedures and implement interventions if needed .Document corrective action taken .Analyze findings from any discrepancy events or substantiated thefts or diversions as part of Performance Improvement . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Physician's admission orders [REDACTED]. Continued review revealed Resident #3 brought a bottle of [MEDICATION NAME] from home. Facility investigation review revealed on 1/30/18 it was discovered 5 pills were missing from the bottle the resident brought in from home. Continued review revealed an investigation was conducted including staff interviews as well as police involvement. Further review revealed one nurse confessed she had taken the pills. Continued review revealed the nurse was terminated and the resident was reimbursed for the missing pills. Review of facility investigation revealed an interview with Registered Nurse (RN) #1 on 1/30/18 who stated she was speaking with the off-going Supervisor about the new admission (Resident #3). Continued review revealed RN #1 stated Resident #3 came in with 20 [MEDICATION NAME] pills but the Supervisor stated the resident had come in with 25 pills because she had counted them. Further review revealed both nurses went to the Narcotic box; counted the pills in the bottle; and arrived at a count of 20 pills. Continued review revealed RN #1 reviewed the narcotic sheet and it was labeled with 20 pills so she called the Administrator. Review of facility investigation revealed an interview with Licensed Practical Nurse (LPN) #2 on 1/30/18 revealed she was asked if she was the one who inventoried the pills of Resident #3 he brought from home and she said she was. Continued investigation revealed LPN #2 stated she counted 20 pills and stated LPN #1 had counted with her. Further investigation revealed LPN #2 was told the pills were counted previously and there were 25 pills but LPN #2 did not know how that was possible. Review of facility investigation revealed an interview with RN #2 who stated she counted 25 pills of [MEDICATION NAME] 10/325 mg which belonged to Resident #3. Review of facility investigation revealed an interview with LPN #1 on 2/1/18, who stated LPN #2 walked over to her chair at the nurses' station and said they had to count narcotics for the new admission. Continued review revealed LPN #1 was in the process of putting the new admission medications into the computer so pharmacy would deliver them. Further interview revealed LPN #1 saw LPN #2 with the bottle of pills but never actually saw her pour them out or physically see her count them but heard her count to 20 twice. Continued interview revealed LPN #1 never touched the pills nor did she physically see the pills. Further review revealed at this point both nurses were suspended pending the outcome of the investigation. Review of facility investigation revealed on 2/1/18 the police called the Administrator to say LPN #2 was requesting to speak with her at the police station. Continued interview revealed LPN #2 said she had done it and when asked what she had done she responded I took those pills and I'm sorry. What happens from here? Further review revealed the Administrator told LPN #2 was terminated and she would be reported to the Board of Nursing. Continued interview revealed LPN #2 was asked if she had taken any other pills and she responded This was the only time I've ever done that; I don't know what I was thinking. Review of facility investigation revealed Resident #3's personal physician as well as the Medical Director were informed of the diversion. Continued review revealed Resident #3 was informed of the situation and the facility reimbursed him for the medication. Facility investigation revealed all nurses were re-educated on narcotic counts with both nurses observing the medications and the count sheets when doing change of shift counts as well as both nurses observing and counting together when a resident brings medications from home. Interview with the DON and Administrator on 3/7/18 at 1:15 PM in the conference room revealed neither was in the facility when the diversion occurred. Review of the employee records of LPN #1 and LPN #2 revealed no previous disciplinary action for either of them.",2020-09-01
761,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2017-08-02,224,D,1,1,RHGV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to prevent misappropriation of medications for 1 resident (#79) of 7 residents reviewed for abuse. The findings included: Review of facility policy, Abuse, released 10/20/16, revealed .Verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, and neglect of the patient as well as mistreatment, injuries of unknown source, and misappropriation of patient property are strictly prohibited .Misappropriation is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent . Review of facility policy, Drug Diversion, released 6/1/16, revealed .Oncoming and offgoing nurses complete a shift to shift count on medication cards or containers containing controlled substance medication; controlled substance medication sheets; controlled substance medications in E-kits (Emergency medications) when the E-kit has been opened .Nurses report any discrepancy in controlled substance medication counts to the Director of Nursing Service (DNS) immediately .Facility management should investigate and make every reasonable effort to reconcile reported discrepancies. Investigation included interview, medical record reviews, observation of facility practices related to handling of controlled substances; evaluate if loss is associated with or attributed to specific individuals; identify any potential negative impact on patient's condition or safety .Notify the Executive Director, pharmacy manager, and consultant pharmacist immediately .Potential theft of controlled substance is reportable to the local law enforcement agency, appropriate professional licensing board; and state agency . Medical record review revealed Resident #79 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED].#79 was ordered [MEDICATION NAME]/[MEDICATION NAME] ([MEDICATION NAME]) 7.5/325 mg (milligrams) 1 tablet QID (four times daily). Review of the Pharmacy Delivery Invoice revealed 30 tablets of [MEDICATION NAME]/[MEDICATION NAME] 7.5/325 mg were delivered to the facility on [DATE] and signed for by the two nurses on duty. Review of the facility investigation revealed: 1/3/17 -card of 7.5/325 mg [MEDICATION NAME] and its narcotic sheet missing -all medication carts were checked -pharmacy was called to verify delivery 1/4/17 - complete MAR (Medication Administration Records) to cart audits were done on on all carts - pharmacy was requested to do a complete audit of delivery - part of the (MONTH) narcotic shift-to-shift tracking log was also missing - interviews were completed with licensed nurses who had access to the carts - Executive Director and corporate office were notified 1/5/17 - inservices for licensed nurses on counts and drug diversion were held - police were notified - suspect nurse was terminated - suspect nurse did not show for her shift 1/4/17 at 6:00 PM - 6:30 AM nor any subsequent shifts - suspect was unable to be reached by telephone The DNS interviewed all nurses who had access to the medication cart during the period of the diversion including Licensed Practical Nurses (LPN) #5, #6, #7, #8, #9 and Registered Nurse (RN #1). Questions asked included did they count; how many medication cards did they see; did they see the card count sheet; who received the drug delivery; and what was done with the drugs after delivery. Review of the Root Cause Analysis Summary revealed the delivery of the [MEDICATION NAME] on 12/31/16. On 1/3/17 the supervisor was doing a verification of narcotics when she noted a card of [MEDICATION NAME] and its narcotic sign sheet were missing. The narcotics were signed in on delivery by 2 licensed nurses and delivered to medication carts to be locked in the narcotic drawer. The carts were kept locked and only the nurse working that hall has the key to the cart. The cards were logged onto the card count sheet. When cards were taken out of the cart they were logged on the card count sheet and nurses signed for them. Reports from pharmacy were sent to the DNS to verify narcotic deliveries and the presence of narcotics. Narcotics were delivered; accepted; and stored correctly. The nurse signed on the narcotic sheet/card count sheet as 29 vs 30 as it should have been. The nurse was made aware of the missing drug and she began to question fell ow nurses as to how it was found out. The suspected nurse became a no call no show for scheduled shifts. The suspected nurse was unable to be reached by telephone and did not return calls. The facility was unable to say definitively she was guilty but she had keys to the cart and access to the narcotics. Resident #79 had multiple cards of drugs in the cart and by changing the card count sheet with next day being a new month, the count would be correct. Interview with the DNS, on 8/2/17 at 9:25 AM in her office confirmed a card of 30 tablets of [MEDICATION NAME] as well as the accompanying sign out sheet were missing and unable to be located. The DNS also confirmed the accused nurse refused to return telephone calls so was unable to be interviewed",2020-09-01
762,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2017-08-02,283,D,0,1,RHGV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provided a discharge summary for 1 resident (#98) of 22 discharged residents reviewed. The findings included: Medical record review revealed Resident #98 was admitted to the facility on [DATE], readmitted on [DATE], and discharged from the facility on 6/7/17 with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum (MDS) data set [DATE] revealed the resident had no cognitive impairment. Medical record review revealed Resident #98 attended a care plan meeting on 5/10/17. Continued medical record review revealed there was no documentation of discharge planning from the facility noted during the meeting. Medical record review of a Nurse Practitioner's progress note dated 5/30/17 revealed the chief complaint was Discharge from facility. Medical record review of physician's orders [REDACTED]. Medical record review of Nursing Progress Notes dated 6/7/17 at 4:31 PM revealed, .here to transport resident to (named facility), all personal belongings sent with resident . Medical record review revealed no discharge summary could be found in the medical record or the electronic medical record for Resident #98. Interview with the Social Worker (SW) on 8/2/17 at 1:10 PM in the SW's office, when asked why there was no discharge summary in the resident's chart or explanation why the resident was discharged from the facility, the SW stated, It happened really quickly. I got a call from the daughter stating she wanted the resident sent back to (named facility). The SW confirmed there was no documentation regarding the discharge in the resident's medical record. Interview with the Director of Nursing on 8/3/17 at 4:15 PM in the Administrator's office confirmed the facility failed to complete a Discharge Summary for Resident #98.",2020-09-01
763,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2017-08-02,371,F,0,1,RHGV11,"Based on observation and interview, the facility's dietary department failed to maintain food preparation equipment in a sanitary manner and failed to maintain storage equipment in a sanitary manner. The findings included: Observation on 8/1/17 beginning at 1:53 PM, with the Certified Dietary Manager (CDM) present, revealed the facility failed to maintain the following food preparation equipment in a sanitary manner: 1. The can opener base had sticky blackened debris covering the exterior side of the slot of the can opener with an accumulation of sticky blackened debris dripping down the exterior sides of the slot. The interior of the can opener slot had a heavy accumulation of blackened sticky debris present. The can opener blade had an accumulation of sticky brown debris present. 2. The interior perimeter of the two convection oven doors had an accumulation of brown and black debris present. 3. The air vent in the hood had blackened debris on the vent fins. There was hanging blackened debris on the air vent fins positioned over the 6 burner range top and food was in preparation in the 2 pots on the burners. 4. The mixer was covered with a plastic bag. The mixer had white powdery residue on the beater arm, white dried splattered debris on the underside of the beater arm, and an accumulation of dried sticky brown debris on the table top in contact with the mixer feet. Interview with the CDM on 8/1/17 beginning at 1:53 PM in the dietary department revealed the plastic covered equipment meant the equipment was clean and ready to use. Further interview confirmed the facility failed to maintain the food preparation equipment in a sanitary manner. Observation on 8/2/17 from 9:03 AM to 9:13 AM, with the CDM present, revealed the dish machine was in operation with dietary staff storing dome lids and insulated bases onto the storage/drying racks. Further observation revealed the dome lid and base storage/drying racks were rusted and sticky with brown debris. Further observation of the dry goods store room revealed the can rack had an accumulation of dried debris on the rungs and the 4 food storage racks were sticky with brown debris. Interview with the CDM on 8/2/17 beginning at 9:03 AM in the dietary department confirmed the facility failed to maintain the storage equipment in a sanitary manner.",2020-09-01
764,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2018-09-26,812,D,0,1,ZSR811,"**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 serve food in a safe and sanitary manner for 2 of 16 residents (#28 and #60) observed during the breakfast meal. The findings include: Review of the facility policy Dining Standards revised 11/2017 revealed .staff uses utensils, deli tissues, dispensing equipment or single use gloves to avoid bare hand contact of ready to eat foods . 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) assessment dated [DATE] revealed Resident #28 required supervision with assistance of 1 person for eating. Observation on 9/24/18 at 8:00 AM in Resident #28's room revealed Certified Nurse Aide (CNA) #1 was setting up breakfast for the resident. Further observation revealed CNA #1 picked up the resident's biscuit with her bare hand, cut the biscuit in half lengthwise using a butter knife, then picked up the sausage with her bare hand and placed it between the two biscuit halves and placed it back on the plate. Medical record review revealed Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual MDS assessment dated [DATE] revealed Resident #60 required supervision with meal setup only. Observation on 9/24/18 at 7:55 AM in Resident #60's room revealed CNA #1 was setting up breakfast for the resident. Further observation revealed CNA #1 picked up the resident's biscuit with her bare hand, cut the biscuit in half lengthwise using a butter knife, then picked up the bacon with her bare hand and placed it between the biscuit halves and put it back on the plate. Interview with CNA #1 on 9/24/18 at 8:01 AM in Resident #28's room confirmed she needed to put gloves on before touching the resident's food. Interview with the Director of Nursing (DON) on 9/25/18 at 8:22 AM in front of her office confirmed the staff needed to wear gloves when touching the resident's food.",2020-09-01
765,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2017-10-26,224,D,1,0,KCFU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of law enforcement arrest report, facility policy, medical record review, facility investigation and interview, the facility failed to ensure 1 resident (#15) of 15 reviewed was free from misappropriation of property. The findings included: Review of facility policy, Abuse, dated 10/20/16 revealed .misappropriation of patient property are strictly prohibited . Medical record review revealed Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE]. Further review of the Minimum (MDS) data set [DATE] revealed Resident #15 had a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. Review of a facility investigation dated 10/14/17 revealed Resident #15 reported a missing $60 gift card. Further review of a written statement by Licensed Practical Nurse (LPN) #6 dated 10/15/17 revealed .(Resident #15) stated that she had a $60.00 gift card stolen from her pink wristlet change purse .(Resident #15) also stated that tech (certified nurse aide) who took the card came to her room on the night of 10/14/17 after hearing that she reported a gift card stolen and tech stated 'Really (Resident #15), you borrow money off of me for weeks and then pay me back with a gift card and then report it stolen.' (Resident #15) stated she never borrowed money from the tech and she would never borrow money from a tech . Continued review of a written statement by Resident #15's sister on 10/16/17 revealed a $50 gift card was purchased on 9/19/17 and given to the resident on the same day. The resident's sister also reported the gift card had been used twice on 10/12/17 at a local store. Review of a law enforcement arrest report dated 10/14/17 revealed .We proceeded to speak with (Resident #15) who advised that she had a visa gift card missing from her change purse and presumed it had been stolen. She further advised the gift card was valued at $60.00. (Resident #15's sister) checked with the visa customer service and found that the card had been used .visa had records indicating that a total of 49.47 had been spent .A check of (local store) video footage .shows a white female making a purchase with the card number provided .A good photo (photograph) was printed and taken to the charge nurse .who recognized the lady as one of the night shift nurses .she (Certified Nurse Assistant (CNA) #7) has admitted to using the card as witnessed on video but claims she paid (Resident #15) cash for the card. To verify this statement I called (Resident #15) and she absolutely denies this ever happened .(CNA #7) showed obvious intent to deprive the owner of certain property without her effective consent. (CNA #7) was placed under arrest . Review of a written statement given to law enforcement by CNA #7 dated 10/14/17 revealed .I (CNA #7) worked on Wednesday night 10/11/12 - 10/12/12 on (the) 700 hall. (Resident #15) asked me if I would give her cash for her prepaid debit card bc (because) it wasn't a cash back card and no one would take her card and get anything for her. I told her I only had sixty dollars and she said it had fifty something on there so I gave her three twenty dollar bills and she gave me the card . Interview with the Administrator on 10/24/17 at 2:20 PM in the conference room revealed the facility investigation was neither substantiated nor unsubstantiated because she was unable to get a statement from CNA #7 and Resident #15 was reluctant to give a detailed statement. The Administrator confirmed CNA #7 was terminated due to the misappropriation of property.",2020-09-01
766,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2017-10-26,280,G,1,0,KCFU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, and interview, the facility failed to update the Care Plan with interventions for 3 residents (#7, #6, #4) of 7 residents reviewed. The facility's failure to identify risk and update the care plan with approporiate interventions resulted in falls with injuries (HARM) for resident #7,#6, #4. The findings included: Review of facility policy, Accidents and Supervision to Prevent Accidents (dated: 4/28/2011), revealed .The center provides an environment that is free from accident hazards .Implementation of interventions to reduce hazard(s) and risk(s) .Monitors to verify interventions are in place .Evaluates interventions at designated interval for effectiveness .Modifies and/or replaces ineffective interventions when necessary . Medical record review revealed Resident #7 admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #7 had a Brief Interview Mental Status (BIMS) score of 5, indicating severe cognitive impairment. Further review revealed the resident required extensive assistance with transfers and Activities of Daily Living (ADL) and had no impairment of the upper and lower extremities. The resident was occasionally incontinent of the bowel and bladder. Medical record review of a Progress Note dated 9/5/17 revealed Resident #7 had a fall with no injury to occur on 9/5/17 and 9/9/17. Review of the Care Plan initiated on 8/7/17 for Resident #7 revealed it was not updated after the fall occurred on 9/5/17, 9/9/17, 9/17/17, and only revised on 10/24/17. Medical record review of a Post Fall Investigation dated 9/17/17 revealed the resident was .heard resident yelling .went to room and the resident was sitting on the floor on the L (left) side of the bed .was sitting on her botttom with her leg bent at the knee under her. When the resident tried to straighten it out she yelled and there was a popping noise . Continued review revealed the resident was transferred to the hospital and admitted for a Nondisplaced Midcervical Fracture of Right Femur. Interview with LPN #9 on 10/26/17 at 9:20 AM in the conference room revealed the nurse was to update the Care Plan with interventions after each fall. LPN #9 confirmed she failed to update the Care Plan after Resident #7 fell on [DATE] and another fall occurred on 9/17/17. Interview with the Administrator on 10/26/17 at 10:52 AM in the Social Services office revealed the Care Plans were to be updated with interventions after every fall by the nurse. After review of the Care Plan, the Administrator confirmed the facility failed to update the Care Plan with interventions after Resident #7 had a fall with injury (HARM) on 9/17/17. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 30-day Minimum Data Set ((MDS) dated [DATE] revealed Resident #6 had severe cognitive impairment with short and long term memory problems. The resident required extensive assistance with bed mobility, transfers, dressing, personal hygiene, eating and toileting and required total dependence for bathing. Continued review revealed Resident #6 was always incontinent of bowel and bladder, had bilateral impairment of both upper and lower extremities and utilized a wheelchair for mobility. Upon admission pt (patient) was identified as falls risk as evidenced by admission Care Plan. Medical record review of Progress Notes dated 8/27/17 and 9/6/17 revealed Resident #6 had falls to occur on these dates. Further review revealed Resident #6 received an injury as a result of the 9/6/17 fall when found on floor. Continued review of a Progress Note dated 9/7/17 revealed .family says he's been c/o (complaining of) left side discomfort . Medical record review of a Radiology Report dated 9/7/17 revealed .Conclusion: Acute right lateral ninth rib fracture . Medical record review of the Care Plan for Resident #6 revealed it was not updated or revised with new interventions after the falls occurred on 8/27/17 and 9/6/17. Interview with Licensed Practical Nurse (LPN) #9 on 10/26/17 at 9:20 AM in the conference room revealed after each fall the nurse was required to update the Care Plan with interventions. LPN #9 confirmed she failed to update the Care Plan with an appropriate intervention after Resident #6 fell on [DATE]. Interview with Administrator on 10/26/17 at 10:52 AM in the Social Services office revealed the Care Plan was to be updated with interventions after every fall by the nurse. After review of the Care Plan, the Administrator confirmed the facility failed to update the Care Plan with interventions after Resident #6 had falls to occur on 8/27/17 and 9/6/17. Medical record review of the Care Plan for Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quartely MDS dated [DATE] revealed the resident has a BMS score of 7 (severe impairment). The Resident was extensive assist with 1 person for transfer, extensive assist with 1 person for transfer, dressing and personal hygeine, independent with ambulationwith wheelchair, set up only, limited assist with 1 person for eating and total dependence with 1 person for bathing. The residnet had impairment on one side for upper and lower extremities and frequesntly incontinent of bowel and bladder. Medical record review of a fall investigation dated 9/17/17 revealed Resident was trying to get in to bed without assist (resident knows to ask for help) and sat on the floor beside the bed. Denies injury at this time .Neuro checks and 30 minute checks started .no injuries noted . Review of a Progress Note dated 9/18/17 revealed the Physician ordered a Tibia/Fibula x-ray. Review of the results of the x-ray dated 9/19/17 revealed an abnormal x-ray and orders to consult with an Orthopedic Medical record review of the Care Plan for Resident #4 revealed the facility failed to update the Care Plan after the 9/17/17 fall. Interview on 10/26/17 with the Administrator at 9:33 AM in her office revealed the facility failed to update the Care Plan after the 9/17/17 fall. The Administrator confirmed the facility failed to update the Care Plan with interventions after falls. Medical record review revealed Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed the resident had a BIMS score of 7 (severe impairment). The resident required extensive assistance with 1 person for transfer, dressing and personal hygiene, independent with ambulation with wheelchair, set up only, limited assist with 1 person for eating and total dependence with 1 person for bathing. The resident had unilateral impairment on one side of upper and lower extremities and frequently incontinent of bowel and bladder. Medical record review of a fall investigation dated 9/17/17 revealed Resident was trying to get in to bed without assist (resident knows to ask for help) and sat on the floor beside the bed. Denies injury at this time .Neuro checks and 30 minute checks started .no injuries noted . Review of Progress Notes dated 9/18/17 revealed the resident with a Tibula/Fibula fracture and placement of a cast. Medical record review of the Care Plan for Resident #4 revealed the facility failed to update the Care Plan after the 9/17/17 fall. Interview with the Administrator on 10/26/17 at 9:33 AM in her office confirmed the facility failed to update the Care Plan after the 9/17/17 fall.",2020-09-01
767,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2017-10-26,323,G,1,0,KCFU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, and interview, the facility failed to maintain an environment free from accidents for 3 residents (#7,#6, #4) of 7 residents reviewed. The facility's failure to recognize fall risk and identify interventions for three residents (#7, #6, #4) resulted in falls with injury (HARM). The findings included: Review of facility policy, Accidents and Supervision to Prevent Accidents, dated 4/28/2011 revealed .The center provides an environment that is free from accidents hazards .Implementation of interventions to reduce hazard(s) and risk(s) .Monitors to verify interventions are in place .Evaluates interventions at designated interval for effectiveness .Modifies and/or replaces ineffective interventions when necessary . Medical record review revealed Resident #7 admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS (Minimum Data Set) dated 10/10/17 revealed Resident #7 had a Brief Interview Mental Status (BIMS) score of 5, indicating severe cognitive impairment. Further review revealed the resident required extensive assistance with transfers and Activities of Daily Living (ADL) and had no impairment of the upper and lower extremities. The resident was occasionally incontinent of the bowel and bladder. Medical record review of a Progress Note dated 9/5/17 revealed Resident #7 had a fall with no injury to occur on 9/5/17 and 9/9/17. Review of the Care Plan initiated on 8/7/17 for Resident #7 revealed it was not updated after the fall occurred on 9/5/17, 9/9/17, 9/17/17, and only revised on 10/24/17. Medical record review of a Post Fall Investigation dated 9/17/17 revealed .heard resident yelling .went to room and the resident was sitting on the floor on the L (left) side of the bed .was sitting on her botttom with her leg bent at the knee under her. When the resident tried to straighten it out she yelled and there was a popping noise . Continued review revealed the resident was transferred to the hospital and admitted for a Nondisplaced Midcervical Fracture of Right Femur. Interview with LPN (Licensed Practical Nurse) #9 on 10/26/17 at 9:20 AM in the conference room revealed the nurse was to update the Care Plan with interventions after each fall. LPN #9 confirmed she failed to update the Care Plan after Resident #7 fell on [DATE] and another fall occurred on 9/17/17. Interview with the Administrator on 10/26/17 at 10:52 AM in the Social Services office revealed the Care Plans were to be updated with interventions after every fall by the nurse. After review of the Care Plan, the Administrator confirmed the facility failed to update the Care Plan with interventions after Resident #7 had a fall with injury (HARM) on 9/17/17. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 30-day MDS dated [DATE] revealed Resident #6 had severe cognitive impairment with short and long term memory problems. The resident required extensive assistance with bed mobility, transfers, dressing, personal hygiene, eating and toileting and required total dependence for bathing. Continued review revealed Resident #6 was always incontinent of bowel and bladder, had bilateral impairment of both upper and lower extremities and utilized a wheelchair for mobility. Medical record review revealed Resident #6 had falls to occur on 8/11/17, 8/12/17, 8/13/17 and 8/14/17. Continued review revealed the following interventions were put in place after the falls occurred: .encourage to participate in activities .Strips to be placed to floor on each side of bed .encourage resident to toilet upon rising, before meals and after meals, and before bed .assist resident to common area .apply dysum pad to w/c (wheelchair) when arising to w/c . Medical record review of a Progress Note dated 8/27/17 revealed Resident #6 had a witnessed fall to occur as he was attempting to get up from the wheelchair. Review of the Care Plan revealed no intervention was put in place after the fall occurred on 8/27/17. Medical record review of a Progress Note dated 9/6/17 revealed Resident #6 had an unwitnessed fall to occur. Resident #6 was found by staff .sitting on his bottom beside of the end of the bed with his legs outstretched and his hands to his side. The residents pants were slightly pulled down as if the resident was trying to go to the restroom and his diaper was wet . Continued review of a Progress Note dated 9/7/17 revealed .MD (Medical Doctor) notified that Pt (patient) is now c/o (complaining of) discomfort in the left ribcage area. Pt grimaces with pain when area is palpated. Received order for x-ray . Medical record review of a Radiology Report dated 9/7/17 revealed .Conclusion: Acute right lateral ninth rib fracture . Review of the Care Plan revealed no intervention was put in place after the fall occurred on 8/27/17. Interview with LPN #9 on 10/26/17 at 9:20 AM in the conference room revealed after each fall the nurse was required to update the Care Plan with interventions. LPN #9 confirmed she failed to update the Care Plan with an appropriate intervention after Resident #6 fell on [DATE]. Interview with the Administrator on 10/26/17 at 10:52 AM in the Social Services office revealed the Care Plan was to be updated with interventions after every fall by the nurse. After review of the Care Plan, the Administrator confirmed the facility failed to maintain an environment free from accidents for Resident #6 who had a fall to occur on 9/6/17 which resulted in a fracture of the rib (HARM). Medical record review revealed Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quartely MDS dated [DATE] revealed the resident has a BIMS score of 7 (severe impairment). The Resident was extensive assist with 1 person for transfer, extensive assist with 1 person for transfer, dressing and personal hygeine, independent with ambulationwith wheelchair, set up only, limited assist with 1 person for eating and total dependence with 1 person for bathing. The residnet had impairment on one side for upper and lower extremities and frequesntly incontinent of bowel and bladder. Medical record review of a fall investigation dated 9/17/17 revealed Resident was trying to get in to bed without assist (resident knows to ask for help) and sat on the floor beside the bed. Denies injury at this time .Neuro checks and 30 minute checks started .no injuries noted . Review of a Progress Note dated 9/18/17 revealed Called mobile with x-ray order. Review of the Progress Notes dated 9/20/17 revealed .Received resident Tibia/Fibula x-ray report on 9/19/17 at 1800 (6:00 PM). Noted abnormal x-ray .Notified NP (Nurse Practitioner) via phone .of x-ray results. Received the following new MD (Medical Doctor) orders. 1. consult with (orthopedic) . Review of a Progress Note dated 9/21/17 revealed MD applied cast at this time to right lower extremeity. MD wants to follow up with an x-ray on Monday 9/25/17 to check placement with new cast. MD wants to follow up in four weeks to change cast on 11/19/17. Family made aware . Medical record review of the Care Plan for Resident #4 revealed the facility failed to update the Care Plan after the 9/17/17 fall and place new interventions in place to prevent falls. Interview on 10/26/17 with the Administrator at 9:33 AM in her office revealed the facility failed to update the Care Plan after the 9/17/17 fall.",2020-09-01
768,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2017-10-26,333,D,1,0,KCFU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, resident observation and interview, the facility failed to ensure residents are free of any significant medication errors for 1 resident (#12) of 13 reviewed for medications with parameters. The findings included: Review of facility policy (undated), Suggested Medication Administration, Assistance or Observation Procedures, revealed .Resident Right's and Dignity must be preserved during medication administration/observation . Medical record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physicians Order Sheet (POS) revealed an order dated 3/7/17 .[MEDICATION NAME] (Antihypertensive) 100 mg (milligram) give 1 tablet by mouth 1 time a day at 7:00 AM [MEDICAL CONDITION](Hypertension). Hold if pulse is 60 or below . Continued review of the POS revealed a second order for [MEDICATION NAME] 200 mg, give 1 tablet 1 time a day at 8:00pm for HTN, re written on 5/24/17 to include, hold if pulse is 60 or below . Medical record review of the Medication Administration Record (MAR) revealed Resident #12 received [MEDICATION NAME] 100 mg 7:AM dose and 200mg PM dose on the following dates with the pulse documented at 60 or below. 4/2/17 pulse 54, medication documented as administered. 4/9/17 pulse 60, medication documented as administered. 4/28/17 pulse 60, medication documented as administered. 6/8/17 pulse 60, medication documented as administered. 6/24/17 pulse 60, medication documented as administered. 7/22/17 pulse 60, medication documented as administered. 7/26/17 pulse 60, medication documented as administered. 7/31/17 pulse 60, medication documented as administered. 8/1/17 pulse 56, medication documented as administered. 8/2/17 pulse 60, medication documented as administered. 8/15/17 pulse 56, medication documented as administered. 8/16/17 pulse 60, medication documented as administered. 9/17/17 pulse 60, medication documented as administered. 10/15/17 pulse 60, medication documented as administered. Resident observation on 10/23/17 at 12:35 PM revealed Resident #12 sitting at bedside, call light in reach, well-groomed and dressed appropriately, conversing with roommate. Further observation on 10/23/17 at 7:45 PM revealed Resident #12 sitting at bedside conversing on the telephone. Interview with Licensed Practical Nurse #2 on 10/23/17 at 7:45 PM on the 700 hall revealed .when the pulse check of Resident #12 is 60 or below the nurse was to hold the medication . Interview with the Nurse Practitioner on 10/24/17 at 11:30 AM in the conference room revealed she .expected the nurses to follow the parameters .and was .concerned .the resident had received [MEDICATION NAME] with heart rate 60 or below .The Nurse Practitioner reviewed the MAR and confirmed the medication was given with a pulse check of 60 and below . Interview with the Medical Director on 10/24/17 at 11:10 AM on the 800 hallway revealed that he .expects the nurses to follow parameters and not to administer [MEDICATION NAME] to (Resident #12) if pulse is 60 or below. Interview with the Director of Nursing (DON) on 10/25/17 at 3:15 PM in her office confirmed .the [MEDICATION NAME] was given to (Resident #12) with pulse documented at 60 and below . The DON confirmed the facility failed to prevent a significant medication error for Resident #12.",2020-09-01
769,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2017-10-26,431,D,1,0,KCFU11,"> Based on review of facility policy, observation, and interview, the facility failed to properly label, date, and/or discard 3 multi-dose vials of insulin according to facility policy on 1 of 4 medication carts reviewed. The findings included: Review of facility policy dated 8/31/12, Medication package insert, Medication Storage, Storage and Expiration Dating of Medications, Biologicals, Syringes and needles, revealed .facility should ensure that medications and biologicals (1) have an expired date on the label; (2) have been retained longer than manufacturers guidelines; or,(3) have been contaminated or deteriorated , are stored separate from other medications until destroyed or returned to the pharmacy .Facility should destroy or return all discontinued, outdated/expired medications or biologicals in accordance with pharmacy return/destruction guidelines and other applicable law . Review of package insert for Novolin R insulin storage revealed instructions to .throw away the vial 42 days after it is taken out of the refrigerator if it is unopened . Observation of Licensed Practical Nurse (LPN) #2 during medication pass on 10/23/17 at 7:30 PM on the 700 Hall revealed 1 vial of Novolin R Insulin multi-dose vial, date opened 8/31/17. Continued observation revealed LPN #2 drew up 2 units of Insulin for Resident #16 from the vial to be administered and placed the syringe on the top of the medication cart. The surveyor advised LPN #2 the vial was expired and LPN #2 immediately discarded the syringe. Further observation of the medication cart revealed a bottle of novolin R insulin multi dose- vial opened, half full, and undated, received from the pharmacy 9/16/17, 1 vial of novalin N insulin multi-dose vial opened, undated and received from the pharmacy on 10/04/17. Interview with LPN #2 accompanied by the Director of Nursing (DON) on 10/23/17 at 8:00 PM at the 700 hall medication cart confirmed .the vial of R Insulin was expired .and the 1 vial of novolin N insulin and 1 vial of novolin R insulin were opened and undated . Interview with the DON on 10/25/17 at 3:15 PM in her office revealed the nurses are expected to label and date insulin medications when opened, discard expired medication, and check for expiration dates before administering medications. The DON confirmed the facility failed to properly label, discard and/or store medication.",2020-09-01
770,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2017-10-26,441,D,1,0,KCFU11,"> Based on facility policy, observation, and interview, the facility failed to follow infection control protocol for glucometer cleaning on 1 of 4 observations and facility failed to prevent cross contamination of medications, and medication cup on 1 of 25 opportunities observed. The findings included: Review of the facility policy dated 8/31/12, Cleaning Diagnostic Equipment In-Between Patients, revealed the procedure is to .clean outside of patient equipment .If no manufacturer's instructions clean with a 10% (percent) bleach solution moistened wipes in-between each patient and as needed .Allow contact with bleach solution for 1 minute .Follow with a cloth dampened with water to remove residual bleach . Further review of facility policy, General Dose Preparation and Medication Administration, Assistance or Observation revealed .The community staff should not touch the medication when opening a bottle or unit dose package . Observation of Licensed Practical Nurse (LPN) #2 on 10/23/17 at 7:40 PM on the 700 Hall at the medication cart revealed LPN #2 cleaning the glucometer without gloves and using an alcohol prep pad. LPN #2 had not used glucometer to check blood glucose level, and when asked by the surveyor how she should clean the glucometer stated .she would find out .and not use the glucometer until she found out how to clean it. Interview with LPN #2 on 10/23/17 at 7:45 PM on the 700 Hall at the medication cart revealed when asked if she knew the policy for cleaning the glucometers she said .No I don't . Interview with the Director of Nursing (DON) on 10/23/17 at 8:00 PM on the 700 Hall at the medication cart confirmed the facility failed to follow infection control protocol and cleaning of the glucometer. Observation of the Medication Pass on 10/25/17 at 7:30 AM on the 500 Hall revealed LPN #3 with 2 capsules and 1 tablet lying on top of medication cart surface. LPN #3 picked up the tablet with her ungloved hand and placed the tablet in the medication pouch to be crushed.Further observation revealed LPN #3 then picked up the 2 capsules with her ungloved hand off the medication cart, opened them and placed the contents into the medication pouch to be crushed. Observation of the Medication Pass on 10/25/17 at 7:30 AM on the 500 Hall revealed LPN #3 placed her ungloved finger into the top of the medication cup, then placed the medication into the cup. Interview with LPN #3 on 10/25/17 at 7:30 AM on 500 Hall confirmed .she should not touch medications with her ungloved hands, let medications come into contact with uncleaned surfaces, or touch other objects with gloved hands and then touch medication . Interview with the Director of Nursing (DON) on 10/25/17 at 3:15 PM in her office confirmed .nursing should not touch medication or the inside of medication cups with their hands or with gloves which have been used to touch other surfaces . The DON confirmed the facility failed to follow facility policy for infection control protocol.",2020-09-01
771,DONALSON CARE CENTER,445173,1681 WINCHESTER HIGHWAY,FAYETTEVILLE,TN,37334,2019-07-15,641,D,0,1,L3LQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure accurate Minimum Data Set (MDS) assessments were conducted for residents with wander/elopement alarms for 2 of 7 (Resident #5 and #70) sampled residents reviewed with elopement risk. The findings include: 1. Medical record review revealed Resident #5 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Progress Note dated 9/24/18 documented, .Wanderguard put on Right leg for safety precautions d/t (due to) wandering in hallways asking how to get out of this place . Medical record review of an annual MDS dated [DATE] revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated severe cognitive impairment and no use of wander/elopement alarms (wanderguard). Medical record review of the quarterly MDS dated [DATE] revealed Resident #5 had a BIMS score of 7, which indicated severe cognitive impairment and no use of wander/elopement alarms (wanderguard). Medical record review of a physician's orders [REDACTED].Wanderguard in place every day and night shift for safety precautions . Observations in Resident #5's room on 7/12/19 at 10:09 AM, revealed Resident #5 had a wanderguard device on her ankle. Interview with MDS Coordinator #2 on 7/13/19 at 3:07 PM, outside the Conference Room, MDS Coordinator #2 confirmed the MDS assessments for Resident #5 dated 9/26/18 and 6/26/19 were inaccurate related to wander/elopement alarms (wanderguard). 2. Medical record review revealed Resident #70 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of Physician orders [REDACTED].Wander guard to ankle d/t possible elopement . Medical record review of an annual MDS dated [DATE] documented a BIMS score of 3, which indicated severe cognitive impairment and no wander/elopement alarms (wanderguards) in use Medical record review of a Progress Note dated 3/13/19 documented, .has a wanderguard in place d/t risk for wandering/exiting building unassisted . Medical record review of Physician orders [REDACTED].Wander guard to ankle d/t possible elopement . Medical record review of the quarterly MDS dated [DATE] documented a BIMS score of 3, which indicated severe cognitive impairment and no wander/elopement alarms in use. Medical record review of a Progress Note dated 6/10/19 documented, .has a wanderguard in place d/t risk for wandering/exiting building unassisted . Observations in the South Dining Room on 7/12/19 at 10:13 AM, revealed Resident #70 seated in a wheelchair coloring and he had a wanderguard device to his ankle. Interview with MDS Coordinator #2 on 7/13/19 at 3:07 PM, outside the Conference Room, MDS Coordinator #2 confirmed the MDS assessments for Resident #70 dated 2/20/19 and 5/22/19 were inaccurate related to wander/elopement alarms.",2020-09-01
772,DONALSON CARE CENTER,445173,1681 WINCHESTER HIGHWAY,FAYETTEVILLE,TN,37334,2019-07-15,657,K,0,1,L3LQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to revise the care plan for smoking safely with effective interventions to prevent accidents for 5 of 5 (Resident #22, #102, #30, #88, and #180) sampled residents reviewed for smoking which placed these residents in Immediate Jeopardy. Immediate Jeopardy (IJ) is 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 Interim Administrator, Assistant Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Infection Preventionist, Quality and Infection Preventionist Director, and Minimum Data Set (MDS) Coordinator #2, were notified of the IJ on 7/12/19 at 9:32 PM, in the Conference Room. The facility was cited at scope and severity of Immediate Jeopardy for F657-K. The extended survey was conducted on 7/12/19 through 7/15/19. The Immediate Jeopardy was effective 9/8/18 through 7/15/19 and the IJ was removed on 7/15/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the jeopardy, was received on 7/14/19 at 5:30 PM, and the corrective actions were validated onsite by the surveyors on 7/14/19 and 7/15/19 through review of assessments, auditing tools, in-service training records, policies, observations, and staff interviews. The noncompliance continues at F657-E for monitoring of effectiveness of the corrective actions. The findings include: 1. The facility's Care Plan policy with a revision date of 10/23/18 documented, .PURPOSE .To provide guidelines for identifying a resident's care needs .To provide guidelines for structuring an approach through interventions to address their care needs .An individualized care plan will be established for each resident to provide effective and person centered care .New Care Plans will be initiated as new needs are identified in order to meet the individualized needs of each resident .The plan should be kept current and flexible to meet the resident's changing problems or needs . 2. The facility's Smoking Policy dated 12/94 and revised 4/11/19 documented, .Residents who were admitted prior to 11/15/12 will be allowed to continue smoking until their discharge .All resident smoking materials are to be kept secured by the facility .Visitors need to check with charge nurse/nurse before giving smoking materials to ANY resident of Care Centers . 3. Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #22's Care Plan for smoking was dated 1/29/18. The Care Plan interventions for smoking had not been revised since the care plan was initiated on 1/29/18. Medical record review of Resident #22's care plan for falls dated 1/29/18 with revisions documented the following: .2/15/19 .Interventions .Resident was witnessed going outside through breakroom door at skilled care and tipping over to the right as his wheels went off side walk pavement .Fence beside side walk was pushed over during the fall. Skin tears to right arm and elbow. Resident counseled to not use this door in the future. Sign posted to keep breakroom door closed and door to outside locked at all times . Medical record review of a MDS assessment dated [DATE] revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 4 which indicated Resident #22 was severely cognitively impaired and was non-compliant. Observations in the Hall 6 Smoking Porch on 7/8/19 at 12:49 PM revealed Resident #22 was smoking without staff supervision. 3. Medical record review revealed Resident #102 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MDS assessment for Resident #102 dated 3/13/19 documented a BIMS score of 12 which indicated Resident #102 was moderately impaired cognitively. A Web Event Summary Report dated 3/23/19 documented, .At 7:30 pm tech (technician) noted cigarette burn to abdomen, ashes in navel, burn hole in pants. Area not draining or wet. Dry with slight redness around it . Medical record review of the Order Audit Report for Resident #102 dated 3/25/19 documented, .Resident to be supervised at all times while smoking (Do Not leave alone while smoking) . The care plan intervention was revised on 4/12/19 for Resident #102 to smoke unsupervised. The care plan for smoking for Resident #102 was not revised until 4/12/19. Revision of the care plan on 6/27/19 documented, .RESIDENT MUST BE SUPERVISED/ACCOMPANIED BY STAFF WHILE SMOKING .RESIDENT IS NOT TO BE LEFT ALONE WHILE SMOKING . Observations in the Hall 6 Smoking Porch on 7/8/19 at 12:49 PM, revealed Resident #102 smoking without staff supervision. Interview with MDS Coordinator #1 on 7/10/19 at 10:30 AM, in the Conference Room, MDS Coordinator #1 was asked if the care plan was updated. MDS Coordinator #1 stated, I need to look at his (physician) progress note. I will get with him for a clarification order. MDS Coordinator #1 failed to answer whether the care plan had been revised. Interview with MDS Coordinator #2 on 7/12/19 at 10:50 AM, in the Conference Room, MDS Cordiantor #2 was asked why Resident #102 had the intervention to be supervised while smoking on 6/27/19. MDS Coordinator #2 stated, .I am not sure .we have been talking about it . Interview with MDS Coordinator #1 on 7/12/19 beginning at 11:04 AM, in the Conference Room, MDS Coordinator #1 was asked about the care plan not being revised for Resident #102 after a burn was found on Resident #102's abdomen. MDS Coordinator #1 stated, .we did not have a care plan meeting, we did not have time for a meeting that week . 4. Medical record review revealed Resident #30 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Progress Note dated 3/30/19 documented, .Behavior is rebellious over the last week. Has been sneaking outside to smoke with another patient despite being told that someone either staff or family must accompany him . Resident #30 did not have a care plan for smoking when he was admitted on [DATE]. Resident #30's care plan was not revised to reflect elopement risk related to history of attempts to leave the facility unattended and impaired safety awareness status until 4/4/19. Observations in the Hall 6 Smoking Porch on 7/8/19 at 12:49 PM revealed Resident #30 smoking without staff supervision. 5. Medical record review revealed Resident #88 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Care Plan dated 3/17/16 for Resident #88 documented, .6/24/19 .Resident is grandfathered in (allowed to smoke) but must smoke in designated area smoke at designated times . Resident #88 was transferred from (Named facility) sister building to present building on 9/19/18. Medical record review of an annual MDS dated [DATE] documented Resident #88 had a BIMS score of 12 which indicated moderate cognitive impairment and had functional impairment to both arm and leg on one side of his body. The smoking care plan for Resident #88 was not revised until 6/24/19. According to the facility's policy there was no designated times for supervised smoking and the smoking materials were to be secured by the facility. 6. Medical record review revealed Resident #180 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an admission MDS dated [DATE] documented Resident #180 had a BIMS score of 12 which indicated moderate cognitive impairment and he had impairment on one side of his body. Medical record review of a Care Plan for Resident #180 dated 12/20/18 revealed Resident #180's care plan did not address smoking and noncompliance by the resident. Observations in the Hall 6 Smoking Porch on 7/8/19 at 12:49 PM revealed Resident #180 smoking without staff supervision. Interview with MDS Coordinator #1 on 7/10/19 at 10:30 AM, in the Conference Room, MDS Coordinator #1 confirmed the care plans were not revised to reflect smoking safely with effective interventions to prevent accidents. Refer to F689. The surveyors verified the A[NAME] by: The Interdisciplinary Team, consisting of the DON, ADON, Infection Preventionist, Activity Director, MDS Coordinators, Dietician, and Social Services will meet daily after morning meeting, to assure review of any updates and revisions to the resident care plans are occurring, appropriately and accurately and that those changes are being properly communicated to the licensed nurses, direct care and dietary staff members. An updated communication system has been developed whereby changes entered into the residents' care plan are updated on the electronic documentation system. Those changes will be reflected on the Nurse Aide Kardex and any significant issues will be discussed face to face during the daily nursing staff huddles and during shift report. The care plans of residents who smoke have been updated to reflect the current Smoking Policy. These care plans will be updated at least quarterly or as necessary by the MDS Coordinators. Being that the facility is going Smoke Free on 8/12/19 newly admitted residents, who smoke, will be educated regarding the Smoke Free policy and will be reflected on their care plans. The surveyors interviewed the ADON and were provided information to review when the care plans will be updated. Audits will be completed to ensure updates are maintained. Noncompliance continues at a scope and severity level of [NAME] for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.",2020-09-01
773,DONALSON CARE CENTER,445173,1681 WINCHESTER HIGHWAY,FAYETTEVILLE,TN,37334,2019-07-15,689,K,0,1,L3LQ11,"**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 a safe environment that provided supervision to eliminate the risk of elopement and accidents for 9 of 9 (Resident #22, #102, #18, #12, #13, #38, #2, #70, and #377) wandering and smoking residents reviewed and failed to ensure residents were supervised while smoking to prevent accident hazards for 5 of 5 (Resident #22, #30, #88, #102, and #180) smoking residents. The 5 of 5 (Resident #22, #30, #88, #102, and #180) smoking residents also had knowledge and used the exit door key pad codes provided to them by the staff, allowing the residents to exit the building independently without staff supervision, were allowed to smoke unsupervised, and were allowed to keep smoking materials (cigarettes and lighters) on their person. The 7 of 7 (Resident #2, #12, #13, #18, #38, #70, and #377) cognitively impaired, vulnerable residents with wanderguards (ankle band tracking system that automatically locked the doors and alarmed) were at elopement risk, when the facility had nonfunctioning sensor alarms or no sensor alarms on 5 of 8 (Hall 1 door, Hall 2 Dining Room door, Hall 3 Dining Room door, Hall 4 West door, and Hall 6 door) exit doors. The facility was 156 feet from a heavily traveled 4 lane state highway. The failure of the facility to provide supervision and to prevent accidents resulted in HARM when Resident #22 and #102 had falls with injury when these residents were allowed to use the exit code to the doors to leave a safe area to an unsafe area. The failure of the facility to ensure the exit doors had functioning wanderguard sensor alarms and the failure to check and repair the exit doors placed Resident #12, #13, and #18 in Immediate Jeopardy when these residents with wanderguards were able to exit the building, and this had the potential to affect the other wandering residents (Resident #2, #38, #70, and #377). The failure of the facility to provide supervision during smoking had the potential to cause serious harm or injury, and placed Resident #22, #30, #88, #102, and #180 in Immediate Jeopardy. Immediate Jeopardy (IJ) is 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. An extended survey was conducted on 7/12/19 through 7/15/19. The Interim Administrator, the Assistant Administrator, the Director of Nursing (DON), the Assistant Director of Nursing (ADON), the Quality and Infection Preventionist Director, the Infection Preventionist, and Minimum Data Set (MDS) Coordinator #2 were notified of the Immediate Jeopardy on 7/12/19 at 9:32 PM, in the Conference Room. The facility was cited IJ at F689 K which is Substandard Quality of Care. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the jeopardy, was received on 7/14/19 at 5:30 PM, and the corrective actions were validated onsite by the surveyors on 7/14/19 and 7/15/19 through review of assessments, auditing tools, in-service training records, policies, observations, and staff interviews. The Immediate Jeopardy was effective from 9/8/18 through 7/15/19 and the IJ was removed on 7/15/19. The noncompliance continues at F689-E for monitoring of effectiveness of the corrective actions. The findings include: 1. The facility's Smoking Policy with a revision date of 4/11/19 documented, .OBJECTIVE .To restrict smoking to a minimum and reduce risks to residents .who smoke, including adverse effects .the risk of fire .All resident smoking materials are to be kept secured by the facility .Visitors need to check with charge nurse/nurse before giving smoking materials to ANY resident of Care Centers . The facility's Oxygen Administration - Hazards and Pitfalls policy with a revision date of 9/17 documented, .The most frequent cause of fire when oxygen is being administered is the lighting of a cigarette. This hazard is greatly increased with the administration of oxygen. Smoking is strictly against the rules and regulations in rooms where oxygen is being administered . Review of the facility's Elopement Risk/ Wanderguard policy with a revision date of 4/11/19 documented, .Any resident with an altered mental status who has demonstrated behavior that puts them at risk for wandering/elopement will be considered an elopement risk .PR[NAME]EDURE .Document behavior in Nursing Notes. Be descriptive as to behavior resident is demonstrating .Resident will wear wanderguard bracelet . 2. Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of a MORSE FALL SCALE assessment dated [DATE] documented, .Moderate Risk for Falling . Medical record review of the Care Plan for Resident #22 revised on 7/8/19 documented, .The resident is (Moderate) risk for falls .Interventions .2/15/19 Resident was witnessed (staff witnessed from inside the building) going outside through (employee) breakroom door at skilled care and tipping over to the right as his wheels went off sidewalk pavement. Fence beside side walk was pushed over during the fall. Skin tears to right arm and elbow. Resident counseled to not use this door in the future. Sign posted to keep breakroom door closed and door to outside locked at all times . Medical record review of a Nurses Progress Incident Note dated 2/15/19 at 12:52 PM documented, .at 0645 (6:45 AM) this am pt (patient) went outside to smoke. he (He) went out the staff lounge door. he (He) was reaching for the door knob to come back into building when his w/c (wheelchair) tipped over the edge of the sidewalk. he (He) and the w/c was found lying on the white fence that was knocked over. he (He) was lying on his rt (right) side. his (His) rt arm has 3 large skin tears and some bruising . Medical record review of a Progress Note Skin/Wound Note dated 2/15/19 at 1:45 PM documented, .3 skin tears to right arm noted .Re-approximated 2 skin tears with steri strips (wound closure device used instead of stitches) . Review of a Web Event Summary Report dated 2/15/19 documented, .Resident (#22) was exiting the building in wheelchair through skilled breakroom when his wheelchair wheels on the right side fell off the pavement causing him to turn over to the right side against a fence that fell over with him .Assisted up x (times) 4 staff members. Skin tears to right arm .Resident (#22) counseled to not attempt to go outside unassisted. Doors to breakroom are to be kept closed at all times (punch lock for staff only) and doors to outside are to be locked at all times. resident (Resident) and staff voice understanding . Medical record review of the admission MDS dated [DATE] revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated severe cognitive impairment, and required limited to extensive staff assistance with activities of daily living (ADLs). Medical record review of a MORSE FALL SCALE assessment for Resident #22 dated 7/8/19 documented, .High Risk for Falling . Interview with Licensed Practical Nurse (LPN) #4 on 7/12/19 at 11:04 AM, in the Conference Room, LPN #4 stated, .I was in the skilled hall and I glanced out window I saw his (Resident #22) arm go up and a body go up. He was outside .said he was reaching to let himself back in .he got there alone .I would call that a witnessed fall . Observations at the Hall 6 Smoking Porch Exit door on 7/8/19 at 12:51 PM, revealed Resident #22 propelled himself to the door and entered a code in the door lock key pad, opened the door with the metal handicap push button, and entered the Smoking Porch. Interview with the ADON on 7/11/19 at 2:35 PM, in the Conference Room, the ADON was asked if Resident #22 had a fall. The ADON confirmed he went into the break room and out the side door, and he turned over his wheelchair. The ADON stated, I'm not sure how he got into the break room door. It .has a key pad on it. After getting in the break room, the door to the outside is unlocked. Observations in the courtyard on 7/11/19 at 2:44 PM, revealed the back door of the breakroom lead to the courtyard. The side walk had a drop off. The courtyard was not a secured area. There was not a secured area outside the building. Resident #22 entered an unsafe area from a safe area, unsupervised, and sustained 3 skin tears requiring steri-strips, which resulted in HARM to Resident #22. 3. Medical record review revealed Resident #102 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan for Resident #102 revised on 6/27/19 documented, .The resident has had an actual fall .Interventions .1/10/19 At 15:30 (3:30 PM) was outside smoking (on Smoking Porch), bent forward to pick up cigarette from ground and fell out of wc (wheelchair) and hit her head .has small hematoma to forehead between eys (eyes), small abrasion to bridge of nose and 5cm (centimeters) x 1.5cm skin tear to shin .Assigned staff supervision with resident when smoking . Review of a Web Event Summary Report dated 1/11/19 documented, .Resident (#102) was outside smoking, she bent forward to pick up cigarette off ground and fell out of wc, hit her head causing a small hematoma to forehead between eyes, and abrasion to bridge of nose and skin tear 5 cm X 1.5 to right shin .steri-strips (wound closure strips) applied The care plan was updated 1/10/19 for Resident #102 to be supervised with smoking. Medical record review of the annual MDS dated [DATE] revealed Resident #102 had a BIMS score of 12, which indicated moderate cognitive impairment. Observations in the Hall 6 Smoking Porch on 7/8/19 at 12:51 PM, revealed Resident #102 propelled herself out the door to the Smoking Porch (an unsecured area). Interview with the DON and MDS Coordinator #1 on 7/10/19 at 9:41 AM, in the Conference Room, MDS Coordinator #1 was asked if residents knew the code to the door. MDS Coordinator #1 and the DON confirmed residents did know the code to the Smoking Porch Exit door. The DON and MDS Coordinator #1 were asked if the residents could go freely out to smoke at any time. The DON and MDS Coordinator #1 stated, Yes. Interview with the Interim Administrator on 7/12/19 at 11:35 AM, in the Conference Room, the Interim Administrator was asked if Resident #102 should have been outside alone. The Interim Administrator stated, We (Administrative staff) don't think so, no . Resident #102 entered an unsafe area from a safe area, unsupervised, and sustained a skin tear requiring steri-strips and a hematoma, which resulted in HARM to Resident #102. 4. Medical record review revealed Resident #18 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of a significant change MDS dated [DATE] and the quarterly MDS dated [DATE] revealed a BIMS score of 8, which indicated moderate cognitive impairment. The Web Event Summary dated 9/14/18 documented, .8:30am Resident went out side door of Hall 4, has wanderguard on. Dtr (daughter) .and FNP (Family Nurse Practitioner) notified . Medical record review of the Care Plan for Resident #18 revised 7/8/19 documented, .The resident is an elopement risk/wanderer r/t (related to) Disorientation to place, Impaired safety awareness .Interventions .9/14/18 Resident was able to get outside door. Tech (Certified Nursing Technician) nearby and retrieved resident without incident. Wanderguard in place. Maintenance contacted to check on door security .Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers . Medical record review of the WANDERING RISK SCALE assessments dated 1/14/19 and 4/14/19 revealed a score of 10 which indicated At Risk to Wander. Review of a Web Event Summary Report for Resident #18 dated 1/31/19 documented, .(on 1/30/19) Resident was sitting outside door on south hall, CNA (Certified Nursing Assistant) student thought that he was waiting to go smoke and let him outside, resident was found up against fence with wc on top of him, he did have small cut to right 4th finger .Intervention .Neurochecks initiated .student tech educated on protocol on letting residents outside and also which residents are allowed to smoke unattended. Discussed smoking policy and protocal (protocol) for letting residents outside in huddle, also put in task a reminder that resident is not allowed outside unattended . Observations in Resident #18's room on 7/8/19 at 12:15 PM revealed Resident #18 seated in his wheelchair and appeared confused. Interview with the ADON on 7/11/19 at 7:15 PM, in the Conference Room, the ADON confirmed Resident #18 exited the building on 9/14/18 and maintenance was contacted and stated, .not sure why maintenance was notified . Interview with LPN #3 on 7/14/19 at 6:26 PM, in the Fine Dining Room, LPN #3 was asked if there had been any problems with the wanderguards functioning correctly. LPN #3 stated, Some of the wanderguards were not working properly with all the doors .I have seen (Resident #18) .he is very persistent .sometimes it doesn't alarm . 5. Medical record review revealed Resident #12 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Web Event Summary Report dated 9/8/18 documented, .2:30 pm Resident and roommate (Resident #13) was outside bldg (building) underneath awning at end of hall 4 .Work order to maintenance to have doors checked . (The Hall 4 West door had a wanderguard sensor that was not functioning appropriately). Medical record review of a Progress Note for Resident #12 dated 9/12/18 documented, .Resident and roommate went to front door on skill hall and attempted to elope. Resident also came to back door by nurse's station and attempted to elope . Review of the physician orders [REDACTED].#12 had a wanderguard since 9/11/18. Medical record review of the annual MDS dated [DATE] revealed a BIMS score of 7, which indicated severe cognitive impairment and used wander/elopement alarms. Medical record review of the Care Plan for Resident #12 revised 7/8/19 documented, .The resident is an elopement risk r/t Impaired safety awareness .Interventions .9/8/18 Resident found standing outside .just getting some fresh air .Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers Date Initiated: 09/11/2018 .WANDER ALERT: Wander guard in place Date Initiated: 09/11/2018 . Medical record review of WANDERING RISK SCALE assessments dated 1/3/19, 4/3/19, and 7/3/19 documented, .High Risk to Wander . Observations in Hall 4 on 7/8/19 at 12:20 PM, revealed Resident #12 ambulating on the hall with a rolling walker. Interview with the ADON on 7/14/19 at 4:32 PM, in the Conference Room, the ADON was asked about Resident #12 exiting the building. The ADON stated, .There was a family member or someone else's family member let them out under the awning on Hall 4 . 6. Medical record review revealed Resident #13 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED].#13 had a wanderguard since 4/24/18. Medical record review of a Web Event Summary Report for Resident #13 dated 9/8/18 documented, .2:30 pm Resident was found with roommate (Resident #12) outside of bldg. underneath awning at end of Hall 4 .has on Wanderguard .Work order to have door checked .9-10-18 . Review of Maintenance Work Orders documented the following: a. 9/10/18 .Door going outside not working properly .hall 5 . b. 9/10/18 .Hall 4 exterior door (where linen is brought in) and the skilled dining room exit door is (are) not locking appropriately (they are suppose to lock automatically) and the wander guard is not working properly on these doors .This needs to be looked at asap (as soon as possible) .Hall 4 exterior door (where linen is brought in) . c. 9/14/18 .Hall 4 doors are not locking down with wander guard .resident (Resident #18) with wander guards opened doors today .Hall 4 (Hall 4 West door)outside doors . There was no documentation the doors were repaired or checked. Medical record review of Progress Notes documented: a. 9/12/18 .Resident and roommate (Resident #12) went to front door on skill hall and attempted to elope. Resident also came to back door by nurse's station and attempted to elope . b. 1/10/19 .has a wander guard in place d/t confusion and risk of elopement . c. 2/12/19 .Roaming halls wanting to leave with pocketbook on shoulder . Medical record review of the quarterly MDS dated [DATE] revealed a BIMS score of 3, which indicated severe cognitive impairment, and daily use of a wander/elopement alarm (wanderguard). Medical record review of the WANDERING RISK SCALE assessments for Resident #13 dated 1/4/19, 4/3/19, and 7/8/19 documented, .High Risk to Wander . Medical record review of the Care Plan for Resident #13 revised 7/8/19 documented, .The resident has impaired cognitive function/dementia or impaired thought processes r/t Alzheimer's, Dementia . Interventions . supervise as needed. Date Initiated: 10/12/2017 .The resident is an elopement risk r/t Impaired safety awareness . Interventions .4/23/18 . Wanderguard anklet applied .9/8/18 Resident found standing just outside door .was getting some fresh air. Resident redirected back into facility without issue. Date Initiated: 09/11/2018 . Observations on Hall 4 on 7/14/19 at 1:57 PM, revealed Resident #13 ambulating in the hall using a rolling walker. She had a wanderguard to her right ankle. Interview with the Facilities Director on 7/12/19 at 12:03 PM, in the Conference Room, the Facilities Director was asked if he had to check the exit doors because a resident had been found outside the building. The Facilities Director stated, No ma'am. Interview with the Maintenance Technician on 7/15/19 at 10:55 AM, in the Conference Room, the Maintenance Technician was asked about the doors that did not alarm or lock on 9/10/18 when a resident with a wanderguard approached. The Maintenance Technician stated, They (staff) told me it just wasn't locking. We had the security guard come over and make sure of the times they (doors) were locking . The Maintenance Technician confirmed the door was not checked or repaired for wanderguard functioning. 7. Medical record review revealed Resident #38 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission MDS dated [DATE] documented moderate cognitive impairment per staff assessment, required supervision with transfers, walking, and locomotion. Medical record review of the Care Plan for Resident #38 with a revision date of 7/8/19 documented, .The resident is an elopement risk/wanderer r/t Disoriented to place, Impaired safety awareness, Resident wanders aimlessly .Interventions .Distract from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers .Date Initiated: 05/02/2019 .WANDER GUARD IN PLACE .Date Initiated: 05/02/2019 . Medical Record review of the Wander Elopement Risk Assessments for Resident #38 dated 4/30/19, 6/28/19 and 7/12/19 documented, .High Risk to Wander . Medical record review of Progress Notes dated 4/30/19 through 7/6/19 documented Resident #38 was frequently wandering in and out of other resident rooms, had unsteady gait with stumbling steps noted at times, had exit seeking behaviors, was difficult to redirect, had poor safety awareness, and needed constant supervision. Medical record review of a Progress Note dated 5/4/19 documented, .Resident (#38) has exhibited exit seeking behavior all day. She walks independently without assistive device. Resident walks from door to door trying to get outside. She was observed walking out the front door with a group of visitors on Skilled Care .Unable to redirect resident from exit seeking due to dementia . Observations in the Skilled Hall on 7/8/19 at 11:20 AM revealed Resident #38 was seated in a chair holding a baby doll, oriented to person only, and talking about wanting to get home with the rest of the family. Interview with the ADON on 7/14/19 at 4:27 PM, in the Conference Room, the ADON stated, She (Resident #38) was really hard to redirect .she would walk until she tired herself out .It (behaviors) started 5/2/19 and ended 6/27/19 when she went out to the hospital. The ADON was asked when the wanderguard was reordered and why. The ADON stated, .7/12/19 .She (Resident #38) showed signs of trying to exit seek again . The ADON confirmed Resident #38 had a history of [REDACTED]. 8. Medical record review revealed Resident #2 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physician order [REDACTED].WANDERGUARD BRACELET AT ALL TIMES every day and night shift for safety . Medical record review of a Progress Note for Resident #2 dated 5/2/19 documented, .Continue to try to get out the front door .said I tried so hard to escape and I could not .Wanderguard on patient left ankle intact . Medical record review of a Progress Note dated 5/5/19 documented, .He has wandered on and off all day. His primary mode of locomotion is by wheelchair. He self propels with his feet, he has tried to exit front doors and is difficult to redirect . Medical record review of a Progress Note for Resident #2 dated 5/10/19 at 9:24 AM documented, .Patient testing doors and wandering up and down hallway and into other patients (patients') rooms. He is difficult to redirect at times and not redirect-able at others . Medical record review of a Progress Note dated 5/10/19 at 12:40 PM documented, .Patient anxious. Testing doors. Propelling self in wheelchair into others (others') rooms . Medical record review of the Care Plan for Resident #2 revised 6/13/19 documented, .The resident has an ADL self-care performance deficit .Interventions .WANDERGUARD BRACELET AT ALL TIMES Date Initiated: 04/04/2019 .The resident has impaired cognitive function/dementia or impaired thought processes r/t memory loss, impaired safety awareness, behavioral symptoms . Interventions . WANDERGUARD BRACELET AT ALL TIMES Date Initiated: 04/04/2019 . Medical record review of the quarterly MDS dated [DATE] revealed moderate cognitive impairment by staff assessment and required the use of wander/elopement alarms. Observations in Resident #2's room on 7/8/19 at 12:35 PM and on 7/8/19 at 4:00 PM, revealed Resident #2 lying in bed, alert with a wanderguard device in place. 9. Medical record review revealed Resident #70 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] documented a BIMS score of 3 which indicated severe cognitive impairment, and required staff assistance for all ADLs. Medical record review of Progress Notes dated 3/13/19 documented, .has a wanderguard in place d/t risk for wandering/exiting building unassisted . Medical record review of the Care Plan for Resident #70 revised 6/4/19 documented, .The resident has impaired cognitive function/dementia or impaired thought processes . Interventions .supervise as needed Date Initiated: 02/23/2018 .Potential for Elopement .Interventions .Wanderguard to be applied (remain in place at all times) d/t possible elopement Date Initiated: 04/19/2018 . Medical record review of Progress Notes dated 6/10/19 documented, .has a wanderguard in place d/t risk for wandering/exiting building unassisted . Medical record review of a Physician order [REDACTED]. Observations in the South Dining Room on 7/12/19 at 10:13 AM revealed Resident #70 seated in a wheelchair coloring. He was alert and confused, and had a wanderguard to his ankle. 10. Medical record review revealed Resident #377 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Progress Note dated 7/9/19 documented, .has been observed ambulating out of other pt's (patient's) rooms .has also attempted to go out of main entrance doors stating that I am going to my daughters (daughter's) house . Medical record review of the Order Summary Report documented, .Wander guard at all times .Start Date .07/10/2019 . Observations in Resident #377's room on 7/11/19 at 2:17 PM revealed Resident #377 seated in a chair with a wanderguard on her left ankle. Interview with the ADON on 7/14/19 at 4:19 PM, in the Conference Room, the ADON was asked why Resident #377 had a wanderguard. The ADON stated, .she did attempt to exit building . 11. Observations at the Hall 4 West Exit door on 7/10/19 at 3:46 PM, revealed the Facilities Director had a wanderguard tester device in his hand and held it near the exit door. No alarm sounded. The Facilities Director held the testing device up to the door again and no alarm sounded. The Facilities Director tried the third time, and the alarm sounded. Interview with the Facilities Director at the Hall 4 West exit door on 7/10/19 at 3:50 PM, the Facilities Director stated, This (door alarm) should have went off . Observations of all facility exit doors on 7/11/19 beginning at 3:35 PM, revealed the Facilities Director used a handheld wanderguard device, for checking the wanderguard alarm system but the Hall 4 West door did not lock when approached on first 2 attempts (the door should have automatically locked and alarmed when approached with the wanderguard device). The Facilities Director stated, It's (alarm) working intermittently. The Facilities Director used a second wanderguard alarm device and the Hall 4 West door only locked or alarmed intermittently. The Facilities Director stated, .left lower door alarm is not working . The Facilities Director stated the West 4 Hall door had an area of the door that was not working, there was only a certain area that was working and this was why the door would lock and alarm intermittently. The Facilities Director was asked if the door was secure to protect residents from elopement. The Facilities Director stated, It's a 1 foot area in the center of the door that's not picking up the wander guard signal .sensors need adjusting . The Facilities Director stated, .(Hall 6) door stays locked all the time, and you put in a code to get out. The Facilities Director had a wanderguard testing device in his hand, entered the door code, opened the door 3 times, and no alarm sounded. The Facilities Director stated, This door .is not equipped with a working wanderguard sensor . Interview with the Interim Administrator on 7/10/19 at 2:10 PM, in the Conference Room, the Interim Administrator was asked if the area where the residents went out to smoke was in an enclosed courtyard. The Interim Administrator confirmed the courtyard was not secured and residents could leave the premises. Interview with the Interim Administrator on 7/11/19 at 4:27 PM, at the Hall 6 Exit door during wanderguard testing, the Interim Administrator stated, A wanderer could get out. Interview with the Interim Administrator and the Facilities Director during observations of all 8 facility exit doors on 7/11/19 beginning at 5:07 PM, the Facilities Director and the Interim Administrator confirmed 4 of 8 (Hall 6 door, Hall 3 Dining Room door, Hall 2 Dining Room door, and Hall 1 door) exit doors were not equipped with wanderguard device alarms and the wanderguard sensor for the Hall 4 West door was not functioning correctly. Observations at the Hall 4 West Hall door by the laundry room on 7/11/19 beginning at 8:10 PM, revealed the door was unlocked and unsecured. Interview with the Interim Administrator, DON, ADON, and the Facilities Director, on 7/12/19 at 11:04 AM, the Facilities Director stated, I thought the keypads were the first defense. We were checking the keypad not the wanderguard. I thought (wanderguard) was our last line of defense . Interview with the Maintenance Technician on 7/15/19 at 10:55 AM, in the Conference Room, the Maintenance Technician was asked what kind of checks he had been doing on the doors related to the wanderguards. The Maintenance Technician stated, I would just check to see if they couldn't stroll on out the door without pressing the keypad number. The Maintenance Technician was asked if all the doors were equipped for the wanderguards. The Maintenance Technician stated, 3 . The Maintenance Technician confirmed there were 4 exit doors in the facility that were not equipped with wanderguard alarms prior to 7/12/19 and the Hall 4 West door wanderguard sensor was not functioning correctly prior to 7/12/19. The Maintenance Technician confirmed he had not been routinely checking the doors for wanderguard functioning. Interview with the Interim Administrator and the Assistant Administrator on 7/15/19 at 11:50 AM, in the Conference Room, the Interim Administrator was asked if he had the measurements to the highway. Measurements provided and confirmed by the Interim Administrator on 7/15/19 at 11:50 AM revealed the facility was 156 feet from a heavily traveled 4 lane state highway. 12. Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission MDS dated [DATE] revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated severe cognitive impairment, required limited to extensive staff assistance with activities of daily living (ADLs), and was coded for current tobacco use and oxygen therapy. Medical record review of the Care Plan fo (TRUNCATED)",2020-09-01
774,DONALSON CARE CENTER,445173,1681 WINCHESTER HIGHWAY,FAYETTEVILLE,TN,37334,2019-07-15,690,D,0,1,L3LQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide care and services for an indwelling urinary catheter for 1 of 1 (Resident #227) sampled residents reviewed for urinary catheters. The findings include: Medical record review revealed Resident #227 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #227's room on 7/12/19 at 8:19 AM revealed Resident #227 had an indwelling urinary catheter. Medical record review of the physician's orders [REDACTED]. Medical record review revealed there was no order for catheter care and there was no documentation of catheter care being performed. Interview with the Infection Preventionist on 7/12/19 at 2:17 PM, at the Administration Desk, the Infection Preventionist confirmed Resident #227 had the indwelling urinary catheter since admission on 7/4/19. Interview with the Staff Development Coordinator (SDC) on 7/12/19 at 2:23 PM at the Skilled Nurses' Station, the SDC was asked if there should be a physician's orders [REDACTED]. The SDC stated, Yes, there should be. The SDC confirmed catheter care should be done twice a day and as needed. Interview with the Assistant Director of Nursing (ADON) on 7/12/19 at 2:57 PM, in the ADON Office, the ADON was asked if there should be an order for [REDACTED]. The ADON stated, Once a shift and as needed. The ADON was asked if the catheter care should be documented. The ADON stated, Yes. The facility was unable to provide a physician's orders [REDACTED].#227.",2020-09-01
775,DONALSON CARE CENTER,445173,1681 WINCHESTER HIGHWAY,FAYETTEVILLE,TN,37334,2019-07-15,835,K,0,1,L3LQ11,"Based on the Interim Administrator's Contract, Director of Nursing Job Description, medical record review, observation, and interview, the Interim Administrator failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain and maintain the highest practicable well-being of the residents. Administration failed to ensure the residents that smoked had adequate supervision, and failed to provide oversight and training of staff to ensure the security devices for the exit doors were operational and the exit codes to the doors remained secure. The Administration's failure placed Residents #2, #12, #13, #18, #22, #30, #38, #70, #88, #102, #180, and #377 in Immediate Jeopardy when staff did not assess, report, implement, evaluate or monitor for resident safety concerns for smoking and elopements. Immediate Jeopardy (IJ) is 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 Interim Administrator, Assistant Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Infection Preventionist, Quality and Infection Preventionist, and the Minimum Data Set (MDS) Coordinator #2, were notified of the Immediate Jeopardy on 7/12/19 at 9:32 PM, in the Conference Room. The facility was cited at scope and severity of Immediate Jeopardy for F657-K, F689-K, F835-K, F841-K, and F867-K. The Immediate Jeopardy was effective 9/8/18 through 7/15/19 and the IJ was removed on 7/15/19. An extended survey was conducted on 7/12/19 through 7/15/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the jeopardy, was received on 7/14/19 at 5:30 PM, and the corrective actions were validated onsite by the surveyors on 7/14/19 and 7/15/19 through review of assessments, auditing tools, in-service training records, policies, observations, and staff interviews. The noncompliance continues at F835-E for monitoring of effectiveness of the corrective actions. The findings include: The facility's Interim Administrator Contract dated 4/12/19 documented, .This Agreement shall be governed by and construed in accordance with the laws of the State of Tennessee .The Contractor agrees to .Oversees all activities of the care center in accordance with established policies and federal and state guidelines .Develop strategic plans for profitability and accountability for all operations and programs .Administer, direct and coordinate the business .Recommend and lead changes to improve the care center .Maintain a state administrator license .Create functional strategies and specific objectives for the care center and develop budgets/policies/procedures to support the functional infrastructure .Implement Administrator-in-Training Program . The facility's Director of Nursing Job Description dated 6/17/19 documented, .Under the direction of the Administrator, the DON has 24-hour responsibility for the effective implementation of the philosophy, goals, policies, and procedures .The DON has authority to make decisions .in the areas of patient care .Demonstrated leadership ability and potential managerial competency .Evidence of this includes, but is not limited to .ability to confront/resolve issues, ability to motivate others, ability to plan, organize, and direct the activities of others .Assist the Administrator in development, implementation and evaluation of on-going service programs that assure quality nursing and resident care programs consistent with health system mission .Evaluates on-going programs as assigned by Administrator .Monitors/maintains care center compliance with regulatory, accrediting and health system policy for resident services, and environmental and personnel safety .and/or universal precautions procedures as evidenced by PI (Performance Improvement) reports, incident follow-ups, staff meeting minutes and direct observation by Administrator .Oversees Care Center PI program which monitors and evaluates critical aspects of care .Accurately identifies real/potential problems affecting the services and implements solutions with follow-through and communications . ensures department delivers quality services in accordance with applicable policies, procedures, and professional standards . Interview with the DON on 7/10/19 at 9:41 AM, in the Conference Room, the DON was asked if the residents knew the security codes to the exit doors and if residents could go out freely at anytime. The DON stated, Yes. Interview with the Interim Administrator, DON, ADON, MDS Coordinator #1 on 7/10/19 at 1:33 PM, in the Conference Room, the Interim Administrator was asked if they had identified problems with smoking at the facility. The Interim Administrator stated, We talked about smoking .June .that's when we formally as a group said, 'guys we need to address this issue' .talked about a supervised schedule . The Interim Administrator was asked if a supervised schedule had been implemented. The Interim Administrator stated, Not yet. The Administrator was asked if the residents were allowed to have their smoking materials, including lighters, in their possession, and allowed to go out unsupervised. The Interim Administrator stated, That's correct . The Interim Administrator confirmed the Hall 6 Smoking Porch opened to a Courtyard that was not secure or enclosed. Interview with the Interim Administrator on 7/11/19 at 4:27 PM, at the Hall 6 exit door during wander guard testing, the Interim Administrator stated, A wanderer could get out. The Interim Administrator was unable to state how long the 5 of 8 wanderguard door alarm devices had not been functioning. Interview with the Interim Administrator and the Assistant Administrator on 7/14/19 at 9:15 AM, in the Conference Room, the Interim Administrator was asked when he became aware that residents were smoking unsupervised. The Interim Administrator stated, .This is really something pretty serious .around the middle of the month of (MONTH) . The Interim Administrator stated, .we would be periodically walking out, and we would say wait a minute. There is nobody out here with these (residents) .I had been working with .the consultant .one of the things she said we need to be jumping on . The Interim Administrator was asked about residents having lighters in their possession in their rooms when they received oxygen therapy. The Interim Administrator stated, .just learning they had lighters, oxygen or not .I don't have this documented but I sat out with (Named Resident #88 and #22), and said I understand you have lighters, and we can't let you have those . Administration failed to provide oversight of staff when they failed to ensure a safe and consistent smoking regimen for residents which resulted in IJ for Resident #22, #30, #88, #102, and #180. The Administration failed to ensure staff maintained the confidential codes to the secure exit doors, which allowed residents to exit the building unsupervised. Administration failed to ensure the safety of residents with elopement risk, by not ensuring the wanderguard security devices on the exit doors were operational which placed Resident #2,#12, #13, #18, #38, #70, and #377 in I[NAME] Refer to F657 and F689. The surveyors verified the A[NAME] by: 1. The facility's Leadership Team consisting of the Interim Administrator, Assistant Administrator, DON, ADON, Minimum Data Set Coordinator #2, Infection Preventionist, and Activity Director have been assessing the procedures related to resident smoking practices in an attempt to balance residents' rights while ensuring the safety of all residents and patients in the building. While the facility's planned goal is to incorporate a Smoke Free Campus policy, a short term intervention providing safe supervision for smoking residents has been implemented until proper notice can be provided to those affected residents and resident representatives. The Leadership Team began the development of an updated Smoking Policy, a Designated Smoking Time Schedule and a Staff Monitoring Tool to ensure there was a structured program in place for oversight and safety assurance for those residents who expressed a desire to smoke. The final policy and protocols were implemented 7/10/19. On 7/10/19 the Leadership Team met with the facility staff members and each affected resident to explain the facility's position on supervised smoking, safety concerns and the processes going forward. Even though there was reluctance and concern expressed by the affected residents, all agreed to voluntarily surrender any smoking paraphernalia on their person and in their rooms. Each resident room was visited to ensure no additional smoking items were overlooked. All such paraphernalia is kept locked up and secured by the Unit 6 Charge Nurse and is only being released to the assigned smoking monitor during the designated smoking times. The surveyors interviewed all facility staff which included all disciplines and staff on each shift. The surveyors reviewed the new smoking policy, staff monitoring tool, and interviewed the Nurse on the medication cart for Hall 5 where the smoking materials were secured. 2. The Interim Administrator and Assistant Administrator met with the five (5) residents, who desire to smoke, on 7/14/19 to discuss the Designated Smoking Time Schedule in order to gain their input and acceptance of the new set time schedule for smoking. They were informed that reasonable accommodations will be provided for those who might not be able to meet the exact Designated Smoking Time Schedule and informed of the impending 8/12/19 date as the time in which the facility will become Smoke Free. All indicated that they understood and had every intention of complying. The surveyors reviewed the new Designated Smoking Time Schedule and the Daily Smoking Monitoring Tool. 3. The Social Service staff have called and reached all but five (5) families/representatives as of 7/14/19 and informed them of the new Smoking and Door Code changes; those who were not reached were left messages and the facility will continue to reach out to all families until all have been properly informed. In addition to personal contact with families, the facility has posted a notice on each outside door, outlining the process for gaining entry into the building. As an additional communication effort the facility has mailed a letter with the same details, officially notifying all family members of the facility's plan to become a Smoke Free Campus. Those letters will be mailed to each responsible party on 7/15/19. The surveyors reviewed resident charts to verify the calls were documented. the surveyors observed the Social Service staff calling the families to update the famlies on the new smoking and Door Code changes. 4. The facility Maintenance Director and Administrator performed a complete operational assessment of all of the facility exit doors on (MONTH) 11, 2019, and determined that five (5) of the eight (8) exit doors had not been completely equipped with full wandering prevention (elopement) capabilities. While these doors were protected by a magnetic locking system, it was determined that an additional antenna alarm system installation would provide additional safety and protection. A certified door alarm vendor was immediately contacted upon discovery and arrived on site at 7:15 [NAME]M. on 7/12/19 and installed the additional monitoring devices. The system was tested by the Maintenance Department and was working as designed. The Facilities Director and Maintenance Technicians will oversee the functionality of the system by conducting daily tests of the exit door equipment and resident/patient transmitting devices for two weeks. If all equipment is found to be functioning properly, checks will move to weekly. The audits will occur no less than weekly going forward. The surveyors reviewed the new maintenance log for monitoring and tested the doors to ensure the doors were functioning appropriately. The door codes were changed and distributed to designated nursing staff only. Noncompliance continues at a scope and severity level of [NAME] for the monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.",2020-09-01
776,DONALSON CARE CENTER,445173,1681 WINCHESTER HIGHWAY,FAYETTEVILLE,TN,37334,2019-07-15,841,K,0,1,L3LQ11,"Based on review of the Medical Director's Agreement Contract, policy review, medical record review, observation, and interview, the Medical Director failed to ensure resident care policies were developed and implemented to use resources effectively and efficiently to attain and maintain the highest practicable functioning of all residents by failing to ensure an effective plan to assure the residents' environment was safe and that vulnerable residents were adequately supervised. The Medical Director failed to identify issues and concerns in the facility related to smoking safety and elopement risk, which resulted in Immediate Jeopardy (IJ) for Resident #2, #12, #13, #18, #22, #30, #38, #70, #88, #102, #180, and #377 when staff failed to assess, report, implement, evaluate or monitor for resident safety concerns related to smoking and elopements. Immediate Jeopardy (IJ) is 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 Interim Administrator, Assistant Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Infection Preventionist, Quality and Infection Preventionist, and Minimum Data Set (MDS) Coordinator #2, were notified of the Immediate Jeopardy on 7/12/19 at 9:32 PM, in the Conference Room. The facility was cited a scope and severity of Immediate Jeopardy for F657-K, F-689-K, F835-K, F841-K, and F867-K. The extended survey was conducted on 7/12/19 through 7/15/19. The Immediate Jeopardy was effective 9/8/18 through 7/15/19 and the IJ was removed on 7/15/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the jeopardy, was received on 7/14/19 at 5:30 PM, and the corrective actions were validated onsite by the surveyors on 7/14/19 and 7/15/19 through review of assessments, auditing tools, in-service training records, policies, observations, and staff interviews. The noncompliance continues at F 841-E for monitoring of effectiveness of the corrective actions. The findings include: 1. The Medical Director's Professional Services Agreement Contract signed 7/24/09 by the Medical Director, documented, .Overall coordination and execution of medical care .Assisting in developing procedures .Participating in establishing policies, procedures and guidelines designed to assure the provision of adequate, comprehensive services .Participating in the resident care management system .Participating in the Centers' inservice education program .Establishing with other health care professionals, policies designed to assure the governing body that all health care professionals practice within the scope .Providing consultation to the Centers' Administrator, Director of Nurses, and Social Services regarding the Centers' ability to meet the psychosocial, medical and physical needs of the residents .Advising the Administrator about the adequacy and appropriateness of the Centers scope of services for residents, medical equipment, and professional support staff .Helping to assure a safe and sanitary environment for residents and personnel .reviewing and evaluating occurrence reports .Identifying hazards to health and safety .Making relevant recommendations to the Administrator .Monitoring and evaluating quality and appropriateness of medical services as an integral part of the overall quality assessment and improvement program .Serving on committees . 2. Telephone interview with the Medical Director on 7/15/19 at 8:18 AM, the Medical Director was asked how he was involved in resident management. The Medical Director stated, I am the attending. That allows me to be directly involved with their care and planning. The Medical Director was asked if he had provided consultation to the facility's Administration staff regarding the facility's ability to meet the needs of the residents. The Medical Director stated, Yes, I do that on daily and weekly basis by reviewing conditions, looking at their needs, if we are able to meet their needs. The Medical Director was asked if he was involved in the implementation of smoking policies when the 2 residents (Resident #88 and #102) were grandfathered in to smoke. The Medical Director stated, No . The Medical Director was asked if he reviewed and evaluated occurrence reports. The Medical Director stated, once a week .I review them. The Medical Director was asked if he had talked with Administration about unsupervised smoking and Resident #102's burn incident. The Medical Director stated, I honestly didn't remember it .I'm sure I signed the incident report .burn on skin and clothing .That would be normal process. The Medical Director was asked if he was aware residents were allowed to keep lighters and cigarettes in their rooms while they received oxygen. The Medical Director stated, That is not good .That is very risky with oxygen involved. I don't think that was a good idea. The Medical Director was asked if unsupervised smoking was appropriate. The Medical Director stated, .It would make sense to supervise them. The Medical Director was asked if he was aware residents were going out the doors unsupervised with wanderguards on. The Medical Director stated, .that's interesting .maintenance definitely should be checking that system. The Medical Director was asked how he assured a safe environment for residents. The Medical Director stated, I think QA (Quality Assurance) meetings are key . The Medical Director was asked if he monitored and evaluated the quality and appropriateness of medical services as an integral part of the overall quality assessment and improvement program and how often he attended. The Medical Director stated, Monthly . 3. The Medical Director failed to ensure the residents received staff supervision for smoking and elopement risk, failed to assist the facility with the establishment, development, and implementation of safe smoking policies, and failed to ensure residents were not allowed to have lighters when oxygen was in use. The Medical Director failed to ensure vulnerable residents with wanderguards and elopement risks were protected from elopement accidents. Refer to F689. 4. The Medical Director failed to ensure Administration was responsible for the identification, development, and implementation of appropriate policies and procedures to maintain the highest practicable well-being of all residents. Refer to F835. 5. The Medical Director failed to ensure the Quality Assurance Performance Improvement Committee provided a safe environment for cognitively impaired residents with at risk behaviors related to smoking safety and elopement and that the residents were supervised and monitored to prevent accidents, which resulted in IJ for Resident #2, #12, #13, #18, #22, #30, #38, #70, #88, #102, #180, and #377. Refer to F867. The surveyors verified the A[NAME] by: 1. The facility's Leadership Team consisting of the Interim Administrator, Assistant Administrator, DON, ADON, Minimum Data Set Coordinator #2, Infection Preventionist, and Activity Director have been assessing the procedures related to resident smoking practices in an attempt to balance residents' rights while ensuring the safety of all residents and patients in the building. While the facility's planned goal is to incorporate a Smoke Free Campus policy, a short term intervention providing safe supervision for smoking residents has been implemented until proper notice can be provided to those affected residents and resident representatives. The Leadership Team began the development of an updated Smoking Policy, a Designated Smoking Time Schedule and a Staff Monitoring Tool to ensure there was a structured program in place for oversight and safety assurance for those residents who expressed a desire to smoke. The final policy and protocols were implemented 7/10/19. On 7/10/19 the Leadership Team met with the facility staff members and each affected resident to explain the facility's position on supervised smoking, safety concerns and the processes going forward. Even though there was reluctance and concern expressed by the affected residents, all agreed to voluntarily surrender any smoking paraphernalia on their person and in their rooms. Each resident room was visited to ensure no additional smoking items were overlooked. All such paraphernalia is kept locked up and secured by the Unit 6 Charge Nurse and is only being released to the assigned smoking monitor during the designated smoking times. The surveyors interviewed all facility staff which included all disciplines and staff on each shift. The surveyors reviewed the new smoking policy, staff monitoring tool, and interviewed the Nurse on the medication cart for Hall 5 where the smoking materials were secured. 2. The Interim Administrator and Assistant Administrator met with the five (5) residents, who desire to smoke, on 7/14/19 to discuss the Designated Smoking Time Schedule in order to gain their input and acceptance of the new set time schedule for smoking. They were informed that reasonable accommodations will be provided for those who might not be able to meet the exact Designated Smoking Time Schedule and informed of the impending 8/12/19 date as the time in which the facility will become Smoke Free. All indicated that they understood and had every intention of complying. The surveyors reviewed the new Designated Smoking Time Schedule and the Daily Smoking Monitoring Tool. 3. The facility Maintenance Director and Administrator performed a complete operational assessment of all of the facility exit doors on (MONTH) 11, 2019, and determined that five (5) of the eight (8) exit doors had not been completely equipped with full wandering prevention (elopement) capabilities. While these doors were protected by a magnetic locking system, it was determined that an additional antenna alarm system installation would provide additional safety and protection. A certified door alarm vendor was immediately contacted upon discovery and arrived on site at 7:15 [NAME]M. on 7/12/19 and installed the additional monitoring devices. The system was tested by the Maintenance Department and was working as designed. The Facilities Director and Maintenance Technicians will oversee the functionality of the system by conducting daily tests of the exit door equipment and resident/patient transmitting devices for two weeks. If all equipment is found to be functioning properly, checks will move to weekly. The audits will occur no less than weekly going forward. The surveyors reviewed the new maintenance log for monitoring and tested the doors to ensure the doors were functioning appropriately. The door codes were changed and distributed to designated nursing staff only. Noncompliance continues at a scope and severity level of [NAME] for the monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.",2020-09-01
777,DONALSON CARE CENTER,445173,1681 WINCHESTER HIGHWAY,FAYETTEVILLE,TN,37334,2019-07-15,842,E,0,1,L3LQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure accurate and complete medical records for 7 of 56 (Resident #2, #22, #30, #88, #102, #180, and #377) sampled residents reviewed. The findings include: 1. Medical record review revealed Resident #2 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Progress Note dated 3/13/19 documented, .Alert and oriented to self . Medical record review of a WANDERING RISK SCALE dated 3/13/19 documented, .The resident is comatose, dependent on ADL (activities of daily living) and cannot move without assistance, and/or stuporous .YES . The Wandering Risk Scale was incomplete and did not have the following areas completed: a. Mental Status b. Mobility c. Speech Patterns d. History of wandering e. Diagnosis. Medical record review of a Progress Notes dated 3/14/19 documented, .alert and oriented and able to verbalize his needs . Observations on 7/8/19 at 12:35 PM revealed Resident #2 in bed, awake and alert. Medical record review of the Wander Risk assessment dated [DATE] revealed it was inaccurate related to documentation the resident was in a comatose state. The Progress Note documented the resident was alert and oriented. The Wander Risk Assessment was incomplete. 2. Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 4 which indicated severe cognitive impairment. The resident required limited to extensive staff assistance with Activities of Daily Living (ADL) and used tobacco and required oxygen therapy. Medical record review of SMOKING-SAFETY SCREEN assessments documented the following: a. 1/30/19 .no cognitive loss, resident can light own cigarette, resident is not going to smoke while a resident in this facility. b. 7/2/19 .no cognitive loss .resident does not need facility to store lighter and cigarettes .Resident can safely light a cigarette and smoke safely without supervision . Medical record review of the Smoking-Safety Screens revealed Resident #22 had no cognitive loss and had the ability to light a cigarette. The MDS assessment documented Resident #22 had severe cognitive impairment and needed extensive assistance with ADLs. 3. Medical record review revealed Resident #30 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed a BIMS score of 15, which indicated no cognitive impairment, and required extensive assistance with ADLs. Medical record review of the Smoking-Safety Screen dated 7/2/19 revealed Resident #30 had no dexterity problems and had the ability to light a cigarette, but medical record review revealed a [DIAGNOSES REDACTED].#30 needed extensive assistance with ADLs. The Smoking - Safety Screen assessment was inaccurate. 4. Medical record review revealed Resident #88 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed Resident #88 had range of motion impairment on one side for upper and lower extremities and required extensive assistance for ADLs. Medical record review of the Smoking Safety Screen dated 6/12/19 revealed Resident #88 had no dexterity problems, but medical record review revealed a [DIAGNOSES REDACTED].#88 required extensive assistance with ADLs. 5. Medical record review revealed Resident #102 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an annual MDS dated [DATE] revealed Resident #102 had a BIMS score of 12 which indicated moderate cognitive impairment and the resident used tobacco and oxygen. Review of a Web Event Summary Report dated 3/23/19 documented the resident received the burn to the abdomen inside the facility. Interview with MDS Coordinator #2 on 7/11/19 at 2:12 PM in the Conference Room, MDS Coordinator #2 confirmed the Web Event Summary Report dated 3/23/19 was inaccurate and stated, This was coded in error it should have been coded 11, which is other, outside. Medical record review of a SMOKING-SAFETY SCREEN dated 12/19/18 documented Resident #102 had cognitive loss, was visually impaired, and retained her own cigarettes and lighter. Medical record review of a SMOKING-SAFETY SCREEN dated 3/19/19 documented, .Does resident have cognitive loss .Yes .visual defects .No .Does resident need facility to store lighter and cigarettes .No . Medical record review of a SMOKING-SAFETY SCREEN dated 4/12/19 documented, .Does resident have cognitive loss .Yes .visual defects .No .Does resident need facility to store lighter and cigarettes No . Medical record review of a SMOKING-SAFETY SCREEN dated 6/19/19 documented, .Does resident have cognitive loss .Yes .visual defects .No .Does resident need facility to store lighter and cigarettes No . Interview with the Assistant Director of Nursing (ADON) on 7/14/19 at 4:21 PM in the Conference Room, the SMOKING-SAFETY SCREEN dated 12/19/18, 3/19/19, 4/12/19, and 6/19/19 were reviewed with the ADON, and she confirmed the Smoking Safety Screens were inaccurate. The ADON was asked if Resident #102 had cognitive loss on the Smoking Safety Screen dated 12/19/19, which was coded as no cognitive loss. The ADON stated, She does (have cognitive loss) The ADON stated, We go over everything in the team meeting. We talk about all the residents then MDS (Coordinator) will go back and fill the screen out. The ADON was asked if Resident #102 had [MEDICAL CONDITION] would that be a cognitive loss. The ADON stated, Yes, as a diagnosis .She should be coded Yes . The ADON was asked if the Resident #102 had any visual deficits on the Smoking Screen dated 3/19/19, 4/12/19, and 6/19/19 which was coded as No. The ADON stated, .Should be marked Yes. The ADON was asked if the resident had any dexterity problems. The ADON stated, It should be marked .Yes. The ADON was asked if Resident #102 could light her own cigarette. The ADON stated, She always did . The ADON was asked if Resident #102 needed the facility to store her lighter and cigarettes. The ADON stated, .she does at this time, We should have stored them . Review of the medical record for Resident #102 revealed the record was inaccurate as to the resident's cognition and smoking safety. 6. Medical record review revealed Resident #180 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of an admission MDS assessment dated [DATE] revealed Resident #180 had a BIMS score of 12 which indicated Resident #180 was moderately cognitively impaired. Medical record review of a WANDERING RISK SCALE dated 4/1/19 documented the resident had dementia and was cognitively impaired. Medical record review of a Progress Note dated 4/4/19 documented, .alert and oriented with episodes of confusion and forgetfulness . Medical record review of a SMOKING-SAFETY SCREEN dated 7/2/19 documented the resident was not cognitively impaired. Interview with the ADON on 7/14/19 at 4:21 PM in the Conference Room, the ADON was asked about the cognition documentation on the Wandering Risk Scale dated 4/1/19 and the Smoking Safety Screen dated 7/2/19. The ADON was asked if the documents were accurate. The ADON stated, They are not correct .He does not have a dementia diagnoses. That one is wrong (pointed to wandering screen) . 7. Medical record review revealed Resident #377 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an admission WANDERING RISK SCALE dated 7/1/19 documented the resident did not have a [DIAGNOSES REDACTED]. Medical record review of a Progress Note dated 7/9/19 documented, .has been observed ambulating out of other pt's (patient's) rooms .pt. (Patient) has also attempted to go out of main entrance doors stating that I am going to my daughter's house . Interview with the ADON on 7/14/19 at 4:19 PM in the Conference Room, the ADON confirmed the Wandering Risk Assessment was inaccurate related to the [DIAGNOSES REDACTED].",2020-09-01
778,DONALSON CARE CENTER,445173,1681 WINCHESTER HIGHWAY,FAYETTEVILLE,TN,37334,2019-07-15,867,K,0,1,L3LQ11,"Based on review of the Administrator's job description, review of the Medical Director's job description, review of the Director of Nursing (DON) job description, medical record review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program recognized an ongoing concern related to smoking safety, residents with elopement risks that had knowledge of exit door codes and nonfunctioning wanderguard sensors on exit doors. The QAPI committee failed to ensure the facility identified the root cause of the concerns, developed appropriate plans of action, ensured systems and processes were in place and were consistently followed by staff to address quality concerns. The QAPI committee failed to ensure interventions to prevent unsupervised smoking were consistently implemented or followed, that the facility was administered in a manner that enabled it to use its resources effectively and efficiently, that the Medical Director assisted the facility with identifying, evaluating, and addressing clinical concerns, coordinated the medical care and provided clinical guidance and oversight regarding the implementation of resident care policies and procedures for residents that smoke and for residents with risk of elopement. The QAPI committee failed to ensure smoking and wandering assessments were timely and accurate. The failure of the QAPI Committee to ensure the facility implemented and/or provided care and services for the residents that smoked and demonstrated exit seeking behaviors placed 5 of 5 residents in Immediate Jeopardy (IJ) when Resident #22, #30, #88, #102, and #180 smoked without supervision and safe smoking care interventions were not provided as recommended. The failure of the QAPI Committee to ensure the facility implemented and/or provided care and services for the residents that demonstrated exit seeking behaviors placed 7 of 7 residents in Immediate Jeopardy when Resident #2, #12, #13, #18, #38, #70, and #377 had nonfunctioning wanderguards and door sensors, and maintenance failed to identify the sensor doors as nonfunctional. Immediate Jeopardy (IJ) is 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 Interim Administrator, Assistant Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Infection Preventionist, Quality and Infection Preventionist for the health system, and the Minimum Data Set (MDS) Coordinator, were notified of the Immediate Jeopardy on 7/12/19 at 9:32 PM, in the Conference Room. The facility was cited a scope and severity of Immediate Jeopardy for F657-K, F689-K, F835-K, F841-K, and F867-K. The Immediate Jeopardy was effective 9/8/18 through 7/15/19 and the IJ was removed on 7/15/19. An extended survey was conducted on 7/12/19 through 7/15/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the Jeopardy, was received on 7/14/19 at 5:30 PM, and the corrective actions were validated onsite by the surveyors on 7/14/19 and 7/15/19 through review of assessments, auditing tools, in-service training records, policies, observations, and staff interviews. The noncompliance continues at F867-E for monitoring of effectiveness of the corrective actions. The findings include: 1. The facility's Interim Administrator Contract dated 4/12/19 documented, .This Agreement shall be governed by and construed in accordance with the laws of the State of Tennessee .The Contractor agrees to .Oversees all activities of the care center in accordance with established policies and federal and state guidelines .Develop strategic plans for profitability and accountability for all operations and programs .Administer, direct and coordinate the business .Recommend and lead changes to improve the care center .Maintain a state administrator license .Create functional strategies and specific objectives for the care center and develop budgets/policies/procedures to support the functional infrastructure .Implement Administrator -in-Training Program . 2. The facility's Director of Nursing Job Description dated 6/17/19 documented, .Under the direction of the Administrator, the DON has 24-hour responsibility for the effective implementation of the philosophy, goals, policies, and procedures of the hospital and the nursing department and their effect on patient care in a designated unit.Evaluates on-going programs as assigned by Administrator .Monitors/maintains care center compliance with regulatory, accrediting and health system policy for resident services, and environmental and personnel safety .Monitors the staff's understanding of established emergency .and/or universal precautions procedures as evidenced by PI (Performance Improvement) reports, incident follow-ups, staff meeting minutes and direct observation by Administrator .Oversees Care Center PI program which monitors and evaluates critical aspects of care .Accurately identifies real/potential problems affecting the services and implements solutions with follow-through and communications .Is responsible for care center's operational excellence; ensures department delivers quality services in accordance with applicable policies, procedures, and professional standards . 3. The facility's Medical Director job description dated 7/2016 documented, .The Medical Director is a licensed physician in this state and is responsible for .Overseeing and helping develop and implement care-related policies and practices .Participating in efforts to improve quality of care and services .Acting as a consultant to the director of nursing services in matters relating to resident care services .Helping assure that residents receive adequate services appropriate to meet their needs .Helping assure that the resident care plan accurately reflects the medical regimen .Participating in staff meetings concerning .quality assurance and performance improvement .resident care policies .Assuring that physician services comply with current rules, regulations, and guidelines concerning long-term care . Interview with the Interim Administrator on 7/13/19 at 3:08 PM, in the Conference Room, the Interim Administrator was asked if the Quality Assurance Committee (QAC) developed appropriate plans of action for smoking or elopements. The Interim Administrator confirmed that the QAC had not discussed the smoking concerns or the security door issue. The Interim Administrator was asked if the QAC had discussed the problem with the doors. The Interim Administrator confirmed he had discovered the problem at the same time we (surveyors) did during the survey this week. The Interim Administrator stated, .My spot checking that I did with (Facilities Director) was good, I just checked the wrong doors . 5. The Facility's QAPI committee failed to identify, develop, and implement appropriate plans of action to ensure care plans were reviewed, updated, and implemented for care of residents with diminished safety awareness.This resulted in IJ for Resident #22, #30, #88, #102, and #180. Refer to F657. 6. The QAPI Committee failed to provide an acceptable standard of care for residents with diminished safety awareness and to prevent elopement. This resulted in Immediate Jeopardy for Resident #2, #12, #13, #18, #22, #30, #38, #70, #88, #180 and #377. Refer to F689. The surveyors verified the A[NAME] by: 1. The facility's Leadership Team consisting of the Interim Administrator, Assistant Administrator, DON, ADON, Minimum Data Set Coordinator #2, Infection Preventionist, and Activity Director have been assessing the procedures related to resident smoking practices in an attempt to balance residents' rights while ensuring the safety of all residents and patients in the building. While the facility's planned goal is to incorporate a Smoke Free Campus policy, a short term intervention providing safe supervision for smoking residents has been implemented until proper notice can be provided to those affected residents and resident representatives. The Leadership Team began the development of an updated Smoking Policy, a Designated Smoking Time Schedule and a Staff Monitoring Tool to ensure there was a structured program in place for oversight and safety assurance for those residents who expressed a desire to smoke. The final policy and protocols were implemented 7/10/19. On 7/10/19 the Leadership Team met with the facility staff members and each affected resident to explain the facility's position on supervised smoking, safety concerns and the processes going forward. Even though there was reluctance and concern expressed by the affected residents, all agreed to voluntarily surrender any smoking paraphernalia on their person and in their rooms. Each resident room was visited to ensure no additional smoking items were overlooked. All such paraphernalia is kept locked up and secured by the Unit 6 Charge Nurse and is only being released to the assigned smoking monitor during the designated smoking times. The surveyors interviewed all facility staff which included all disciplines and staff on each shift. The surveyors reviewed the new smoking policy, staff monitoring tool, and interviewed the Nurse on the medication cart for Hall 5 where the smoking materials were secured. 2. The Interim Administrator and Assistant Administrator met with the five (5) residents, who desire to smoke, on 7/14/19 to discuss the Designated Smoking Time Schedule in order to gain their input and acceptance of the new set time schedule for smoking. They were informed that reasonable accommodations will be provided for those who might not be able to meet the exact Designated Smoking Time Schedule and informed of the impending 8/12/19 date as the time in which the facility will become Smoke Free. All indicated that they understood and had every intention of complying. The surveyors reviewed the new Designated Smoking Time Schedule and the Daily Smoking Monitoring Tool. 3. The facility Maintenance Director and Administrator performed a complete operational assessment of all of the facility exit doors on (MONTH) 11, 2019, and determined that five (5) of the eight (8) exit doors had not been completely equipped with full wandering prevention (elopement) capabilities. While these doors were protected by a magnetic locking system, it was determined that an additional antenna alarm system installation would provide additional safety and protection. A certified door alarm vendor was immediately contacted upon discovery and arrived on site at 7:15 [NAME]M. on 7/12/19 and installed the additional monitoring devices. The system was tested by the Maintenance Department and was working as designed. The Facilities Director and Maintenance Technicians will oversee the functionality of the system by conducting daily tests of the exit door equipment and resident/patient transmitting devices for two weeks. If all equipment is found to be functioning properly, checks will move to weekly. The audits will occur no less than weekly going forward. The surveyors reviewed the new maintenance log for monitoring and tested the doors to ensure the doors were functioning appropriately. The door codes were changed and distributed to designated nursing staff only. Noncompliance continues at a scope and severity level of [NAME] for the monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.",2020-09-01
779,DONALSON CARE CENTER,445173,1681 WINCHESTER HIGHWAY,FAYETTEVILLE,TN,37334,2017-08-16,371,E,0,1,E58911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure food was prepared and served under sanitary conditions as evidenced by expired foods, wet nested baking pans and cups, food not kept at the proper temperature on the steam table, and food placed next to a cleaning bottle. The facility had a census of 135 with 43 of those residents receiving a meal tray from the[NAME]kitchen. The findings included: 1. Observations in the[NAME]kitchen on 8/15/17 at 4:26 PM, revealed the following: a. two baking sheet pans and 34 drinking cups that were wet nesting. b. three cans of Beef Ravioli with a best by date of [DATE], (YEAR). Interview with the Registered Dietician (RD) on 8/15/17 at 5:50 PM, in the[NAME]kitchen, the RD was shown the wet drinking cups and asked what that was. The RD stated, Wet nesting. The RD was asked should you have that. The RD stated, No, ma'am. The RD was asked should you have expired food. The RD stated, No. Interview with the Certified Dietary Manager (CDM) on 8/16/17 at 5:26 PM, in the[NAME]kitchen, the CDM was asked should you have wet baking pans and drinking cups. The CDM stated, No .was in too big of a hurry . The CDM was asked should you have expired foods. The CDM stated, No. 2. The facility's Food Temperatures policy documented, Foods will be served at proper temperatures to ensure food safety .All foods kept in a hot holding unit (steam table .) must be kept at 140F (Fahrenheit) or higher .Reheat foods .165F . The facility's Dietary (Food & (and) Nutrition) policy documented, Food .are stored separate from cleaning supplies . Observations in the kitchen on 8/15/17 beginning at 4:55 PM, revealed the following: Barbecue Ribettes were 131 F, the CDM removed the ribs and placed them in the oven. At 5:38 PM, the CDM removed the ribs from the oven and placed on a table beside Redi-San Cleaning solution. The ribs were 160 F. Trays had already been served to 1 hall of residents. Interview with the RD on 8/15/17 at 5:40 PM, in the[NAME]kitchen, the RD was asked should food be placed next to cleaning solution. The RD stated, No, should be used and put up .",2020-09-01
780,DONALSON CARE CENTER,445173,1681 WINCHESTER HIGHWAY,FAYETTEVILLE,TN,37334,2018-08-22,623,D,0,1,1WHL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to send the Ombudsman a notice of transfer for 1 of 7 (Resident #101) sampled residents reviewed for transfer/discharge requirements. The findings included: Medical record review revealed Resident #101 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Telephone/Verbal Order Signature Details documented, .Order .Send to (Named) ER (emergency room ) for eval (evaluation) and treatment .Order Date/Created Date 06/17/2018 . Review of the medical record revealed Resident #101 returned to the facility on [DATE]. The facility was unable to provide documentation that the Ombudsman had been notified of the transfer to the hospital on [DATE]. Interview with the Social Worker on 8/21/18 at 5:55 PM, in the Social Service and Admission office, the Social Worker confirmed Resident #101 was not listed on the Emergency Transfers from Facility form that was sent to the Ombudsman for the month of (MONTH) (YEAR) and stated .we have only been notifying them of the long term residents, they (Ombudsman) told us we did not have to notify them of the skilled transfers because they were short term and this was not considered their home .",2020-09-01
781,DONALSON CARE CENTER,445173,1681 WINCHESTER HIGHWAY,FAYETTEVILLE,TN,37334,2018-08-22,690,D,0,1,1WHL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview the facility failed to ensure services were provided as ordered for documentation of intake and output (I&O) of an indwelling urinary catheter for 1 of 4 (Resident #78) sampled residents reviewed for indwelling urinary catheters. The findings included: Medical record review revealed Resident #78 was admitted to the facility on [DATE] with a readmission date of [DATE] with the [DIAGNOSES REDACTED]. The significant change Minimum Data Set ((MDS) dated [DATE] revealed the presence of an indwelling urinary catheter. The physician's orders [REDACTED].I&O Q (every) shift . Review of the Documentation Survey Report revealed staff failed to document the intake and output as ordered on the following dates: a. 6/1/18, 6/2/18, 6/5/18, 6/11/18, 6/14/18, 6/15/18, 6/16/18, 6/17/18, 6/18/18, 6/19/18, 6/20/18, 6/22/18, 6/24/18, 6/25/18, 6/26/18, and 6/30/18. b. 7/4/18, 7/7/18, 7/8/18, 7/9/18, 7/10/18, 7/13/18, 7/14/18, 7/15/18, 7/16/18, 7/20/18, 7/21/18, 7/22/18, 7/25/18, 7/26/18, 7/27/18, 7/28/18, 7/29/18, 7/30/18 and 7/31/18. c. 8/1/18, 8/2/18, 8/4/18, 8/5/18, 8/6/18, 8/7/18, 8/8/18, 8/9/18, 8/9/18, 8/10/18, 8/11/18, 8/12/18, 8/13/18, 8/14/18, 8/15/18, 8/16/18, 8/17/18, 8/18/18, 8/20/18 and 8/21/18. Interview with the Assistant Director of Nursing (ADON) on 8/22/18 at 1:00 PM, in the ADON office, the ADON was asked if it was acceptable not to follow the doctors order for monitor and documenting of the I&O's. The ADON stated, No ma'am.",2020-09-01
782,DONALSON CARE CENTER,445173,1681 WINCHESTER HIGHWAY,FAYETTEVILLE,TN,37334,2018-08-22,692,D,0,1,1WHL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to follow physician's orders for nutritional supplements for 2 of 6 (Residents #39 and 82) sampled residents reviewed for nutrition. The findings included: 1. The facility's Unintended Weight Loss policy with effective date of 6/1/11 documented, .if a resident is identified with a weight loss of 5% (percent) or more .the following interventions will be considered for implementation .3. Resident will be placed on an appropriate supplement .per dietary recommendations . 2. Medical record review revealed Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] assessed Resident #39 with moderate impaired cognition, total dependence on staff for eating, and significant weight loss. Review of the Care Plan dated 6/22/18 documented, .alteration in nutrition r/t (related to) ES (End Stage) Alzheimer's, Dementia, swallowing/chewing impairment and advanced maturation .dependent diner .6/4/18-significant weight loss .Interventions .4 oz (ounces) Ensure [MEDICATION NAME] po (by mouth) TID (three times daily) . Review of the facility's Nutrition/Dietary Note dated 6/19/18 revealed a weight of 79# (pounds) significant weight loss of 15.1% with recommendation of 4oz Ensure [MEDICATION NAME] po (oral) TID. The facility's Order Review History Report for (MONTH) (YEAR) documented, .Ensure three times a day for Supplement Ensure [MEDICATION NAME] TID .Active .order date 06/19/2018 . Review of the Medication Administration Records for (MONTH) (YEAR) through (MONTH) (YEAR) revealed the 4oz Ensure [MEDICATION NAME] TID was not administered and documented by the facility. Observations in Resident #39's room on 8/21/18 at 8:00 AM, revealed Resident #39 was being assisted with her meal by staff, she received a puree diet, with ice cream and magic cup on the tray, the resident only took a couple of sips of water. Observations Resident #39's room on 8/22/18 at 8:00 AM, revealed Resident #39 was being assisted with her meal by staff, she received a puree diet, with ice cream and magic cup on the tray. Resident #39 only consumed 25 percent (%), the staff were coaxing and cueing the resident to eat but this resident was refusing and only would drink a couple sips of water. Telephone interview with Resident #39's physician on 8/22/18 at 1:07 PM, in the conference room, the physician was asked if he was familiar with Resident #39 and her weight loss history. He stated, .yeah .she is [AGE] years .vegetative state and she is comfort measures . Telephone interview with Resident #39's physician on 8/22/18 at 2:00 PM, in the Social Worker Office, the physician stated, .her (Resident #39) weight loss is due to her age and her vegetative state . 3. Medical record review revealed Resident #82 admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] assessed Resident #82 with extensive assistance from 1 staff member for eating. The Care Plan revised on 7/25/18 documented, resident has actual nutritional problem r/t (related to)[MEDICAL CONDITION]([MEDICAL CONDITION] Disease), Dysphagia, [MEDICAL CONDITION] .provide supplements as ordered: 1/20/18-4oz Glucerna po BID (twice daily) date initiated: 01/20/2018 . The facility's Nutrition/Dietary Note dated 1/20/18 documented, .He has poor oral intakes .Will start 4oz. Glucerna BID po due to suboptimal oral intakes . The facility's Order Summary Report for (MONTH) (YEAR) documented, .Glucerna 4 oz bid two times a day .Active .order date 1/20/18 . The facility's Nutrition/Dietary Note dated 3/15/18 documented, .He is offered 4 oz. Glucerna po BID due to variable intakes & gradual weight decline . Review of the Medication Administration Records for (MONTH) (YEAR) through (MONTH) (YEAR) revealed the 4oz Glucerna BID was not administered or documented by the facility. Observations in Resident #82'3 room on 8/21/18 at 12:00 PM, revealed Resident #82 was being assisted with lunch by a member, his appetite was good, and he consumed 100% of his meal. Interview with Registered Nurse (RN) #2 on 8/21/18 at 3:35 PM, at the South Hall nurses station, RN #2 was asked if Resident #82 receives any dietary supplements for weight loss. RN #2 stated, His order says Glucerna 4oz BID but I do not see it on his MAR . RN #2 was asked what time should he have received it if it was ordered BID. RN #2 stated, . 8AM and 8PM . RN #2 was then asked had he received the supplement today. RN #2 stated, He has not . Interview with Licensed Practical Nurse (LPN) #1 on 8/21/18 at 3:35 PM, at the South Hall nurses station, LPN #1 stated, It is showing up in his (Resident #82) orders but it is not on the MAR/TAR (treatment administration record) to be documented .because it is not put in to show up on there so it will not be on there . LPN #1 was asked should it have been on the MAR indicated [REDACTED]. Interview with the Director of Nursing (DON) on 8/22/18 at 1:48 PM, in the DON office, the DON was asked should the 4oz of Glucerna for Resident #82 be on Resident #82's MAR indicated [REDACTED]. The DON stated, Yes, ma'am it should have . The DON was then asked to review Resident #39's MARS from (MONTH) (YEAR) to present and was asked if she was aware that Resident #39 had an order for [REDACTED].No I am not (aware) .I will fix it . The DON was then asked should Resident #39 have been receiving the supplement. The DON stated, .yes.",2020-09-01
783,DONALSON CARE CENTER,445173,1681 WINCHESTER HIGHWAY,FAYETTEVILLE,TN,37334,2018-08-22,812,F,0,1,1WHL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared and served under sanitary conditions as evidenced by opened, undated and expired foods stored in a walk in cooler, not recording temperatures prior to serving food and inappropriate tray line serving temperatures. The facility had a census of 128 residents, with 100 of those residents receiving a meal tray from the kitchen. The findings included: 1. The facility's Labeling Expiration Dates policy dated ,[DATE] and reviewed ,[DATE] documented, .All food products will be labeled with a received date and or expiration date . 2. The facility's Food Temperatures policy dated ,[DATE] and reviewed/revised ,[DATE] documented, .Foods will be served at proper temperatures to ensure food safety .3 .Record temperature reading on food temperature chart form at beginning of tray line. Take the temperature of each pan of product before serving .4 .All foods kept in a hot holding unit (steam table .) must be kept at 140 F (Fahrenheit) or higher .5 .Proper cold holding: .ensure temperatures remains at 41F or lower . 3. Observations in the walk in cooler on [DATE] beginning at 12:15 PM, revealed a 3 pound plastic container of diced tomatoes opened and not dated with manufacturer's best by date of [DATE], 2 unopened whipped cream cheese spread plastic containers with manufacturer's best by date of [DATE], and a 3 pound plastic container of cranberry sauce with manufacturer's expiration date of [DATE]. Interview with the Systems Director on [DATE] at 9:30 AM, in the Registered Dietician office, the Systems Director was asked should food that is open and not dated, stored past their manufacturer's use best by date and past their expiration date be stored in the walk in cooler. The Systems Director stated, .No, it should not . 4. Observations in the kitchen on [DATE] beginning at 5:00 PM, revealed the following: a. The Cook was asked by the Registered Dietician (RD) if she had recorded her temperatures. The Cook (searching around looking with no result) stated, .yes .I put them on a piece of paper. The RD stated to the Cook, Please obtain your temperatures again. b. chopped ham: 130 F degrees c. mandarin orange delight: 80 F degrees d. puree mandarin orange delight: 65 F degrees e. tossed salad: 70 F degrees f. pudding milk: 60 F degrees Interview with the Cook on [DATE] 5:31 PM, in the kitchen, the Cook was asked what should the holding temperature be for hot food. The Cook stated, .141 or higher . The Cook was then asked what should the holding temperature be for cold food. The Cook stated, .40 or below . The Cook was then asked is the chopped ham, mandarin orange delight, puree mandarin orange delight, tossed salad or pudding milk at the appropriate temperatures. The Cook stated, .no, they are not. Interview with the Registered Dietician (RD) on [DATE] at 5:45 PM, in the kitchen, the RD was asked what the process was for recording temperatures prior to meals. The RD stated, Record them on the log before the meal start . The RD was then asked if it is safe practice to record temperatures on loose pieces of paper and fail to record them on the log. The RD stated, .no.",2020-09-01
784,DONALSON CARE CENTER,445173,1681 WINCHESTER HIGHWAY,FAYETTEVILLE,TN,37334,2018-08-22,880,D,0,1,1WHL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, 1 of 2 (Registered Nurse (RN) #1) nurses failed to ensure infection control practices were maintained to prevent the potential spread of infection during dressing change observations. The findings include: 1. The facility's Wound Care Management policy effective 5/02 and reviewed on 5/17 documented, .Remove old dressing and discard .Wash hands and apply gloves .Place bag in a red bag .Dispose of bag in BFI (biohazard) box . 2. Observations during dressing change in Resident #66's room on 8/22/18 at 9:29 AM, revealed RN #1 removed the dirty dressing and packing, failed to preform hand hygiene, and irrigated the wound with dakins solution. RN #1 packed the undermining of the wound with the [MEDICATION NAME] packing strip guiding it from the bottle with the same cotton tip applicator, then cut off the contaminated [MEDICATION NAME] packing strip with her scissors and placed them in her front pocket. RN #1 did not disinfect the scissors after use. RN #1 gathered her dirty supplies in a trash bag and placed the trash bag out in the trash bin in the hallway. RN #1 did not place the contaminated supplies in the biohazard room. Interview with the Director of Nursing (DON) on 8/22/18 at 2:13 PM, in the conference room, the DON was asked if it was acceptable not to perform hand hygiene after removing a soiled dirty dressing. The DON stated, .Absolutely not . The DON was asked where should the nurses dispose of dirty dressings. The DON stated, Use a garbage bag .take it to the biohazard room. The DON was asked if it was acceptable to place dirty dressing in the regular trash bin in the hallway. The DON stated, No. The DON was asked when she expected the nurses to clean their scissors during dressing change. The DON stated, Before .after use .with a disinfectant wipe.",2020-09-01
785,BROOKHAVEN HEALTH AND REHABILITATION,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2018-01-24,677,D,1,0,9MDX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation and interview, the facility failed to provide incontinence care for 1 resident (#1) of 5 residents reviewed for incontinence care. The findings included: Medical record review revealed Resident #1, was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged from the facility on 1/12/18. Review of the Minimum Data Set with a reference date of 10/14/17 revealed Resident # 1 was rarely or never understood. Continued review revealed he required total dependence on nursing staff for toilet use and personal hygiene. Medical record review of Resident #1's Bladder Evaluation dated 10/26/17 revealed the resident was incontinent of bowel and bladder at times. Continued review revealed he also went to the bathroom to void at times. Medical record review of the Care Plan dated 11/1/17 revealed Resident #1revealed the resident was to be toileted every 2 hours and as needed and his clothing was to be changed after each incontinent episode. Continued review revealed the resident required assistance with hygiene and showering. Interview with LPN #1 (regarding the 1/11/18 allegation by the caregiver) on 1/22/18 at 6:00 PM in the front conference room, confirmed .His brief was very very wet .Looked like he had voided more than once .His brief was really very wet. Telephone interview with Resident #1's caregiver on 1/23/18 at 4:18 PM confirmed the resident was saturated with urine on 1/9/18 and 1/11/18, when she visited the resident in the facility. Telephone interview with Resident #1's wife on 1/23/18 at 4:50 PM confirmed the resident was saturated with urine on 1/9/18, when she visited the resident in the facility. Interview with the Administrator and the DON on 1/24/18 at at 12:11 PM in the conference room, confirmed they were aware of the 1/11/18 incident with Resident #1, and staff re-education had been provided.",2020-09-01
786,BROOKHAVEN HEALTH AND REHABILITATION,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2019-01-30,655,D,0,1,M8R511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to update a baseline care plan for 1 resident (#29) with an indwelling urinary catheter of 2 residents' baseline care plans reviewed of 27 residents sampled. The findings include: Medical record review revealed Resident #29 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #29 was incontinent of urine and stool, oxygen dependent, and required assistance of 2 staff for transfers. Further review revealed the resident scored a 15 on the Brief Interview for Mental Status indicating no cognitive impairment. Medical record review of Resident #29's Baseline Care Plan dated 1/22/19 revealed no documentation the resident's care plan was revised to identify the resident had a urinary catheter. Medical record review of a Physician's telephone order dated 1/23/19, timed 11:20 AM, revealed .Insert FC (brand name indwelling urinary catheter) 16fr (French-denotes type of catheter)/10cc (cubic centimeters - size of balloon on tip of catheter to secure catheter placement) per patient request for comfort .Indication - DX (diagnosis) exacerbated respiratory status decline . Medical record review of a Nursing Weekly Summary dated 1/23/19 revealed, .redness on buttocks, excoriation to inner thighs, barrier cream applied .catheter put into place due to skin breakdown . Observation of Resident #29 on 1/29/19 at 10:00 AM revealed the resident seated in a high back chair in her room. Continued observation revealed the tubing for the catheter was draining clear yellow urine into a covered urinary bag. Interview with the Unit Supervisor/Licensed Practical Nurse (LPN) #1 on 1/29/19 at 3:20 PM, in the 200 Unit nursing station confirmed Resident #29's Baseline Care Plan did not indicate the resident had an indwelling urinary catheter. Interview with the Assistant Director of Nursing (ADON) on 1/30/19 at 4:10 PM, in the ADON's office confirmed the resident's skin had improved, and a long term plan for the continued use of the urinary catheter had not been determined.",2020-09-01
787,BROOKHAVEN HEALTH AND REHABILITATION,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2019-01-30,656,G,0,1,M8R511,"**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 implement a care plan intervention to prevent falls for 1 resident (#39) of 3 residents reviewed for falls of 27 residents sampled. The facility's failure resulted in Harm to Resident #39. The findings include: Review of facility policy Care Plans, Comprehensive Person-Centered revised 12/2016, revealed .A comprehensive, person-centered care plan is developed and implemented for each resident . Medical record review revealed Resident #39 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #39's Quarterly Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status score of 11, indicating moderate cognitive impairment. Further review revealed the resident required total assistance of 1 staff member for bed mobility and transfers. Medical record review of Resident #39's Care Plan dated 11/9/18 revealed .at risk for falls r/t (related to) [MEDICAL CONDITION], Shy drager syndrome (neurological disorder affecting the body's involuntary functions), difficulty with functional mobility .hx (history) of falls .9/23/18 - Fall mats to exit side of bed .12/8/18 Staff to position bed . Medical record review of Resident #39's Skilled Daily Nurses Note dated 12/8/18 revealed .RESIDENT ON FLOOR @ (at) SIDE OF BED .BED AGAINST WALL, WAIST HIGH, FALL MAT ROLLED UP @ FOOT OF BED . Medical record review of the facility fall investigation dated 12/10/18 revealed Resident #39 had a fall from the bed on 12/8/18 at 11:30 AM. Further review revealed .Resident states that she was trying to turn in the bed and slid out of bed into the floor . Continued review revealed .Resident was admitted to (named hospital) with [DIAGNOSES REDACTED].staff will adjust bed height to attempt to prevent further falls from bed . Observation of Resident #39 on 1/28/19 at 11:46 AM, in the resident's room, revealed the resident lying on the bed with the electric bed control within reach of the resident. Observation of Resident #39 on 1/29/19 at 1:04 PM, in the resident's room, revealed the resident lying on the bed with the electric bed control by the right side rail within the resident's reach. Interview with Licensed Practical Nurse (LPN) #2 on 1/29/19 at 2:29 PM, on the 400 hallway, confirmed the resident's electric bed control was kept within the resident's reach. Interview with Certified Nursing Assistant (CNA) #3 on 1/29/19 at 2:40 PM, at the 400 hallway nurse's station, revealed the CNA worked on the date of the fall and .I saw her in the floor .the bed was up higher . Continued interview revealed .she (Resident #39) uses the remote (to adjust the bed height) .she still does sometimes but not as frequent .it lays right there beside her usually . During further interview, CNA #3 confirmed the fall mat was not in place at the time of Resident #39's fall on 12/8/18. Interview with the Risk Manager on 1/29/19 at 2:48 PM, in the conference room, confirmed Resident #39's care plan intervention for a fall mat had not been in place at the time of the fall. Further interview confirmed after the resident's fall on 12/8/18 the facility implemented an intervention that the staff were to control the bed positioning and the bed controls should not be kept within reach of the resident. Interview and observation with the Risk Manager on 1/29/19 at 2:58 PM, in the resident's room, confirmed the care plan intervention to keep the electric bed controls out of the resident's reach had not been followed. Telephone interview with Physician #1/Medical Director on 1/30/19 at 2:06 PM revealed it was .his expectation .if the resident had a fall mat care planned to be at the bedside, it would be there at all times .",2020-09-01
788,BROOKHAVEN HEALTH AND REHABILITATION,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2019-01-30,689,G,0,1,M8R511,"**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 provide adequate supervision to ensure fall interventions were implemented for 1 resident (#39) resulting in a fall with [MEDICAL CONDITION] of 3 residents reviewed for falls of 27 residents sampled. The facility's failure resulted in actual Harm to Resident #39. The findings include: Review of the facility policy Falls and Fall Risk, Managing revised 12/2007, revealed .Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . Medical record review revealed Resident #39 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Quarterly Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status score of 11, indicating the resident had moderate cognitive impairment. Further review revealed the resident required total assistance of 1 staff member for bed mobility and transfers. Medical record review of Resident #39's Care Plan dated 11/9/18 revealed .at risk for falls r/t (related to) [MEDICAL CONDITION], Shy drager syndrome (neurological disorder affecting the body's involuntary functions), difficulty with functional mobility .hx (history) of falls .9/23/18-Fall mats to exit side of bed . Medical record review of Resident #39's Skilled Daily Nurses Note dated 12/8/18 revealed .RESIDENT ON FLOOR @ (at) SIDE OF BED .BED AGAINST WALL, WAIST HIGH, FALL MAT ROLLED UP @ FOOT OF BED . Medical record review of the facility fall investigation dated 12/10/18 revealed Resident #39 had a fall from the bed on 12/8/18 at 11:30 AM. Further review revealed .Resident states that she was trying to turn in the bed and slid out of bed into the floor .Observation noted the bed in its highest position at time of fall . Continued review revealed .Resident was admitted to (named hospital) with [DIAGNOSES REDACTED].staff will adjust bed height to attempt to prevent further falls from bed . Medical record review of an acute care emergency room record dated 12/8/18 revealed .PATIENT (#39) IS BROUGHT IN FROM THE NURSING HOME AFTER SHE SLID OUT OF BED. SHE IS COMPLAINING OF LEFT HIP PAIN . Further review revealed .PATIENT HAS A COMMINUTED LEFT INTERTR[NAME]HANTERIC [MEDICAL CONDITION] (a break of the upper part of the thigh bone into more than two fragments). SHE WILL BE admitted for FURTHER EVALUATION TREATMENT . Medical record review of Resident #39's Orthopedic Surgery consult from the acute care hospital dated 12/8/18 revealed .Obtain consent for left hip Cephalomedullary (treatment of [REDACTED].Will proceed with operative fixation following medical optimization . Medical record review of Resident #39's acute care hospital discharge note dated 12/13/18 revealed .Admission Diagnoses: [REDACTED].Procedures: Intramedullary nail fixation (rod) . Observation of Resident #39 on 1/28/19 at 11:46 AM, in the resident's room, revealed the resident lying on the bed with the electric bed control within reach of the resident. Observation of Resident #39 on 1/29/19 at 1:04 PM, in the resident's room, revealed the resident lying on the bed with the electric bed control by the right side rail within the resident's reach. Interview with Certified Nursing Assistant (CNA) #3 on 1/29/19 at 2:40 PM, at the 400 hallway nurse's station, revealed .I saw her in the floor .the bed was up higher . Further interview with CNA #3 confirmed the fall mat was not in place at the time of the fall. Interview with the Risk Manager on 1/29/19 at 2:48 PM, in the conference room, confirmed the fall mat was not in place at the time of Resident #39's fall. Interview with CNA #4 on 1/30/19 at 8:28 AM at the 400 hall nurse's station, confirmed the fall mat was not in place at the time of the fall. Interview with CNA #5 on 1/30/19 at 1:38 PM, on the 400 hallway, confirmed if a resident has a fall mat ordered it is to be kept at the bedside .no matter what . Telephone interview with Physician #1 on 1/30/19 at 2:06 PM confirmed it is his expectation if the resident had a fall mat care planned to be at the bedside, it would be there at all times. Continued interview confirmed if the fall mat had been in place at the time of Resident 39's fall it would have .decreased the risk for the fracture .",2020-09-01
789,BROOKHAVEN HEALTH AND REHABILITATION,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2019-01-30,692,G,0,1,M8R511,"**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 ensure fluids were provided to maintain hydration for 1 resident (#45) of 2 residents reviewed for hydration of 27 sampled residents. The facility's failure resulted in actual Harm to Resident #45. The findings include: Review of facility policy Nutrition and Hydration to Maintain Skin Integrity revised 10/2010, revealed .General Guidelines . Ensure the resident's intake of fluid is sufficient. 'Sufficient fluid' means the amount of fluid needed to prevent dehydration and maintain health .The Dietician, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission .A general guideline for determining baseline daily fluids needs is to multiply the residents body weight in kilograms (kg) times 30 ml (milliliters) .Risk factors for dehydration include .Coma/decreased sensorium .Functional impairments that make it difficult to drink, reach fluids, or communicate fluid needs (e.g.,(example) [MEDICAL CONDITION]) . Medical record review revealed Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed Resident #45 was emergently discharged to an acute care hospital on [DATE] and admitted with Altered Mental Status and Dehydration. Continued review revealed Resident #45 was readmitted to the facility on [DATE]. Medical record review of the facility's Weight Change History document revealed Resident #45's initial weight on 12/8/18 was 156.8 pounds (71.27 kg). According to the facility's policy for determining fluid needs, Resident #45 would have required 2138 ml of fluids daily based on her weight in kilograms (71.27 kg x 30 ml of fluid equals total daily fluid requirement). Medical record review of the Certified Nursing Assistant Activities of Daily Living Flow Record for Resident #45 dated 12/8/18 to 12/17/18 revealed the resident required total dependence for eating. Continued review revealed the following fluid intake was recorded daily for each 24 hour period: 12/8/18 - 295 milliliters (ml) 12/9/18 - 210 ml 12/10/18 - 190 ml 12/11/18 - 200 ml 12/12/18 - 705 ml 12/13/18 - 340 ml 12/14/18 - 50 ml 12/15/18 - 25 ml 12/16/18 - 75 ml 12/17/18 - 0 ml (prior to transfer) Medical record review of Resident #45's Admission Minimum (MDS) data set [DATE] revealed the resident had short and long term memory loss, was rarely understood, totally dependent on staff assistance for bed mobility, transfers, dressing, eating, and had been identified for choking during meals. Continued review revealed cognitive skills for daily decision making were severely impaired. Medical record review of Resident #45's nursing note dated 12/8/18 revealed .CNA (Certified Nursing Assistant) feeding pt (patient) at present, sl (slight) diff. (difficulty) swallowing noted . Medical record review of Physician #2's order for Resident #45 dated 12/10/18 revealed .ST (speech therapist) to eval/tx (evaluate/treat) as indicated .[MEDICAL CONDITION] .dysphagia .Tx (treatment) to include dysphagia management . Medical record review of Resident #45's nursing note dated 12/10/18 revealed .Diff. (difficulty) swallowing noted . Medical record review of Physician #2 order dated 12/10/18 revealed .Diet change to Puree with Nectar Thick liquids . Medical record review of nursing note dated 12/11/18 revealed .continues to have a very difficult time swallowing . Medical record review of Physician #2's History and Physical dated 12/11/18 revealed .transferred here for admission on 12/7/2018 (after hospitalization ) .patient's level of alertness has varied from being lethargic to alert but not verbally responsive .She is minimally responsive. She is very sleepy and unarousable to my aggressive stimuli .Patient is unresponsive to the point that I cannot perform a full neurological exam . Medical record review of Resident #45's Interdisciplinary Team note dated 12/12/18 revealed .Severe deficits-hydration et (and) nutrition risk based on aspiration - may consider TF (tube feeding) option if it is her wish . Medical record review of a physician's orders [REDACTED].Limited Additional Interventions .use medical treatment, antibiotics, IV (intravenous) fluids and cardiac monitoring as indicated .Transfer to hospital if indicated .Artificially Administered Nutrition. Oral fluids & (and) nutrition must be offered if feasible .Long-term artificial nutrition by tube . Medical record review of Resident #45's ST note dated 12/13/18 revealed .Family present at bedside .Education re: (regarding) pt's (patient's) severe deficits-oropharyngeal (part of the throat just behind the mouth) swallow, significant concern for dehydration, malnutrition, inability to swallow medications, aspiration risk .Recommend consideration of alternative means of hydration and nutrition. Consent to pursue alternative means of hydration and nutrition-nursing notified . Medical record review of Physician #2's order dated 12/13/18 revealed .GI (gastrointestinal) consult for alternative means for hydration & nutrition (PEG - Percutaneous Endoscopic Gastrostomy - tube inserted into the stomach to provide nutrition and fluids) . Medical record review of Nurse Practitioner (NP) #2's order dated 12/14/18 revealed .CBC (complete blood count/lab test), CMP (comprehensive metabolic panel/lab test) on 12/15/18 . Medical record review of NP #2's Progress Note dated 12/14/18 revealed .Poor p.o. (by mouth) intake .Nurse reports patient with very little p.o. intake .Family is requesting alternative means of hydration and nutrition. GI appointment for PEG tube evaluation is set for Monday (12/17/18) . Medical record review of Resident #45's nursing note dated 12/14/18 revealed .Resident has been nonverbal and was unable to swallow medications . Medical record review of Resident #45's nursing note dated 12/15/18 revealed .was unable to swallow medications during this shift . Medical record review of Resident #45's nursing note dated 12/17/18 revealed .she is very lethargic .held her medication in fear of her aspirating . Medical record review of Resident #45's ST note dated 12/17/18 revealed .CNA reports that pt had reduced level of alertness over weekend, poor PO (by mouth) intake. This SLP (Speech Language Pathologist) communicated with nursing re (regarding): pt's poor intake, concern for dehydration .Pt has GI consult this morning .concern .of pt's hydration risk .Addendum: Pt was sent to hospital at doctor appointment . Review of the Ambulance Service documentation dated 12/17/18 revealed .8:52 (AM) .Pulse 100, RR (respiratory rate) 26 was dispatched to (name of facility) .to transport (Resident #45) to (GI office) .the patient presented to be unresponsive in the room while attending CNAs and LPN (Licensed Practical Nurse) #3 were getting her ready .poor skin turgor .Per attendant, patient has declined over the weekend with poor oral intake .(LPN #1) nursing supervisor entered the room and quickly assessed the patient's condition. He (LPN #1/Unit Manager) requested .transport would proceed to (GI office) instead of the recommended ER (emergency room ) . Continued review revealed .At destination .Physician (GI office Physician) .refused to consult this patient as she stated that patient should go to the ER based on current conditions .patient was transported to (acute care center) . Review of Resident #45's History and Physical from an acute care hospital dated 12/17/18 revealed .Patient is obtunded (altered level of consciousness), unresponsive and nonverbal to deep noxious (very unpleasant) stimuli. Oral mucosa is very dry, cracked. Skin is generally dry with tenting. A .(indwelling urinary catheter) is in place, draining blood-tinged/purulent (containing pus) urine. Hypertensive (elevated), BP (blood pressure) 167/79. [MEDICAL CONDITION] (elevated heart rate) upon ED (emergency department) arrival, resolved with IV fluid bolus (large amount of fluid) .Meds given in ER .1 L (liter) NS (normal saline/ fluid electrolyte) bolus, IV (Intravenous) .Assessment Principle Problems .Dehydration .Active problems .UTI (urinary tract infection) Acute [MEDICAL CONDITION], Leukocytosis (increased number of white cells in the blood), Altered mental status, [MEDICAL CONDITION] (A rise in serum sodium concentration .caused by a decrease in total body water), Hypertension . Medical record review of Resident #45's facility Physician's Progress Note dated 12/26/18 revealed .returned from the hospital on 12/23 .admitted to (named hospital) with dehydration and dysphagia . Review of the Data Collection/Evaluation Nutritional assessment dated [DATE] revealed the resident was receiving nutritional support through a tube feeding. Continued review revealed Resident #45 was receiving [MEDICATION NAME] 1.2 at 68 ml per hour with 26 ml per hour of water flush for a 22 hour period. Continued review revealed the resident's fluid needs including tube flushes with water before, during, and after medication administration were calculated at 1923 ml. Medical record review of a Physician's Progress Note dated 1/22/19 revealed .she was readmitted here on 12/23/18 after PEG tube placement and an admission for significant dehydration associated with aggressive dysphagia. She is now receiving tube feedings and tolerating them well. She continues to have persistent [MEDICAL CONDITION]. Her weight has gone from the 140s now up to 151.8 pounds . Random observations of Resident #45 during the survey conducted from 1/28/19 to 1/30/19 in the resident's room revealed the resident resting in bed with tube feeding being administered via pump as prescribed. Continued observations revealed Resident #45 was not responsive to conversation and kept her eyes closed during attempts to communicate with her. Interview with the ST on 1/29/19 at 1:45 PM, at the nurse's station, confirmed on 12/17/18 she contacted the Unit Supervisor/LPN #1 regarding concerns for Resident #45's poor PO intake, dehydration, and stated the resident .may need to go to the emergency room instead of the GI consult appointment . Interview with NP #2 on 1/30/19 at 9:30 AM, in the conference room confirmed he was asked to evaluate Resident #45 on 12/14/18 for poor PO intake. Further interview revealed the NP was not aware of Resident #45's decline in PO intake. Continued interview confirmed it was the responsibility of nursing to notify the NP on call if a resident's condition deteriorates. Continued interview confirmed if he had been notified he would have ordered IV fluids. Interview with Physician #2 on 1/30/19 at 11:45 AM, in the conference room, revealed it was nursing's responsibility to notify the on call NP if a resident's condition changes or deteriorates. Further interview revealed Physician #2 was not made aware of the resident's decreased PO fluid intake and if she had been made aware she would have ordered IV fluids, which may have prevented Resident #45's dehydration and subsequent readmission to the hospital on [DATE].",2020-09-01
790,BROOKHAVEN HEALTH AND REHABILITATION,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2019-01-30,759,D,0,1,M8R511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to correctly administer medication for 2 residents (#3, #23) of 29 opportunities resulting in a 6.896% medication error rate. The findings include: Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #3's Physicians order dated 12/6/18 revealed [MEDICATION NAME] (mood stabilizer) Delayed Release (DR) 125 milligram (mg) take 1 tablet by mouth 3 times daily. Observation of medication administration with Licensed Practical Nurse (LPN) #3 on 1/29/19 at 12:15 PM, outside Resident #3's room, revealed LPN #3 crushed the delayed release [MEDICATION NAME] tablet, mixed it with applesauce, and administered it to the resident. Interview with LPN #3 on 1/29/19 at 12:20 PM, in the hallway confirmed the [MEDICATION NAME] delayed release medication should not be crushed but .I can't give it whole, she may choke, she is on a pureed diet . Interview with the Unit Supervisor/LPN #1 on 1/30/19, at 3:45 PM, at the nurse's station confirmed delay released or extended release medications should not be crushed and the facility failed to notify the Physician to obtain the appropriate medication for Resident #3. Medical record review revealed Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician's Recapitulation orders dated 1/1/19-1/31/19 revealed .[MEDICATION NAME] (medication for pain) 500MG TAB (tablet) .TAKE 2 TABLETS (1000MG) BY MOUTH TWICE DAILY .8AM . Observation of a medication administration with LPN #3 on 1/29/19 at 7:37 AM, in Resident #23's room, revealed the LPN administered 1 tablet of 500 mg [MEDICATION NAME] to Resident #23. Interview with LPN #3 on 1/29/19 at 8:45 AM, at the 200 hallway nurse's station confirmed he administered 1 tablet of 500 mg [MEDICATION NAME] to Resident #23. Further interview confirmed the order was for 2 tablets to equal 1000 mg. Continued interview confirmed an incorrect dose had been administered.",2020-09-01
791,BROOKHAVEN HEALTH AND REHABILITATION,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2019-01-30,812,E,0,1,M8R511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, and interview, the facility failed to properly store 12 stainless steel pans used for food service and failed to ensure expired foods and nutritional supplements were discarded and not available for resident use in 1 of 1 milk coolers, 1 of 1 kitchens, and 1 (wing 4) of 2 nourishment refrigerators observed. The findings include: Review of facility policy Food Receiving and Storage revised ,[DATE], revealed .Foods shall be .stored in a manner that complies with safe food handling practices .Dry foods .will be .labeled and dated (use by date) .All foods stored in the refrigerator .will be .labeled and dated (use by date) .Food items and snacks kept on the nursing units must be maintained as indicated below .All food items to be kept .must be placed in the refrigerator and labeled with a use by date . Review of facility policy Refrigerators and Freezers revised ,[DATE], revealed .This facility will ensure .and will observe food expiration guidelines .Supervisors will be responsible for ensuring food items in pantry, and refrigerators are not expired or past perish dates . Review of facility policy Sanitization revised ,[DATE], revealed .The food service area shall be maintained in a clean and sanitary manner .Food preparation equipment .will be .allowed to air dry . Observation during the initial tour of the kitchen with the Dietary Manager on [DATE] at 9:50 AM revealed the following: *Twelve 4 ounce (oz) containers of yogurt with a use by date of [DATE] stored in the milk cooler *Four small stainless steel pans stacked wet *Four medium stainless steel pans stacked wet *Four large stainless steel pans stacked wet *Five 4 oz containers of yogurt with a use by date of [DATE] stored in the walk-in cooler *Eight 32 fluid (fl) oz containers of high calorie, high protein vanilla supplements with a use by date of [DATE] stored in the dry storage room *Sixteen 4.2 fl oz boxes of cranberry juice with a use by date of [DATE] stored in the dry storage room *Two 8 pound 6 oz containers of yellow mustard with a use by date [DATE] stored in the dry storage room Interview with the Dietary Manager on [DATE] at 8:26 AM, in the Dietary Manager's office, confirmed the food items were past the use by dates and were available for resident use. Continued interview confirmed the facility failed to properly store stainless steel pans used for food services. Observation on [DATE] at 8:50 AM, in the Wing 4 nourishment room refrigerator, revealed one 32 fl oz container of high calorie, high protein vanilla supplement with a use by date of [DATE]. Interview with Licensed Practical Nurse (LPN) #4 on [DATE] at 8:55 AM, in the Wing 4 nourishment room, confirmed the supplement was past the use by date and was available for resident use.",2020-09-01
792,BROOKHAVEN HEALTH AND REHABILITATION,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2019-01-30,842,D,0,1,M8R511,"**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 medical record for 2 residents (#17, #42) of 27 sampled residents. The findings include: Medical record review revealed Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #17's Treatment Record (TAR) dated 12/2018 revealed .cleanse (with) NS (normal saline) and apply calcium alginate to heel daily cover (with) dry dressing . Further review revealed completion of wound care was not documented on the following dates: 12/2/18, 12/4/18, 12/5/18, 12/6/18, 12/7/18, 12/11/18, 12/12/18, 12/14/18, 12/15/18, 12/16/18, 12/17/18, 12/18/18, 12/20/18, 12/21/18, 12/23/18, 12/24/18, 12/26/18, 12/30/18, and 12/31/18 for a total of 19 out of 30 days (12/2/18-12/31/18). Medical record review revealed Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physician's Recapitulation orders dated 1/1/19 through 1/31/19 revealed .[MEDICATION NAME] (antibiotic) 1.25 GM (gram) .every 12 hours . Medical record review of a Medication Administration Record [REDACTED]. Interview with the Director of Nursing (DON) on 1/30/19 at 3:26 PM, in the DON's office, confirmed the facility failed to maintain an accurate TAR for Resident #17 and an accurate MAR for Resident #42.",2020-09-01
793,BROOKHAVEN HEALTH AND REHABILITATION,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2018-03-21,622,J,1,0,9RON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, facility record review and interview, the facility failed to ensure resident wasn't discharged during the appeal process, for an involuntary discharge of 1 resident (#123), of 3 residents reviewed for discharge. The facility's failure to ensure a safe and orderly discharge resulted in Resident #123 being discharged to an unsafe environment and placed Resident #123 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death). The Immediate Jeopardy was effective 2/9/18 and is ongoing. The findings included: Review of facility policy Transfer or Discharge Notice, not dated, revealed, .1. A resident .will be given a thirty (30) day written notice of an impending transfer or discharge .3. The resident will be notified in writing .c. The location to which the resident is being transferred or discharged .4. A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman .10. At the time of notification, the facility will provide each resident .with the following information: a. The plan for the transfer and adequate relocation of the resident .c. Assurances the resident will be transferred to the most appropriate facility or setting to meet his or her needs in terms of quality, services and location . Medical record review revealed Resident #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed the facility admission followed an acute care hospital stay due to a Traumatic Subdural Hemorrhage requiring surgery. Further review revealed 2 additional [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, out of a possible 15, indicating the resident was cognitively intact. Review of an Interdisciplinary Progress Note dated 12/21/17 at 9:20 AM revealed .Staff brought to administrator team concern that resident may have been smoking in one of the common areas of the facility this morning. Administrator and this writer met with resident in his room to discuss .Resident denies smoking in common area. Initially he refused to allow administrator to search his room but then consented (and) also submitted a blue lighter that he had on his person .Smoking policy/agreement reviewed with resident (and) he was informed that smoking privileges are now suspended. Resident acknowledged this. Also informed resident that he would be issuing him a 30 day discharge . Continued medical record review revealed no evidence the resident had received education and training on the smoking policy and the consequences of noncompliance, prior to this incident. Review of the facility's, Notice of Involuntary Discharge, revealed the notice was hand delivered to Resident #123 on 12/21/17. Review of the Notice revealed, .you have recently had multiple violations of the Resident Smoking Rules . Review of a Nurse's Note dated 1/20/18 revealed, .Voices needs without diff (difficulty). Forgetful @ (at) times . independent c (with) transfers and ADLs (activities of daily living). Propels self about facility in w/c (wheel chair). Continent of B&B (bowel and bladder), toilets self. Feeds self .sets up own tray . Review of a Nurse's Note dated 1/21/18 revealed, .Q (every) 15 minute checks/Smoking in bathroom! Continued review revealed the record of the every 15 minute checks began at 7:30 AM on 1/21/18 and continued until 6:15 PM on 1/30/18. Review of the Nurse Practitioner's (NP) #1 Progress Note dated 2/9/18 revealed, .I am seeing pt (patient/Resident #123) today to discharge. Pt was caught again smoking in a restricted area. Pt is hostile at assessment. Refuses to give name of PCP (primary care physician) or pharmacy. Has letter of court date continuation and believes he can stay here by law. He allows me to assess him, but tells me 'you cannot discharge me!!' Has general body pain, but denies C/P (chest pain), N&V (nausea and vomiting), chills or fever. SS (social services) to arrange for hotel .meds (medications) will be faxed to a local pharmacy .transfer care to Dr. (formal name) . Interview with the Interim Administrator and the Social Services Director (SSD) on 3/7/18 at 10:50 AM, in the Social Services office, confirmed Resident #123 filed an appeal on 1/3/18 related to the Involuntary Discharge notice dated 12/21/17. Continued interview revealed on 2/2/18, a conference call was conducted with Resident #123, his sister, the Interim Administrator, the SSD, the Commissioner's Designee for the Tennessee Department of Finance and Administration, and the presiding Administrative Law Judge (ALJ). Further interview confirmed the ALJ issued a continuation of the appeal and set the next court date for 2/21/18 to allow time for Resident #123 to obtain an attorney. Interview continued and the Interim Administrator stated Resident #123, .broke his contract with me (on 2/9/18) .he smoked unsupervised in the designated outside smoking area .he refused to give me his igniter (clarified lighter or matches) . Interview continued and the Interim Administrator stated the facility had a right to emergently discharge the resident, .he would not give me his igniter .he endangered the safety of the other residents . Continued interview revealed the Interim Administrator clarified the contract with Resident #123 was a verbal agreement between the Interim Administrator and the resident, not a written agreement. Resident #123 was discharged on [DATE] to a hotel via the facility's van. Continued interview with the SSD on 3/7/18 at 10:50 AM, in the Social Services office, revealed the SSD notified the resident's sister by phone on 2/9/18, at 4:00 PM after the resident's discharge and gave her his hotel room number. Further interview revealed the sister was not the resident's responsible party and the Interim Administrator stated .he was responsible for himself .we paid for 3 nights .our van took him to the hotel .the hotel provided a phone and complimentary breakfast meal. Further interview confirmed the SSD did not know if Resident #123 had any money, and no other arrangements had been made for Resident #123 to receive meals. Continued interview with the SSD on 3/7/18 at 10:50 AM, in the Social Services office, confirmed the resident's prescribed medications were called to a local pharmacy for delivery to the resident at the hotel. Continued interview confirmed the medications had not been delivered to the resident. Further interview confirmed the SSD and Licensed Practical Nurse (LPN) #4 had taken some of the prescribed medications that remained at the nursing home to the resident's hotel room on 2/13/18. Continued interview confirmed the resident had been visited at the Long Term Care Facility and assessed by the TennCare Choices (part of the state Medicaid program) Transition Coordinator and a representative from a local group living home. Further interview confirmed the Choices Transition Coordinator had not been informed of the resident's impending discharge on 2/9/18. Interview with the Interim Administrator on 3/19/18 at 3:30 PM, in room [ROOM NUMBER], revealed the Interim Administrator began working at the facility on 1/29/18. Interview continued and in response to why the documented every 15 minute checks on Resident #123 began on 1/21/18, had ended on 1/30/18, the Interim Administrator responded, First I have heard of every 15 minute checks . Interview with the Interim Administrator on 3/20/18 at 11:40 AM, in room [ROOM NUMBER], revealed .He was discharged because he had continued to violate the smoking policy. I don't know if I would have discharged him but he refused to give me the matches or lighter and he refused to give them to either of us (reference to the SSD) .were not aware of a plan for him to visit (group homes) the following Thursday (2/15/18). Continued interview revealed the facility's interdisciplinary team, the supervising Administrator for the Interim Administrator, the resident's Medicaid insurance case manager, and the Medical Director had not been consulted prior to the decision to discharge Resident #123 to a hotel room on 2/9/18. Interview continued and the Interim Administrator responded to the question of why the Commissioner's Designee was not informed of the impending discharge, I am not required to contact them . Refer to F623, F624",2020-09-01
794,BROOKHAVEN HEALTH AND REHABILITATION,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2018-03-21,623,J,1,0,9RON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility records, and interview, the facility failed to notify the Long Term Care Ombudsman of 1 resident (#123) who had an ongoing appeal of a 30 day Involuntary Discharge Notice, of 3 residents reviewed for discharge. The facility's failure to provide advance notice as well as a plan resulted in Resident #123 being discharged to an unsafe environment and placed Resident #123 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death). The Immediate Jeopardy was effective 2/9/18 and is ongoing. The findings included: Review of facility policy Transfer or Discharge Notice, not dated, revealed, .1. A resident .will be given a thirty (30) day written notice of an impending transfer or discharge .3. The resident will be notified in writing .c. The location to which the resident is being transferred or discharged .4. A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman . Medical record review revealed Resident #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed the facility admission followed an acute care hospital stay due to a Traumatic Subdural Hemorrhage requiring surgery. Further review revealed 2 additional [DIAGNOSES REDACTED]. Review of an Interdisciplinary Progress Note dated 12/21/17 at 9:20 AM revealed .Staff brought to administrator team concern that resident may have been smoking in one of the common areas of the facility this morning. Administrator and this writer met with resident in his room to discuss .Resident denies smoking in common area. Initially he refused to allow administrator to search his room but then consented (and) also submitted a blue lighter that he had on his person .Smoking policy/agreement reviewed with resident (and) he was informed that smoking privileges are now suspended. Resident acknowledged this. Also informed resident that he would be issuing him a 30 day discharge . Review of the facility's Notice of Involuntary Discharge revealed the notice was hand delivered to Resident #123 on 12/21/17. Review of the Notice revealed, .you have recently had multiple violations of the Resident Smoking Rules . Review of the Nurse Practitioner's (NP #1, employed by the resident's attending physician) progress note dated 2/9/18 revealed, I am seeing pt (patient/Resident #123) today to discharge. Pt was caught again smoking in restricted area. Pt is hostile at assessment. Refuses to give name of PCP (primary care physician) or pharmacy. Has letter of court date continuation and believes he can stay here by law. He allows me to assess him, but tells me 'you cannot discharge me!!' Has general body pain, but denies C/P (chest pain), N&V (nausea and vomiting), chills or fever. SS (social services) to arrange for hotel .meds (medications) will be faxed to a local pharmacy .transfer care to Dr. (formal name) . Medical record review of a NP order dated 2/9/18 revealed .DC (discharge) patient (Resident #123) .today (to hotel) . Interview with the Interim Administrator and the Social Services Director (SSD) on 3/7/18 at 10:50 AM, in the social services office, confirmed Resident #123 filed an appeal for the Involuntary Discharge on 1/3/18. Continued interview revealed on 2/2/18, a conference call was conducted with Resident #123, his sister, the Interim Administrator, the SSD, the Tennessee Department of Finance and Administration Commissioner's Designee, and the presiding Administrative Law judge (ALJ). Further interview confirmed the ALJ issued a continuation of the appeal and set the next court date for 2/21/18 to allow time for Resident #123 to obtain an attorney. Continued interview with the Interim Administrator and the Social Services Director (SSD) on 3/7/18 at 10:50 AM, in the social services office, confirmed a previous Administrator had not provided documentation of notification to the Long Term Care Ombudsman of the Notice of Involuntary Discharge issued to Resident #123 on 12/21/17. Continued interview confirmed the current IA and the SSD had not notified the Ombudsman of the Notice of Involuntary Discharge, the pending appeal, or of the resident's discharge on 2/9/18 to a hotel room. Interview with Resident #123's NP #1 on 3/20/18 at 9:30 AM, in room [ROOM NUMBER], confirmed the NP cared for the resident on behalf of his attending physician. Continued interview revealed, .the physician on call, not sure if it was (name of the resident's attending physician) was called and notified that day . Further interview confirmed the notification was after the resident had been discharged to a hotel. Interview by telephone with the Ombudsman for the East Tennessee Region, District 1, on 3/20/18 at 10:30 AM, confirmed the Ombudsman was not aware Resident #123 was discharged on [DATE] and revealed, No one knew he was being discharged . Interview continued and revealed, .the attorney from Legal Aid came to my office early on Monday (2/12/18) and told me he had a voice mail from the resident's sister about the discharge .I went to the nursing home .I told them he didn't have a phone .I saw the social worker (SSD) call his room in front of me and then call the front office of the hotel about his phone not working .I told them (the nursing home) he didn't have his meds when I was there (at the nursing home ) .there about 9:00 AM .the sister paid for another night at the hotel .After I got back (to her office) I called the State Director of the Ombudsman Program . Interview with the Interim Administrator on 3/20/18 at 11:40 AM, in room [ROOM NUMBER], revealed .He was discharged because he had continued to violate the smoking policy . were not aware of a plan for him to visit (group homes) the following Thursday (2/15/18). Continued interview confirmed the facility's Ombudsman had not been notified prior to the discharge of Resident #123 to a hotel room on 2/9/18. Interview continued and the IA responded to the question of why the Commissioner's Designee was not informed of the impending discharge, I am not required to contact them . Refer to F622, F624",2020-09-01
795,BROOKHAVEN HEALTH AND REHABILITATION,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2018-03-21,624,J,1,0,9RON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of facility records, medical record review and interview, the facility failed to ensure a safe and orderly discharge for 1 resident (#123) of 3 residents reviewed for discharge. The facility's failure to ensure a safe and orderly discharge resulted in Resident #123 being discharged to an unsafe environment and placed Resident #123 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death). The Immediate Jeopardy was effective 2/9/18 and is ongoing. The findings included: Review of facility policy, Transfer or Discharge Notice, not dated, revealed, .1. A resident .will be given a thirty (30) day written notice of an impending transfer or discharge .3. The resident will be notified in writing .c. The location to which the resident is being transferred or discharged .10. At the time of notification, the facility will provide each resident .with the following information: a. The plan for the transfer and adequate relocation of the resident .c. Assurances the resident will be transferred to the most appropriate facility or setting to meet his or her needs in terms of quality, services and location . Medical record review revealed Resident #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed the resident was admitted following an acute care hospital stay due to a Traumatic Subdural Hemorrhage that required surgery. Further review revealed 2 additional [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, out of a possible 15, indicating he was assessed as cognitively intact. Review of Resident #123's Admission MDS dated [DATE] revealed, .Problem .does have cognitive deficit . Continued review revealed the Quarterly MDS assessment dated [DATE] revealed a problem, .potential for skin breakdown r/t (related to) cognition and decreased safety awareness. Review of an Interdisciplinary Progress Note dated 12/21/17 at 9:20 AM revealed .Staff brought to administrator team concern that resident may have been smoking in one of the common areas of the facility this morning. Administrator and this writer met with resident in his room to discuss .Resident denies smoking in common area. Initially he refused to allow administrator to search his room but then consented (and) also submitted a blue lighter that he had on his person .Smoking policy/agreement reviewed with resident (and) he was informed that smoking privileges are now suspended. Resident acknowledged this. Also informed resident that he would be issuing him a 30 day discharge . Continued medical record review revealed no evidence the resident had received education and training on the smoking policy and the consequences of noncompliance, prior to this incident. Review of the facility's Notice of Involuntary Discharge revealed the notice was hand delivered to Resident #123 on 12/21/17. Review of the notice revealed, .you have recently had multiple violations of the Resident Smoking Rules . Medical record review of the facility Attending Physician's History and Physical dated 1/5/18 revealed, .he (Resident #123) has been followed by psych (psychiatric services) and requires [MEDICATION NAME] (antipsychotic medication) to try to prevent mood swings .he continues to smoke. He has been caught smoking in his room twice and he was given a 30 day notice of discharge about 2 weeks ago due to this issue . Review of a Nurse's Note dated 1/20/18 revealed, .Voices needs without diff (difficulty). Forgetful @ (at) times . independent c (with) transfers and ADLs (activities of daily living). Propels self about facility in w/c (wheel chair). Continent of B&B (bowel and bladder), toilets self. Feeds self .sets up own tray . Review of a Nurse's Note dated 1/21/18 revealed, .Q (every) 15 minute checks/Smoking in bathroom! Continued review revealed the record of the every 15 minute checks began at 7:30 AM on 1/21/18 and continued until 6:15 PM on 1/30/18. Medical record review of Resident #123's Physician order [REDACTED]. Review of a Social Progress Note by the Social Services Director (SSD) dated 2/2/18 revealed, This writer contacted (Choices Transition Coordinator-State Medicaid program) for update. He (Transition Coordinator) said he would set up transportation for resident to look at house and meet roommates next week. Medical record review of Nurse Practitioner's (NP) #1 progress note dated 2/9/18 revealed, .I am seeing pt (patient) today to discharge. Pt was caught again smoking in a restricted area. Pt is hostile at assessment. Refuses to give name of PCP (primary care physician) or pharmacy. Has letter of court date continuation and believes he can stay here by law. He allows me to assess him, but tells me 'you cannot discharge me!!' Has general body pain, but denies C/P (chest pain), N&V (nausea and vomiting), chills or fever. SS (social services) to arrange for hotel .meds will be faxed to a local pharmacy .transfer care to Dr. (formal name) . Medical record review of the NP orders written 2/9/18, revealed the orders for Resident #123 at discharge included: Diet-NAS (no added salt); Activity as tolerated; Resident to follow up with his primary physician on 2/27/18; Social Service to arrange Home Health services to include skilled nursing, physical and occupational therapy; Discharge meds-see discharge Medication Administration Record; DME (durable medical equipment) O2 concentrator with tubing; O2 at 2Lpm (oxygen at 2 liters per minute) - continuous; Overnight pulse ox test (used to measure oxygen levels in the bloodstream during the hours of sleeping); Review of the medication list prepared for the discharge revealed the following medications checked to be included on the discharge list: multivitamin/mineral tablet 1 daily (vitamin replacement); [MEDICATION NAME] HCL 20 milligrams (mg) 1 tablet every morning (for [MEDICAL CONDITION]); [MEDICATION NAME] 100 mg (vitamin replacement); [MEDICATION NAME] 10 Grams per 15 milliliters (ml) solution 30 ml twice a day (reduces blood ammonia level); [MEDICATION NAME] 500 mg 1 tablet twice a day (for [MEDICAL CONDITION]); [MEDICATION NAME] 5 percent patch apply 1 patch per day (for pain); [MEDICATION NAME] 25 mg 1 tablet twice per day (for lowering blood pressure); [MEDICATION NAME] Extended Release 1200 mg 1 tablet twice per day (for congestion); [MEDICATION NAME] 150 mg tablet 1 tablet twice per day (for reflux disorder); [MEDICATION NAME] inhaler 2 puffs by mouth twice per day; [MEDICATION NAME] 10 mg capsule 1 three times per day (for anxiety disorder); [MEDICATION NAME] 100 mg 1 tablet at bedtime (antipsychotic medication); [MEDICATION NAME] 2.25 inhale contents of one vial by mouth per nebulizer every 4 hours as needed for breathing; [MEDICATION NAME] 2.5-0.5 mg per 3 ml one vial by mouth per nebulizer every 6 hours as needed for wheezing and [MEDICATION NAME] HFA 90 micrograms inhale 1-2 puffs by mouth as needed for wheezing. Review of a document signed by Licensed Practical Nurse (LPN) #4 and Resident #123, dated 2/13/18 at 11:00 AM, revealed the resident acknowledged the receipt of the following medications, at the hotel, from the facility: [MEDICATION NAME] 10 Gm per 15 ml-1 whole bottle, and 1/2 bottle; iprat-albut nebs-1 box (to be used for respiratory treatments with nebulizer); asthmanefrin inhale-1 box (to be used for respiratory treatments with nebulizer); [MEDICATION NAME] 500 mg-27 tablets and [MEDICATION NAME]-12 patches. Interview with NP #1 on 3/7/18 at 9:50 AM, in the conference room, confirmed she wrote the 2/9/18 discharge orders for Resident #123. Continued interview revealed his order for oxygen was PRN (as needed) in the nursing home. Interview continued and revealed the order she wrote on 2/9/18 for an overnight pulse ox test was to evaluate the resident's oxygen levels and see if he would qualify for oxygen. Interview with the Interim Administrator and the SSD on 3/7/18 at 10:50 AM, in the Social Services office, confirmed Resident #123 had filed an appeal on 1/3/18 of the Involuntary Discharge Notice dated 12/21/17. Continued interview revealed on 2/2/18, a conference call was conducted with Resident #123, his sister, the Interim Administrator, the SSD, the Commissioner's Designee for the Tennessee Department of Finance and Administration, and the presiding Administrative Law Judge (ALJ). Further interview confirmed the ALJ issued a continuation of the appeal and set the next court date for 2/21/18 to allow time for Resident #123 to obtain an attorney. Interview continued and the Interim Administrator stated Resident #123, .broke his contract with me (on 2/9/18) .he smoked unsupervised in the designated outside smoking area .he refused to give me his igniter (clarified lighter or matches) . Interview continued and the Interim Administrator stated the facility had a right to emergently discharge the resident, .he would not give me his igniter .he endangered the safety of the other residents . Continued interview revealed the Interim Administrator clarified the contract with Resident #123 was a verbal agreement between the Interim Administrator and the resident, not a written agreement. Continued interview with the Interim Administrator and the SSD on 3/7/18 at 10:50 AM, in the Social Services office, revealed the SSD notified the resident's sister by phone on 2/9/18, at 4:00 PM, after the resident's discharge, .I gave her his hotel room number . Interview continued and the Interim Administrator stated .he was responsible for himself .we paid for 3 nights .our van took him to the hotel .the hotel provided a phone and complimentary breakfast meal. Further interview confirmed the SSD did not know if Resident #123 had any money, and no other arrangements had been made for Resident #123 to receive meals. Continued interview confirmed the resident's prescribed medications were called to a local pharmacy for delivery to the resident at the hotel. Further interview confirmed on 2/12/18 the SSD became aware the medications had not been delivered to the resident. Continued interview confirmed the SSD and LPN #4 had delivered some of Resident #123's prescribed medications remaining at the Long Term Care facility to the resident at his hotel room on 2/13/18. Interview with the van driver on 3/19/18 at 12:10 PM, in room [ROOM NUMBER], confirmed he transported Resident #123 to the hotel on 2/9/18. Continued interview revealed he transported him .in the 2 o'clock (2:00 PM) hour .helped him put his stuff in the room .he stayed in the his wheelchair the whole time .he (the resident) asked me what was going to happen to him .when I got off work, I took him a (name of fast food) meal .I knew if I had been in that situation I would appreciate it . Interview with LPN #5 on 3/19/18 at 5:50 PM, in room [ROOM NUMBER], revealed, .Me and him (Resident #123) got along quite well .He could do everything for himself .he said often to me that he was forgetful .sometimes he would come to me for his meds (medications) after he had forgotten his meds had been taken . Continued interview revealed LPN #5 answered No to the question of whether Resident #123 could manage his medications on his own. Interview with LPN #6 on 3/19/18 at 6:30 PM, in room [ROOM NUMBER], revealed, .Always complained of not being able to breathe .would forget when he had his inhalers . Continued interview revealed LPN #6 answered No to the question of whether Resident #123 could manage his own medications. Telephone interview with the Ombudsman for the facility, on 3/20/18 at 10:30 AM, confirmed the Ombudsman was not made aware Resident #123 was being discharged on [DATE] and stated, No one knew he was being discharged . Interview continued and revealed, .the attorney from Legal Aid came to my office early on Monday (2/12/18) and told me he had a voice mail from the resident's sister about the discharge .I went to the nursing home .I told them he didn't have a phone .I saw the social worker (SSD) call his room in front of me and then call the front office of the hotel about his phone not working .I told them he didn't have his meds on Monday when I was there (at the Long Term Care facility .I was there about 9:00 AM .the sister paid for another night at the hotel . Interview with the Interim Administrator on 3/20/18 at 11:40 AM, in room [ROOM NUMBER], revealed .not aware of a plan for him to visit (group homes) the following Thursday (2/15/18) .I just started 1/29/18. Continued interview revealed the facility's interdisciplinary team, the supervising Administrator for the Interim Administrator, the resident's Medicaid insurance case manager, and the Medical Director had not been consulted prior to the decision to discharge Resident #123 to a hotel room on 2/9/18. Telephone interview with the Choices Transition Coordinator on 3/20/18 at 1:30 PM revealed the Coordinator learned Monday evening (3/12/18) from an Ombudsman about Resident #123's discharge and stated, I called him Tuesday morning (3/13/18) at the hotel and he (Resident #123) told me, 'in contact with .state legal people' .he told me his last meal was Friday evening .and that he didn't have his meds .he was anxious about what would happen next . Interview with Resident #123's attending physician on 3/20/18 at 5:00 PM, in room [ROOM NUMBER], revealed she was aware of an ongoing plan for (Resident #123) to be discharged to a local area group home in the near future. Continued interview revealed she was not consulted prior to the discharge to the hotel on 2/9/18, but was notified later. Further interview revealed the resident had impulse control problems and failed a gradual dose reduction of [MEDICATION NAME] . Continued interview revealed he needed the psychoactive medications to help him maintain control. (Note: The resident did not have prescribed psychoactive medications of [MEDICATION NAME] at bedtime (from the evening of 2/9/18-2/13/18, [MEDICATION NAME] 3 times a day (from the evening of 2/9/18-2/13/18), or [MEDICATION NAME] each morning (from 2/10/18-2/13/18). Telephone interview with Resident #123 on 3/20/18 at 8:10 PM revealed he had difficulty maintaining focus on the immediate events before and after his discharge on 2/9/18 to the hotel room. At the beginning of the interview, he stated, I have difficulty with days of the week and dates .ever since they put three holes in my head for surgery. Continued interview revealed, They told me get your stuff ready .you will be leaving here .they already had my stuff packed .I thought my meds were packed up .they didn't ask me about a pharmacy, I would have used (name of his previous pharmacy) .at the hotel I went twice to the main office and asked for a phone and didn't get one . Further interview related to food revealed Resident #123 stated he had 1 meal on Friday night and 2 boxes of peanut butter crackers and some candy to eat for the following 3 days. Further interview included a question of whether he went to the breakfast the hotel provided and he responded, .that continental breakfast .stale rolls, I didn't go back . Continued interview revealed, Don't know how the people knew to come and get me (referring to group home personnel). Further interview confirmed he did not have his medications after he was discharged to the hotel and revealed, .my thinking was off. Interview with LPN #4 on 3/21/18 at 8:10 AM, in front of the 200 hall nursing station, confirmed the medications for Resident #123's nebulizer treatments were not provided to him before 2/13/18 when she and the SSD took the medications remaining at the facility to his hotel room, which included 2 medications for respiratory treatments with a nebulizer, an anti-[MEDICAL CONDITION] medication, a medication to lower ammonia level in bloodstream, and [MEDICATION NAME]es for back pain. Interview with LPN #3 on 3/21/18 at 9:45 AM, in room [ROOM NUMBER], revealed, .I guess between 9 and 10 (9:00 AM to 10:00 AM) when (SSD) came to me and asked me to find a PCP and pharmacy for him (Resident #123) .I did try to find a pharmacy that would deliver .Honestly, (SSD) came up with (name of pharmacy) .I went over his meds with him .he came back and asked me to go over his meds with him a second time .he did get forgetful .about whether or not he had taken his meds (medications) and I would jog his memory. Telephone interview by phone with the Advanced Practice Nurse (APN) on 3/21/18 at 11:37 AM revealed the APN stated the psychologist in her practice co-treated Resident #123. Further interview revealed, .he had a negative thought process .impatient .he instigated, argued .I can remember at some points thinking he could be at home and at other times thinking not so much .impulsiveness .didn't think about consequences . Telephone interview with the durable medical equipment (DME) oxygen supplier on 3/21/18 at 11:48 AM revealed, .provided him (Resident #123) with a nebulizer on 2/9/18 .didn't run an O2 sat (saturation) overnight, did not receive an order for [REDACTED]. Telephone interview with the Legal Aid Attorney on 3/21/18 at 5:05 PM, .first actual contact was on 2/12/18 when I heard the voice mail his (Resident #123's) sister had left me on Friday (2/9/18) .she said the facility called her around 4:00 PM after the resident had already been discharged to the hotel .I went to the hotel on Monday morning (2/12/18) and he didn't have a good memory and seemed extremely distressed, especially about what was going to happen to him and about not having his medications . In summary, Resident #123 had an involuntary discharge from the nursing facility, planned and executed on the day of 2/9/18. The attending Physician and Medical Director were not consulted prior to the discharge. The facility paid for 3 nights at the hotel over the weekend (Friday, Saturday, Sunday). By the time the family was notified, Resident #123 had already been discharged to the hotel and plans for more appropriate living arrangements could not be pursued prior to the opening of business on Monday, 2/12/18 . The facility had not ensured the resident received his medications. The facility had not made any arrangements for meals, and did not know if the resident had funds to purchase meals. The facility failed to ensure the resident had a working phone. The facility Interim Administrator and SSD had not contacted anyone in the Choices program who was able to pursue alternative living arrangements. The facility was not aware of the resident not having a working phone and not receiving his medications from the pharmacy until the Ombudsman's visit to the facility on [DATE] at 9:00 AM. The facility had made no plans to check on the resident's wellbeing and did not visited the resident until 2/13/18, when the SSD and LPN #4 delivered some medications to the resident. Refer to F622, F623",2020-09-01
796,BROOKHAVEN HEALTH AND REHABILITATION,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2018-03-21,745,J,1,0,9RON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, facility record review, and interview, the facility failed to ensure the Social Services Director fulfilled their duties and responsibilities when a resident was discharged , during the appeal process for an involuntary discharge of 1 resident (#123), of 3 residents reviewed for discharge. The facility's failure to ensure a safe and orderly discharge resulted in the discharge of Resident #123 to an unsafe environment and placed Resident #123 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death). The Immediate Jeopardy was effective 2/9/18 and is ongoing. The facility was cited F 745 at a scope and severity of J, which constitutes Substandard Quality of Care (SQC). The findings included: Review of facility policy Transfer or Discharge Notice, not dated, revealed, .1. A resident .will be given a thirty (30) day written notice of an impending transfer or discharge .3. The resident will be notified in writing .c. The location to which the resident is being transferred or discharged .10. At the time of notification, the facility will provide each resident .with the following information: a. The plan for the transfer and adequate relocation of the resident .c. Assurances the resident will be transferred to the most appropriate facility or setting to meet his or her needs in terms of quality, services and location . Medical record review revealed Resident #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed the facility admission followed an acute care hospital stay due to a Traumatic Subdural Hemorrhage requiring surgery. Further review revealed 2 additional [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, out of a possible 15, indicating the resident was cognitively intact. Review of an Interdisciplinary Progress Note dated 12/21/17 at 9:20 AM revealed .Staff brought to administrator team concern that resident may have been smoking in one of the common areas of the facility this morning. Administrator and this writer met with resident in his room to discuss .Resident denies smoking in common area. Initially he refused to allow administrator to search his room but then consented (and) also submitted a blue lighter that he had on his person .Smoking policy/agreement reviewed with resident (and) he was informed that smoking privileges are now suspended. Resident acknowledged this. Also informed resident that he would be issuing him a 30 day discharge . Continued medical record review revealed no evidence the resident had received education and training on the smoking policy and the consequences of noncompliance, prior to this incident. Review of the facility's Notice of Involuntary Discharge revealed the notice was hand delivered to Resident #123 on 12/21/17. Review of the Notice revealed, .you have recently had multiple violations of the Resident Smoking Rules . Review of a Social Progress Note by the SSD dated 12/29/17 revealed, Received phone call from Choices (State Medicaid program) case manager asking why (Resident #123) had been issued 30 day notice. I told her it was rule violation (smoking). She stated she was getting ready to call (Resident #123's) sister .Spoke with her again later and was advised (sister) is going to start hunting place . Review of a Social Progress Note by the SSD dated 2/2/18 revealed, This writer contacted (Choices Transition Coordinator) for update. He said he would set up transportation for resident to look at house and meet roommates next week. Interview with the Interim Administrator and the SSD (Social Services Director) on 3/7/18 at 10:50 AM, in the Social Services office, revealed Resident #123 filed an appeal on 1/3/18 for the Involuntary Discharge issued 12/21/17. Continued interview revealed on 2/2/18, a conference call was conducted with Resident #123, his sister, the Interim Administrator, the SSD, the Commissioner's Designee for the Tennessee Department of Finance and Administration, and the presiding Administrative Law Judge (ALJ). Further interview confirmed the ALJ issued a continuation of the appeal and set the next court date for 2/21/18 to allow time for Resident #123 to obtain an attorney. Continued interview revealed the SSD notified the resident's sister by phone on 2/9/18, at 4:00 PM of the resident's discharge and gave her his hotel room number. Further interview revealed the sister was not the resident's responsible party. Continued interview revealed the facility paid for 3 nights in a hotel (Friday, Saturday, and Sunday from 2/9/18-2/11/18). Further interview revealed .the hotel provided a phone and complimentary breakfast meal. Continued interview confirmed the SSD did not know if Resident #123 had any money, and no other arrangements had been made for Resident #123 to receive meals. Further interview confirmed the resident's prescribed medications were called to a local pharmacy for delivery to the resident at the hotel. Continued interview confirmed the medications had not been delivered to the resident and the SSD had not known this prior to the Ombudsman's visit on 2/12/18. Further interview confirmed the Choices Transition Coordinator (State Medicaid Care Coordinator) had not been contacted on 2/9/18 with information of the resident's impending discharge. Continued interview revealed the facility had not made a plan to check on the resident's wellbeing and did not visit the resident until 2/13/18, when the SSD and LPN #4 delivered some medications to the resident. Interview with the SSD on 3/19/18 at 3:30 PM, in room [ROOM NUMBER], revealed she had been in her position at the facility for [AGE] years. Continued interview confirmed she had not made contacts with other facilities in an effort to seek placement for Resident #123 after the 30 day notice was issued and revealed, .it was up to Choices . Interview continued and the question of why Choices was not contacted on 2/9/18, was asked and revealed, .something that didn't even come to mind. Refer to F622, F624",2020-09-01
797,BROOKHAVEN HEALTH AND REHABILITATION,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2018-03-21,835,J,1,0,9RON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, review of facility records, medical record review and interview, the Administrator failed to provide adequate oversight for 1 resident (#123) discharged during an appeal process of an involuntary discharge of 3 residents reviewed for discharge. The Administrator's failure to ensure a safe and orderly discharge resulted in Resident #123 being discharged to an unsafe environment and placed Resident #123 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death). The Immediate Jeopardy was effective 2/9/18 and is ongoing. The findings included: Review of facility policy, Transfer or Discharge Notice, not dated, revealed, .1. A resident .will be given a thirty (30) day written notice of an impending transfer or discharge .3. The resident will be notified in writing .c. The location to which the resident is being transferred or discharged .4. A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman .10. At the time of notification, the facility will provide each resident .with the following information: a. The plan for the transfer and adequate relocation of the resident .c. Assurances the resident will be transferred to the most appropriate facility or setting to meet his or her needs in terms of quality, services and location . Medical record review revealed Resident #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed the facility admission followed an acute care hospital stay due to a Traumatic Subdural Hemorrhage requiring surgery. Further review revealed 2 additional [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, out of a possible 15, indicating the resident was cognitively intact. Review of an Interdisciplinary Progress Note dated 12/21/17 at 9:20 AM revealed .Staff brought to administrator team concern that resident may have been smoking in one of the common areas of the facility this morning. Administrator and this writer met with resident in his room to discuss .Resident denies smoking in common area. Initially he refused to allow administrator to search his room but then consented (and) also submitted a blue lighter that he had on his person .Smoking policy/agreement reviewed with resident (and) he was informed that smoking privileges are now suspended. Resident acknowledged this. Also informed resident that he would be issuing him a 30 day discharge . Continued medical record review revealed no evidence the resident had received education and training on the smoking policy and the consequences of noncompliance, prior to this incident. Review of the facility's Notice of Involuntary Discharge revealed the notice was hand delivered to Resident #123 on 12/21/17. Review of the Notice revealed, .you have recently had multiple violations of the Resident Smoking Rules . Review of a Nurse's Note dated 1/21/18 revealed, .Q (every) 15 minute checks/Smoking in bathroom! Continued review revealed the record of the every 15 minute checks began at 7:30 AM on 1/21/18 and continued until 6:15 PM on 1/30/18. Review of the Nurse Practitioner's progress note dated 2/9/18 revealed, .I am seeing pt (patient/Resident #123) today to discharge. Pt was caught again smoking in a restricted area. Pt is hostile at assessment. Refuses to give name of PCP (primary care physician) or pharmacy. Has letter of court date continuation and believes he can stay here by law. He allows me to assess him, but tells me 'you cannot discharge me!!' Has general body pain, but denies C/P (chest pain), N&V (nausea and vomiting), chills or fever. SS (social services) to arrange for hotel .meds (medications) will be faxed to a local pharmacy .transfer care to Dr. (formal name) . Interview with the Interim Administrator and the Social Services Director (SSD) on 3/7/18 at 10:50 AM, in the Social Services office, confirmed Resident #123 filed an appeal on 1/3/18 for the Involuntary Discharge notice dated 12/21/17. Continued interview revealed on 2/2/18, a conference call was conducted with Resident #123, his sister, the Interim Administrator, the SSD, the Commissioner's Designee for the Tennessee Department of Finance and Administration, and the presiding Administrative Law Judge (ALJ). Further interview confirmed the ALJ issued a continuation of the appeal and set the next court date for 2/21/18 to allow time for Resident #123 to obtain an attorney. Interview continued and the Interim Administrator stated Resident #123, .broke his contract with me (on 2/9/18) .he smoked unsupervised in the designated outside smoking area .he refused to give me his igniter (clarified lighter or matches) . Interview continued and the Interim Administrator stated the facility had a right to emergently discharge the resident, .he would not give me his igniter .he endangered the safety of the other residents . Continued interview revealed the Interim Administrator clarified the contract with Resident #123 was a verbal agreement between the Interim Administrator and the resident, not a written agreement. Continued interview with the Interim Administrator and the Social Services Director (SSD) on 3/7/18 at 10:50 AM, in the Social Services office, revealed the SSD notified the resident's sister by phone on 2/9/18, at 4:00 PM after the resident had been discharged , and gave her his hotel room number. Further interview revealed the sister was not the resident's responsible party and the Interim Administrator stated .he was responsible for himself .we paid for 3 nights .our van took him to the hotel .the hotel provided a phone and complimentary breakfast meal. Further interview confirmed the SSD did not know if Resident #123 had any money, and no other arrangements had been made for Resident #123 to receive meals. Continued interview confirmed the resident's prescribed medications were called to a local pharmacy for delivery to the resident at the hotel. Continued interview confirmed the medications had not been delivered to the resident. Further interview confirmed the SSD and Licensed Practical Nurse (LPN) #4 had taken some of the prescribed medications that remained at the Long Term Care facility to the resident's hotel room on 2/13/18. Further interview confirmed the Choices (part of the state medicaid program) Transition Coordinator had not been contacted on 2/9/18 with information of the resident's impending discharge. Continued interview with the Interim Administrator and the Social Services Director (SSD) on 3/7/18 at 10:50 AM, in the Social Services office, confirmed the prior Administrator had not provided documentation of notification to the Long Term Care Ombudsman of the Notice of Involuntary Discharge issued to Resident #123 on 12/21/17. Continued interview confirmed the current Interim Administrator and the SSD had not notified the Ombudsman of the Notice of Involuntary Discharge, the pending appeal, or of the resident's discharge on 2/9/18 to a hotel room. Interview with the Interim Administrator on 3/19/18 at 3:30 PM, in room [ROOM NUMBER], revealed she began working at the facility on 1/29/18. Interview continued and in response to why the documented every 15 minute checks on Resident #123 began on 1/21/18, had ended on 1/30/18, she responded, First I have heard of every 15 minute checks . Interview with the Interim Administrator on 3/20/18 at 11:40 AM, in room [ROOM NUMBER], revealed .He was discharged because he had continued to violate the smoking policy. I don't know if I would have discharged him but he refused to give me the matches or lighter and he refused to give them to either of us (reference to the SSD) .not aware of a plan for him to visit (group homes) the following Thursday (2/15/18). Continued interview revealed the facility's interdisciplinary team, the supervising Administrator for the Interim Administrator, the resident's Medicaid insurance case manager, and the Medical Director had not been consulted prior to the decision to discharge Resident #123 to a hotel room on 2/9/18. Interview continued and the Interim Administrator responded to the question of why the Commissioner's Designee was not informed of the impending discharge, she replied, I am not required to contact them . Refer to F-622 (J), F-623 (J), F-624 (J), F-745 (J), F-837 (J), and F-867 (J).",2020-09-01
798,BROOKHAVEN HEALTH AND REHABILITATION,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2018-03-21,837,J,1,0,9RON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility records and interview, the Governing Body failed to ensure the facility followed the discharge policy to develop a safe and orderly discharge for 1 resident (#123) of 3 residents reviewed for discharge. The facility's failure to ensure a safe and orderly discharge resulted in Resident #123 being discharged to an unsafe environment and placed Resident #123 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death). The Immediate Jeopardy was effective 2/9/18 and is ongoing. The findings included: Review of facility policy, Transfer or Discharge Notice, not dated, revealed, .1. A resident .will be given a thirty (30) day written notice of an impending transfer or discharge .3. The resident will be notified in writing .c. The location to which the resident is being transferred or discharged .10. At the time of notification, the facility will provide each resident .with the following information: a. The plan for the transfer and adequate relocation of the resident .c. Assurances the resident will be transferred to the most appropriate facility or setting to meet his or her needs in terms of quality, services and location . Medical record review revealed Resident #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed the facility admission followed an acute care hospital stay due to a Traumatic Subdural Hemorrhage requiring surgery. Further review revealed 2 additional [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, out of a possible 15, indicating the resident was cognitively intact. Review of an Interdisciplinary Progress Note dated 12/21/17 at 9:20 AM revealed .Staff brought to administrator team concern that resident may have been smoking in one of the common areas of the facility this morning. Administrator and this writer met with resident in his room to discuss .Resident denies smoking in common area. Initially he refused to allow administrator to search his room but then consented (and) also submitted a blue lighter that he had on his person .Smoking policy/agreement reviewed with resident (and) he was informed that smoking privileges are now suspended. Resident acknowledged this. Also informed resident that he would be issuing him a 30 day discharge . Continued medical record review revealed no evidence the resident had received education and training on the smoking policy and the consequences of noncompliance, prior to this incident. Review of the facility's Notice of Involuntary Discharge revealed the notice was hand delivered to Resident #123 on 12/21/17. Review of the Notice revealed, .you have recently had multiple violations of the Resident Smoking Rules . Interview with the Interim Administrator and the Social Services Director (SSD) in the Social Services office on 3/7/18 at 10:50 AM, revealed Resident #123 filed an appeal on 1/3/18 for the Involuntary Discharge issued 12/21/17. Continued interview revealed on 2/2/18, a conference call was conducted with Resident #123, his sister, the Interim Administrator, the SSD, the Commissioner's Designee for the Tennessee Department of Finance and Administration, and the presiding Administrative Law Judge (ALJ). Further interview confirmed the ALJ issued a continuation of the appeal and set the next court date for 2/21/18 to allow time for Resident #123 to obtain an attorney. Continued interview with the Interim Administrator and the Social Services Director (SSD) on 3/7/18 at 10:50 AM, in the Social Services office, revealed the SSD notified the resident's sister by phone on 2/9/18, at 4:00 PM after the resident's discharge and gave her his hotel room number. Further interview revealed the sister was not the resident's responsible party. Continued interview revealed the facility paid for 3 nights in a hotel (Friday, Saturday, and Sunday from 2/9/18-2/11/18). Further interview revealed .the hotel provided a phone and complimentary breakfast meal. Continued interview confirmed the SSD did not know if Resident #123 had any money, and no other arrangements had been made for Resident #123 to receive meals. Continued interview confirmed the resident's prescribed medications were called to a local pharmacy for delivery to the resident at the hotel. Further interview confirmed the medications had not been delivered to the resident, and the facility did not know this prior to the Ombudsman's visit on 2/12/18. Continued interview revealed the facility had not made a plan to check on the resident's wellbeing. Telephone interview with the Ombudsman for the facility, on 3/20/18 at 10:30 AM, confirmed the Ombudsman was not aware Resident #123 was discharged on [DATE] and stated, No one knew he was being discharged . Interview continued and revealed, .the attorney from Legal Aid came to my office early on Monday (2/12/18) and told me he had a voice mail from the resident's sister about the discharge .I went to (the facility's proper name) .I told them he didn't have a phone .I saw the social worker (SSD) call his room in front of me and then call the front office of the hotel about his phone not working .I told them he didn't have his meds . Interview with the Supervisor Administrator on 3/21/18 at 3:00 PM, in room [ROOM NUMBER], revealed the Supervisor Administrator provided oversight of the facility as needed. Continued interview with concurrent review of the organizational chart revealed the Supervisor Administrator reported directly to the President of the Governing Body. Further interview revealed the Supervisor Administrator was not onsite on 2/9/18 and did not have full knowledge of the circumstances of Resident #123's discharge, and stated .I didn't know he didn't have his medications . In summary, Resident #123 had a discharge from the nursing facility planned and executed on the day of 2/9/18. The attending physician and Medical Director were not consulted prior to Resident #123's discharge to a hotel room. The facility paid for 3 nights over the weekend (Friday, Saturday, Sunday). By the time the family was notified, Resident #123 had already been discharged to the hotel and plans for more appropriate living arrangements could not be pursued prior to the opening of business on Monday, 2/12/18 . The facility had not ensured the resident received his medications. The facility had not made any arrangements for meals, and did not know if the resident had funds to purchase meals. The facility failed to ensure the resident had a working phone. The facility Interim Administrator and SSD had not contacted anyone in the Choices program who was able to pursue alternative living arrangements. The facility did not become aware of the resident not having a working phone and not receiving his medications from the pharmacy until the Ombudsman's visit to the facility on [DATE] at 9:00 AM. The facility had made no plans to check on the resident's wellbeing and had not visited the resident until 2/13/18, when the SSD and Licensed Practical Nurse (LPN) #4 delivered some medications to the resident at the hotel. Refer to F-622 (J), F-623 (J), F-624 (J), F-745 (J), F-835 (J) and F-867 (J).",2020-09-01
799,BROOKHAVEN HEALTH AND REHABILITATION,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2018-03-21,867,J,1,0,9RON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the facility's profile, facility's policy, review of the Quality Assurance Performance Improvement (QAPI) committee monthly meetings, and interview, the QAPI committee failed to ensure sustained compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities by identifying issues and implementing a corrective action plan with monitors to ensure the adverse event of an Involuntary Discharge Notice, issued 12/21/17, was appropriate and acceptable as a safe discharge. The QAPI committee failed to identify the untoward outcomes and take corrective action related to the unplanned discharge, which took place during the appeals process, and resulted in an unsafe discharge for 1 resident (#123) of 3 residents reviewed for discharge. The failure of the QAPI committee to ensure a safe and orderly discharge resulted in Resident #123's discharge to an unsafe environment and placed Resident #123 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death). The Immediate Jeopardy was effective 2/9/18 and is ongoing. The findings included: Review of the facility profile revealed the facility had a Federal recertification survey on 12/7/16 and was cited Immediate Jeopardy for the following: 483.10 - Notification of Changes for failure to notify the Physician of the presence of 2 pressure ulcers; 483.12 - Freedom from Abuse, Neglect, and Exploitation for failure to prevent abuse, neglect, report allegations, and complete thorough investigations of allegations. 483.21 - Comprehensive Resident Centered Care Plans for failure to revise the care plan. 483.25 - Quality of Care for failure to provide wound assessment and treatment for [REDACTED]. 483.24 - Quality of Life for failure to provide timely incontinence care. 483.35 - Nursing Services for failure to ensure adequate staffing to provide necessary personal care assistance and incontinence care in a timely manner. 483.70 - Administration, Governing Body, and Medical Director for failure to provide oversight of the facility in a manner to ensure residents attain the highest practicable well-being possible. 483.75 - Quality Assurance and Performance Improvement (QAPI) for failure to ensure the QAPI committee identified issues, implemented corrective action plans when needed, monitored and enforced facility policy. The facility was entered into the Special Focus Facility Program on 3/20/17. Review of the facility's policy, Transfer or Discharge Notice, not dated, revealed, .1. A resident .will be given a thirty (30) day written notice of an impending transfer or discharge .3. The resident will be notified in writing .c. The location to which the resident is being transferred or discharged .10. At the time of notification, the facility will provide each resident .with the following information: a. The plan for the transfer and adequate relocation of the resident .c. Assurances the resident will be transferred to the most appropriate facility or setting to meet his or her needs in terms of quality, services and location . Review of the QAPI committee monthly meetings from (MONTH) (YEAR) through (MONTH) (YEAR) revealed the Administrator, the Medical Director, and the Social Services Director were all members of the committee and present at the meetings. Further review revealed the last meeting of the committee submitted for review by the survey team was 12/12/17. Review of the facility's document, Notice of Involuntary Discharge, revealed the notice was hand delivered to Resident #123 on 12/21/17. Review of the notice revealed, .you have recently had multiple violations of the Resident Smoking Rules . Medical record review of the Attending Physician's History and Physical dated 1/5/18 revealed, .he (Resident #123) has been followed by psych (psychiatric services) and requires [MEDICATION NAME] (antipsychotic medication) to try to prevent mood swings .he continues to smoke. He has been caught smoking in his room twice, and he was given a 30 day notice of discharge about 2 weeks ago due to this issue . Review of a Social Progress Note by the SSD dated 2/2/18 revealed, This writer contacted (Choices Transition Coordinator-State Medicaid program) for update. He (Transition Coordinator) said he would set up transportation for resident to look at house and meet roommates next week. Medical record review of the Nurse Practitioner's (NP) progress note dated 2/9/18 revealed, .I am seeing pt (patient) today to discharge. Pt was caught again smoking in a restricted area. Pt is hostile at assessment. Refuses to give name of PCP (primary care physician) or pharmacy. Has letter of court date continuation and believes he can stay here by law. He allows me to assess him, but tells me 'you cannot discharge me!!' Interview with the Interim Administrator and the Social Services Director (SSD) in the Social Services office on 3/7/18 at 10:50 AM, confirmed Resident #123 filed an appeal on 1/3/18 of the Involuntary Discharge Notice dated 12/21/17. Continued interview revealed on 2/2/18, a conference call was conducted with Resident #123, his sister, the Interim Administrator, the SSD, the Commissioner's Designee for the Tennessee Department of Finance and Administration, and the presiding Administrative Law Judge (ALJ). Further interview confirmed the ALJ issued a continuation of the appeal and set the next court date for 2/21/18 to allow time for Resident #123 to obtain an attorney. Interview continued and the Interim Administrator stated Resident #123, .broke his contract with me (on 2/9/18) .he smoked unsupervised in the designated outside smoking area .he refused to give me his igniter (clarified lighter or matches) . Interview continued and the Interim Administrator stated the facility had a right to emergently discharge the resident, .he (Resident #23) would not give me his igniter .he endangered the safety of the other residents . Continued interview revealed the Interim Administrator clarified the contract with Resident #123 was a verbal agreement between the Interim Administrator and the resident, not a written agreement. Continued interview on 3/7/18 at 10:50 AM, in the Social Services office revealed the SSD notified the resident's sister by phone on 2/9/18, at 4:00 PM, after the resident's discharge, .I gave her his hotel room number . Interview continued and the Interim Administrator stated .he was responsible for himself .we paid for 3 nights .our van took him to the hotel .the hotel provided a phone and complimentary breakfast meal. Further interview confirmed the SSD did not know if Resident #123 had any money, and no other arrangements had been made for Resident #123 to receive meals. Continued interview confirmed the resident's prescribed medications were called to a local pharmacy for delivery to the resident at the hotel. Further interview confirmed on 2/12/18 the SSD became aware the medications had not been delivered to the resident. Continued interview confirmed the SSD and Licensed Practical Nurse #4 had delivered some of Resident #123's prescribed medications remaining at the Long Term Care facility to the resident at his hotel room on 2/13/18. Telephone interview with the Ombudsman for the facility, on 3/20/18 at 10:30 AM, confirmed the Ombudsman was not made aware Resident #123 was being discharged on [DATE] and stated, No one knew he was being discharged . Interview continued and revealed, .the attorney from Legal Aid came to my office early on Monday (2/12/18) and told me he had a voice mail from the resident's sister about the discharge .I went to the nursing home .I told them he didn't have a phone .I saw the social worker (SSD) call his room in front of me and then call the front office of the hotel about his phone not working .I told them he didn't have his meds on Monday when I was there (at the nursing home) .I was there about 9:00 AM .the sister paid for another night at the hotel . Interview with the Interim Administrator on 3/20/18 at 11:40 AM, in room [ROOM NUMBER], revealed .not aware of a plan for him to visit (group homes) the following Thursday (2/15/18) .I just started 1/29/18. Continued interview revealed the facility's interdisciplinary team, the supervising Administrator for the Interim Administrator, the resident's Medicaid insurance case manager, and the Medical Director had not been consulted prior to the decision to discharge Resident #123 to a hotel room on 2/9/18. Interview with the Medical Director on 3/20/18 at 4:00 PM, in room [ROOM NUMBER], revealed he did not know of the 2/9/18 discharge prior to Resident #123's being discharged to a hotel room, I wasn't called .I knew there was a dust up or whatever because of smoking. Continued interview revealed he did not know until 3/20/18 the resident did not have his meds at discharge, I didn't know he didn't have his meds for those days. Continued interview revealed, I didn't know about Choices planning a transfer. Continued interview revealed the involuntary discharge notice of 12/21/17 had not been addressed by the QAPI committee as an adverse event. The QAPI committee did not convene to identify the cause and take corrective action when the facility failed to ensure a safe and orderly discharge for Resident #123 resulting in Immediate Jeopardy. Refer to F-622 (J), F-623 (J), F-624 (J), F-745 (J), F-835 (J) and F-837 (J).",2020-09-01
800,BROOKHAVEN HEALTH AND REHABILITATION,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2019-06-19,561,D,0,1,S00P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, medical record review, observation and interview the facility failed to ensure 2 residents (#44, #154) received their scheduled showers of 13 sampled residents. The findings include: Review of the facility policy, Shower/Tub Bath, revised 10/2010 revealed .The following information should be recorded on the resident's medical record .The date and time the shower/tub bath was performed .The name and title of the individual(s) who assisted the resident with the shower/tub bath .Notify the supervisor if the resident refuses the shower/tub bath . Medical record review revealed Resident #44 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 had a BIMS (Brief Interview for Mental Status) score of 15, indicating he was cognitively intact, required limited assist of 1 for transfers, toileting and dressing, and was totally dependent on staff for bathing. Medical record review of the care plan dated 3/25/19, revealed resident has a self-care deficit with an intervention to give shower/bed bath per resident's preference as scheduled. Medical record review of the CNA (Certified Nursing Assistant) ADL (Activities of Daily Living) FLOW RECORD dated 6/1/19-6/18/19 revealed the resident received 1 shower indicating the resident had only received 1 of 5 scheduled showers. Interview with Resident #44 during the resident council meeting on 6/18/19 at 3:00 PM, in the dining room, confirmed he had not received his scheduled showers. Interview with the Corporate Nurse on 06/18/19 at 4:10 PM, in the conference room confirmed Resident #44 had 1 shower on 6/6/19 for the month of June. Interview with CNA #1 on 6/18/19 at 4:35 PM, in the conference room confirmed there have been times, especially lately that she has been unable to complete her assigned showers. Medical record review revealed Resident #154 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the care plan dated 5/28/19, revealed .has potential for self care deficit .Assist with showering per schedule and prn (as needed) . Medical record review of an Activity Evaluation dated 5/28/19 revealed .Interview for Daily Preferences .how important is it to you to choose between a tub bath, shower, bed bath, or sponge bath .1. Very important . Medical record review of an Admission MDS dated [DATE] revealed a BIMS score of 15, indicating the resident is cognitively intact. Review of a Nurse Aide Information Sheet revealed the resident prefers a shower and required the assistance of 1 staff for locomotion and transfer with a wheelchair. Review of the facility's CNA ADL FLOW RECORD dated (MONTH) 2019 revealed no showers or baths were completed from 6/7/19-6/16/19. Medical record review of the Social Services Director (SSD) notes revealed the SSD spoke with staff regarding Resident #154's shower concerns on 5/29, 5/30, 6/5 and 6/6/19. Continued review revealed on 6/6/19 the SSD spoke with the Administrator regarding Resident #154's lack of showers. Further review revealed the resident received a shower on 6/6/19, indicating the resident received 2 of the 4 scheduled showers. Interview with Resident #154 on 6/17/19 at 1:51 PM, in the resident's room, confirmed the resident had not received her scheduled showers. Continued interview confirmed the resident was able to sponge bath at the sink but was unable to wash her hair. Interview with Social Services Director on 6/18/19 at 1:25 PM, in the conference room confirmed Resident #154 wanted a female present during the shower and staff were aware of the residents request. Further interview confirmed the facility is still .missing the mark . on completing scheduled showers. Interview with the Director of Nursing on 6/18/19 at 10:55 AM, in the conference room confirmed residents should be offered a shower or bath two times a week and she was aware residents had not received all of the scheduled showers.",2020-09-01
801,BROOKHAVEN HEALTH AND REHABILITATION,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2019-06-19,758,D,0,1,S00P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview the facility failed to provide a 14 day stop date for a prn (as needed) anti-psychotic drug for 1 resident (#40) of 5 residents reviewed for unnecessary medications of 13 sampled residents. The findings include: Medical record review revealed Resident #40 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident was admitted to hospice services on 2/20/19. Medical record review of the Significant Change Minimum (MDS) data set [DATE] revealed the resident was severely cognitively impaired. Continued review revealed Resident #40 experienced physical and verbal behaviors towards others, as well as, other behavioral symptoms not directed towards others 1-3 days of the week and required extensive to total assist with 1 staff member for activities of daily living. Medical record review of Resident #40's physician telephone order dated 3/1/19 revealed .[MEDICATION NAME] (antipsychotic medication) 5 mg (milligrams) po (by mouth) q (every) 4 (hours) prn (as needed) agitation . Continued review revealed no stop date for the medication. Medical record review of the Consultant Pharmacist Communication to the Physician dated 4/2019 revealed .Communication/Recommendation .Patient safety, and the safety of others, is a primary concern. However, PRN Antipsychotics are considered a form of restraint, and should be used only for behaviors that could be harmful to the resident or others. The most recent CMS guidelines restrict the use of PRN Antipsychotics to 14 days . Medical record review of Resident #40's Medication Administration Record [REDACTED]. Continued review revealed the resident received two doses on 3/23, 3/24, and 3/25/19. Medical record review of Resident #40's Medication Administration Record [REDACTED]. Interview with the Director of Nursing on 6/19/19 at 8:14 AM, at the nurse's station confirmed Resident #40's physician's orders [REDACTED]. Continued interview confirmed Resident #40 continued to receive 12 doses of [MEDICATION NAME] after the required 14 day stop date of a PRN antipsychotic .it should have been discontinued and reordered .",2020-09-01
802,"NHC HEALTHCARE, LAWRENCEBURG",445180,374 BRINK ST PO BOX 906,LAWRENCEBURG,TN,38464,2019-05-01,557,D,0,1,MD3811,"**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 a resident's dignity and respect during dressing changes for 1 of 2 (Resident #73) sampled resident's reviewed. The findings include: The facility's undated Privacy policy documented, .Privacy is also maintained during toileting, bathing and other activities . Medical record review revealed Resident #73 was admitted on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #73's room on 5/1/19 beginning at 9:20 AM, revealed the Assistant Director of Nursing (ADON) assisted with Resident #73's dressing changes. The ADON exposed the resident from the waist down, exposing Resident #73's genitalia from 9:20 AM until 10:02 AM. Interview with the Director of Nursing (DON) on 5/1/19 at 11:24 AM, in the Conference Room, the DON was asked if she expected residents to be covered during a dressing change. The DON stated, We should keep the private parts covered.",2020-09-01
803,"NHC HEALTHCARE, LAWRENCEBURG",445180,374 BRINK ST PO BOX 906,LAWRENCEBURG,TN,38464,2019-05-01,604,D,0,1,MD3811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to complete assessments before or during use of a position change alarm for 2 of 2 (Resident #63 and #346) sampled residents reviewed for physical restraints. The findings included: 1. The facility's undated RESTRAINTS policy documented, .Restraints shall only be used for the safety and well-being of the patient(s) and only after other alternatives have been tried unsuccessfully .Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body .Restraints shall only be used upon the written order of a physician .The order shall include .The specific reason for the restraint .How the restraint will be used to benefit the resident's medical symptom .the type of restraint, and period of time for the use of the restraint . 2. Medical record review revealed Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #63's room on 4/29/19 at 11:57 AM, and 4/30/19 at 4:04 PM, revealed Resident #63 was sitting in a scoot chair with a position change alarm attached to the cushion she was sitting on. Observations in the Activity Room on 4/29/19 at 2:51 PM, and 4/30/17 at 10:17 AM, revealed Resident #63 sitting in a scoot chair with a position change alarm attached to the cushion she was sitting on. Interview with Certified Nursing Assistant (CNA) #1 on 5/1/19 at 8:40 AM, at the 300 Hall Nursing Station, CNA #1 was asked what type of alarms Resident #63 had. CNA #1 stated, She has a pull-away (alarm) in the bed, and a pressure alarm in her chair. CNA #1 was asked why the alarms were in use. CNA #1 stated, She tends to like to stand up, and she is a fall risk. CNA #1 was asked if Resident #63 could remove the pull-away alarm herself. CNA #1 stated, Not that I'm aware of. CNA #1 was asked how long the alarms would be used. CNA #1 stated, I'm not sure. 3. Medical record review revealed Resident #346 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The baseline Care Plan dated 4/18/19 documented, .Problem Start Date .4/18/2019 .Fall Risk .Approach .Personal alarm/s to alert partners of unsafe attempts to transfer . Observations in Resident #246's room on 4/29/19 at 10:29 AM and 4:43 PM, revealed Resident #346 was lying in bed with a pull-away position change alarm in place. Observations in Resident #346's room on 4/29/19 at 11:41 AM and 12:31 PM, and 4/30/19 at 11:53 AM, revealed Resident #346 sitting in a wheelchair with a pull-away position change alarm in place. Observations in Resident #346's room on 4/30/19 at 5:01 PM, revealed Resident #346 sitting in a bedside chair with a pull-away position change alarm in place. Interview with CNA #1 on 5/1/19 at 8:40 AM, at the 300 Hall Nursing Station, CNA #1 was asked what type of alarms Resident #63 had. CNA #1 confirmed she had pull away alarms for the bed and chair. CNA #1 was asked why the alarms were in use. CNA #1 stated, She is a fall risk. CNA #1 was asked if Resident #63 could remove the pull-away alarm herself. CNA #1 stated, Not that I'm aware of. Interview with the Director of Nursing (DON) on 5/1/19 at 11:17 AM, in the Conference Room, the DON was asked if any other interventions were attempted before the pull-away alarms were put in place for Resident #346 on the day of her admission. The DON stated, I think her family insisted for it to be on her. I think that was why that got put on immediately. The DON was asked if there were any assessments related to resident alarms. The DON confirmed there were no assessments. The facility was unable to provide any policies or protocols for the use of position change alarms. The facility was unable to provide assessments for the alarms before use or ongoing evaluations during use, and was unable to provide documentation for the expected duration of the alarm use.",2020-09-01
804,"NHC HEALTHCARE, LAWRENCEBURG",445180,374 BRINK ST PO BOX 906,LAWRENCEBURG,TN,38464,2019-05-01,690,D,0,1,MD3811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to provide appropriate care and services for 2 of 2 (Resident #22 and #73) residents with an indwelling catheter. The findings include: 1. The facility's undated Catheter Drainage System, Closed policy documented, .Never allow drainage bag to be at a level above the bladder . 2. Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed moderate cognitive impairment, total dependence on staff for all activities of daily living, and use of an indwelling urinary catheter. Observations in Resident #22's room on 4/30/19 at 11:55 AM, revealed Resident #22 lying in bed with the indwelling catheter drainage bag lying in bed beside her. Interview with the Director of Nursing (DON) on 5/1/19 at 11:12 AM, in the Conference Room, the DON was asked if it was acceptable for staff to leave the indwelling catheter drainage bag in the bed with the resident. The DON stated, .They are supposed to put it right back down. 3. Medical record review revealed Resident #73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed moderate cognitive impairment, required extensive to total assistance with activities of daily living, and had an indwelling catheter. Observations in Resident #73's room on 5/1/19 beginning at 9:20 AM, revealed the Assistant Director of Nursing (ADON) assisted with Resident #73's dressing changes. She placed Resident #73's bed side drainage bag on the bed with the resident from 9:20 AM to 10:02 AM. Interview with the DON on 5/1/19 at 11:25 AM, in the Conference Room, the DON was asked if a bedside drainage bag should be lying on the bed during a lengthy dressing change. The DON stated, No.",2020-09-01
805,"NHC HEALTHCARE, LAWRENCEBURG",445180,374 BRINK ST PO BOX 906,LAWRENCEBURG,TN,38464,2019-05-01,698,D,0,1,MD3811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, [MEDICAL TREATMENT] Communication Worksheets, and interview, the facility failed to provide appropriate care and services of a resident receiving [MEDICAL TREATMENT] for 1 of 1 (Resident #60) sampled residents receiving [MEDICAL TREATMENT]. The findings include: 1. The facility's undated [MEDICAL TREATMENT] Communication policy documented, .PR[NAME]EDURE .Complete [MEDICAL TREATMENT] Communication Worksheet form a. Center (Nursing Home) nurse complete on [MEDICAL TREATMENT] days . 2. Medical record review revealed Resident #60 was admitted to the facility with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] and the 60 day MDS dated [DATE] documented Resident #60 was cognitively intact and received [MEDICAL TREATMENT]. The [MEDICAL TREATMENT] Communication Worksheet dated 4/25/19, 4/27/19, and 4/30/19 revealed the pre-[MEDICAL TREATMENT] information for Resident #60 was not completed. 3. Interview with the Director of Nursing (DON) on 5/1/19 at 10:29 AM, in the Conference Room, the DON was asked to explain the [MEDICAL TREATMENT] communication process. The DON stated, .supposed to send a [MEDICAL TREATMENT] Communication Worksheet with the resident to [MEDICAL TREATMENT] and they are to bring the form back .the pre-[MEDICAL TREATMENT] part of the sheet is supposed to be completed by the staff . The DON was asked did the facility communicate a pre-[MEDICAL TREATMENT] report to the [MEDICAL TREATMENT] center on the [MEDICAL TREATMENT] Communication Worksheets dated 4/25/19, 4/27/19, and 4/30/19. The DON stated, No .",2020-09-01
806,"NHC HEALTHCARE, LAWRENCEBURG",445180,374 BRINK ST PO BOX 906,LAWRENCEBURG,TN,38464,2019-05-01,761,D,0,1,MD3811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation and interview, the facility failed to ensure medications were stored properly and safely in 1 of 6 (300 Hall Medication Cart) medication storage areas. The findings include: 1. The facility's MEDICATION STORAGE IN THE FACILITY policy dated 6/2016 documented, .Orally administered medications are kept separate from externally used medications and treatments such as suppositories, ointments, creams .by physical barrier including but not limited to baggies, storage containers, boxes . 2. Observations in the 300 Hall Medication Cart on 4/30/19 at 12:20 PM, revealed the following items in the same drawer with no separation: a. 1 container of menthol roll-on pain reliever labeled, .External use only . b. 1 container of aspirin c. 1 container of [MEDICATION NAME] d. 1 container of stool softener e. 1 container of antidiarrheal medication Observations in the 300 Hall Medication Cart on 4/30/19 at 12:24 PM, revealed the following items in the same drawer with no separation: a. 2 containers of antacid b. 1 container of eye drops c. 1 container of foot cream Interview with Licensed Practical Nurse (LPN) #1 on 4/30/19 at 12:27 PM, at the 300 Hall Medication Cart, LPN #1 was asked if external and internal medications should be stored together without a divider. LPN #1 stated, No. Interview with the Director of Nursing (DON) on 5/1/19 at 11:31 AM, in the Day Room, the DON was asked if internal and external medications should be stored side by side with no divider in the medication cart. The DON stated, No .should be separated by a divider.",2020-09-01
807,"NHC HEALTHCARE, LAWRENCEBURG",445180,374 BRINK ST PO BOX 906,LAWRENCEBURG,TN,38464,2019-05-01,812,D,0,1,MD3811,"Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 5 of 25 (Certified Nursing Assistant (CNA) #2, Nursing Assistant (NA) #1, CNA #3, #4, and NA #2) staff members failed to perform proper hand hygiene during dining. The findings include: The facility's .INFECTION CONTROL MANUAL .HANDWASHING policy dated 10/1/08 documented, .Wash hands before and after contact with each patient, after toileting, smoking or eating, and before and after removal of gloves . Observations in Resident #29's room on 4/29/18 beginning at 12:15 PM, revealed CNA #2 touched the overbed table, positioned the table, then placed her bare hands on the Resident #29's sandwich while cutting the sandwich into 4 sections. Observations in Resident #15's room on 4/29/19 at 12:26 PM, revealed NA #1 delivered Resident #15's meal tray and placed it on the overbed table. NA #1 moved the overbed table around the bed, picked up a wedge pillow and placed it on the top of the bed, moved a chair around the bed, applied a clothing protector to Resident #15, put a straw in the tea using her bare hands, removed a glove from her pocket and placed it on her right hand, and assisted Resident #15 with her meal. NA #1 failed to perform hand hygiene after touching objects in Resident #5's room and assisting the resident with her meal. Observations in Resident #29's room on 4/30/18 beginning at 8:03 AM, revealed CNA #3 touched the bed control, touched the overbed table, donned gloves, and handled Resident #29's biscuit. CNA #3 did not perform hand hygiene prior to donning the gloves and touching Resident #29's biscuit. Observations in Resident #50's room on 4/30/19 at 8:05 AM, revealed CNA #4 donned gloves and assisted Resident #50 with her dentures. CNA #4 continued to set up the breakfast tray wearing the same gloves. CNA #4 did not remove her gloves and perform hand hygiene after touching the dentures and before setting up Resident #50's meal tray. Observations in Resident #37's room on 4/30/19 at 4:50 PM, revealed CNA #2 delivered Resident #37's meal tray. Resident #37 stated, I'm wet . CNA #2 applied gloves and performed pericare. CNA #2 removed her gloves, set up the meal tray, placed a spoon in the bowl, opened the straw, and placed it in the drink without performing hand hygiene. Observations in Resident #5's room on 4/30/19 at 5:48 PM, revealed NA #2 delivered Resident #5's dinner tray an placed it on the overbed table. NA #2 repositioned Resident #5 in bed, removed a pillow from Resident #5's roommate's chair and placed it on the roommate's bed, pulled the chair from the roommate's bedside to Resident #5's bedside, sat in the chair, raised the head of bed using the remote, unwrapped Resident #5's silverware, applied a clothing protector to Resident #5, and assisted Resident #5 with her meal. NA #2 failed to perform hand hygiene after touching objects in Resident #5's room and before assisting the resident with her meal. Interview with CNA #2 on 4/30/19 at 5:36 PM, in the 200 Hall Nurses' Station, CNA #2 was asked what she should have done after performing pericare and before setting up the meal tray. CNA #2 stated, .wash my hands .just forgot . Interview with the Director of Nursing (DON) on 5/1/19 at 9:36 AM, in the DON office, the DON was asked if it was appropriate to perform perineal care, then set up a meal tray without performing hand hygiene. The DON stated, No . Interview with the (DON) on 5/1/19 at 11:21 AM, in the Conference Room, the DON was asked when she expected staff to perform hand hygiene during dining. The DON stated, Before and after, and if they contaminate themselves, touch part of their body, adjust the patient, or touch another item . The DON was asked if she expected them to perform hand hygiene before and after glove use. The DON stated, Yes, before and after. Interview with the DON on 5/1/19 at 11:28 AM, in the Day Room, the DON was asked if it was appropriate for staff to touch residents' food with their bare hands. The DON stated, No. The DON was asked it it was appropriate for staff to touch inanimate objects in the resident's room with gloves and wear those same gloves to handle the residents' food and tray items. The DON stated, No.",2020-09-01
808,"NHC HEALTHCARE, LAWRENCEBURG",445180,374 BRINK ST PO BOX 906,LAWRENCEBURG,TN,38464,2019-05-01,880,D,0,1,MD3811,"**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 1 of 25 (Certified Nursing Assistant (CNA) #5) staff members failed to cover a bedside commode while transporting it through the hall and when 2 of 3 (Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #1) nurses failed to change gloves and perform hand hygiene before administering eye drops, failed to rinse and dry a used nebulizer before placing it in a storage bag, and failed to obtain a new piston syringe to administer gastrostomy medications to a resident. The findings include: 1. The facility's .INFECTION CONTROL MANUAL .HANDWASHING policy dated 10/1/08 documented, .Wash hands before and after contact with each patient, after toileting, smoking or eating, and before and after removal of gloves . The facility's .RESPIRATORY SERVICES PROGRAM policy dated 10/99 documented, Cautions .Nebulizer can become contaminated resulting in infection .INFECTION CONTROL .The nebulizer should be allowed to air dry . 2. Observations in Resident #78's room on 4/29/19 at 12:14 PM, revealed CNA #5 had a glove on her right hand only and took a bedside commode with urine in it out into the hall and emptied it in the Soiled Linen Room. CNA #5 did not cover the commode prior to transporting it through the hall to the Soiled Linen Room. Interview with the Director of Nursing (DON) on 5/1/19 at 11:21 AM, in the Conference Room, the DON was asked how staff should empty bedside commodes. The DON stated, They should wear gloves, take them out of the room to the hopper room. They should have a lid or a cover. The DON was asked if it was appropriate for a CNA to take an uncovered commode containing urine out into the hall. The DON stated, It should have been covered. 3. Medical record review revealed Resident #80 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #80's room on 4/30/19 beginning at 9:30 AM, revealed RN #1 donned gloves, listened to Resident #80's breath sounds, and checked her oxygen level. RN #1 then placed medication in the breathing treatment nebulizer, attached it to the mask, placed the nebulizer mask on Resident #80, and turned on the breathing treatment machine. RN #1 then administered 1 drop of eye medication to both of Resident #80's eyes. RN #1 did not remove her gloves and perform hand hygiene between preparing the breathing treatment and administering the eye drops. Interview with the DON on 5/1/19 at 11:32 AM, in the Day Room, the DON was asked if it was appropriate to touch the patient and other items in the room while wearing gloves and continue to wear those same gloves to administer eye drops to a resident. The DON stated, No. 4. Observations in Resident #80's room on 4/30/19 at 9:50 AM, revealed RN #1 removed the breathing treatment mask and reservoir from Resident #80 and handed it to LPN #1. LPN #1 placed the used mask and nebulizer in the nebulizer storage bag. LPN #1 did not rinse the used nebulizer and allow it to air dry prior to placing it in the storage bag. Interview with the DON on 5/1/19 at 11:34 AM, in the Day Room, the DON was asked what staff should do after a breathing treatment was completed. The DON stated, .Wash the medicine reservoir after removing it from the mask, let it dry .then place it in the bag . Interview with LPN #1 on 5/1/19 at 11:58 AM, in the 300 Hall, LPN #1 was asked if the nebulizer should have been rinsed and air dried before it was placed in the storage bag. LPN #1 confirmed the nebulizer should have been rinsed and allowed to air dry before it was placed in the storage bag. 5. Observations in Resident #80's room on 4/30/19 at 9:58 AM, revealed RN #1 used a 60 ml (milliliter) piston syringe dated 4/29/19 to administer medications through Resident #80's gastrostomy tube. Interview with RN #1 on 4/30/19 at 10:00 AM, in Resident #80's room, RN #1 looked at the date on the piston syringe and stated, Oh, today's the 30th .it should have been changed . Interview with the DON on 5/1/19 at 11:42 AM, in the Day Room, the DON was asked how often piston syringes for gastrostomy tube medication administration should be changed. The DON stated, Daily .there should have been a new one with the current date for the nurse when she came to the room for med (medication) pass.",2020-09-01
809,"NHC HEALTHCARE, LAWRENCEBURG",445180,374 BRINK ST PO BOX 906,LAWRENCEBURG,TN,38464,2017-06-02,441,D,0,1,I3EX11,"Based on policy review, observation, and interview 1 of 5 (Licensed Practical Nurses (LPN) #1) nurses observed during medication administration and 1 of 16 (Nurse Aide #1) staff members observed during dining failed to perform hand hygiene to prevent the spread of infection. The findings included: 1. Review of the facility's MEDICATION ADMINISTRATION PER FEEDING TUBE policy documented .1. Knock on patient's door .4. Wash hands and DON gloves 5. Check tube placement .7. Administer medications . Observations at the 100 hall nurses station on 5/30/17 at 11:54 AM, revealed LPN #1 prepared Resident #74's medication, donned gloves, walked to Resident's 74's room, knocked on the door, stopped the tube feeding pump, turned on the faucet with her gloved hand, obtained a cup of water, and turned the water off with her gloved hand. LPN #1 then disconnected the feeding, checked placement by aspiration and auscultation, flushed the tube with water, administered the medication through the tube, flushed the tube with water, reconnected the feeding, discarded her trash, rinsed the syringe used to administer the medication, and placed the syringe in a bag. LPN #1 failed to remove her soiled gloves and perform hand hygiene prior to administering medication to Resident #74. Interview with the Director of Nursing (DON) on 5/31/17 at 10:11 AM, in the DON office, the DON was asked if it was acceptable to put on gloves at the nurses station, touch items in the room, obtain water from a faucet, turn off the faucet and administer medications through a Percutaneous Endoscopic Gastrostomy (PEG) tube without performing hand hygiene and changing gloves. The DON stated, No. 2. Review of the facility's INFECTION CONTROL MANUAL, HANDWASHING policy documented, .wash hands before and after contact with each patient . Observations during dinning on 5/30/17 at 12:19 PM, revealed Nurse Aide #1 washed her hands, touched the remote control to the bed, set up the meal tray, touched the chair, then began feeding the resident without performing hand hygiene. Interview with Certified Nursing Assistant (CNA) #1 and Nurses Aid #1 on 5/30/17 2:39 PM, on the 200 hall CNA #1, and Nurses Aid #1 were asked if it was appropriate to touch the remote control on the bed, move the bedside table, touch a chair and set up the meal tray and not wash their hands before assisting a resident with their meal. CNA #1 stated .we are to wash our hands or use hand sanitizer after touching anything . Interview with the Assistant Director of Nursing (ADON) on 6/1/17 at 8:11 AM, in the day room, the ADON was asked if it was appropriate to touch the remote control on the bed, move the bedside table, and touch the chair without performing hand hygiene, before assisting a resident with a meal. The ADON stated .she should have washed her hands . Interview with Registered Nurse (RN) #1 on 6/01/17 at 10:52 AM, in the conference room, RN #1 was asked if it was appropriate for the nurses aid to touch the remote control, move the bedside table and touch the chair and assist a resident without performing hand hygiene. RN #1 stated, .No, they are taught to wash their hands .",2020-09-01
810,"NHC HEALTHCARE, LAWRENCEBURG",445180,374 BRINK ST PO BOX 906,LAWRENCEBURG,TN,38464,2017-06-02,514,D,0,1,I3EX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to ensure the medical record was complete and accurate for 1 of 14 (Resident #51) sampled residents of the 32 residents included in the stage 2 review. The findings included: 1. Review of the facility's D[NAME]UMENTATION GUIDELINES policy documented .Nurses Notes/Progress Notes are used to record the patient's status and track changes in condition .b) Pertinent nursing observations c) Nursing interventions .2) Progress notes also document: a) Any occurences which are not consistant with the routine care of the patient, b) Nursing interventions to those occurences . Review of the facility's POLICIES AND PR[NAME]EDURES REGARDING CHANGE IN PATIENTS STATUS policy documented .The charge nurse on duty is notified immediately of any change in a patient's condition. The charge nurse will then assess the patient's condition and notify the physician or physician extender and the patient's family/legal representative . 2. Medical record review revealed Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #51 expired at the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a nurses note dated [DATE] at 11:00 PM, revealed Resident #51 was alert and oriented, receiving oxygen at liters per minute, and had no shortness of breath or pain. The Discharge Summary dated [DATE] documented , .Staff was tending to roommate (roommate) then proceeded to check on Pt (patient) found him w/ (with) (symbol for no) BP (blood pressure), (symbol for no) P (pulse), (symbol for no) Resp (Respirations) . Resident #51 was discharged to the funeral home at 2:20 AM. The facility was unable to provide documentation that the charge nurse, physician or family was notified. Interview with the Director of Nursing (DON) on [DATE] at 2:43 PM, in the DON office, the DON was asked if there was a nurse's note that documented the events between [DATE] at 11:00 PM and the discharge to the funeral home on [DATE] at 2:20 AM. The DON stated, .but we were unable to find it in the chart .",2020-09-01
811,"NHC HEALTHCARE, LAWRENCEBURG",445180,374 BRINK ST PO BOX 906,LAWRENCEBURG,TN,38464,2018-06-20,689,D,0,1,2RWO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the For Your Guidance form, observation, and interview, the facility failed to keep the environment free of accident hazards as evidenced by the presence of mouth wash and aerosol cans in 2 of 54 (room [ROOM NUMBER], and 113) resident rooms. The findings included: Review of the For Your Guidance form (from the Admission packet) documented, To assure our safety of our patients, we have developed the following list to help you with items the patient may use .Items that the patient cannot keep in their room .Any items in aerosol cans . Observations in room [ROOM NUMBER] on 6/8/18 at 7:06 AM, 10:13 AM and 4:05 PM, revealed a can of aerosol hair spray sitting on the bedside chest. Observations in room [ROOM NUMBER] on 6/18/18 at 7:14 AM, 10:50 AM, and 4:10 PM, revealed a can of aerosol hair spray sitting on the bedside table. Interview with the Director of Nursing (DON) on 6/18/18 at 3:55 PM, in the DON office, the DON was asked if it was acceptable to have aerosol cans of hairspray at the bedside. The DON stated, No.",2020-09-01
812,"NHC HEALTHCARE, LAWRENCEBURG",445180,374 BRINK ST PO BOX 906,LAWRENCEBURG,TN,38464,2018-06-20,692,D,0,1,2RWO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide nutritional supplements for 1 of 5 (Resident #28) sampled residents reviewed for nutrition. The findings included: Medical record review revealed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Nutrition Narrative Note dated 6/15/18 documented, She (Resident #28) has lost 7.5 # (pounds) in the past month (6% (percent)) .Will continue to provide regular diet with strawberry mighty shakes to provide extra calories and protein . The Care Plan dated 4/26/18 and revised on 6/15/18 documented, .is a dependent diner .with significant weight .loss .APPROACHES .Regular diet provided .with strawberry mightyshake (mighty shake) at mealtime . Observations in Resident #28s room on 6/19/18 at 2:20 PM and 6/20/18 at 8:23 AM, revealed Resident #28 did not receive a strawberry mighty shake at meal time. Interview with the Dietary Manager (DM) on 6/20/18 at 9:05 AM, in the Dietary office, the DM was asked about Resident #28s diet. The DM stated, .strawberry mighty shakes with meals . The DM was asked when does Resident #28 get her mighty shakes. The DM stated, We will provide on her meal trays. The DM was asked how the staff knew to send the mighty shakes on her tray. The DM stated, It should be on the tray card. The DM was shown the tray card and she confirmed the mighty shakes were not on the tray card. The DM stated, It should be on there. The DM was asked if she expected the mighty shakes to be on the meal trays. The DM stated, Um'huh and shook her head yes.",2020-09-01
813,"NHC HEALTHCARE, LAWRENCEBURG",445180,374 BRINK ST PO BOX 906,LAWRENCEBURG,TN,38464,2018-06-20,761,D,0,1,2RWO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure medications were stored securely and safely as evidenced by unattended medications in 3 of 54 (room [ROOM NUMBER], 114, and 301) resident rooms. The findings included: Review of the MEDICATION STORAGE IN THE FACILITY policy documented, .Medications and biologicals are stored safely, securely, and properly .The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff member lawfully authorized to administer medications . Review of the For Your Guidance form (from the Admission packet) documented, To assure our safety of our patients, we have developed the following list to help you with items the patient may use .Items that the patient cannot keep in their room .Any medicated items .Over the counter medications . Observations in room [ROOM NUMBER] on 6/18/18 at 7:06 AM,10:13 AM, and 4:05 PM, revealed a [MEDICATION NAME] inhaler in the room. Observations in room [ROOM NUMBER] on 6/18/18 at 7:17 AM, 10:25 AM, and 12:53 AM, revealed 1 bottle of aspirin, 1 box of medicated pain patches, and a jar of [MEDICATION NAME] skin protectant in the room. Observations In room [ROOM NUMBER] on 6/18/18 at 4:18 PM, revealed a tube of Icy Hot (pain relieving cream) sitting by the sink. Interview with the Director of Nursing (DON) on 6/18/18 at 3:55 PM, in the DON office, the DON was asked if it was acceptable for a resident to have a [MEDICATION NAME] inhaler at the bedside. The DON stated, No . The DON was asked if it was acceptable to have a bottle of aspirin stored in the resident's room. The DON stated, No. The DON as asked if it was acceptable to have a box of medicated pain patches stored at the bedside. The DON stated, No. The DON was asked if it was acceptable to have [MEDICATION NAME] skin protectant stored at the bedside. The DON stated, No. Interview with the DON on 6/18/18 at 4:19 PM, in room [ROOM NUMBER], the DON confirmed a tube of Icy Hot was sitting by the sink.",2020-09-01
814,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2018-02-23,656,D,1,0,42HQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview, the facility failed to develop a plan of care to address moods for 1 of 7 samples residents (Resident #6). Findings include: Review of the undated facility policy MDS/Care Plans revealed .The facility must develop a comprehensive care plan to meet a resident's .needs . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed adequate hearing and vision, clear speech, usually made self understood, and understood others; Brief Interview for Mental Status (BIMS) was 13/15, indicating he was cognitively intact, and exhibited little interest, feeling down/depressed, tired, and change of appetite for 2-6 days of the review period. Medical review of the Quarterly MDS dated [DATE] revealed the BIMS score of 14/15; and exhibited feeling down/depressed for 2-6 days of the review period. Medical record review of the care plan with completion date of 11/30/17 and revised in 1/19/18 revealed feeling down/depressed and tired were not addressed. Interview with the Registered Nurse (RN) #1/ MDS Coordinator on 2/21/18 at 8:45 AM in the conference room confirmed the care plan with completion date of 11/30/17 failed to address the resident was down/depressed and tired. Further interview confirmed the care plan with the completion date of 1/19/18 failed to address feeling down/depressed.",2020-09-01
815,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2018-02-23,657,D,1,0,42HQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility documentation review, and interview, the facility failed to timely revise a plan of care to address manipulative behaviors for 1 of 7 samples residents (Resident #6). Findings include: Review of the undated facility policy MDS/Care Plans revealed .The facility must develop a comprehensive care plan to meet a resident's .needs .are reviewed and/or revised . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed adequate hearing and vision, clear speech, usually made self understood, and understood others; Brief Interview for Mental Status (BIMS) was 13/15, indicating he was cognitively intact; exhibited no [MEDICAL CONDITIONS], or behaviors; exhibited little interest, feeling down/depressed, tired, change appetite for 2-6 days of the review period. Medical review of the Quarterly MDS dated [DATE] revealed adequate hearing and vision, clear speech, usually made self understood, and understood others; BIMS score of 14/15; exhibited feeling down/depressed for 2-6 days of the review period; and exhibited no [MEDICAL CONDITIONS], or behaviors. Medical record review of facility documentation dated 1/31/18 revealed Resident #6 informed Certified Nurse Aide (CNA) #3 of CNA #1 got in bed with Resident #6 on 1/30/18. Further facility documentation review revealed the resident had made a false accusation. Medical record review of the care plan dated 2/12/18 revealed on a problem was initiated addressing the resident .exhibiting behavior symptoms as making false accusations toward staff while providing care and being manipulative toward staff when providing care . The approaches dated 2/12/18 included .Acknowledge resident feelings & (and) try to negotiate an agreement to stay until all concerned parties can be brought together to satisfactorily strategize the resident's needs; Document behaviors. Attempt to identify pattern to target interventions; Staff will enter (resident's) room with two people to provide care due to making false allegations . The approach dated 2/16/18 revealed .Will be refer to psych (psychiatric) for evaluation . Interview with the Registered Nurse (RN) #1/MDS Coordinator on 2/21/18 at 8:45 AM in the conference room revealed the comprehensive care plan and the Certified Nurse Aide (CNA) Bedside Care Plans, addressing resident care and needs, were updated with any new concerns or interventions. Further interview confirmed the facility failed to timely revise the care plan after the false allegation and manipulation of staff was reported on 1/31/18. Interview with the Social Worker (SW) on 2/21/18 at 9:32 AM in the conference room confirmed the SW was responsible to address behaviors on the MDS and the care plan. Further interview confirmed the facility failed to timely revise the care plan after the resident's false allegation and manipulation of staff was reported on 1/31/18. Interview with the Administrator on 2/21/18 at 10:52 AM in the conference room confirmed the facility failed to revise the care plan timely after the event was reported on 1/31/18.",2020-09-01
816,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2019-03-26,686,D,0,1,KVF711,"**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 follow physician's orders related to wound care dressing change for 1 resident (#133) of 15 residents receiving wound care. The findings include: Facility policy review, Dressings, Dry/Clean, dated (MONTH) 2013, revealed .Verify that there is a physician's order for this procedure .Apply the ordered dressing .Label with date and initials to top of dressing . Medical record review revealed Resident #133 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Order Summary Report dated (MONTH) 2019 through (MONTH) 2019 revealed .clean with NS (normal saline) pat dry, pack wound with calcium alginate AG (silver), cover with bordered foam dressing every day shift and as needed if dressing becomes dislodged or soiled . Observation of the wound care performed by Licensed Practical Nurse (LPN, wound care nurse) #4 for Resident #133, with the Wound Director present, on 3/25/19 at 12:32 PM in Resident #133's room, revealed the resident's wound dressing was dated 3/22/19. Interview with LPN #4 on 3/25/19 at 12:32 PM in Resident #133's room confirmed the wound dressing was dated 3/22/19. Interview with the Wound Director on 3/25/19 at 12:48 PM in the 100 Hallway confirmed Resident #133's wound dressing was dated 3/22/19 and the dressing was ordered to be changed daily. Interview with the Director of Nursing on 3/26/19 at 3:17 PM in her office confirmed she expected the nurses to follow physician's orders exactly how they are written.",2020-09-01
817,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2019-03-26,695,D,0,1,KVF711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the medical record review, observation and interview, the facility failed to provide necessary respiratory care for residents 2 (#24 and #482 ) of 37 residents receiving respiratory services. The findings include: Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #24's physician order [REDACTED].Change nebulizer mask and tubing weekly; date and place in dated plastic bag (Sun. night). Place in dated bag when not in use . Medical record review of the Care Plan dated 2/25/19 revealed .has [MEDICAL CONDITION] r/t (related to) history of [MEDICAL CONDITION] . Medical record review of the Care Plan dated 3/1/19 to 3/26/19 revealed .at risk for altered breathing pattern r/t (related to) congestion, use of supplemental oxygen, Pneumonia . Observation of Resident #24 in the residents room on 3/24/19 at 9:10 AM and again at 11:35 AM revealed the Nebulizer and tubing lying on the bedside stand unbagged and undated. Medical record review revealed Resident #482 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of Resident #482 in the residents room on 3/24/19 at 9:45 AM and again at 3:17 PM revealed the Bilevel Positive Airway Pressure mask ([MEDICAL CONDITION]) and tubing drapped over the bedside stand unbagged and undated. Further observation on 3/24/19 at 12:39 PM revealed nasal cannual oxygen tubing on the floor. Interview with Licensed Practical Nurse #9 on 3/24/19 at 3:18 PM in Resident #24's room and Resident #482's room confirmed . that the nebulizer and tubing needed to be in the bag when not in use .",2020-09-01
818,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2019-03-26,726,D,0,1,KVF711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the medical record review, observation, and interview, the facility failed to ensure nursing staff have the knowledge and competencies, and skill sets for staging pressure ulcer 1 resident (#100) of 15 residents with staging pressure ulcers. The findings include: Review of the Medical record revealed Resident #100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Wound Admission assessment dated [DATE] revealed . unstageable to bilateral heels, golf size black/purple areas bilaterally . Medical record review of the of the Weekly Wound Report dated 1/16/19 revealed .suspected deep tissue injury of bilateral heels . Interview with the Regional Wound Care Consultant on 3/26/19 at 4:30 PMin the Director of Nursing office revealed, the wound assessment dated [DATE] was . inaccurate . Continued interview revealed the wound was a . deep tissue injury as described on 1/16/19 . Interview with the Regional Wound Care Consultant and Director of Nursing (DON) on 3/26/19 at 5:30 PM and 6:30 PM, respectfully, in the DON's office confirmed wound competencies on the staging of pressue ulcers with the nursing staff have not been done.",2020-09-01
819,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2019-03-26,756,D,0,1,KVF711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview the pharmacist failed to make recommendations for a stop date related to a prn (as needed) anti-psychotic medication for 1 resident (#121) of 32 residents reviewed receiving anti-psychotic medications. The findings include: Review of the undated facility policy, [MEDICAL CONDITION] Medication, revealed .[MEDICAL CONDITION] medications include any drug that affects brain activities associated with mental processes and behavior, including: anti-anxiety/hypnotic, antipsychotic and antidepressant classes of drugs. Physicians and physician-extenders (Ex. Physician Assistant, Nurse Practitioner) will use [MEDICAL CONDITION] medications appropriately, working with the interdisciplinary team to ensure appropriate use, evaluation and monitoring .An appropriate [DIAGNOSES REDACTED].The facility supports the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of [REDACTED].Efforts to reduce dosage or discontinue of psychopharmacological medications will be ongoing as appropriate for the clinical situation .Findings including continued need will be documented in the medical record .PRN (as needed) orders for [MEDICAL CONDITION] medications ate limited to 14 days unless the primary care provider reviews, evaluates and documents the rationale for extension .Documents rational and [DIAGNOSES REDACTED].Evaluates with the interdisciplinary team, effects and side effects of psychoactive medications within 14 days of initiation, increasing, or decreasing dose and during routine visits thereafter .Orders for PRN [MEDICAL CONDITION] medications will be time limited to 14 days and only for specific clearly documented circumstances .Monitors [MEDICAL CONDITION] drug use daily, noting any adverse effects such as increased somnolence or functional decline . Medical record review revealed Resident #121 was admitted to the facility admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident was admitted to hospice services on 2/1/19. Medical record review of Resident #121's physician order [REDACTED].[MEDICATION NAME] Concentrate (an antipsychotic drug used to treat certain types of mental disorders, trade name [MEDICATION NAME]) 2 milligrams per milliliter (mg/ml) give 1 mg by mouth every 3 hours as needed for agitation for 90 days or sublingual .end date 4/28/19 . Medical record review of Resident #121's Order Summary Report dated (MONTH) through (MONTH) 2019 revealed no [MEDICAL CONDITION] drug side effect or behavior monitoring in place for the [MEDICATION NAME]. Medical record review of Resident #121's Medication Administration Record [REDACTED]. Medical record review of Resident #121's monthly drug regimen reviews performed by the pharmacist dated 10/3/18, 10/29/18, 11/28/18, 12/19/18, 1/29/19 and 2/24/19 revealed .The medication regimen of the resident was reviewed, and there were no apparent irregularities noted . Interview with the Director of Nursing on 3/26/19 at 3:11 PM in her office when asked to look at Resident #121's physicians orders confirmed the resident did not have a 14 day stop date for [MEDICATION NAME]. Continued interview confirmed the pharmacist evaluates each resident's medications monthly and sends the facility a report of the recommendations. Telephone interview with the Pharmacist on 3/26/19 at 4:07 PM and at 5:25 PM confirmed when a resident has a prn antipsychotic/[MEDICAL CONDITION] drug ordered, it is limited to 14 days and the resident has to be reevaluated by the physician to extend the prn 14 day stop date. Continued interview when asked about pharmacy recommendations for Resident #121 she stated if she (Resident #121) had an order for [REDACTED].#121).",2020-09-01
820,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2019-03-26,757,D,0,1,KVF711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview the facility failed to have [MEDICAL CONDITION]/antipsychotic drug side effect or behavior monitoring in place for 1 resident (#121) of 32 residents reviewed receiving anti-psychotic medications. The findings include: Review of the undated facility policy, [MEDICAL CONDITION] Medication, revealed .[MEDICAL CONDITION] medications include any drug that affects brain activities associated with mental processes and behavior, including: anti-anxiety/hypnotic, antipsychotic and antidepressant classes of drugs. Physicians and physician-extenders (Ex. Physician Assistant, Nurse Practitioner) will use [MEDICAL CONDITION] medications appropriately, working with the interdisciplinary team to ensure appropriate use, evaluation and monitoring .An appropriate [DIAGNOSES REDACTED].The facility supports the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of [REDACTED].Efforts to reduce dosage or discontinue of psychopharmacological medications will be ongoing as appropriate for the clinical situation .Findings including continued need will be documented in the medical record .PRN (as needed) orders for [MEDICAL CONDITION] medications are limited to 14 days unless the primary care provider reviews, evaluates and documents the rationale for extension .Documents rational and [DIAGNOSES REDACTED].Evaluates with the interdisciplinary team, effects and side effects of psychoactive medications within 14 days of initiation, increasing, or decreasing dose and during routine visits thereafter .Orders for PRN [MEDICAL CONDITION] medications will be time limited to 14 days and only for specific clearly documented circumstances .Monitors [MEDICAL CONDITION] drug use daily, noting any adverse effects such as increased somnolence or functional decline . Medical record review revealed Resident #121 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident was admitted to hospice services on 2/1/19. Medical record review of Resident #121's physician order [REDACTED].[MEDICATION NAME] (trade name [MEDICATION NAME]) [MEDICATION NAME] Concentrate (an antipsychotic drug used to treat certain types of mental disorders) 2 milligrams per milliliter (mg/ml) give 1 mg by mouth every 3 hours as needed for agitation for 90 days or sublingual .end date 4/28/19 . Medical record review of Resident #121's Order Summary Report dated (MONTH) thru (MONTH) 2019 revealed there were no [MEDICAL CONDITION] drug or behavior monitoring in place for [MEDICATION NAME]. Medical record review of Resident #121's Medication Administration Record [REDACTED]. Medical record review of Resident #121's monthly drug regimen reviews performed by the pharmacist dated 10/3/18, 10/29/18, 11/28/18, 12/19/18, 1/29/19 and 2/24/19 revealed .The medication regimen of the resident was reviewed, and there were no apparent irregularities noted . Telephone interview with Resident #121's Hospice Physician on 3/26/19 at 12:18 PM confirmed side effect monitoring is a team effort between hospice and the facility and side effects should be monitored and documented. Interview with the Director of Nursing on 3/26/19 at 3:11 PM in her office when asked to look at Resident #121's physicians orders confirmed the resident did not have any [MEDICAL CONDITION] side effect or behavior monitoring in place.",2020-09-01
821,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2019-03-26,758,D,0,1,KVF711,"**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 an adequate [DIAGNOSES REDACTED].#121) of 32 residents reviewed receiving anti-psychotic medications. The findings include: Review of the undated facility policy, [MEDICAL CONDITION] Medication, revealed .[MEDICAL CONDITION] medications include any drug that affects brain activities associated with mental processes and behavior, including: anti-anxiety/hypnotic, antipsychotic and antidepressant classes of drugs. Physicians and physician-extenders (Ex. Physician Assistant, Nurse Practitioner) will use [MEDICAL CONDITION] medications appropriately, working with the interdisciplinary team to ensure appropriate use, evaluation and monitoring .An appropriate [DIAGNOSES REDACTED].The facility supports the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of [REDACTED].Efforts to reduce dosage or discontinue of psychopharmacological medications will be ongoing as appropriate for the clinical situation .Findings, including continued need will be documented in the medical record .PRN (as needed) orders for [MEDICAL CONDITION] medications are limited to 14 days unless the primary care provider reviews, evaluates and documents the rationale for extension .Documents rational and [DIAGNOSES REDACTED].Evaluates with the interdisciplinary team, effects and side effects of psychoactive medications within 14 days of initiation, increasing, or decreasing dose and during routine visits thereafter .Orders for PRN [MEDICAL CONDITION] medications will be time limited to 14 days and only for specific clearly documented circumstances .Monitors [MEDICAL CONDITION] drug use daily, noting any adverse effects such as increased somnolence or functional decline . Medical record review revealed Resident #121 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident was admitted to hospice services on 2/1/19. Medical record review of Resident #121's physician order [REDACTED].[MEDICATION NAME] Concentrate (an antipsychotic drug used to treat certain types of mental disorders, trade name [MEDICATION NAME]) 2 milligrams per milliliter (mg/ml) give 1 mg by mouth every 3 hours as needed for agitation for 90 days or sublingual .end date 4/28/19 . Medical record review of Resident #121's monthly drug regimen reviews performed by the pharmacist dated 10/3/18, 10/29/18, 11/28/18, 12/19/18, 1/29/19 and 2/24/19 revealed .The medication regimen of the resident was reviewed, and there were no apparent irregularities noted . Telephone interview with Resident #121's Hospice Physician on 3/26/19 at 12:18 PM confirmed she was aware of the 14 day stop date for [MEDICAL CONDITION] medications and stated with hospice patients we have prn (as needed) [MEDICATION NAME] for [MEDICAL CONDITION] and terminal agitation. Continued interview when asked if agitation was a correct [DIAGNOSES REDACTED]. Continued interview confirmed she stated side effect monitoring is a team effort between hospice and the facility and side effects should be monitored and documented. Interview with the Director of Nursing on 3/26/19 at 3:11 PM in her office when asked to look at Resident #121's physicians orders confirmed the resident did not have a 14 day stop date for the prn [MEDICATION NAME]. Continued interview when asked to look at the resident's [DIAGNOSES REDACTED]. Continued interview confirmed the resident has to be reevaluated by the physician to extend the 14 day stop date for a prn anti-psychotic. Continued interview when asked if Resident #121 was re-evaluated by the physician to extend the prn medication stop date she stated no.",2020-09-01
822,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2019-03-26,761,D,0,1,KVF711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, and interview, the facility failed to refrigerate and properly store medications on 4 of 12 medication carts. The findings include: Review of facility policy, Administering Medications, dated 2001, revised (MONTH) 2012, revealed .When opening a multi-dose container, the date opened shall be recorded on the container .Staff shall follow established facility infection control procedures for the administration of medications . Review of facility policy, Storage of Medications, dated 2001, revised (MONTH) 2007, revealed .Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received .The nursing staff shall be responsible for maintaining medication storage AND preparation areas .The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals .Drugs for external use, as well as poisons, shall be clearly marked as such, and shall be stored separately from other medications .Medications requiring refrigeration must be stored in a refrigerator . Observation of the 300B medication cart on [DATE] at 5:20 PM in the hallway with Licensed Practical Nurse (LPN) #1revealed the following: a multiple dose bottle of Optimum Lacto Bacillus (a medication used for the restoration of normal intestinal bacteria after antibiotic use) opened and not dated; a multiple dose bottle of [MEDICATION NAME] (a medication used for pain or fever) 325 milligram (mg) 100 count bottle opened and not dated; a multiple dose bottle of [MEDICATION NAME] 500 mg 100 count bottle opened and not dated; a multiple dose bottle of Aspirin (a medication given for pain, fever, or as an anticoagulant) 325 mg 100 count bottle opened and not dated; a multiple dose bottle of [MEDICATION NAME] (a liquid medication used for upset stomach) 355 milliliters (ml) opened not dated; 1 tube of Preparation H (an ointment used for relief of Hemorrhoids) opened, not dated and not labeled with a resident identifier. Continued observation revealed 1 intravenous (IV) catheter adapter dated ,[DATE], expired. Observation of the 100A medication cart on [DATE] at 5:45 PM in the hallway with LPN #5 revealed the following: a multiple dose bottle of [MEDICATION NAME] (a medication used to thin mucous secretions) 400 mg opened and not dated; a multiple dose bottle of [MEDICATION NAME] solution (a liquid medication used for constipation) 10 milligram per milliliter (mg/ml) opened and not dated; a multiple dose bottle of Dakins solution (a liquid medication used to irrigate wounds) opened and not dated; a multiple dose bottle of Valporic acid (a medication used for treating [MEDICAL CONDITION]) opened and not dated; and a [MEDICATION NAME] suppository (a stimulant/laxative) not labeled with a resident identifier, and not stored in the original container. Observation of the 200B medication cart on [DATE] at 2:30 PM in the 200B nurses station with LPN #7 revealed the following: a multiple dose bottle of [MEDICATION NAME] 5 mg tablets 150 count opened with expiration date [DATE]; 4 [MEDICATION NAME] (used for inhalation treatment for [REDACTED]. Observation of the 400B medication cart on [DATE] at 3:00 PM in the hallway with LPN #8 revealed the following: a FirVanq suspension (an oral form of the antibiotic [MEDICATION NAME] used to treat infections) 25 mg/ml 150 ml bottle unrefrigerated and at room temperature; 2 individually packaged [MEDICATION NAME] (a medication for [MEDICAL CONDITION]) capsules loose in drawer unlabeled; 10 [MEDICATION NAME] not in their original protective foil package, and undated; [MEDICATION NAME] powder (a topical used for fungal rashes) undated and unlabeled; a tube of Vit A&D ointment, a tube of Skin Protective ointment, a tube of Skin Repair ointment, and a tube of [MEDICATION NAME] ointment (all 4 topicals used for prevention and treatment of [REDACTED]. Interview with the Director of Nursing on [DATE] at 6:16 PM in her office confirmed .medications should be stored appropriately on all med carts .",2020-09-01
823,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2019-03-26,880,D,0,1,KVF711,"**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 maintain ice storage container and scoop in a sanitary manner. The findings include: Review of the facility's policy, Ice Machines and Ice Storage chest, revised (MONTH) 2012, revealed .Ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice .Ice making machines, ice storage chests/containers, and ice can all become contaminated by: Unsanitary manipulation by employees, residents, and visitors; Improper storage or handle of ice .To prevent contamination of ice machines, ice storage chests/containers or ice, staff shall follow these precautions: Limit access to ice machines or ice storage chests/containers to employees only; Do not handle ice directly by hand; Keep the ice scoop/bin in a covered container when not in use . Medical record review revealed Resident #146 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #146's quarterly Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 8, indicating the resident was moderately cognitively impaired. Observation on 3/25/19 at 8:30 AM on the 200 hall revealed an unattended ice storage container cart with an empty clear plastic bag sitting on the top of the cart. Continued observation revealed no ice scoop placed in the plastic bag or on top of the cart. Observations on 3/25/19 at 8:55 AM and 10:18 AM on the 200 hall revealed Resident #146 walked up to the unattended ice cart and took the top off of her water pitcher and placed it on top of the cart. Continued observation revealed the resident opened the lid of the ice chest, reached into the chest with her bare hands obtaining the ice scoop from inside the chest. Continued observation revealed the resident filled her cup with ice, replaced the ice scoop back into the ice chest and closed the lid. Interview with Resident #146 on 3/25/19 at 8:55 AM on the 200 hall by the ice storage cart revealed when asked if she got ice from that container she stated I always get my own ice with the scooper, I never touch the ice just the scooper and then I put the scooper back in the container. Interview with the Director of Nursing on 3/25/19 at 10:43 AM on the 200 hall by the ice storage cart confirmed the ice scoop was to be stored in a bag and not in the ice chest. Continued interview when asked the process of passing ice confirmed the CNA's (Certified Nurse Aides) use the cart to pass ice, they are supposed to pass the ice and remove the cart from the hall; Residents should not be getting ice out of it.",2020-09-01
824,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-06-04,224,D,0,1,35VZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview the facility failed to prevent misappropriation of resident medication for 1 of 14 (Resident #58) residents reviewed with controlled substance records. The findings included: 1. The facility's Administering Medications policy documented, .Medications ordered for a particular resident may not be administered to another resident, unless permitted by state law and facility policy, and approved by the Director of Nursing Services. 2. Medical record review revealed Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME]) 5 mg (milligrams)/325 mg tab (1) po (by mouth) q (every) 6 hrs (hours) PRN (as needed) Pain . Review of the CONTROLLED SUBSTANCES record for Resident #58's [MEDICATION NAME] administration tracking revealed the following: 1/27/17 9:15 PM - 1 [MEDICATION NAME] was signed out by the nurse, and the nurse documented, 1 Borrowed for (Resident #213) 1/28/17 6:00 AM - 1 [MEDICATION NAME] was signed out by the nurse, and the nurse documented, 1 Borrowed for (Resident #213) 1/28/17 7:00 AM - 1 [MEDICATION NAME] was signed out by the nurse, and the nurse documented, Borrowed for (Resident #213) 1/30/17 12:15 PM - 1 [MEDICATION NAME] was signed out by the nurse, and the nurse documented, Borrowed for (Resident #194) Review of Resident #58's Medication Administration Record [REDACTED]. 3. Medical record review revealed Resident #213 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME]/acet. ([MEDICATION NAME]) 5-325 mg tab - take (1) po q 6 hours PRN pain . Review of Resident #213's (MONTH) (YEAR) MARs revealed Resident #213 received [MEDICATION NAME] on 1/27/17 at 9:15 PM, on 1/28/17 at 6:00 AM, and on 1/28/17 at 7:00 AM. 4. Medical record review revealed Resident #194 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A PHYSICIAN'S TELEPHONE ORDERS dated 1/30/17 documented, .[MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME]) 5/325 (mg) take 1 tablet BID (twice a day) PRN pain . Review of Resident #194's (MONTH) (YEAR) MAR indicated [REDACTED]. Interview with the Administrator on 6/3/17 at 7:57 PM, in the conference room, the Administrator was asked if it was appropriate for nursing staff to borrow a resident's medication in order to given it to another resident. The Administrator stated, No.",2020-09-01
825,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-06-04,225,E,0,1,35VZ11,"Based on policy review, personnel file review, and interview, the facility failed to conduct abuse registry screenings for 40 of 225 newly hired employees. The findings included: The facility's Abuse Mistreatment and Neglect policy documented, .It is the policy of the facility to respect resident's rights to be free from abuse, mistreatment and neglect .Screening .Pre-employment includes reference checks, screening through the Nurse Aide Registry, background checks and license/registry verification . The Employee Abuse Registry Release Form and Drug Screen Consent Form revealed statements signed by the newly hired employees documented, I hereby authorize (name of the facility) to submit my name, address, social security number and any other data deemed necessary to the appropriate state registry containing information relating to finding of patient abuse or misappropriation of patient's property. The Facility failed to conduct the abuse registry screenings for the following staff members: 25 Certified Nursing Assistants (CNA) 6 Licensed Practical Nurses (LPN) 1 Registered Nurse (RN) 2 Speech Therapists 1 Physical Therapist 1 Housekeeping Employee 1 Activity Employee 1 Business Office Employee 1 Occupational Therapist 1 Certified Occupational Therapy Assistant Review of the (Named company) BACKGROUND CHECK reviewed the following items were listed as being checked by the company: Multi State Criminal, Sex Offender Registry, Social Security Trace, OFAC (Office of Foreign Asset Control), OIG (Office of Inspector General) Healthcare Sanction, Past Address History, and 3 County Criminal Search. The Abuse Registry was not listed. Interview with the Human Resource Manager on 6/1/17 at 11:22 AM, in the Human Resource Manager's office, the Human Resource Manager was asked who conducted the Abuse Registry screenings for newly hired employees. The Human Resource manager stated, We are using a new company that checks our Abuse Registry .as of 4/4/17. The Human Resource Manager was asked whether the Abuse Registry screenings were being conducted for new employees. The Human Resource manager stated, .On the contract it is not listed as being checked . The Human Resource manager was asked if the new employees hired after 4/4/17 were screened for the Abuse registry. The Human Resource manager stated, No.",2020-09-01
826,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-06-04,241,D,0,1,35VZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview the facility failed to treat a resident with dignity and respect when 1 of 3 (Licensed Practical Nurse (LPN) #7) nurses failed to introduce self or explain all procedures to a resident prior to performing care for that resident. The findings included: The facility's Quality of Life - Dignity policy documented, .Residents shall be treated with dignity and respect at all times .Staff shall keep the resident informed and oriented to their environment. Procedures shall be explained before they are performed . Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #25's room on 6/1/17 at 8:18 AM, revealed LPN #7 checked placement of Resident #25's Percutaneous Endoscopic Gastrostomy (PEG) tube, administered medications through the PEG tube, administered eye drops to both Resident #30's eyes, administered insulin by subcutaneous injection into Resident #25's left arm, turned Resident #25 on her side in the bed and applied a medicated patch to Resident #25's back. LPN #7 did not introduce self or explain the procedures prior to beginning the treatments, and did not talk to the resident during the care. Interview with LPN #7 on 6/02/17 at 5:06 PM, at the Station 1 Nurses' Station, LPN #7 was asked if it was acceptable to provide care to a nonverbal resident or any other resident without informing the resident what was being done. LPN #7 stated, Absolutely not. LPN #7 was asked if a resident should be informed before they are given an injection or turned. LPN #7 stated, Yes. Interview with the interim Director of Nursing (DON) on 6/3/17 at 12:29 PM in the conference room, the interim DON was asked if it was acceptable to provide care, give injections, administer eye drops, or turn a resident without explaining what is being done to the resident. The interim DON stated, No, it doesn't matter whether they are cognitively impaired, aphasic or whatever, you introduce yourself to the patient and explain what you are doing.",2020-09-01
827,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-06-04,242,D,0,1,35VZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview the facility failed to honor a resident's choice for meal intake for 1 of 1 (Resident #273) residents reviewed for choices. The findings included: The facility's Resident Rights policy documented, .Freedom of choice to make their own, independent decisions (including refusal of treatment) .Quality care and treatment .have care provided in accordance with their care plan .Participate in care planning . Medical record review revealed Resident #273 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment, and received insulin injections. Observation on 5/30/17 at 4:44 PM, 5/31/17 at 9:18 AM, and 5/31/17 at 10:03 AM, revealed a sign posted on Resident #273's door which documented, No sugar please. Interview with Resident #273's family member on 6/1/17 at 5:35 PM, in Resident #273's room, Resident #273's family member was asked if the facility had tried to change Resident #273's diet according to her wishes for a diabetic diet and supplements. Resident #273's family member stated, I have talked to the Dietitian, and she told me they don't have a special diabetic menu .she could leave things off of her tray .she was getting desserts .she got sweet tea, and we requested unsweet tea .they stated they only have one kind of tea and it's sweet tea .so I asked for milk .the Ensure is a problem too because they are not sugar free . Resident #273's family member was asked whether the facility provided choices for Resident #273. Resident #273's family member stated, No . Interview with Certified Nursing Assistant (CNA) #2 on 6/2/17 at 11:52 AM, on the Station 4A hall, CNA #2 was asked whether she gave Resident #273 her meal tray today. CNA #2 stated, Yes. CNA #2 was asked what type of tea Resident #273 had with her lunch tray. CNA #2 stated, Sweet tea. CNA #2 was asked if she was aware Resident #273 was a diabetic. CNA #2 stated, No .I know there is a sign on the door that says no sugar. Interview with Registered Dietitian (RD) #1 on 6/2/17 at 3:38 PM, in the conference room, RD #1 was asked what type of tea is served on the halls. RD #1 stated, It's sweet tea. RD #1 was asked what interventions were in place for the diabetic residents. RD #1 stated, I tell them we don't have a therapeutic diet . Interview with the interim Director of Nursing (DON) on 6/3/17 at 3:48 PM, in the conference room, the interim DON was asked if a diabetic resident could get a diabetic diet if requested. The interim DON stated, .we should provide what their preferences are. The interim DON was asked if it was acceptable not to honor the resident and family request for no sugar. The interim DON stated, .we should honor their preferences.",2020-09-01
828,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-06-04,282,G,0,1,35VZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to follow the resident care plan interventions related to nutrition and dignity for 2 of 22 (Resident #30 and 25) sampled residents reviewed for care planning of the 41 residents included in the Stage 2 review. Failure of the facility to follow care plan interventions for nutrition resulted in actual harm to Resident #30 who suffered significant weight loss. The findings included: 1. Medical record review revealed Resident #30, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [MEDICAL CONDITIONS], Constipation and Dietary Calcium were acquired after admission to the facility. The care plan dated 9/14/16 revealed, .PROBLEM .POTENTIAL FOR WEIGHT LOSS .INTERVENTIONS .DINING ASSIST (Assistance): LIMITED TO EXT (EXTENSIVE) ASSIST .OFFER SUBSTITUTES IF RESIDENT CONSUMES LESS THAN 50% OF MEALS .OBSERVE AND RECORD ALL INTAKE . Review of the monthly and weekly weight records revealed the following: On 3/6/17 the resident weighed 171 pounds (lbs). On 4/13/17 the resident weighed 166 lbs. On 4/17/17 the resident weighed 166 lbs. On 4/24/17 the resident weighed 163 lbs. On 5/1/17 the resident weighed 160 lbs. There were no weights documented for the week of 5/8/17. A physician's telephone order dated 5/12/17 documented.House Supplement BID . The resident's care plan was revised on 5/12/17 and included an intervention to administer supplements per order and observe for intake. Review of the weight records revealed on 5/17/17 the resident weighed 160 lbs. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #30 had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment, and required supervision such as encouragement or cueing with eating. On 5/24/17 the resident weighed 155 lbs, revealing a 16 pound, 9.3 percent (%) severe and significant weight loss since 3/6/17. Review of the 5/31/17 Bedside Care Plan (used by the Certified Nursing Assistants (CNAs) to provide care for the resident) documented, .Feed self after set up . Limit distractions during meals No TV (television) during meals . Review of the resident's written plan of care revealed the plan was revised on 6/2/17 and reflected to continue to assist with meals. The CNAs bedside care plan was not updated with the revision to assist with meals. Observations in Resident #30's room on 5/31/17 at 5:38 PM, revealed Resident #30 lying in bed with her supper set up on her bedside table in a divided plate that contained Salisbury steak, lima beans, potatoes, Angel Food cake, and a glass of tea. There was no house supplement on Resident #30's tray. There were no staff in the room assisting, cueing or encouraging the resident with eating and the television was on. Observations in Resident #30's room on 6/1/17 at 8:20 AM, revealed Resident #30 lying in bed with a half-eaten piece of toast and had a carton of 2% milk, instead of whole milk. Toast was the only finger food the resident was served, as the resident preferred finger foods. Observations on 6/1/17, in Resident #30's room, revealed the following: At 11:47 AM- Resident #30 was sitting in a Broda chair. A lunch tray was delivered to Resident #30 by Certified Nursing Assistant (CNA) #4, who set the tray up on the bedside table, left the roll in the paper wrapper, and walked out of the room. At 11:55 AM- Resident #30 was holding her fork and was starring off. At 12:08 PM- No staff had assisted the resident with her meal. At 12:49 PM- Resident #30 had finished her tea and poured her House Supplement into her tea glass. Resident #30 had not eaten any of the food on the tray. At 12:52 PM- CNA #4 entered the room, stood in front of Resident #30, and stated, Are you through with your lunch and did you get full? Well, that's all that matters. Let me take your clothes protector off. CNA #4 took the clothes protector off and laid it over the top of Resident #30's plate and glass of house supplement and walked out of the room. The television was on. The lunch tray was in Resident #30's room for over 1 hour and no staff came in the room to supervise, cue, assist or encourage her to eat her lunch. Observations in Resident's #30's room on 6/1/17 at 6:04 PM, revealed Resident #30 lying in the bed with the supper tray on the bedside table. The plate had not been taken off the tray and set up for Resident #30. The tray had a meal ticket which documented that gravy should have been served on her supper tray. No gravy was served with the supper meal and the television was on. Observations in Resident #30's room on 6/2/17 at 9:30 AM, revealed Resident #30 lying in bed asleep with the breakfast tray on the bedside table. The plate had not been set up for Resident #30. The tray had a meal ticket which documented that toast as one of her breakfast foods. Resident #30's breakfast tray contained ground sausage, a biscuit, gravy, Rice Krispies, and orange juice. There was no toast on the tray, the resident had only eaten the Rice Krispies and the television was on. Interview with Occupational Therapist (OT) #1 on 6/2/17 at 9:42 AM, in the Rehabilitation Office, OT #1 was asked if she had seen the CNA's provide cueing and encouragement for Resident #30. OT #1 stated, No, I have not . Interview with the Speech Pathologist on 6/2/17 at 9:56 AM, in the Rehabilitation office, the Speech Pathologist was asked what type of therapy was provided for Resident #30. The Speech Pathologist stated, .received a referral from nursing and the dietician regarding weight loss .she consumed consistently under 50%, she was very distractible. The Speech Pathologist was asked what her recommendations were for Resident #30. The Speech Pathologist stated, That her meal was set up very accessible .She preferred finger foods . The Speech Pathologist was asked, since there was an attention issue with Resident #30, would having someone assist or encourage her help her with eating. The Speech Pathologist stated, Yes . Interview with the interim Director of Nursing (DON) on 6/2/17 beginning at 10:23 AM, in the interim DON office, The interim DON was asked to look at the care plan which indicated to assist with meal intake thru 6/2/17. The interim DON was then asked if she thought Resident #30 was encouraged, cued, or assisted when a CNA delivered the meal, set it up, and was out of the room in a minute and never returned for over an hour. The interim DON stated, No. The interim DON confirmed that Resident #30 should have received assistance with eating all along. Interview with the Registered Dietician (RD) #1 on 6/2/17 at 11:45 AM, in the Conference Room, RD #1 was asked if she had done a caloric needs assessment for Resident #30's weight loss. RD#1 stated, No . RD #1 was asked about doing a caloric needs assessment when Resident #30 had significant weight loss. RD #1 stated, I will, moving forward. But, no, that has not been my practice. RD#1 was asked if gravy was listed on the meal ticket should the resident have gravy with the meal. The RD #1 stated, Yes. RD #1 was asked if the meal ticket listed toast, should the resident have toast on the tray. RD #1 stated, Yes. RD #1 was asked if Resident #30 should receive 2% milk or whole. RD #1 stated the resident should have received Whole milk. RD #1 was asked if there should have been a house supplement on Resident #30's supper tray. RD #1 stated, We will have to educate our staff. Resident #30 sustained severe and significant weight loss and the facility failed to implement the care plan interventions to prevent weight loss. 2. Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 6/22/16 documented, .PROBLEM .SEVERELY COGNITIVELY IMPAIRED .RESIDENT IS NON VERBAL AND COMMUNICATES ONLY BY NODDING HER HEAD .INTERVENTIONS .INTRODUCE SELF AND EXPLAIN CARE PRIOR TO BEGINNING, TALK TO RESIDENT DURING CARE . Observations in Resident #25's room on 6/1/17 at 8:18 AM revealed LPN #7 checked placement of Resident #25's Percutaneous Endoscopic Gastrostomy (PEG) tube, administered medications through the PEG tube, administered eye drops to both eyes, administered insulin by subcutaneous injection into Resident #25's left arm, turned Resident #25 on her side in the bed and applied a medicated patch to Resident #25's back. LPN #7 did not introduce self or explain the procedures prior to beginning the treatments and did not talk to the resident during the care. Interview with Licensed Practical Nurse (LPN) #7 on 6/02/17 at 5:06 PM, at the Station 1 Nurse's station, LPN #7 was reminded about the care plan intervention to introduce themselves and explain care prior to beginning and talk with the resident during care. LPN #7 was then asked if she followed that intervention during her care of Resident #25. LPN #7 stated, I don't remember. LPN #7 was asked if it was acceptable to provide care to a nonverbal resident or any resident without informing the resident what is being done. LPN #7 stated, Absolutely not. LPN #7 was asked if a resident should be informed before they are given an injection or turned. LPN #7 stated, Yes. Interview with the interim DON on 6/3/17 at 12:29 PM, in the conference room, the interim DON was asked if it was acceptable to provide care, give injections, administer eye drops, or turn a resident without explaining what is being done to the resident. The interim DON stated, No, it doesn't matter whether they are cognitively impaired, aphasic or whatever, you introduce yourself to the patient and explain what you are doing.",2020-09-01
829,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-06-04,319,E,1,1,35VZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, and interview, the facility failed to provide behavioral care and services for 2 of 2 (Resident #205 and 232) residents with behaviors reviewed in the stage 2 review. The findings included: 1. The Behavior Assessment and Monitoring policy documented, .Problematic behavior will be identified and managed appropriately . 2. Medical record review revealed Resident #205 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed that Resident #205 had a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognition, had delusions, physical behavioral symptoms, and had wandering behaviors that placed Resident #205 at risk of getting to a dangerous place. A PHYSICIAN'S TELEPHONE ORDERS dated 2/27/17 documented, .consult psych (psychiatric) services NP (nurse practitioner) . Review of Resident #205's medical record revealed no documentation of a psychiatric nurse practitioner evaluation. Interview with the Administrator on 6/3/17 at 7:56 PM, in the conference room, the Administrator was asked if Resident #205 had been seen by the psychiatric nurse practitioner. The Administrator stated, No. The Administrator was asked if there was a reason Resident #205 was not evaluated as ordered. The Administrator stated, He should have been . 3. Medical record review revealed Resident #232 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of NURSE'S NOTES dated 2/20/17 at 4:00 PM, revealed that Resident #232 was being admitted to the facility at that time and that the wife told the nurse during the nursing admission assessment that Resident #232 became very agitated and anxious when he did not get his nerve pill and pain pill. A Psychiatric Progress Note dated 2/24/17 documented, .Good medication compliance is noted. He needs assistance or cues for self care tasks. He is socializing less with family and friends. More angry outbursts are occurring. Impulsive behaviors continue to be displayed. He needs to be coaxed to eat and drink .is sometimes confused . The care plan dated 3/7/17 documented, PROBLEM .PERSISTENT MOOD STATE AND BEHAVIORAL ISSUES R/T (related to) DX (diagnoses) OF [MEDICAL CONDITION], DEPRESSION, ANXIETY, AND [MEDICAL CONDITION] .OPIATE AND BENZODIAZEPINE DEPENDENCE AND ABUSE .INTERVENTIONS .Family/caregiver to stay (with) resident during HS (hour of sleep), family agreed to provide 1:1 (one to one) (care) . The care plan signature page did not include a family/caregiver signature. A NURSE'S NOTES dated 3/7/15 at 12:15 AM, documented, .This nurse contacted wife to see if she could come to facility and sit with resident to assist in behaviors .contacted (former) DON (Director of Nursing) . A NURSE'S NOTES dated 3/7/17 at 12:30 AM, documented, .Residents son called this nurse back and stated wife could not come sit (with) resident because 'he hates her and it will only make it worse' . A NURSE'S NOTES dated 3/7/17 at 12:40 AM, documented, .Contacted (former) DON to make her aware that resident's son stated wife could not come up here. Spoke at length (with) (former) DON and agreed to contact son again to see if anyone in the family could come to facility to sit with resident . A NURSE'S NOTES dated 3/7/17 at 12:45 AM documented, .Called son back .asked if anyone could come sit with resident . A NURSE'S NOTES dated 3/7/17 at 2:00 AM, documented, .Resident's son arrived and resident appeared to be resting in bed with his eyes closed. Son waited approximately 10 minutes then went ahead and left . Review of NURSE'S NOTES revealed the following: 3/8/17 2:00 AM Resident sat up in bed and yelled out, pain pill! pain pill! pain pill! There was no documentation of one on one care. 3/11/17 7:30 PM Resident was found on the floor after the nurse witnessed him placing himself there. He told the nurse if she would give him his medicine he wouldn't put himself on the floor. There was a family member with Resident #232. 3/12/17 6:10 AM The nurse witnessed the resident stand up and put himself on the floor and he told her that he wouldn't throw himself in the floor if he got his pills. There was no documentation of one on one care. 3/12/17 7:00 PM The resident was continuously yelling out for his pills and the nurse told him his pills were due at 8 PM and that she always brings him his medication at 8 PM. The resident continued to yell out until he received his medication at 8 PM and he rested the rest of the shift. There was no documentation of one on one care. 3/14/17 2:05 AM Resident #232 was intermittently yelling out, yelling out for medications. The nurse told him no medications were due. There was no documentation of one on one care. 3/14/17 3:00 AM The resident threw urine on one of his roommates and told another roommate that if he didn't shut up he was going to throw his urinal at him. The former DON was contacted by the nurse and the former DON advised the nurse to send the resident to the hospital because he was a danger to himself and others. The resident refused to go to the hospital. Mobile Crisis was called. They came to the facility. There was no documentation of one on one care. 3/14/17 6:00 AM Mobile Crisis representative in facility to evaluate resident. 3/14/17 1:00 PM The daughter was told by the nurse that Resident #232 would need one on one care from family during the night, 9 PM to 7 AM. 3/15/17 6:40 PM to 9:30 PM Resident #232 was yelling out, putting himself on the floor. At 9:30 PM, the family arrived to stay with him. 3/16/17 7:45 PM The resident told his daughter he wanted to kill his wife. A one on one sitter was provided by the facility. 3/17/17 7:25 PM The resident's wife came to the nurse and told her she was not going to stay the night with him per the agreement due to him attempting to hit her and cursing and yelling at her. The nurse held his 8:00 PM medications because she was concerned for her own safety. She did not administer the medications until 10:30 PM. He did have a nurse sitting one on one with him. 3/17/17 9:50 PM Resident poured coke on himself, yelling out. There was no documentation of one on one care. 3/17/17 11:20 PM The resident's daughter told the nurse that the family was not going to sit with the resident as agreed. The family talked with the former DON and the Mobile Crisis representative and left the building. 3/17/17 11:50 PM to 1:45 AM The resident yelled, dumped contents of his urinal out in the drawer and on the floor. There was no documentation of one on one care. 3/20/17 9:10 PM Resident #232 was yelling for help. Asking for pain pill. There was no documentation of one on one care. 4/11/17 1:00 AM Resident #232 was yelling out. There was no documentation of one on one care. Phone interview with LPN #5 on 6/1/17 at 5:55 PM, LPN #5 was asked if it was a normal facility practice to get the family to come and sit one on one with residents when they have behaviors. LPN #5 stated, If they can, yes. LPN #5 was asked if Resident #232's family family appreciated having to do that. LPN #5 stated, No, absolutely not. The wife was so upset that the family was asked to stay with him. They were upset with that, they didn't want to do it. LPN #5 was asked about how the family interacted with Resident #232. LPN #5 stated it was normal family dynamics for the family to yell, curse and make threats to one another. LPN #5 was asked if the facility ever had a staff member sit with him one on one. LPN #5 stated, No. After that was put in effect his wife came to me in tears and said she couldn't stay, he just cussed her and tried to hit her. The (former) DON told them they had to stay, it was in their contract or their agreement. Interview with the Administrator on 6/01/17 at 7:15 PM, in the conference room, the Administrator was asked if she was aware that Resident #232 had some violent behaviors. The Administrator stated, I knew he threw the urinal at the nurse. The Administrator was asked about the care plan intervention that the family provide one on one care for the resident from 9 PM to 7 AM. The Administrator stated, Because of his behaviors, we asked the family to assist. Sometimes the wife would yell back at him, we encouraged her when it would escalate to just leave. He seemed better when the family was there. The Administrator was asked if she was aware that the staff had reported that his behaviors increased when his family was here. The Administrator stated, His behaviors did increase with the wife .We wanted them to help us care for him, I think it's reasonable, we needed some help to provide care for him .I have 170 other patients I have to worry about. The Administrator was asked if it was safe to leave Resident #232 in his room with 2 roommates. The Administrator stated, There's a potential .for everything .he could have woken up and thrown another urinal. The Administrator was asked what kind of training the staff received about behavioral interventions. The Administrator stated, .we do general training on abuse, resident on resident, as well as staff to resident, dementia care tips, how to approach the situation, how to handle outbursts, how to step away, that sort of thing. That's the orientation I do. Interview with LPN #6 on 6/02/17 at 9:51 AM, at Station 1 Nurses' Station, LPN #6 was asked if Resident #232 ever exhibited behavior problems when he provided his care. LPN #6 stated, (Resident #232) .had something against women, if he had behaviors they were directed toward women. LPN #6 stated, He didn't have behaviors when I was here. He was a whole lot different behavior wise. He had a different respect for me. LPN #6 was asked if he was the only male nurse on staff. LPN #6 stated, No. LPN #6 then named 3 other male nurses on staff. Interview with the Administrator on 6/03/17 at 10:22 AM, in the conference room, the Administrator was asked if the secure unit in the facility was a behavior unit. She stated, It's secure and behavior, all of the above. The Administrator was asked if there was a reason the facility didn't utilize the behavior unit as an intervention for Resident #232. The Administrator stated, I don't know the answer to that. I didn't think of that at the time. The Administrator was asked if that would have been an option for Resident #232. The Administrator stated, To put him in the behavior unit? I don't see why it wouldn't be. The Administrator was asked if she was aware that the family was not doing the one on one for Resident #232. The Administrator stated, I met with the daughters and they said they were not going to do it. The Administrator was asked what was put in place when the family refused to do the one on one. The Administrator stated, He was by the nurses' station, so he had much more supervision; the room was very accessible. Interview with the Administrator in the conference room on 6/03/17 at 7:55 PM, the Administrator was asked if placing a resident closer to the nurses' station was considered one on one supervision. The Administrator stated, No.",2020-09-01
830,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-06-04,325,G,0,1,35VZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to follow physician orders [REDACTED].#30, 113, and 277) sampled residents reviewed for nutrition of the 31 included in the stage 2 review. The failure to provide nutritional interventions resulted in an severe and significant weight loss and actual harm to Resident #30. The findings included: 1. The facility's Weight Assessment and Intervention policy statement documented, .The multidisciplinary team will strive to prevent, monitor .and intervene for undesirable weight loss for our residents . The facility's High Calorie/High Protein Supplements policy documented, .The nursing staff will supervise the delivery and consumption of all supplements and record appropriately in the medical record and/or the medication administration record .Individual acceptance of supplements will be monitored and adjustments will be made as needed . 2. Medical record review revealed Resident #30 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The [MEDICAL CONDITIONS], Constipation and Dietary Calcium Deficiency were acquired after admission to the facility. The care plan dated 9/14/16 documented, .PROBLEM .POTENTIAL FOR WEIGHT LOSS .WILL CONTINUE TO ASSIST WITH MEAL INTAKE THRU 6/2/17 .INTERVENTIONS .DINING ASSIST (ASSISTANCE) .LIMITED TO EXT. ASSIST .OFFER SUBSTITUTES IF RESIDENT CONSUMES LESS THAN 50% OF MEALS .DIETARY WILL ASSESS NUTRITIONAL STATUS/NEEDS . Review of the weight records revealed on 3/6/17 the resident weighed 171 pounds (lbs) and on 4/17/17 the resident weighed 166 lbs. Review of Occupational Therapy .Evaluation & Plan of Treatment report dated 4/21/17 revealed, .Clinical impressions indicate that (Resident #30) has had a decline with self feeding . The Nutritional Progress Notes dated 4/24/17 documented, .Resident with gradual decrease wt (weight) Noted ST (Speech Therapy) note on 4/20 regarding Resident's daughter not wanting staff to provide any assistance . Review of the weight records revealed on 4/24/17 the resident weighed 163 lbs, on 5/1/17 the resident weighed 160 lbs, there were no weights documented for the week of 5/8/17 A physician's telephone order dated 5/12/17 documented.House Supplement BID with snack cart . The care plan was updated on 5/12/17 to include supplement administration per the physician's orders [REDACTED]. Review of the weight records revealed on 5/17/17 the resident weighed 160 lbs. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #30 had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment, and and required supervision such as encouragement or cueing with eating. The NUTRITIONAL EVALUATION/RE-EVALUATION dated 5/18/17 documented.MP (Med Pass) BID (twice a day) House supp (supplement) with lunch and dinner . Review of the weight records revealed on 5/24/17 the resident weighed 155 lbs, resulting in a severe and significant weight loss of 9.3 % since 3/6/17. Review of the NAR (Nutritionally at Risk) report dated the week of 5/26/17, documented, .Nutrition Interventions and Comments .Daughter does not want resident fed .Daughter wants plate taken off of tray and base and placed directly on table so it won't spin . Review of the 5/31/17 Bedside Care Plan used by the Certified Nursing Assistants (CNAs) to care for Resident #30, documented, .Feed self after set up . Limit distractions during meals No TV (television) during meals . The CNA bedside care plan did not reflect the nursing care plan intervention for staff to assist Resident #30 with eating. Observations in Resident #30's room on 5/31/17 at 5:38 PM, revealed Resident #30 lying in bed with her supper set up on her bedside table. There was no house supplement on Resident #30's tray. There were no staff in the room assisting, cueing or encouraging the resident with eating and the television was on. Observations in Resident #30's room on 6/1/17 at 8:20 AM, revealed Resident #30 was lying in bed and had been served a carton of 2% milk, instead of whole milk, on her breakfast tray. Observations on 6/1/17, in Resident #30's room, revealed the following: At 11:47 AM- Resident #30 was sitting in a Broda chair. CNA #4 delivered and set up the lunch tray on the bedside table, left the roll in the paper wrapper, and walked out of the room. At 11:55 AM- Resident #30 was holding her fork and just staring into space. At 12:08 PM- Staff had not come back in Resident #30's room to check on her progress with eating or to supervise, cue or encourage her to eat. At 12:49 PM- Resident #30 had finished her tea but had not eaten any of the food on the tray. At 12:52 PM- CNA #4 entered the room, stood in front of Resident #30, and stated, Are you through with your lunch . CNA #4 removed the clothing protector, laid it over Resident #30's plate, and walked out of the room. The television was on. CNA #4 did not offer Resident #30 a substitute. The lunch tray was in Resident #30's room for over 1 hour and no staff came in the room to supervise, cue or encourage her to eat her lunch and the resident's television was on. Observations in Resident's #30's room on 6/1/17 at 6:04 PM, revealed Resident #30 lying in the bed with the supper tray on the bedside table. The plate had not been taken off the tray and set up for Resident #30. The tray had a meal ticket which documented that gravy should be on her supper tray. No gravy was served with the supper meal. The television was on. Observations in Resident #30's room on 6/2/17 at 9:30 AM, revealed Resident #30 lying in bed asleep with the breakfast tray on the bedside table. The plate had not been set up for Resident #30. The tray had a meal ticket which documented toast was one of her favorite breakfast foods. Resident #30's breakfast tray contained ground sausage, a biscuit, gravy, Rice Krispies, and orange juice. There was no toast on the tray and the television was on. Interview with Occupational Therapist (OT) #1 on 6/2/17 at 9:42 AM, in the Rehabilitation Office, OT #1 was asked if she was aware of a significant weight loss for Resident #30. OT #1 stated, Yes . OT #1 confirmed that the CNAs were to give her supervision, and provide cueing and encouragement. OT #1 was asked if she ever saw the CNAs doing that. OT #1 stated, No, I have not. Interview with the Speech Pathologist on 6/2/17 at 9:56 AM, in the Rehabilitation office, the Speech Pathologist was asked what type of therapy was provided for Resident #30. The Speech Pathologist stated, .received a referral from nursing and the dietician regarding weight loss .she consumed consistently under 50%, she was very distractible. The Speech Pathologist was asked what her recommendations were for Resident #30. The Speech Pathologist stated, That her meal was set up very accessible, feed her out in the 300 Dining Room .She preferred finger foods . The Speech Pathologist was asked, since there was an attention issue with Resident #30, would having someone assist or encourage her help her with eating. The Speech Pathologist stated, Yes . Interview with the interim Director of Nursing (DON) on 6/2/17 beginning at 10:23 AM, in the interim DON's office, the interim DON was asked if she was aware that Resident #30 had a significant weight loss. The interim DON stated, We talk about her .in NAR meetings on Fridays . The interim DON was asked if she knew that the daughter did not want Resident #30 to be fed. The interim DON stated, No, I do not . The interim DON was asked if she thought loss of independence was a valid reason not to feed a resident with significant weight loss. The interim DON stated, In my professional opinion, I would say no .we need to help and the patient should be helped first. The interim DON was asked if she thought Resident #30 was encouraged, cued, or assisted when a CNA delivered the meal, set it up, and was out of the room in a minute, and didn't return for over an hour. The interim DON stated, No. The interim DON was asked if she thought assistance should be provided for Resident #30 for eating. The interim DON stated, Yes . Interview with the Registered Dietician (RD) #1 on 6/2/17 at 11:45 AM, in the Conference Room, RD #1 was asked if she had done a caloric needs assessment for Resident #30's weight loss. RD #1 stated, No . RD #1 was asked about doing a caloric needs assessment when Resident #30 had significant weight loss. RD #1 stated, I will, moving forward. But, no, that has not been my practice. RD#1 was asked if gravy was listed on the meal ticket should the resident have gravy with the meal. The RD #1 stated, Yes. RD #1 was asked if the meal ticket listed toast, should the resident have toast on the tray. RD #1 stated, Yes. RD #1 was asked if Resident #30 should receive 2% milk or whole. RD #1 stated, Whole. RD #1 was informed that there was 2% milk on Resident #30's breakfast tray on 6/1/17. The RD #1 stated, That was just us trying to rotate our stock. RD #1 was asked if there should have been a house supplement on Resident #30's supper tray. RD #1 stated, We will have to educate our staff. There was no documentation the facility reassessed the resident's continued weight loss to determine why the interventions were not effective. The failure of the facility to follow physician orders [REDACTED].#30. 3. Medical record review revealed Resident #113 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the weight records revealed on 2/7/17 the resident weighed 121 pounds, on 2/13/17 the resident weighed 119 lbs, on 2/20/17 the resident weighed 116 lbs (a 4.13% weight loss in 2 weeks) and on 3/6/17 the resident weighed 114 lbs (a 5.7% severe and significant weight loss in 1 month). A PHYSICIAN'S TELEPHONE ORDERS dated 3/10/17 documented, .House Supplement TID (3 times a day) (with) meals . Review of the weight records revealed on 3/14/17 the resident weighed 111 lbs (a 8.26% significant weight loss in 4 weeks. Review of the intake sheet for (MONTH) (YEAR) revealed that the supplement was not administered with breakfast or lunch 3/10-3/24, and 3/27-3/31, and was not administered with supper 3/10-3/31. Review of the Nutritional Progress Note dated 3/31/17 documented, .Resident does not like house supplement so will D/C (discontinue) it .Resident agreeable to ice cream: will try NJD (with) breakfast . A PHYSICIAN'S TELEPHONE ORDERS dated 3/31/17 documented, .D/C (discontinue) House Supplement .NJD (nutritional juice drink) QD (with) Bkft (Breakfast) . There was no documentation the facility reassessed the resident's dislike for the supplement and that the resident was not taking the supplement for the month of (MONTH) (YEAR) until 3/31/17. Review of the weight records revealed on 4/12/17 the resident weighed 106 lbs. (a 12.4% severe and significant weight loss in 8 weeks) and on 4/18/17 the resident weighed 104 lbs. which is a 14% severe weight loss in 9 weeks. Review of a Computed [NAME]ography (CT) scan dated 4/18/17 documented, .Reason for Exam: Chronic Nausea, Epigastric Pain .Impression .There is persistent distention .Again, direct visualization (colonoscopy) is recommended to exclude an underlying malignancy in this location . Review of the weight records revealed on 4/24/17 the resident weighed 103 lbs. which is a 14.9% severe weight loss in 10 weeks. The Nutritional Progress Notes dated 4/27/17 documented, .Resident (with) continued (decreased) weight .Resident has been tried on multiple supplements (with) poor intake .Resident unavoidable wt. (weight) loss R/T (related to) poor PO intake .potential for further unavoidable wt. loss . Review of the weight records revealed on 5/2/17 the resident weighed 101 lbs which is a 16.5% severe weight loss in 11 weeks. Review of the Nutritional Progress Notes dated 5/5/17 revealed no documentation that additional interventions were implemented to address the continued severe weight loss. Review of the weight records revealed on 5/24/17 the resident weighed 100 lbs which is a 17.3% severe weight loss in 13 weeks. Review of the intake sheets for April, May, and (MONTH) (YEAR) revealed the following: Breakfast - Supplement not administered 4/1-4/17, 4/19-4/31, 5/1-5/15, 5/18, 5/21, 5/23 -5/31, 6/1 and 6/2. Lunch - Supplement was not administered 4/1-4/31, 5/1-5/31, 6/1 and 6/2. Supper - Supplement was not administered 4/1-4/13, 4/15-4/31, 5/1-5/26, 5/28-5/31, 6/1 and 6/2. Review of an RD note dated 6/5/17, faxed to the State office on 6/5/17, after the survey revealed the RD documented, .Most recent CT scan of the abdomen recommends colonoscopy due to underlying malignancy (potential per CT scan) in the ascending colon. Family declined work-up due to patient not wanting treatment . Interview with Licensed Practical Nurse (LPN) #4 on 6/03/17 at 9:21 AM at the Station 2B nurses station, LPN #4 was asked how she ensured that residents get their supplements. LPN #4 stated, They (CNAs) chart it on their ADL (activities of daily living) intake sheets. LPN #4 was asked if the supplement was documented. LPN #4 stated, They didn't chart .I don't understand why it's not charted . Telephone interview with RD #1 on 6/3/17 at 9:42 AM, RD#1 was asked if the nutritional juice drink is considered a supplement. RD #1 stated, Yes. RD #1 was asked if she expected the CNAs to chart the supplement on the intake sheet. RD #1 stated, Yes. RD #1 was asked how often she reviews the intake logs. RD #1 stated, When I do an assessment. RD #1 confirmed her notes for March, (MONTH) and May, and confirmed she also reviewed the intake sheets for those months. RD #1 was asked if it was acceptable that the supplement had not been documented consistently. RD #1 stated, No . RD #1 was asked if, when she reviewed the (MONTH) intake log and realized the supplement was not being documented, she had addressed it with the Administrator or the Director of Nursing (DON). RD #1 stated, No. RD #1 was asked how she was able to adequately assess nutritional status without periodically doing a thorough assessment with nutritional needs and calculations. She stated, I use the intakes and the weights and talk with the staff. Interview with the interim DON on 6/03/17 at 10:01 AM, in the conference room, the interim DON was asked if the supplement had been documented on the April, (MONTH) and (MONTH) intake sheets for Resident #113. The interim DON stated, Inconsistently in May, no, no, it's not been charted. The interim DON was asked how the RD could do a thorough nutritional evaluation without documentation of supplement intake. The interim DON stated, I don't see how she could. 4. Medical record review revealed Resident #277 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the weight records revealed on 4/26/17 the resident weighed 105 lbs, on 5/3/17 the resident weighed 98 lbs (a 6.67% severe and significant weight loss in 1 week). A physician's telephone order dated 5/1/17 documented, .med pass 3 oz (ounces) BID .record % consumed in MAR (Medication Administration Records) . Review of the weight records revealed on 5/8/17 the resident weighed 93 lbs (a 11.4% severe weight loss in 2 weeks). A physician's telephone order dated 5/10/17 documented, .Ensure (chocolate) po TID . Review of the (MONTH) and (MONTH) (YEAR) MARs revealed that there was no documentation that Resident #277 was receiving the Med Pass as ordered. Review of the intake sheets for (MONTH) and (MONTH) (YEAR) revealed the following: Breakfast - Supplement was not administered 5/1-5/8, 5/10-5/31, and 6/1 Lunch - Supplement was not administered 5/1, 5/3, 5/5-5/25, 5/27, 5/28, 5/30, 5/31, and 6/1 Supper - Supplement was not administered 5/1-5/10, 5/13-5/23, 5/25, 5/26, and 5/29-5/31. The facility failed to follow the physician's orders [REDACTED]. Interview with the CNA #5 on 6/3/17 at 8:45 AM, on the Station 4B Nurse's station, CNA #5 was asked where CNAs documented supplements for residents. The CNA stated, We document it on the CNA ADL (activities of daily living) sheet under supplement. Interview with LPN #1 on 6/3/17 at 8:48 AM, on the Station 4B Nurse's station, LPN #1 was asked where she documented supplements for residents. LPN #1 stated, On the MAR (medication administration record). LPN #1 was asked where the percent consumed for the Med Pass should be documented. LPN #1 stated, On the MAR. LPN #1 looked at the (MONTH) and (MONTH) (YEAR) MARs. LPN #1 confirmed there was no documentation of percent consumed on the MARs. LPN #1 was asked if it was acceptable to not follow doctor's orders for supplements. LPN #1 stated, No, we have to do what the doctor tells us to do. Interview with the interim DON on 6/3/17 at 9:12 AM, in the conference room, the interim DON was asked where the Med Pass supplement should be documented. The interim DON stated, The Med Pass would be documented on the MAR. The interim DON was asked if the Med Pass was documented on the (MONTH) and (MONTH) MARs. The interim DON stated, No . The interim DON was asked if it was acceptable to not follow physician's orders [REDACTED]. Interview with the interim DON on 6/3/17 at 9:58 AM, in the conference room, the interim DON was asked where the Ensure supplement should be documented. The interim DON stated, On the ADL sheet. The interim DON was asked if the supplement had been documented for (MONTH) and June. The interim DON stated, I don't see it .it's not consistently documented .no. The interim DON was asked if it was acceptable to not document the supplements according to the physician's orders [REDACTED]. The interim DON stated, No, it should be documented. Telephone interview with the RD #1 on 6/3/17 at 10:30 AM, RD #1 was asked if Resident #277 had a significant weight loss. RD #1 stated, Yes. RD #1 was asked how she made sure residents received their supplements. RD #1 stated, .I ' m in the kitchen a lot I serve on the tray line .I know what we are providing to each resident. RD #1 was asked if she reviewed supplement documentation. RD #1 stated, I look at them to see how they are taking the Med Pass and the percent. RD #1 was asked whether Resident #277 was getting her supplements. RD #1 stated, I don't remember if I looked at her MARs or ADL sheets .No. RD #1 was asked if it was acceptable that Resident #277's supplements were not documented. RD #1 stated, No, that is not our practice .",2020-09-01
831,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-06-04,329,D,0,1,35VZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to document behaviors and side effects for [MEDICAL CONDITION] medications for 1 of 5 (Resident #205) residents reviewed for unnecessary medications of the 41 sampled residents in the Stage 2 review. The findings included: Medical Record review revealed Resident #205 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 4, indicating severe cognitive impairment, Resident # 206 received antipsychotic, antianxiety, and antidepressant medications 7 out of 7 days and had wandering behaviors daily. Review of the quarterly MDS dated [DATE] revealed a BIMS of 3, indicating severe cognitive impairment, received antipsychotic and antidepressant medications 7 out of 7 days and antianxiety medications 3 out of 7 days, and did not have behaviors. Review of the care plan revealed, Focus .Alteration in mood state and behaviors r/t (related to) [MEDICAL CONDITION] and anxiety .experiencing agitation, wandering with exit seeking behaviors, delusional ideations, low frustration tolerance .Interventions Administer [MEDICAL CONDITION] meds (medications) per order and observe for .Anxiety, [MEDICAL CONDITION], nausea, diarrhea, involuntary muscle movements, muscle stiffness, [MEDICAL CONDITION], constipation, eps (extrapyramidal symptoms) . Review of the physician's orders [REDACTED].#205 had an order for [REDACTED]. Review of the (YEAR) PSYCHOACTIVE MEDICATION MONTHLY FLOW RECORD revealed the following: a. Psychoactive Medication monitoring: Behavioral Symptoms: not documented 5/4, 5/5, 5/9, 5/13, 5/14, 5/18, 5/19, 5/23, 5/24, and 5/27. Side Effects: not documented 5/4, 5/5, 5/9, 5/13, 5/14, 5/18, 5/19, 5/23, 5/24, and 5/27. b. Antidepressant Medication monitoring: Side Effects: not documented 5/4, 5/5, 5/9, 5/13, 5/14, 5/18, 5/19, 5/23, 5/24, and 5/27. Interview with the interim Director of Nursing (DON) on 6/1/17 at 5:20 PM, in the conference room, the interim DON was asked to explain the blanks on the the PSYCHOACTIVE MEDICATION MONTHLY FLOW RECORD. The interim DON stated, .if I see this, it looks like it was not done. The interim DON was asked whether Resident #205 should be monitored daily. The interim DON stated, .typically that's what is recommended, for psych (psychoactive), [MEDICAL CONDITION], antianxiety, the antidepressants, they are monitoring for side effects. Interview with Licensed Practical Nurse (LPN) #9 on 6/1/17 at 5:35 PM, on the 200 hall, LPN #9 was asked how frequently behavior monitoring should be done. LPN #9 stated, Normally it should be done every shift. Interview with LPN #9 on 6/2/17 at 5:09 PM, on the 200 A hall, LPN #9 was asked what monitoring was done for each high risk medication administered to residents. LPN #9 stated, Monitor every shift and chart any changes that occur . LPN #9 was asked what monitoring tools or systems are used. The LPN #9 stated, The behavior monitoring form.",2020-09-01
832,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-06-04,361,G,0,1,35VZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on job description, medical record review, and interview, the Registered Dietitian (RD) or a Nutritional Professional failed to ensure interventions were implemented to maintain nutritional status for 3 of 5 (Resident #30, 113, and 277) sampled residents reviewed for nutrition of the 41 included in the Stage 2 review. The failure to provide accurate assessments and effective nutritional interventions for residents with significant and severe weight loss resulted in actual harm to Resident #30. The findings included: 1. The facility's Dietician job description documented, .The primary purpose of your job position is to plan, organize, develop and direct the overall operation of the Food Services Department .As Dietitian, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties .Ensure that charted food service progress notes are informative and descriptive of the services provided and of the resident's response to the service .Review the dietary requirements of each resident admitted to the facility and assist the attending physician in planning for the resident's prescribed diet plan .Encourage the resident/family to participate in the development and review of the resident's assessment and plan of care .Review nurses' notes to determine if the dietary care plan is being followed .Discuss problem areas with the Director of Nursing Services .Be sure that substitute foods of similar nutritive value are provided to residents who refuse foods served . 2. The facility's Weight Assessment and Intervention policy statement documented, .The multidisciplinary team will strive to prevent, monitor .and intervene for undesirable weight loss for our residents . The facility's High Calorie/High Protein Supplements policy documented, .The nursing staff will supervise the delivery and consumption of all supplements and record appropriately in the medical record and/or the medication administration record .Individual acceptance of supplements will be monitored and adjustments will be made as needed . 3. Medical record review revealed Resident #30 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The [MEDICAL CONDITIONS], Constipation and Dietary Calcium Deficiency were acquired after admission to the facility. The resident's care plan dated 9/14/16 identified the resident was at risk for weight loss and revealed the interventions to provide dining assistance, substitutes and dietary to assess the resident's nutritional status/needs. Review of Occupational Therapy Evaluation and Plan of Treatment report dated 4/21/17 revealed the resident has had a decline in the ability to feed herself. A physician's telephone order dated 5/12/17 documented.House Supplement BID (twice a day) with snack cart . The care plan was updated on 5/12/17 to include supplement administration per the physician's orders [REDACTED]. The Nutritional Evaluation dated 5/18/17 documented.MP (Med Pass) BID House supp (supplement) with lunch and dinner . There was no documentation a Nutritional Professional or RD conducted an assessment to determine if the resident was receiving the supplements as ordered. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had severe cognitive impairment, and should have supervision with eating. There was no documentation a Nutritional Professional or the RD conducted an assessment to determine if the resident was receiving needed assistance for eating and implement interventions to address assistance. Review of the weight records revealed the resident weighed 171 pounds (lbs) on 3/6/17. The resident continued to loose weight and on 5/24/17 the resident weighed 155 lbs, a 9.3 % severe and significant weight loss in less than 3 months. Review of the Nutritionally at Risk (NAR) report dated the week of 5/26/17, documented the daughter requested that the resident not be fed. The daughter also requested that the resident's plate be taken off the tray to prevent the plate from spinning. There was no documentation a Nutritional Professional or RD conducted an assessment to determine why the daughter did not want the resident to be fed, if the plate was being taken off the tray to allow easier handling of the plate and implement interventions to address these issues. Observations in Resident #30's room revealed the following: On 5/31/17 at 5:38 PM, revealed the resident did not receive the house supplement on her her tray. On 6/1/17 at 8:20 AM, revealed this resident with severe weight loss received a carton of 2% milk instead of whole milk, on her breakfast tray. On 6/1/17 at 6:04 PM, revealed the resident should have received gravy on her supper tray and the gravy was not served to the resident. On 6/2/17 at 9:30 AM, revealed the resident had a meal ticket which documented toast was a breakfast food she liked. Resident #30's breakfast tray did not contain toast on the tray. Interview with the interim Director of Nursing (DON) on 6/2/17 beginning at 10:23 AM, in the interim DON's office, the interim DON was asked if she was aware that Resident #30 had a significant weight loss. The interim DON stated, We talk about her .in NAR meetings on Fridays . The interim DON was asked if she knew that the daughter did not want Resident #30 to be fed. The interim DON stated, No, I do not . The interim DON was asked if she thought loss of independence was a valid reason not to feed a resident with significant weight loss. The interim DON stated, .I would say no .we need to help and the patient should be helped first. Interview with RD #1 on 6/2/17 at 11:45 AM, in the conference room, RD #1 was asked if she had done a caloric needs assessment for Resident #30's weight loss. RD #1 stated, No . RD #1 was asked about doing a caloric needs assessment when Resident #30 had significant weight loss. RD #1 stated, I will, moving forward. But, no, that has not been my practice. RD #1 was asked if gravy was listed on the meal ticket should the resident have gravy with the meal. RD #1 stated, Yes. RD #1 was asked if the meal ticket listed toast, should the resident have toast on the tray. RD #1 stated, Yes. RD #1 was asked if Resident #30 should receive 2% milk or whole. RD #1 stated, Whole. RD #1 was informed that there was 2% milk on Resident #30's breakfast tray on 6/1/17. RD #1 stated, That was just us trying to rotate our stock. RD #1 was informed that on 5/31/17, there was not a house supplement on Resident #30's supper tray. RD #1 was asked if there should there have been a house supplement on the supper tray. RD #1 stated, We will have to educate our staff. The RD or other Nutritional Professional failed to ensure all recommended and ordered interventions were implemented and effective for this resident with a severe and significant weight loss, resulting in actual harm. 3. Medical record review revealed Resident #113 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the weekly weight records revealed the on 2/7/17 the resident weighed 121 lbs, on 2/20/17 the resident weighed 116 lbs (which is a 4.13% loss in 2 weeks), on 3/14/17 the resident weighed 111 lbs (which is an 8.26% significant weight loss in 4 weeks), on 4/18/17 the resident weighed 104 lbs (which is a 14% severe weight loss in 9 week), and on 5/24/17 the resident weighed 100 lbs (which is a 17.3% severe weight loss in 13 weeks). Review of the 3/10/17 physician's orders [REDACTED]. Review of the intake sheet for (MONTH) (YEAR) revealed that the supplement was not administered with breakfast or lunch 3/10-3/24, and 3/27-3/31, and was not administered with supper 3/10-3/31. On 3/31/17 the physician ordered that the house supplement be discontinued and to start a Nutritional Juice Drink (NJD) supplement every day with breakfast. Review of the intake sheets for April, May, and (MONTH) (YEAR) revealed the following: Breakfast - Supplement not administered 4/1-4/31, 5/1-5/15, 5/18, 5/21, 5/23 -5/31, 6/1 and 6/2. Lunch - Supplement was not administered 4/1-4/31, 5/1-5/31, 6/1 and 6/2. Supper - Supplement was not administered 4/1-4/13, 4/15-4/31, 5/1-5/26, 5/28-5/31, 6/1 and 6/2. The Nutritional Progress Notes dated 4/27/17 documented, .Resident (with) continued (decreased) weight .Resident has been tried on multiple supplements (with) poor intake .Resident unavoidable wt. (weight) loss R/T (related to) poor PO (by mouth) intake .potential for further unavoidable wt. loss . Review of the Nutritional Progress Notes dated 5/5/17 revealed there was no documentation a Nutritional Professional or RD conducted an assessment to determine why the supplements were not being consumed by the resident and implemented other interventions. Telephone interview with RD #1 on 6/3/17 at 9:42 AM, RD #1 was asked if the nutritional juice drink is considered a supplement. RD #1 stated, Yes. RD #1 was asked if she expected the CNAs to chart the supplement on the intake sheet. RD #1 stated, Yes. RD #1 was asked how often she reviews the intake logs. RD #1 stated, When I do an assessment. RD #1 confirmed her notes for March, (MONTH) and May, and confirmed she also reviewed the intake sheets for those months. The RD was asked if it was acceptable that the supplement had not been documented consistently. RD #1 stated, No . RD #1 was asked if, when she reviewed the (MONTH) intake log and realized the supplement was not being documented, she had addressed it with the Administrator or the Director of Nursing (DON). RD #1 stated, No. RD #1 was asked how she was able to adequately assess the residents' nutritional status without periodically doing a thorough assessment with nutritional needs and calculations. She stated, I use the intakes and the weights and talk with the staff. Interview with the interim DON on 6/03/17 at 10:01 AM, in the conference room, the interim DON was asked if the supplement had been documented on the April, (MONTH) and (MONTH) intake sheets for Resident #113. The DON stated, Inconsistently in May, no, no, it's not been charted. The interim DON was asked how the RD could do a thorough nutritional evaluation without documentation of supplement intake. The interim DON stated, I don't see how she could. Review of an RD note dated 6/5/17, faxed to the State office on 6/5/17, after the survey revealed the RD documented, .Most recent CT scan of the abdomen recommends colonoscopy due to underlying malignancy (potential per CT scan) in the ascending colon. Family declined work-up due to patient not wanting treatment . 4. Medical record review revealed Resident #277 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's telephone order dated 5/1/17 documented, .med pass 3 oz (ounces) BID .record % (percent) consumed in MAR (Medication Administration Records) . A physician's telephone order dated 5/10/17 documented, .Ensure (chocolate) po TID . Review of the weight records revealed on 4/26/17 the resident weighed 105 lbs, on 5/3/17 the resident weighed 98 lbs, a 6.67% significant weight loss in 1 week and on 5/8/17 the resident weighed 93 lbs, an 11.4% severe weight loss in 2 weeks Review of the (MONTH) and (MONTH) (YEAR) MARs revealed that there was no documentation that Resident #277 was receiving the Ensure or the Med Pass as ordered. Review of the intake sheets for (MONTH) and (MONTH) (YEAR) revealed the following: Breakfast - Supplement was not administered 5/1-5/8, 5/10-5/31, and 6/1. Lunch - Supplement was not administered 5/1, 5/3, 5/5-5/25, 5/27, 5/28, 5/30, 5/31, and 6/1. Supper - Supplement was not administered 5/1-5/10, 5/13-5/23, 5/25, 5/26, and 5/29-5/31. Interview with the interim DON on 6/3/17 at 9:12 AM, in the conference room, the interim DON stated, The Med Pass would be documented on the MAR. The interim DON was asked if the Med Pass was documented on the (MONTH) and (MONTH) MARs. The interim DON stated, No . The interim DON was asked if it was acceptable to not follow physician's orders [REDACTED]. Interview with the interim DON on 6/3/17 at 9:58 AM, in the conference room, the interim DON was asked where the Ensure supplement should be documented. The interim DON stated, On the ADL sheet. The interim DON was asked if the supplement had been documented for (MONTH) and June. The interim DON stated, I don't see it .it's not consistently documented .no. The interim DON was asked if it was acceptable to not document the supplements according to the physician's orders [REDACTED]. The interim DON stated, No, it should be documented. Telephone interview with RD #1 on 6/3/17 at 10:30 AM, RD #1 was asked if Resident #277 had a significant weight loss. RD #1 stated, Yes. RD #1 was asked if she reviewed supplement documentation. RD #1 stated, I look at them to see how they are taking the Med Pass and the percent. RD #1 was asked whether Resident #277 was getting her supplements. RD#1 stated, I don't remember if I looked at her MARs or ADL sheets .No. RD #1 was asked if it was acceptable that Resident #277's supplements were not documented. RD #1 stated, No, that is not our practice .",2020-09-01
833,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-06-04,362,D,0,1,35VZ11,"Based on policy review, observation, and interview, the facility failed to ensure adequate dining staff was available to provide timely delivery of meals on 1 of 4 (2B) halls. The findings included: 1. The facility's Timely Meal Service policy documented, .Food will be delivered promptly to assure proper temperatures and high quality food .Meals will be placed in the cart in sequence to achieve the most effective service .Meals are distributed promptly with supervision as needed by nursing staff . 2. Observations on the 2B hall on 6/2/17 at 11:50 AM, revealed the non-insulated lunch meal tray cart arrived on the hall containing meals for 22 residents. Certified Nursing Assistant (CNA) #8 began delivering meal trays to residents. The meal cart was left on the hall while CNA #8 delivered trays and served the residents. 3. Observations on the 2B hall on 6/2/17 at 12:55 PM, revealed CNA #8 removed a tray from the same meal cart that had been sitting in the hall for 1 hour and 5 minutes, delivered it to Resident #130 in her room, and began assisting the resident to eat. 4. Interview with the Administrator on 6/2/17 at 6:23 PM, in the conference room, the Administrator was asked whether it was acceptable for the meal cart to sit out in the hall for over an hour before all the meals were served to the residents. The Administrator stated, .we have 84 feeders in the building .that's why we utilize the feeding assistant program .",2020-09-01
834,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-06-04,371,F,0,1,35VZ11,"Based on policy review, observation and interview the facility failed to ensure food was stored, prepared and served under sanitary conditions as evidenced by frost build-up in the ice cream freezer, undated foods, hair not properly restrained, and wet-nesting of dishes in the kitchen, and dirty nourishment room refrigerators/freezers that contained undated food items. The facility had a census of 168 with 167 of those residents receiving a meal tray from the kitchen. The findings included: 1. Review of the facility's Cleaning Instructions: Freezers policy documented, .Freezers will be defrosted as needed (when frost is (greater than or equal to) 1/4 inch thick, the freezer should be defrosted) . Observations in the kitchen on 5/30/17 at 11:13 AM, and on 5/31/17 at 9:20 AM, revealed a build-up of frost greater than 1/4 inch thick on the ice cream freezer. Interview with Registered Dietician (RD) #1 on 6/2/17 beginning at 12:05 PM, RD #1 was asked whether the ice cream freezer should be defrosted with a build-up greater than 1/4 inch thick of frost. RD #1 stated, We'll get maintenance to start that today . 2. Review of the facility's Food Storage policy documented, .Frozen Foods .All foods should be stored, labeled and dated . Observations in the kitchen on 5/30/17 at 11:13 AM, revealed undated bags of green beans, okra, and mixed vegetables in the freezer. Interview with the RD #1 on 5/31/17 at 9:20 AM, in the walk in freezer, RD #1 was asked whether all the frozen foods in the freezer should be dated. RD #1 stated, Yes . 3. Review of the facility's Employee Sanitary Practices policy documented, .Wear hair restraints (hairnets, hat, and/or beard restraints) to prevent hair from contacting exposed food . Observations in the kitchen revealed the following: a. On 5/30/17 at 11:13 AM, RD #1 and Dietary employees #1, #2, #3, #4, #6, and #7 did not have hair properly restrained. Dietary employee #5's facial hair was not covered. b. On 5/31/17 at 9:20 AM, RD #1 and Dietary employees #3, #8 and #9 did not have their hair properly restrained. Interview with RD #1 on 6/2/17 at 12:05 PM, in the conference room, RD #1 was asked whether staff members that had a beard should wear a facial covering in the kitchen. RD #1 stated, Yes. RD #1 was asked whether it was acceptable for hair to be exposed out of the hairnets while in the kitchen. RD #1 stated, No. 4. Review of the facility's Cleaning Dishes/Dish Machine policy documented, .Allow the dishes to air dry on the dish racks . Observations on 5/31/17 at 9:20 AM, revealed Dietary Employee #8 stacking wet serving trays and plates. Interview with RD #1 on 6/2/17 at 12:05 PM, in the conference room, RD #1 was asked whether dishes should be air dried. RD #1 confirmed wet-nesting was unacceptable. 5. Observations of the nourishment refrigerators revealed the following: a. 5/31/17 at 4:21 PM, at Nurses' Station #3, the nourishment refrigerator contained a (named fast food restaurant) drink with no name or date on it. There was a brown substance on the interior of the refrigerator. b. 6/1/17 at 8:20 AM, at Nurses' Station #1, the nourishment refrigerator freezer contained an undated ice cream container. There was a red substance spilled and refrozen on the interior of the freezer along with small brown particles scattered throughout the interior of the freezer. c. 6/1/17 at 11:30 AM, at the Nurses' Station #3, the nourishment refrigerator revealed a bottle of water half full with no date or name on it. Interview with LPN #2 on 5/31/17 at 4:21 PM, at Nurses' Station #3, LPN #2 was asked about the unlabeled (named fast food restaurant) drink in the refrigerator. LPN #2 stated, I do not know where it came from, or who it belongs to. Interview with LPN #3 on 6/1/17 at 11:30 AM, at Nurses' Station #3, LPN #3 was asked whether the unlabeled water bottle should be in the refrigerator. LPN #3 stated, No, and threw it away. Interview with RD #1 on 6/2/17 at 12:05 PM, in the conference room, RD #1 was asked who was responsible for monitoring the nourishment refrigerators. RD #1 stated, I check them in the morning. RD #1 was asked whether the unlabeled McDonald's drink should bed stored in the nourishment refrigerator. RD #1 stated No. RD #1 was asked whether an unlabeled bottle of water, half full, should bed stored in the refrigerator. RD #1 stated, No. RD #1 was asked whether the container of ice cream in the nourishment freezer should be dated. RD #1 stated, Yes. RD #1 was asked who was responsible for cleaning the nourishment refrigerators. RD #1 stated, Housekeeping.",2020-09-01
835,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-06-04,385,D,0,1,35VZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, the facility failed to obtain a physician's order for transfer to a geriatric psychiatric (geri-psych) facility for 1 of 2 (Resident #206) residents reviewed for behaviors in the stage 2 review. The findings included: The Transfer or Discharge Documentation policy documented, .Should the resident be transferred or discharged .the basis for the transfer or discharge must be documented in the resident's clinical record by the resident's Attending Physician . Medical record review revealed Resident #206 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a nurses note dated 3/9/17 at 5:55 PM, revealed that Resident #206 was transported by Emergency Medical Services to (named geri-psych facility). Review of the physician's orders revealed no order for transfer to a geri-psych facility. Interview with the Administrator on 6/3/17 at 7:56 PM, in the conference room, the Administrator was asked if there should be a physician's order when a resident is discharged or transferred to another facility. The Administrator stated, Yes. The Administrator was asked if she had found an order to transfer Resident #206 to the (named geri-psych facility). The administrator stated, No.",2020-09-01
836,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-06-04,431,D,0,1,35VZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure medications were not stored past their expiration date in 3 of 17 storage areas (1 A/B treatment cart, 4B treatment cart, and wound treatment cart). The findings included: 1. The facility's Administering Medications policy documented .The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container . Observations in the 100 hall A/B treatment cart on [DATE] at 11:47 AM, revealed the following medications were stored past their expiration date: a. 3 ounce bottle antifungal powder with an expiration date of [DATE] b. 2 16 ounce bottles Hydrogen Peroxide with an expiration date of [DATE] c. 1 32 ounce Hydrogen Peroxide bottle with an expiration date of [DATE] d. 1 8 ounce Povidone Iodine bottle with an expiration date of ,[DATE] Observations in the 400 A hall medication cart on [DATE] at 3:12 PM, revealed Germ-X 15 ounce bottle with an expiration date of ,[DATE]. Observations in the 400 B hall medication cart on [DATE] at 3:43 PM, revealed an 8 ounce bottle of Hydrogen Peroxide with an expiration date of ,[DATE]. Interview with LPN #8 on [DATE] at 3:10 PM, on the 100 hall at the A/B treatment cart, LPN #8 was asked whether it was acceptable to have medications that are expired in the treatment cart. LPN #8 stated, Oh no, ma'am, no ma'am. Interview with Registered Nurse (RN) #3 on [DATE] at 3:20 PM, on the 400 A hall, RN #3 was asked whether it was acceptable to have medications and disinfectants that are expired in the treatment cart. RN #3 stated, No, I would say expired Germ-X is not acceptable. Interview with LPN #1 on [DATE] at 3:43 PM, on the 400 B hall, LPN #1 was asked whether it was acceptable to have medications that are expired in the treatment cart. LPN #1 stated, No. Interview with the Administrator on [DATE] at 8:01 PM, in the conference room, the Administrator was asked if it was acceptable to have expired Povidone Iodine, Hydrogen peroxide, Miconazole Powder, and Germ-X on the medication or treatment carts. The Administrator stated, No, it is not acceptable.",2020-09-01
837,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-06-04,441,D,0,1,35VZ11,"**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 as evidenced by failure of the facility to maintain contact isolation precautions for 1 of 2 (Resident #36) sampled residents in contact isolation, by failure of 2 of 2 (Registered Nurse (RN) #1, Certified Nursing Assistant (CNA) #6) staff members to handle linens appropriately after performing patient care, by failure of 2 of 2 (Registered Nurse (RN) #1, Certified Nursing Assistant (CNA) #1) to perform proper hand hygiene, and by failure of 1 of 2 (RN #1) staff to properly dispose of biohazardous materials during wound care. The findings included: 1. The facility's .Isolation - Categories of Transmission-Based Precautions documented, .Transmission-Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent or control the spread of infection .Contact Precautions .In addition to Standard Precautions, implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment .Examples of infections requiring Contact Precautions include .Infections with multi-drug resistant organisms .Place the individual in a private room if possible .In addition to wearing gloves as outlined under Standard Precautions, wear gloves (clean, non-sterile) when entering the room .While caring for a resident, change gloves after having contact with infective material .Remove gloves before leaving the room and perform hand hygiene .After removing gloves and washing hands, do not touch potentially contaminated environmental surfaces or items in the resident's room .Wear a disposable gown upon entering the Contact Precautions room .After removing the gown, do not allow clothing to contact potentially contaminated environmental surfaces .For individuals with .excretions, secretions, or drainage that is difficult to contain, maintain precautions . The facility's Handwashing/Hand Hygiene policy documented, .Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel . The facility's Laundry and Bedding, Soiled policy documented, .Place and transport contaminated laundry in bags or containers in accordance with established policies governing the handling and disposal of contaminates items . 2. Medical record review revealed Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] documented, .Brief Interview for Mental Status (BIMS) .BIMS Summary Score .12 (moderate cognitive impairment) .Urinary .Frequently incontinent .7 or more episodes of urinary incontinence . The quarterly MDS dated [DATE] documented, .Urinary .Occasionally incontinent . The care plan dated 4/21/17 documented, .DIURETIC THERAPY .5/29 (2017) .ESBL (Extended Spectrum Beta-Lactamase) .Contact Isolation .FREQ (frequent) BLADDER INCONT (incontinence) R/T (related to) URGE, REQUIRES ASSIST WITH .TOILETING .Interventions/Tasks .INCONT CARE Q (every) 2HRS (2 hours) AND PRN (as needed) .TOILETING .EXT (extensive) ASSIST FOR TRANSFERS, PERICARE (perineal care), CLOTHING . The nurse's note dated 5/30/17 documented, .incontinent of B (bowel) (and) B (bladder) (with) Pericare (perineal) care provided . The Activity of Daily Living (ADL) documentation sheets documented Resident #36 had urinary incontinence episodes daily from 5/1/17-5/31/17. The urinalysis with culture and sensitivity with a collection date of 5/25/17 documented, .ESCHERICHIA COLI ES RESISTANCE DUE TO (ESBL) EXTENDED SPECTRUM B-LACTAMASE .Started on .Contact Iso (isolation) . The telephone physician's orders [REDACTED].Contact .Isolation x (times) 7 days .ESBL . Observations in the front lobby of the facility on 5/31/17 at 2:40 PM, and 6/1/17 at 11:34 AM, revealed Resident #36 sitting on a folded incontinence pad in a wheelchair with other residents present in the lobby. Interview with Certified Nursing Assistant (CNA) #7 on 6/3/17 at 10:20 PM, at the Station 1 Nurses' Desk, CNA #7 was asked whether Resident #36 was continent of urine. CNA #7 stated, Not during the night. CNA #7 was asked whether Resident #36 was normally wet when she goes in to do incontinence checks on her. CNA #7 stated, Yes. CNA #7 confirmed she performs incontinence care for Resident #36 due to urinary incontinence. Interview with Registered Nurse (RN) #2 at the Station 1 Nurses' Desk on 6/3/17 at 10:30 PM, RN #2 was asked whether res #36 was continent of bowel and bladder. RN #2 looked in the medical record and stated, .She is incontinent of B&B (bowel and bladder) .staff always performs pericare. Interview with the Director of Nursing (DON) on 6/3/17 at 11:39 PM, in the conference room, the DON was asked whether it was appropriate for a resident that is incontinent of urine and that has a [DIAGNOSES REDACTED]. The DON stated, Not if incontinent . 3. Observations on the Station 1 Hall on 6/1/17 at 11:24 AM, revealed CNA #6 walking down the hall holding numerous linens, including a gown that had a wet brown substance on it. CNA #6 was carried the items and held them against the door of the dirty linen room, as she attempted to open the door. Observations in Resident #273 room on 6/1/17 at 4:49 PM, 5:04 PM, and 5:11 PM, revealed RN #1 washed her hands, and turned off the faucet with the same wet paper towel she dried her hands with. Observations in Resident #273's room on 6/1/17 at 5:10 PM and 5:17 PM, revealed CNA #1 washed her hands and turned off the faucet with the same wet paper towel she dried her hands with. Observations in Resident #273's room on 6/1/17 at 5:20 PM, revealed RN #1 removed the barrier pad used during dressing change of Resident #273's bilateral heels. RN #1 picked up the barrier pad with a paper towel, and carried the soiled pad down the hall for disposal. Observations on the treatment cart outside of Residents #273's room on 6/1/17 at 5:25 PM, revealed RN #1 placed the biohazard bag in the regular trash can on the treatment cart. Interview with CNA #6 on 6/1/17 at 11:26 AM, in the soiled linen room, CNA #6 was asked how soiled linen should be carried to the soiled linen room. CNA #6 stated, It should be carried in a plastic bag . CNA #6 was asked whether the linen she just took into the soiled linen room had been carried out into the hallway in a bag. CNA #6 stated, No ma'am, I did not. Interview with RN #1 on 6/1/17 at 5:29 PM, at the treatment cart, RN #1 was asked what is standard procedure for turning off the faucet after hand hygiene. The RN #1 stated, You would use a paper towel to turn it off .a clean paper towel. RN #1 was asked if it was acceptable to turn off the faucet with the same wet paper towel you dried your hands with. RN #1 stated, I don't know. RN #1 was asked if was acceptable to carry dirty linen down the hallway without placing it in a plastic bag. The RN #1 stated, If it was soiled, I would put it in a bag . RN #1 was asked what is policy for removing linen from a resident's room. RN #1 stated, We would put it in a plastic bag and carry it to the linen barrel. Interview with the Director of Nursing (DON) on 6/1/17 5:48 PM, in the front office, the DON was asked if it was acceptable to turn off the faucet with the same wet paper towel after hand washing. The DON stated, No .now you have contaminated that sink and your hands. The DON was asked if it was acceptable to place a biohazard bag in the treatment cart trash can in a regular trash bag. The DON stated, No it is not. The DON was asked if it was acceptable to carry used linen from a resident room in the hallway without placing it in plastic bag. The DON stated, No .they should not be carrying it down the hall without a plastic bag. Interview with the Administrator on 6/2/17 at 11:24 AM, at the Station 4 Nursing Station, the Administrator was if it was appropriate for soiled linens to be carried through the hallway to the soiled linen area without being contained. The Administrator stated, No, it should be placed in a bag before it leaves the room.",2020-09-01
838,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-06-04,520,G,0,1,35VZ11,"Based on policy review, medical record review, observation and interview, the facility failed to ensure an effective Quality Assurance (QA) program that recognized an ongoing concern with weight loss, identified the root cause of the problems, developed appropriate plans and ensured systems and processes were in place and consistently followed by staff to address quality concerns. Failure of the facility to implement and/or provide interventions for residents with significant weight loss resulted in actual harm to Resident #30. The findings included: 1. The QA program failed to identify and develop interventions to prevent significant and severe weight loss resulting in actual harm to Resident #30. Refer to F325. 2. The QA program failed to ensure the Registered Dietitian or a Nutritional Professional reassessed the nutritional intervention implementation for all residents. Resident #30 had a severe and significant weight loss and the nutritional interventions were not implemented. Refer to F361. 3. Interview with the interim Director of Nursing (DON) and the Administrator on 6/03/17 11:10 PM, the DON stated, I think it falls under both of our realms (DON and Administrator) for the QA responsibility. The only QA information provided by the DON or Administrator related to nutritional concerns was that the DON stated, .I went out and put it on the ADL sheets and did an in-service related to nutritional supplements. The DON stated this was conducted today on 6/3/17, after the survey team identified the nutritional concerns.",2020-09-01
839,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2019-06-12,550,J,1,0,HPNL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility video footage review, and interview the facility failed to ensure 1 resident (Resident #2) of 3 residents reviewed was treated with respect, dignity, and quality of life when restrained with a gait belt to his wheelchair. The findings include: Review of the facility policy, Abuse, Neglect and Exploitation of Residents, undated, revealed .It is the policy of the facility that the acts of abuse directed against residents are absolutely prohibited .unlawful restraint is intentionally or knowingly using a physical or chemical restraint . Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed a Significant Change Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) of 01, indicating severe cognitive impairment. Further review revealed no restraints were used for Resident #2. Medical record review of Resident #2's (MONTH) 2019 Order Summary Reports revealed no order for a restraint. Review of the facility's video footage on 5/2/19 and interview with the Administrator on 6/11/19 at 11:52 AM in the conference room confirmed the Alleged Perpretrator (AP) restrained Resident #2 to his wheelchair by putting a gait belt around his chest and fastening the gait belt to the back of the wheelchair, restraining Resident #2 in his wheelchair. Interview with the Administrator revealed the AP, Certified Nursing Assistant (CNA) #3 and CNA #4 were identified by the Administrator on the video footage. Further review of the facility's video footage revealed CNA #4 was standing at the nurses station facing the AP and Resident #2 and it appeared that CNA #3, wearing a pink shirt, was in the sideline of the camera then CNA #3 walked by the AP and Resident #2 after the gait belt was applied. Further review revealed the facility's video footage did not show removal of the gait belt. Interview with the Administrator revealed the video footage containing conversation between the Respiratory Therapist (RT) and Resident #2 was unavailable due to the system rolls over video footage after 14 days, and some video footage is self-erased. Interview with the Director of Nursing (DON) on 6/11/19 at 8:00 AM in the conference room revealed the DON was informed of the abuse on 5/2/19 around 9:00 AM by Licensed Practical Nurse (LPN) #5. Continued interview revealed by the time the DON informed the Administrator, the Respiratory Therapist (RT) had already reported it to the Administrator. Continued interview revealed when asked when staff were to report abuse the DON confirmed all staff were expected to report suspected or witnessed abuse immediately. Interview with the Administrator on 6/11/19 at 8:15 AM in the conference room revealed the Administrator was notified on 5/2/19 around 10:00 AM by RT #1 of Resident #2 being restrained in his wheelchair with a gait belt around his chest. Continued interview revealed the Administrator reported the allegation to the State Agency as soon as he was aware of the allegation. Further interview when asked when staff were to report abuse the Administrator stated, Immediately, I expect them to notify me as soon as it happens. Interview on 6/11/19 at 1:45 PM with LPN #5 at nurses station 2A revealed she reported for work on 5/2/19 at 7:30 AM. Continued interview revealed she stated, RT (#1) reported to me that (Resident #2 ) was sitting in his wheelchair at the nurses station with a gait belt around his chest, secured to the wheelchair; I went immediately and assessed Resident #2 and he was in the bed with no restraint on and no injuries noted. Continued interview with LPN #5 stated, I reported to the Director of Nursing around 8:30 AM the RT witnessed Resident #2 being in a wheelchair with a gait belt around his chest, secured (restrained) to the wheelchair. Interview with RT #1 on 6/11/19 at 1:15 PM in the conference room revealed on arrival to the facility on [DATE] around 5:30 AM she observed Resident #2 sitting in a wheelchair yelling come here. and look what that [***] did to me. RT #1 stated the resident had a gait belt around the upper part of the chest, attached to the wheelchair, and fitted snugly against the resident's chest. Continued interview revealed RT #1 reported what she saw to the Administrator around 9:00 to 9:30 AM on 5/2/19. She stated, I guess I should have called someone and reported it sooner, I don't know, I just told (LPN #5) as soon as she got here. Validation of the IJ removal plan was completed on 6/12/19 through review of the facility documentation, observations and interviews. Surveyor verified the IJ removal plan by: 1. Review of the personnel file for the AP revealed abuse training was appropriately provided at orientation and as needed. Continued review revealed the facility obtained background checks and reference checks with no negative findings. Immediately following the incident on 5/2/19 the AP was suspended pending investigation. Further review revealed the AP was terminated on 5/2/19 following review of video footage confirming application of a gait belt as a restraint by the AP to Resident #2. 2. Review of resident audits for all the residents on the secured unit. 3. Review of the restraint policy and abuse policy was completed and the policies were appropriate. In-service education was completed for all staff on 5/3/19 to 5/6/19 as evidenced by sign-in rosters and staff interviews. Verification through interviews of internal audits initiated 6/12/19 to ongoing every 2 weeks then weekly for 3 months to assess for restraint use. 4. Presentation of all audits to the Quality Assurance Committee (QAC) monthly for 3 months; with the first presentation at the 6/12/19 meeting.",2020-09-01
840,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2019-06-12,604,J,1,0,HPNL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, review of the facility investigation, medical record review, facility video footage review and interview the facility failed to ensure 1 resident (Resident #2) of 3 residents was free from the use of restraints related to Resident #2 being restrained with a gait belt to his wheelchair. The findings include: Review of the facility policy, Use of Restraints, undated, revealed .Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted . Review of facility policy, Gait Belts, undated, revealed .Gait belts must be used by all Therapy Rehabilitation staff during balance activities, transfers, and gait training of patients to promote safety during therapeutic activities, unless contraindicated . Review of the facility investigation revealed an investigation was started on 5/2/19 related to allegation of abuse by the alleged perpertrator (AP) to Resident #2. Continued review revealed initial written statements were obtained from the Respiratory Therapist (RT #1) Certified Nurse Aide (CNA) #3 and CNA #4. Further review revealed RT #1's initial written statement revealed I walked over to 2A's nsg (nursing) station at approximately 04:45 to discuss this [MEDICAL CONDITION] Care. As I arrived in the common area, I saw the Resident (#2) sitting in his wheelchair. He was secured (restrained) to the chair with a pink and grey gait belt. The belt was wrapped around the Resident (#2's) chest and the wheelchair. I talked briefly with him. He said the word [***] and motioned his hand as he pointed to the nurses station. When I looked at the nursing station the AP was the only person sitting there. The gait belt was obviously tightly secured because he could not lift his back off of the back of the wheelchair. Continued review of CNA #4's statement revealed I would like to see the video footage because I don't remember seeing any resident being abused while I was working 2A on 5/2/19. Further review revealed CNA #3's statement revealed I don't know really when I came out (of) the room (Resident #2) was already in the chair strapped in. Continued review revealed the initial statement for the AP dated 5/6/19 revealed .there was no intent of abuse .it was placed for his safety . Further review revealed the AP received abuse training upon employment with the facility on 8/22/18. Continued review revealed the AP's employment was terminated on 5/6/19. Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed a Significant Change Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) of 01, indicating severe cognitive impairment. Further review revealed no restraints were used for Resident #2. Medical record review of Resident #2's Order Summary Report dated (MONTH) 2019 revealed no order for a restraint. Review of the facility's video footage on 5/2/19 with the Administrator on 6/11/19 at 11:52 AM in the conference room confirmed the AP restrained Resident #2 to his wheelchair at approximately 4:39 AM by putting a gait belt around his chest and fastening the gait belt to the back of the wheelchair, restraining Resident #2 in his wheelchair. Interview with the Administrator revealed the AP, CNA #3 and CNA #4 were identified by the Administrator on the video footage. Further review of the facility's video footage revealed CNA #4 was standing at the nurses station facing the AP and Resident #2 and it appeared that CNA #3, wearing a pink shirt, was in the sideline of the camera then CNA #3 walked by the AP and Resident #2 after the gait belt was applied. Further review revealed video footage did not show removal of the gait belt. Interview with the Administrator revealed the video footage containing conversation between RT #1 and Resident #2 was unavailable due to the system rolls over video footage after 14 days, and some video footage is self-erased. Interview with the Director of Nursing (DON) on 6/11/19 at 8:00 AM in the conference room revealed she was informed of the alleged abuse on 5/2/19 around 9:00 AM by Licensed Practical Nurse (LPN) #5. Continue interview revealed by the time the DON informed the Administrator, RT #1 had already reported it to the Administrator. Continued interview when asked when staff were to report abuse the DON confirmed all staff were expected to report suspected or witnessed abuse immediately. Interview with the Administrator on 6/11/19 at 8:15 AM in the conference room revealed the Administrator was informed on 5/2/19 around 10:00 AM by RT #1 of Resident #2 being restrained in his wheelchair with a gait belt around his chest. Continued interview revealed the Administrator reported the allegation to the State Agency as soon as he was aware of the allegation. Further interview when asked when staff were to report abuse the Administrator stated, Immediately, I expect them to notify me as soon as it happens. Interview on 6/11/19 at 1:45 PM with LPN #5 at nurses station 2A revealed she reported for work on 5/2/19 at 7:30 AM. Continued interview revealed, she stated, the RT (#1) reported to me that (Resident #2) was sitting in his wheelchair at the nurses station with a gait belt around his chest, secured to the wheelchair; I went immediately and assessed Resident #2 and he was in the bed with no restraint on and no injuries noted. Continued interview with LPN #5 revealed I reported to the DON around 8:30 AM RT #1 witnessed (Resident #2) being in a wheelchair with a gait belt around his chest, secured to the wheelchair. Interview with the RT #1 on 6/11/19 at 1:15 PM in the conference room revealed she reported for work on 5/2/19 around 5:30 AM to educate the night shift nurses on [MEDICAL CONDITION] care. Continued interview revealed when she went to station 2A around 5:45 AM and she observed Resident #2 sitting in a wheelchair with his back facing the nurses station. Resident #2 hollered (yelled) come here and motioned for RT #1 to come over to him. RT #1 went over to Resident #2 and he pointed at a gait belt that was around his chest, and said look what that [***] did to me, pointing toward the nurses station where the AP was sitting. Further interview revealed, when asked how was the gait belt placed on Resident #2 she confirmed the gait belt was around the upper part of Resident #2's chest snugly, and attached to the wheelchair. When asked to explain snuggly, RT #1 replied, he could not raise his back off the back of the wheelchair. Continued interview revealed RT #1 went inside the nurses station and spoke to the AP related to the training she was doing and the AP spoke hatefully saying, I don't have time to do the training. RT #1 left nurses station 2A and went to the 400 hall. Further interview revealed RT #1 reported her observation of Resident #2 with a gait belt around his chest restraining Resident #2 to his wheelchair to LPN #5 (Unit Manager for 200 Hall) when she (LPN #5) arrived at the facility at 7:30 AM. Continued interview revealed RT #1 reported her observation of Resident #2 in his wheelchair with a gait belt around his chest to the Administrator during the morning stand up meeting around 9:00 to 9:30 AM on 5/2/19. She stated, I guess I should have called someone and reported it sooner, I don't know, I just told ( LPN #5) as soon as she got here. Telephone interview with CNA #3 on 6/12/19 at 7:25 AM revealed she has been employed with the facility since (MONTH) (YEAR) and usually worked station 2A, the secured unit. Continued interview revealed CNA #3 was trained on abuse upon hire and quarterly. Further interview revealed CNA #3 named the types of abuse and had never suspected or witnessed abuse and would report suspected or witnessed abuse immediately to the supervisor and the DON. Continued interview when asked if she ever witnessed abuse, stated No I've never witnessed abuse, when they (Administrator and DON) called me and asked me about the (AP) securing (restraining) (Resident #2), I told them that I didn't know what they were talking about and I never seen anything, I even wrote a statement saying I never seen nothing. Further interview revealed CNA #3 was again questioned about observing abusive behavior toward residents, CNA #3 stated, I have never seen nobody being abused when I've worked. Telephone interview with CNA #4 on 6/12/19 at 8:17 AM revealed she has been employed with the facility for one year and usually worked on station 2A, the secured unit. Continued interview revealed CNA #4 received training on abuse upon hire during orientation and every month. CNA #4 named the types of abuse and would report suspected or witnessed abuse immediately to the supervisor. Further interview revealed CNA #4 had never observed any resident being abused while working at the facility. CNA #4 stated she had worked with the AP and had never observed her abuse any resident. Continued interview when asked if she recalled Resident #2 being restrained by the AP she stated I never saw him (Resident #2) with a gait belt on him, I only saw him sitting in the wheelchair. Further interview revealed CNA #4 was again questioned about observing abusive behavior toward residents with same answer given as stated above. Validation of the IJ removal plan was completed on 6/12/19 through review of the facility documentation, observations and interviews. Surveyor verified the IJ removal plan by: 1. Review of the personnel file for the AP revealed abuse training was appropriately provided at orientation and as needed. Continued review revealed the facility obtained background checks and reference checks with no negative findings. Immediately following the incident of 5/2/19 the AP was suspended pending investigation. Further review revealed the AP was terminated on 5/2/19 following review of video footage confirming application of a gait belt as a restraint by the AP to Resident #2. The disciplinary action was completed on 5/6/19. 2. Review of resident audits for all the residents on the secured unit. 3. Review of the restraint policy and abuse policy was done and the policies were appropriate. In-service education was completed for all staff on 5/3/19 to 5/6/19 as evidenced by sign-in rosters and staff interviews. Verification through interviews of internal audits initiated 6/12/19 to ongoing every 2 weeks then weekly for 3 months to assess for restraint use. 4. Presentation of all audits to the Quality Assurance Committee (QAC) monthly for 3 months; with the first presentation at the 6/12/19 meeting.",2020-09-01
841,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2019-06-12,609,J,1,0,HPNL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation, employee files and interviews the facility failed to follow the facility policy related to reporting abuse immediately to the supervisor. The findings include: Review of the facility policy, Abuse, Neglect and Exploitation of Residents, undated, revealed .It is the policy of the facility that acts of abuse directed against residents are absolutely prohibited .All personnel (including volunteers) in all departments will be alert to indicators of suspected or actual abuse, neglect and exploitation. The resident is assisted to safety and is protected against (further) harm, and if abuse is suspected, personnel will report their observations to their supervisor immediately and without delay . Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed a Significant Change Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) of 01, indicating severe cognitive impairment. Further review revealed no restraints were used for Resident #2. Review of the facility investigation and a Respiratory Therapist (RT #1) initial written statement dated 5/2/19 revealed I walked over to 2A's nsg (nursing) station at approximately 4:45 AM to discuss this [MEDICAL CONDITION] Care. As I arrived in the common area, I saw (Resident #2) sitting in his wheelchair. He was secured (restrained) to the chair with a pink and grey gait belt. The belt was wrapped around (Resident #2's) chest and the wheelchair. I talked briefly with him. He said the word '[***] ' and motioned his hand as to point to the nurses station. When I looked at the nsg station the (AP) was the only person sitting there. The gait belt was obviously tightly secured because he could not lift his back off of the back of the wheel chair. Review of the RT #1's employee file on 6/12/19 revealed RT #1 received training on abuse and reporting abuse upon hire in (MONTH) 2019. Interview with the Director of Nursing (DON) on 6/11/19 at 8:00 AM in the conference room revealed the DON was informed of the alleged abuse on 5/2/19 around 9:00 AM by Licensed Practical Nurse (LPN) #5. Continued interview revealed by the time the DON informed the Administrator, the RT #1 had already reported it to the Administrator. Continued interview when asked when staff are to report abuse the DON confirmed all staff were expected to report suspected or witnessed abuse immediately. Interview with the Administrator on 6/11/19 at 8:15 AM in the conference room revealed the Administrator was informed on 5/2/19 around 10:00 AM by RT #1 of Resident #2 being secured (restrained) in his wheelchair with a gait belt around his chest. Continued interview revealed the Administrator reported the allegation to the State Agency as soon as he was aware of the allegation. Further interview when asked when staff were to report abuse the Administrator stated, Immediately, I expect them to notify me as soon as it happens. Interview with the RT #1 on 6/11/19 at 1:15 PM in the conference room revealed she reported for work on 5/2/19 around 5:30 AM to educate the night shift nurses on [MEDICAL CONDITION] care. Continued interview revealed when she went to station 2A around 5:45 AM and she observed Resident #2 sitting in a wheelchair with his back facing the nurses station. Resident #2 hollered (yelled) come here and motioned for the RT (#1) to come over to him. RT #1 went over to Resident #2 and he pointed at a gait belt that was around his chest, and said look what that [***] did to me, pointing toward the nurses station where the (AP) was sitting. Further interview, when asked how was the gait belt placed on Resident #2 she confirmed the gait belt was around the upper part of Resident #2's chest snuggly, and attached to the wheelchair. When asked to explain snugly, RT #1 replied, he could not raise his back off the back of the wheelchair. Continued interview revealed RT #1 went inside the nurses station and spoke to the AP related to the training she was doing and the AP spoke hatefully saying, I don't have time to do the training. The RT left nurses station 2A and went to the 400 hall. Further interview revealed the RT reported her observation of Resident #2 with a gait belt around his chest securing (restraining) Resident #2 to his wheelchair to LPN #5 (Unit Manager for 200 Hall) when she (LPN #5) arrived at the facility at 7:30 AM. Continued interview revealed RT #1 reported her observation of Resident #2 in his wheelchair with a gait belt around his chest to the Administrator during the morning stand up meeting around 9:00 to 9:30 AM on 5/2/19. She stated, I guess I should have called someone and reported it sooner, I don't know, I just told (LPN #5) as soon as she got here. Interview on 6/11/19 at 1:45 PM with LPN #5 at nurses station 2A revealed she reported for work on 5/2/19 at 7:30 AM. Continued interview revealed she stated, the (RT #1) reported to me that (Resident #2) was sitting in his wheelchair at the nurses station with a gait belt around his chest, secured (restrained) to the wheelchair; I went immediately and assessed (Resident #2) and he was in the bed with no restraint on and no injuries noted. Continued interview with LPN #5 revealed I reported to the DON around 8:30 AM (RT #1) witnessed (Resident #2) being in a wheelchair with a gait belt around his chest, secured to the wheelchair. Validation of the IJ removal plan to remove the IJ was completed on 6/12/19 through review of the facility documentation, observations and interviews. Surveyor verified the IJ removal by: 1. Review of the personnel file for the AP revealed abuse training was appropriately provided at orientation and as needed. Continued review revealed the facility obtained background checks and reference checks with no negative findings. Immediately following the incident of 5/2/19 the AP was suspended pending investigation. Further review revealed the AP was terminated on 5/2/19 following review of video footage confirming application of a gait belt as a restraint by the AP to Resident #2. 2. Review of resident audits for all the residents on the secured unit. 3. Review of the restraint policy and abuse policy was done and the policies were appropriate. In-service education was completed for all staff on 5/3/19 to 5/6/19 as evidenced by sign-in rosters and staff interviews. Verification through interviews of internal audits initiated 6/12/19 to ongoing every 2 weeks then weekly for 3 months to assess for restraint use. 4. Presentation of all audits to the Quality Assurance Committee (QAC) monthly for 3 months; with the first presentation at the 6/12/19 meeting.",2020-09-01
842,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2019-06-12,689,J,1,0,HPNL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, and interview the facility failed to prevent elopement from the facility to the facility parking lot for 1 resident (Resident #1) of 3 residents reviewed. The findings include: Review of facility policy, Elopements, revealed .when a departing individual returns to the facility the Director of Nursing Services or Charge Nurse shall .complete and file Report of Incident /Accident . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an annual Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status score of 8 indicating moderate cognitive impairment. Medical record review of an elopement risk evaluation dated 4/22/19 revealed a score of 9 (9 or greater indicated a risk of elopement). Continued medical record review of an elopement risk evaluation dated 5/18/19 revealed a score of 21. Further review of the medical record revealed Resident #1 was care planned for wandering and exit seeking. Interview with the Director of Nursing (DON) on 6/11/19 at 8:40 AM in the conference room revealed video footage of Resident #1's elopement on 5/17/19 was reviewed. Continued interview confirmed the DON stated the video showed the resident pushing open the door (key pad coded) and self-propelling from inside the facility to outside the facility. Further interview revealed the video footage was no longer available due to the facility video system auto-erasing every 14 days. The DON confirmed an investigation was not done for Resident #1's elopement on 5/17/19. Interview with Licensed Practical Nurse (LPN) #1 on 6/11/19 at 12:10 PM in the Unit Manager's office revealed Resident #1 self-propelled from the resident's room to the rehabilitation (rehab) unit as he desired. Continued interview with LPN #1 revealed the resident had a pattern of going to the rehab unit most everyday. Further interview with the LPN revealed when the station 3 nursing staff could not locate the resident they would look in the rehab unit. LPN #1 confirmed the resident had exit seeking behaviors. Interview with LPN #3 on 6/11/19 at 4:35 PM in the conference room revealed as she was leaving the facility on 5/17/19 at approximately 7:00 PM she observed an empty wheelchair with a person sitting by a truck, on his butt, on the asphalt and touching the truck. Continued interview revealed she observed the person as was Resident #1. Further interview revealed the resident stated he was working on this truck; I've been meaning to get to it all day. LPN #3 did a quick assessment of Resident #1 for injuries as she used her cellular phone to call the nursing staff for assistance with the resident. Continued interview revealed LPN #3 was told by Resident #1 he was unsure how he got outside. Interview with the Administrator on 6/12/19 at 9:05 AM in the conference room revealed the video footage from 5/17/19 was auto-erased by the video program system. Continued interview revealed the Administrator gave a description of the video to this surveyor. Further interview revealed the Administrator stated Resident #1 was seen rounding the corner of the hall into the area in front of the door #13 (key pad coded). The Administrator confirmed the resident was seen on the video to push open the door and self-propel himself outside. Continued interview confirmed Resident #1 was unable to be seen on the video in the parking lot. Further interview confirmed the video monitor for the facility was not watched 24/7. The Administrator confirmed the time frame Resident #1 was out of the building was unknown. Validation of the IJ removal plan was completed on 6/12/19 through review of the facility documentation, observations and interviews. Surveyor verified the IJ removal plan by: 1. Resident #1 was returned to the facility and the facility policy for elopement appropriately followed as evidenced by nursing progress notes, event notes and staff interviews. The resident was checked every hour by physician's orders [REDACTED]. 2. In-service education was provided 5/20/19 for wandering and elopement as evidenced from sign-in rosters and staff interviews. Daily door audits were initiated 5/20/19 and performed by the department heads. Audits were ongoing every shift for 2 weeks then weekly for 3 months. Key pad coded doors (4) in the rehab unit were scheduled for installation of alarms the week of 6/17/19. 3. Resident assessments were checked for current status to match condition on 6/12/19 and performed by the DON and nursing staff. The maintenance director will continue daily door audits for proper operation for an additional 2 weeks and then resume daily audits. 4. Presentation of all audits by the DON and maintenance director to the Quality Assurance Committee (QAC) monthly for 3 months; with the first presentation at the 6/12/19 meeting.",2020-09-01
843,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2018-06-20,761,D,0,1,QBCZ11,"**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 a medication in a locked compartment for 1 of 159 residents (Resident #59) reviewed. Findings include: Review of facility policy Storage of Medications, revised (MONTH) 2007, revealed .Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems .the nursing staff shall be responsible for maintaining medication storage . Medical record review revealed the facility admitted Resident #59 on 11/12/16 then readmitted the resident on 6/12/18 with [DIAGNOSES REDACTED]. Review of Quarterly Minimum Data Set (MDS) for Resident #59 dated 5/4/18 revealed the resident had a Brief Interview of Mental Status (BIMS) score of 7 indicating the resident was severely cognitively impaired. Medical record review of the physician's orders [REDACTED].#59 revealed .[MEDICATION NAME]-[MEDICATION NAME] Solution ([MEDICATION NAME][MEDICATION NAME]) 0.5-2.5 (3) milligram (mg) 3 milliliter (ml) 3 ml inhale orally every 6 hours related to [MEDICAL CONDITION] (acute) Exacerbation . Observation on 6/18/18 at 10:40 AM in Resident #59's room revealed an unopened single dose vial of [MEDICATION NAME]/[MEDICATION NAME] 0.5mg/2.5ml laying in a chair beside a nebulizer machine. Interview with Licensed Practical Nurse (LPN) #1 on 6/18/18 at 10:44 AM in Resident #59's room confirmed nurses perform residents' nebulizer treatments. Further interview with LPN #1 confirmed the facility failed to properly store the medication. LPN #1 stated No medicine should ever be laying there.",2020-09-01
844,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2018-06-20,880,D,0,1,QBCZ11,"**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 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 3 of 159 residents, (Resident #59, Resident #349, and Resident #350), reviewed related to labeling and storage of oxygen tubing and masks, and 1 of 8 residents (Resident #128) reviewed related to labeling and storage of irrigation syringes. Findings include: Review of facility policy Oxygen Administration, not dated, revealed .Oxygen tubing will be changed as ordered and PRN, and tubing will be dated to indicate last date of tubing change . Medical record review revealed the facility admitted Resident #59 on 11/12/16 then readmitted the resident on 6/12/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) for Resident #59 dated 5/4/18 revealed the resident had a Brief Interview of Mental Status (BIMS) score of 7 indicating the resident was severely cognitively impaired. Further review of the MDS section O revealed Resident #59 was receiving oxygen (02) therapy. Review of the physician's orders [REDACTED].change 02 tubing and humidifier every night shift every Sun (Sunday) .02 at 2L/min (2 liters per minute) via nasal cannula. every shift related to [MEDICAL CONDITION] with (Acute) Exacerbation . Observations of Resident #59 on 6/18/18 at 10:40 AM and at 4:25 PM and on 6/19/18 at 7:48 AM revealed oxygen via nasal cannula (n/c) at 2 liters per minute (l/m), the oxygen tubing was not dated. Further observations revealed a nebulizer mask and tubing lying in a chair not dated or stored in a bag. Continued observation revealed a portable oxygen tank with oxygen tubing attached to the tank. The oxygen tubing was not dated or stored in a bag. Record review revealed Resident #349 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS for Resident #349 dated 6/13/18 revealed the resident had a BIMS score of 15 indicating the resident was cognitively intact. Further review of the MDS section O revealed the resident had a [MEDICAL CONDITION] and was receiving oxygen therapy. Medical record review of the physician's orders [REDACTED].oxygen [MEDICAL CONDITION] to keep sats (Saturations) above 90% . Observations of Resident #349 on 6/18/18 at 10:28 AM and on 6/19/18 at 7:31 AM revealed oxygen in use via [MEDICAL CONDITION] mask with the oxygen tubing not dated. Continued observation revealed a portable oxygen tank was sitting at the end of the bed with a [MEDICAL CONDITION] mask attached and the mask was not stored in a bag and was not dated. Further observation on 6/18/18 at 4:19 PM revealed oxygen in use via [MEDICAL CONDITION] per portable oxygen tank and the oxygen tubing was not dated. Medical record review revealed Resident #350 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].change and date 02 tubing and humidification every night shift every Sun (Sunday) .02 (Oxygen) @ (at) 3L/M (3 liters per minute) via NC (Nasal Cannula) every shift . Observations of Resident #350 on 6/18/18 at 11:10 AM and at 4:28 PM and on 6/19/18 at 7:44 AM revealed the resident sitting up in a recliner with 02 via n/c at 3 l/m and the oxygen tubing was not dated. Further observation revealed an oxygen mask and tubing hanging on an IV (Intravenous) pole not in use and not dated or stored in a bag. Review of facility policy Enteral Feeding Tubes and Care, not dated revealed .Store bulb syringe in its dated wrapper and discard after 24 hours . Medical record review revealed Resident #128 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 14 day MDS for Resident #128 dated 6/8/18 section K revealed the resident had a feeding tube. Review of the physician's orders [REDACTED].two times a day (BID) 120ml (milliters) water flush BID when TF (Tube Feeding) is started and stopped .every shift may mix all allowable medications and administer via [DEVICE] (Gastrostomy Tube) . Observation in Resident #128's room on 6/18/18 at 11:15 AM and at 4:24 PM and on 6/19/18 at 7:41 AM revealed an irrigation syringe lying on a bedside table opened and not dated. Further observation revealed the syringe had clear liquid and debris in the end of the syringe. Interview with the Director of Nursing (DON) on 6/19/18 at 8:14 AM on the 400 hall confirmed all oxygen tubing and masks should be dated and bagged if not in use. The DON stated the nurses are responsible for changing oxygen tubing and tubing should be changed weekly. Continued interview with the DON confirmed all irrigation syringes when opened should be dated and stored in a bag after use and the facility failed to properly date and store masks, tubing, and syringes.",2020-09-01
845,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-09-13,226,E,1,0,DOIC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, observation, and interview, the facility staff failed to report bruises, injury of unknown origin, to the administrative staff for 2 residents (#1, #2) of 3 residents reviewed with bruising. The findings included: Review of facility policy, Accidents and Incidents, revised (MONTH) 2011 revealed .All accidents or incidents involving residents .occurring on our premises shall be invested and reported to the Administration .The Nurse Supervisor/Charge Nurse and/or department director or supervisor shall promptly initiate and document investigation of the accident or incident .The Nurse Supervisor/Charge Nurse and/or department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Sets ((MDS) dated [DATE] and 8/17/17 revealed Resident #1 had moderate difficulty with hearing, clear speech, could make self understood and usually understood others; was moderately cognitively impaired, had no [MEDICAL CONDITION], mood, [MEDICAL CONDITION] or behaviors; required extensive 1 person assistance with bed mobility, transfers, walking in the room, dressing, toileting, personal hygiene; balance was not steady and required staff to stabilize and had no issue with range of motion in upper and lower extremities. Medical record review of the Physician order [REDACTED].#1 received Aspirin (anti-coagulant) 81 milligrams (mg) by mouth once a day. Medical record review of the care plan initiated 11/29/16, and updated on 2/17/17, 5/25/17, and 8/24/17, revealed .Problem .Requires staff assist with toileting needs for safety and hygiene purposes, communicates needs for toileting, is at risk for skin alteration r/t (related to) presence of frail/fragile skin .Interventions .Assess skin daily during routine care for redness, shearing, blisters, or open areas . Further review revealed the .Problem .Potential for abnormal bleeding/bruising, clotting r/t medication therapy. Receives ASA (Aspirin) .Interventions .Observe, document, and report to MD/NP (Medical Doctor/Nurse Practitioner) PRN (as needed) any .bruising .Protect from injury as able . Observation and interview with Resident #1 on 9/12/17 at 12:43 PM revealed Resident #1 in her room fully reclined with feet extended in a recliner with 2 reddish purple bruises to the top of the right hand. When the resident was asked how the bruises to the right hand occurred the resident pointed to the left side of the over bed table in front of her and stated I hit it right there. Further interview revealed the resident was not sure when the bruise occurred and that she .takes Aspirin every day and bruises real easy . Interview with Registered Nurse (RN) #2 on 9/12/17 at 12:50 PM at the 100 hall nursing station, confirmed she was assigned to Resident #1 and had been on duty 1 hour due to Licensed Practical Nurse (LPN) #8, assigned to Resident #1, leaving the facility ill. Further interview revealed the RN was not aware of the bruise to the right hand. Interview with LPN #6 on 9/12/17 at 12:54 PM in the conference room revealed the LPN was the Unit Manager for Resident #1 and was not aware of the bruise on the right hand. Interview with Certified Nurse Aide (CNA) #8 on 9/12/17 at 1:05 PM outside room [ROOM NUMBER] confirmed the CNA was assigned to Resident #1. Further interview revealed the CNA was aware of the bruise at 10:30 AM on 9/12/17 when she took the resident to the bathroom. Further interview revealed she went to inform the Charge Nurse, LPN #8, but could not find him and the CNA continued with her duties. Further interview confirmed the CNA failed to report the bruise to any person in administrative capacity. Interview with Resident #1's daughter on 9/13/17 beginning at 7:55 AM in the resident's room revealed the daughter was asked regarding the right hand bruise observed on 9/12/17 when the Resident stated .I hit it there . as she pointed to the left corner of the over bed table and the daughter stated That's what she told me too but my brother saw it happen and it was in the bathroom at the sink . Interview with the Director of Nursing (DON) and the Assistant DON (ADON) on 9/13/17 at 6:00 PM in the conference room confirmed the facility staff failed to report the right hand bruise to the administrative staff timely. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician order [REDACTED]. Medical record review of the Admission Minimum (MDS) data set [DATE] revealed Resident #2 was highly impaired with hearing; had clear speech, sometimes could make self understood, and sometimes could understand others; had short and long term memory impairment with moderately impaired cognitive skills for daily decision making; no [MEDICAL CONDITION]; was feeling down/depressed/hopeless and tired/little energy for 2-6 days; and was physically abusive 1-3 days during the review period. Further review revealed the resident required extensive 1 person assistance with bed mobility, dressing, eating, hygiene, and extensive 2 person assistance with transfers, and toilet use. Medical record review of the care plan dated 8/11/17 revealed .Problem .Potential for abnormal bleeding or clotting r/t (related to) medication therapy, anticoagulant .Interventions .Observe, document, and report to MD/NP (Medical Doctor/Nurse Practitioner) PRN (as needed) any .bruising .Protect from injury as able . Observation on 9/12/17 at 11:58 AM revealed Resident #2 in the Memory Unit dining room in a speciality chair with a tray attached and the resident's arms, torso, head and legs were in continuous motion. Further observation revealed the left hand had a dark purple bruise on the wrist bone and another bruise on the top of the hand. Further observation revealed the right hand had a bruise at the wrist and another at the thumb joint. Further observation at 5:38 PM, with the Administrator present, revealed Resident #2 in the specialty chair on the Memory Unit by the nursing station. Interview with the Administrator on 9/12/17 at 5:38 PM on the Memory Unit by the nursing station confirmed Resident #2 had 2 bruises on each hand. Interview with LPN #3 on 9/12/17 at 5:40 PM on the Memory Unit by the nursing station confirmed Resident #2's medical record, binder with Skin Reports, and Nurse's Notes did not have documentation addressing the 4 bruise sites observed on 9/12/17. Interview with the Director of Nursing on 9/13/17 at 6:15 PM in the conference room confirmed the facility staff failed to report the 4 bruises for Resident #2 timely to the administrative staff.",2020-09-01
846,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2019-09-25,626,D,1,0,GEY211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview, the facility failed to document its inability to meet the resident's needs for 1 (#5) of 7 residents reviewed for Admission/Transfer/Discharge criteria. The findings include: Review of facility policy, Transfer Agreement, revised 3/2017, revealed .Our facility has a transfer agreement in place with a designated hospital should our residents need care that is beyond the scope of our available care and services .The agreement ensures that residents are transferred from the facility to the hospital and admitted in a timely manner in an emergency situation by another practitioner .The agreement specifies restrictions with respect to the types of services available and types of residents or health conditions that will not be accepted by the hospital or the facility .Inquiries related to the transfer agreement should be referred to the Administrator . Medical record review revealed Resident #5 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #5 scored 15 on the Brief Interview for Mental Status (BIMS) indicating he was alert, oriented, and able to make his needs known. Continued review of the MDS revealed Resident #5 was dependent on 2 people for transfers and bathing; required extensive assistance of 2 people with bed mobility, dressing, toileting, and grooming; and was frequently incontinent of bowel and bladder. Medical record review revealed multiple episodes of refusing care; yelling and cursing at staff; family trying to use a mechanical lift to transfer him without staff being present; and family bringing in medications and other materials not associated with his care. Medical record review revealed Resident #5 was sent to the hospital with unresponsiveness and the facility refused to allow him to return due to inability to meet his needs. Medical record review revealed no documentation the Ombudsman was notified of the Residents discharge. Medical record review revealed no documentation in the record of the specific needs which could not be met at the facility; attempts made by the facility to meet those needs, or the services another facility could provide. This failure of documentation was confirmed by the Administrator on 9/25/19 at 4:40 PM in the conference room.",2020-09-01
847,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2018-11-29,609,D,1,0,E9TM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record, and interview the facility failed to report an investigation for 1 resident ( #24) of 24 residents reviewed to the state agency. The findings include: Review of the facility policy revised 7/2017 Abuse Investigation and Reporting revealed .All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his /her designee, to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility . Review of the facility policy dated 7/2017 Abuse Investigation and Reporting revealed .The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of findings of the investigationb within 5 working days of occcureence of the incident . Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record of the facility investigation dated 10/18/18 revealed there not an investigation completed. Interview with the Administrator on 11/21/18 at 3:52 PM in his office revealed Resident #24 reported an allegation of abuse. Further interview when asked why the allegation was not reported to the state agency the Administrator responded .Resident #24 told us in conversation that nurse was rough with her and then she retracted her statement . Further interview confirmed .we proceeded as an informal investigation .",2020-09-01
848,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2018-11-29,610,D,1,0,E9TM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record, and interview the facility failed to do a completed investigation for 1 resident (#24) of 24 residents reviewed for abuse. The finidings include: Review of the facility policy dated 7/2017 Abuse Investigation and Reporting revealed .The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of findings of the investigationb within 5 working days of occcureence of the incident . Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Interview with the Director Of Nursing on 11/27/18 at 12:22 PM in the conference room revealed completed an informal investigation. Further interview confirmed she did not complete a formal interview because the resident retracted her statement.",2020-09-01
849,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2018-11-29,690,D,1,0,E9TM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview revealed the facility failed to have a [DIAGNOSES REDACTED].#24) of 6 with Foley catheters. The findings include: Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Medical record review of the physician orders [REDACTED].Foley-insert for diuresis . Observation on 11/21/18 and 11/26/18 Resident #24 had a Foley Catheter in place. Interview Resident #24 on 11/21/18 at 3:01 PM in her room revealed she had requested for a Foley Catheter. Interview with Nurse Practitioner (NP) on 11/21/18 at 1:24 PM in the conference room revealed Resident #24 never had urine retention, and could void. Further interview confirmed it was for her comfort that is the reason for the catheter. She does not have it for [MEDICAL CONDITION] nor does she need it. It was never intended for long term use, only for a short amount of time.",2020-09-01
850,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-12-19,580,D,1,0,RPNN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to notify the physician services of the failure to administer an as needed diuretic as ordered after a weight gain as ordered; the failure to obtain daily weights as ordered; the failure to obtain laboratory tests as ordered; and the failure to administer a daily diuretic as ordered for 1 resident (#1) of 9 residents reviewed. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged home from the facility on 11/15/17. Medical record review of the hospital discharge Physician order [REDACTED]. 1. [MEDICATION NAME] (diuretic) 40 milligrams (mg) 1 tab by po (by mouth) once every day as needed (PRN) fluid retention. Patient Instruction: Take when short of breath (SOB), lower extremity swelling ([MEDICAL CONDITION]), or if you gain 2 pounds (lb) in 1 day or 5 pounds in 5 days. Medical record review of the facility Physician order [REDACTED]. 1. [MEDICATION NAME] 40 mg 1 po Q D PRN (every day as needed) r/t (related to) SOB, or BLE (bilateral lower extremity) [MEDICAL CONDITION], or 2 lb wt (weight) gain in 1 day (D) or 5 lb in 5 days. 2. Daily Weights. Review of the Telephone Physician order [REDACTED]. On 11/9/17 .Daily weights-record on MAR (Medication Administration Record) . On 11/10/17 .CBC (Complete Blood Count), BMP (Basic Metabolic Panel), BNP (B-type Natriuretic Peptide) ([MEDICAL CONDITION], shortness of breath) Please call provider for any critical values . On 11/13/17 .1. Daily weights .2. [MEDICATION NAME] 20 mg Q daily x 7 days .3. Repeat CBC, BMP,BNP on Wednesday 11/15/17 . Review of the Pharmacy Delivery Ticket dated 11/13/17 revealed [MEDICATION NAME] 20 mg had been delivered to the facility for Resident #1. Medical record review of the 11/2017 MAR revealed the following: 1. [MEDICATION NAME] 40 mg po Q D PRN r/t SOB, or BLE [MEDICAL CONDITION], or 2 lb wt gain in 1 day or 5 lb in 5 days was administered on 11/13/17 and 11/14/17. [MEDICATION NAME] 20 mg Q D x 7 days ordered on [DATE] was not on the 11/2017 MAR. Medical record review of the weight, in pounds, documentation on the Admission Screen, 11/2017 MAR, the computer, or Daily AM Weight form revealed: 11/2/17-181 11/3/17-180 11/4/17-183.4 (an increase of 3.4 lb in 1 day, required PRN [MEDICATION NAME], not administered) 11/5/17-183.8 11/8/17-187 11/13/17-187.4 11/14/17- 192.6 (received 40 mg [MEDICATION NAME] administration) 11/15/17-196 (received 40 mg [MEDICATION NAME] administration) The facility failed to obtain and document weights for 6 of 14 days of the admission on 11/6/17, 11/7/17, 11/9/17, 11/10/17, 11/11/17 and 11/12/17. Medical record review revealed no laboratory test results for 10/10/17 as ordered for the CBC, BMP and BNP. Review of the Admission Nursing Note dated 11/2/17 revealed Resident #1 had 1+ [MEDICAL CONDITION] on bilateral lower extremities. Interview with Licensed Practical Nurse (LPN) #6 on 12/13/17 at 2:40 PM in the conference room confirmed the LPN provided direct care to Resident #1. Further interview confirmed the LPN signed the 11/13/17 Physician order [REDACTED]. Interview with the Director of Nursing (DON) on 12/13/17 at 4:05 PM, 12/14/17 at 1:55 PM, 12/18/17 at 2:55 PM, and 12/19/17 at 10:00 AM in the conference room confirmed the facility failed to transcribe the 11/13/17 [MEDICATION NAME] 20 mg order onto the MAR and failed to administer the mediation as ordered. Further interview revealed if the medication was not administered the DON expected the reason to be documented on the back of the MAR. Further interview revealed the nursing staff .would have to weigh the person to know if the weight increased in order to administer the 40 mg [MEDICATION NAME] . Further interview confirmed the facility failed to obtain daily weights for the resident and failed to administer the PRN 40 mg [MEDICATION NAME] on 11/4/17 after a weight gain. Further interview confirmed the facility failed to obtain the 10/10/17 laboratory tests as ordered and failed to notify the physician. Interview with the Nurse Practitioner (NP) #1 on 12/18/17 at 2:30 PM in the conference room confirmed the NP had not been notified the daily weights had not been obtained, the PRN [MEDICATION NAME] had not been administered after the weight gain on 11/4/17, the 10/10/17 laboratory tests were not obtained and the [MEDICATION NAME] 20 mg daily order had not been transcribed or administered.",2020-09-01
851,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-12-19,607,D,1,0,RPNN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, video review, facility investigation review, and interview, the facility staff failed to report an allegation of abuse to the facility administration per policy for 1 resident (#2) of 9 residents reviewed. The findings included: Review of the undated facility policy, Abuse, Neglect and Exploitation of Residents, revealed .Responsibilities .All personnel .if abuse is suspected, personnel will report their observations to their supervisor immediately and without delay .will .report any signs of suspected abuse, neglect and exploitation . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged as a 911 at 5:24 PM to the emergency room following the event. Review of the video dated 9/19/17 from 4:07:45 PM to 4:07:55 PM revealed Certified Nurse Aide (CNA) #1 leaning against the hallway wall when Resident #2 aggressively and with fisted hands attempting to strike the second employee. Further review of the 2 views of the video revealed these were the only 2 employees in the area at the time of the event. Review of the facility investigation included CNA #1's interview on 10/24/17 revealed the CNA was asked why she did not report the event when it occurred the CNA .stated due to all the staff being there that the event was reported . Interview with the Administrator on 12/12/17 at 9:30 AM in the conference room revealed the event which occurred on 9/19/17 was reported on 10/24/17 when the agency CNA #1 involved informed the shift supervisor. The shift supervisor then called the Administrator to report the allegation and the investigation was started. Further interview confirmed the facility staff failed to report the allegation to the facility administration immediately per policy.",2020-09-01
852,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-12-19,684,D,1,0,RPNN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to follow physician orders [REDACTED].#1) of 9 residents reviewed. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged home from the facility on 11/15/17. Medical record review of the hospital discharge Physician order [REDACTED]. 1. [MEDICATION NAME] (diuretic) 40 milligram (mg) 1 tab by po (by mouth) once every day (Q D) as needed ( PRN) fluid retention. Patient Instruction: Take when short of breath (SOB), lower extremity swelling, or if you gain 2 pounds (lb) in 1 day or 5 pounds in 5 days. Medical record review of the facility Physician order [REDACTED]. 1. [MEDICATION NAME] 40 mg 1 po Q D PRN r/t (related to) SOB, or BLE (bilateral lower extremity) [MEDICAL CONDITION], or 2 lb wt (weight) gain in 1 day (D) or 5 lb in 5 days. 2. Daily Weights. Review of the Telephone Physician order [REDACTED]. On 11/9/17 .Daily weights-record on MAR (Medication Administration Record) . On 11/10/17 .CBC (Complete Blood Count), BMP (Basic Metabolic Panel), BNP (B-type Natriuretic Peptide) ([MEDICAL CONDITION], shortness of breath) Please call provider for any critical values . On 11/13/17 .1. Daily weights .2. [MEDICATION NAME] 20 mg Q daily x 7 days .3. Repeat CBC, BMP,BMP on Wednesday 11/15/17 . Review of the Pharmacy Delivery Ticket dated 11/13/17 revealed [MEDICATION NAME] 20 mg had been delivered to the facility for Resident #1. Medical record review of the 11/2017 MAR revealed the following: 1. [MEDICATION NAME] 40 mg po Q D PRN r/t SOB, or BLE [MEDICAL CONDITION], or 2 lb wt gain in 1 day or 5 lb in 5 days was administered on 11/13/17 and 11/14/17. [MEDICATION NAME] 20 mg Q D x 7 days ordered on [DATE] was not on the 11/2017 MAR. Medical record review of the weight documentation on the Admission Screen, 11/2017 MAR, the computer, or Daily AM Weight form revealed: 11/2/17-181 11/3/17-180 11/4/17-183.4 (an increase of 3.4 lb in 1 day, required PRN [MEDICATION NAME], not administered) 11/5/17-183.8 11/8/17-187 11/13/17-187.4 11/14/17- 192.6 (received 40 mg [MEDICATION NAME] administration) 11/15/17-196 (received 40 mg [MEDICATION NAME] administration) The facility failed to obtain and document weights for 6 of 14 days of the admission on 11/6/17, 11/7/17, 11/9/17, 11/10/17, 11/11/17 and 11/12/17. Interview with Licensed Practical Nurse (LPN) #6 on 12/13/17 at 2:40 PM in the conference room confirmed the LPN provided direct care to Resident #1. Further interview confirmed the LPN signed the 11/13/17 order for [MEDICATION NAME] 20 mg and failed to transcribe the order on the MAR. Interview with the Director of Nursing (DON) on 12/13/17 at 4:05 PM, 12/14/17 at 1:55 PM, 12/18/17 at 2:55 PM, and 12/19/17 at 10:00 AM in the conference room confirmed the facility failed to transcribe the 11/13/17 [MEDICATION NAME] 20 mg order onto the MAR and failed to administer the mediation as ordered. Further interview revealed the nursing staff .would have to weigh the person to know if the weight increased in order to administer the 40 mg [MEDICATION NAME] . Further interview confirmed the facility failed to obtain daily weights for the resident and failed to administer the PRN 40 mg [MEDICATION NAME] on 11/4/17 after a weight gain. Further interview confirmed the facility failed to obtain the 10/10/17 laboratory tests as ordered and failed to notify the physician.",2020-09-01
853,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-12-19,732,C,1,0,RPNN11,"> Based on observation and interview, the facility failed to post the current daily staffing for 1 of 5 days of the survey. The findings included: Observation on 12/12/17 at 7:15 AM in the main lobby and hall area, with various informational postings for families and residents, revealed the posted staffing and census form was dated 11/20/17. Interview with Licensed Practical Nurse #11 on 12/12/17 at 7:30 AM in the conference room, after reviewing the posted staffing form, confirmed the posted staffing and census was dated 11/20/17. Interview with the Director of Nursing at 8:35 AM in the conference room confirmed the posted staffing form dated 11/20/17 was not current.",2020-09-01
854,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-12-19,842,D,1,0,RPNN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to maintain a complete and accurate medical record for 1 resident (#1) of 9 residents reviewed. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged home from the facility on 11/15/17. Medical record review of the hospital discharge Physician order [REDACTED]. 1. [MEDICATION NAME] (diuretic) 40 milligram (mg) 1 tab by po once every day (Q D) as needed (PRN) fluid retention. Patient Instruction: Take when short of breath (SOB), lower extremity swelling, or if you gain 2 pounds (lb) in 1 day or 5 pounds in 5 days. 2. [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME] a [MEDICATION NAME][MEDICATION NAME]) 0.5 mg-2.5mg/3 milliliters (ml) 3 ml inhalation 4 times daily (QID). Medical record review of the facility Physician order [REDACTED]. 1. [MEDICATION NAME] 40 mg 1 po Q D PRN r/t (related to) SOB, or BLE (bilateral lower extremity) [MEDICAL CONDITION], or 2 lb wt (weight) gain in 1 day (D) or 5 lb in days. 2. [MEDICATION NAME] 0.5-2.5mg/3 ml inhalation QID (4 times a day) 3. Daily Weights. Review of the Telephone Physician order [REDACTED]. On 11/9/17 .Daily weights-record on MAR (Medication Administration Record) . On 11/10/17 .CBC (Complete Blood Count), BMP (Basic Metabolic Panel), BNP (B-type Natriuretic Peptide) ([MEDICAL CONDITION], shortness of breath) Please call provider for any critical values . On 11/13/17 .1. Daily weights .2. [MEDICATION NAME] 20 mg Q daily x 7 days .3. Repeat CBC, BMP,BNP on Wednesday 11/15/17 . Review of the Pharmacy Delivery Ticket dated 11/13/17 revealed [MEDICATION NAME] 20 mg had been delivered to the facility for Resident #1. Medical record review of the 11/2017 MAR revealed the following: 1. [MEDICATION NAME] 40 mg po Q D PRN r/t SOB, or BLE [MEDICAL CONDITION], or 2 lb wt gain in 1 day or 5 lb in 5 D was administered on 11/13/17 and 11/14/17. 2. [MEDICATION NAME] 0.5-2.5mg/3 ml inhalation QID at 8:00 AM, 12:00 PM, 4:00 PM and 8:00 PM. Of the 50 opportunities for administration 16 treatments were not administered with no supporting documentation for 14 administrations. [MEDICATION NAME] 20 mg Q D x 7 days ordered on [DATE] was not on the 11/2017 MAR. Medical record review of the weight documentation on the Admission Screen, 11/2017 MAR, the computer, or Daily AM Weight form revealed: 11/2/17-181 11/3/17-180 11/4/17-183.4 (an increase of 3.4 lb in 1 day, required PRN [MEDICATION NAME], not administered) 11/5/17-183.8 11/8/17-187 11/13/17-187.4 11/14/17- 192.6 (received 40 mg [MEDICATION NAME] administration) 11/15/17-196 (received 40 mg [MEDICATION NAME] administration) The facility failed to obtain and document weights for 6 of 14 days of the admission on 11/6/17, 11/7/17, 11/9/17, 11/10/17, 11/11/17 and 11/12/17. Interview with Licensed Practical Nurse (LPN) #6 on 12/13/17 at 2:40 PM in the conference room confirmed the LPN provided direct care to Resident #1. Further interview confirmed the LPN signed the 11/13/17 order for [MEDICATION NAME] 20 mg and failed to transcribe the order on the MAR. Further interview revealed the LPN was not aware she was to document the reason for not administering a medication on the back of the MAR. Interview with the Director of Nursing (DON) on 12/13/17 at 4:05 PM, 12/14/17 at 1:55 PM, 12/18/17 at 2:55 PM, and 12/19/17 at 10:00 AM in the conference room confirmed the facility failed to transcribe the 11/13/17 [MEDICATION NAME] 20 mg order onto the MAR. Further interview revealed if the medication was not administered the DON expected the reason to be documented on the back of the MAR and the facility failed to do so. Further interview revealed the nursing staff .would have to weigh the person to know if the weight increased in order to administer the 40 mg [MEDICATION NAME] . Further interview confirmed the facility failed to obtain daily weights for the resident. The facility failed to maintain a complete and accurate medical record.",2020-09-01
855,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2020-02-27,623,E,0,1,0FU611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to send the Ombudsman a notice of transfer for 2 of 2 sampled residents (Resident #3 and #51) reviewed for transfer/discharge requirements. The findings include: 1. Review of the medical record, showed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED].#3 to the emergency room for tube placement confirmation. Review of the Physician order [REDACTED].#3 to the hospital. Review of the Physician order [REDACTED].#3 to the hospital for respiratory distress. Review of the Physician order [REDACTED].#3 to the emergency room for evaluation and treatment. Review of the Physician order [REDACTED].#3 to the emergency room for evaluation and treatment. Review of the Physician order [REDACTED].#3 to the emergency room for feeding tube placement and verification. Resident #3 returned to this nursing home after each transfer. The facility was unable to provide documentation that the Ombudsman had been notified of Resident #3's transfers to the hospital on [DATE], 10/9/2019, 10/27/2019, 11/7/2019, 11/28/2019, and 1/6/2020. 2. Review of the medical record, showed Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED].#51 to the emergency room for increased behaviors. Resident #51 did return to this nursing home after the transfer. The facility was unable to provide documentation that the Ombudsman had been notified of the transfer to the hospital on [DATE]. During an interview conducted on 2/26/2020 at 3:29 PM, the Administrator confirmed the Ombudsman was not notified of the transfers to the hospital. The Administrator was asked for a policy for Ombudsman notification of emergency transfers and discharges. The Administrator stated, We apparently don't have one, so we will just follow the regulations.",2020-09-01
856,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2020-02-27,812,E,0,1,0FU611,"Based on policy review, observation, and interview, the facility failed to ensure food was stored and served under sanitary conditions as evidenced by opened, undated, and unlabeled foods in 1 of 1 nourishment refrigerators (Secured Unit/Activity Room). This had the potential to affect the 18 residents residing in the Secure Unit. The facility had a census of 57. The findings include: 1. Review of the facility policy titled, LABELING AND DATING, dated (YEAR), showed, .Proper labeling and dating ensures that all foods are stored, rotated, and utilized in a First in First Out (FIFO) manner .All foods should be dated upon receipt before being stored .Food labels must include .The food item name .The date of preparation/receipt/removal from freezer .The use by date as outlined in the attached guidelines .Leftovers must be labeled and dated with the date they are prepared and the use by date . 2. Observation of the Secured Unit Dining/Activity Room Nourishment Refrigerator and Freezer on 2/26/2020 at 4:15 PM, showed the following: a. 1 gallon pitcher that contained a dark, brown liquid, undated and unlabeled. b. (1) 11 ounce (oz.) package of hot dog buns with 3 hot dogs in the package, opened, undated, and unlabeled. c. (1) 15 oz. package of hot dogs, opened, undated, and unlabeled. d. 1 quart size zippered plastic bag with 7 grilled hot dogs, opened, undated, and unlabeled. e. (1) 240 milliliter sized plastic cup that contained a white, powdery substance, uncovered, undated, and unlabeled. f. (1) 3.5 oz. bag of sunflower seeds, opened, undated, and unlabeled. g. (1) 6 count bag of 3 oz. ice cream cups, opened, unlabeled, and undated. During an interview conducted on 2/26/2020 at 4:35 PM, the Certified Dietary Manager (CDM) was asked if opened items in the refrigerator and freezer should be dated and labeled. The CDM stated, Yes, it should be .",2020-09-01
857,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2019-04-17,550,D,0,1,B3ST11,"Based on policy review, observation, and interview, the facility failed to maintain the resident's dignity and respect when 3 of 13 (Registered Nurse (RN) #1, Director of Nursing (DON), and Certified Nursing Assistant (CNA) #1 and #9) staff members failed to knock on the resident's door prior to entering the resident's room and referred to residents as feeders during dining observations. The findings include: 1. The facility's undated Right to Dignity policy documented, .The elder will always be addressed by the name preferred by the elder Staff will knock on the door and wait for permission to enter when entering the elder's personal space . 2. Observations outside Resident #19's room on 4/15/19 beginning at 12:29 PM, revealed RN #1 entered the resident's room to deliver a meal tray without knocking. RN #1 returned to the meal cart and took a meal tray to Resident #43, and did not knock prior to entering the resident's room. RN #1 then walked out of Resident #43's room, re-entered the room to awaken Resident #15, and found Resident #15 wet. RN #1 left the room to find housekeeping, re-entered Resident #15's room to clean and dry the resident without knocking. Observations outside Resident #13's room on 4/15/19 at 12:54 PM, revealed the DON entered Resident #13's room with a meal tray without knocking. Observations outside Resident #39's room on 4/16/19 at 7:50 AM, revealed CNA #1 entered the resident's room to deliver a meal tray without knocking. 3. Observations in the Dining Room on 4/17/19 at 7:30 AM, revealed CNA #9 stated, She is a feeder . referring to Resident #26. There was another resident sitting at the table with Resident #26. Interview with the DON on 4/17/19 at 6:40 PM, in the Administrator Office, the DON was asked if staff should call residents feeders. The DON stated, No, ma'am.",2020-09-01
858,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2019-04-17,565,D,0,1,B3ST11,"Based on the Resident Council Meeting Minutes, observation, and interview, the facility failed to respond to the Resident Councils concerns for 6 of 6 months (November and (MONTH) (YEAR), and January, February, March, and (MONTH) 2019). The findings include: 1. The Resident Council Minutes dated 11/16/18 documented, .Ice still isn't being passed . 2. The Resident Council Minutes dated 12/5/18 documented, .Bathroom floors being wet .Water pitches (pitchers) / ice not being passed . 3. The Resident Council Minutes dated 1/10/19 documented, .Beds are not being made . 4. The Resident Council Minutes dated 2/6/19 documented, .staff being in hallway, talking to other staff discussing other resident's information .Playing on their phones not responding to resident's requesting assistance . 5. The Resident Council Minutes dated 3/6/19 documented, .staff discussing other resident's information has not improved .playing on their phones in the hallways not responding to resident's request hasn't improved .water pitchers not being passed .call lights not being answered . 6. Resident Council Meetings dated 4/3/19 documented, .water pitchers being passed has not improved .call lights being answered has not improved . 7. The Resident Council was held on 4/16/19 at 1:47 PM, in the Dining Room, Resident #39 and residents attending the meeting unanimously agreed that the shower water ran around the toilet area and they could not go to the bathroom without soaking their feet, staff members discussed other resident's information while rounding continued, and water pitchers and ice were not passed. 8. Interview with the Activities Director on 4/16/19 at 5:34 PM, in the Administrator Office, the Activities Director was asked what was the process for reporting grievances from the Resident Council. The Activities Director stated, .I give the complaints to the appropriate department heads . The Activities Director was asked how does she know when issues are resolved. The Activities Director stated, .they tell me they have done an audit or an inservice with the appropriate staff . The Activities Director was asked if the resident's complaints were being resolved. The Activities Director stated, .well .they don't seem to be . 9. Interview with the Administrator on 4/17/19 at 7:30 AM, in the Administrator Office, the Administrator was asked to provide the method by documentation that Resident Council complaints or grievances had been resolved. The documentation on how resident's complaints were resolved was never provided.",2020-09-01
859,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2019-04-17,569,D,0,1,B3ST11,"Based on review of the residents' trust accounts and interview, the facility failed to ensure residents receiving Medicaid funding did not have trust fund balances that exceed the Supplemental Security Income (SSI) limit for 2 of 55 (Resident #11 & #36) resident trust accounts reviewed for the quarter ending 3/29/19. The findings include: 1. The quarterly statements dated 3/29/19 were reviewed, and revealed the following: a. Resident #11's balance was $4514.97 b. Resident #36's balance was $4416.98 2. Interview with the Business Office Manager on 4/16/19 at 2:31 PM, in the Administrator Office, the Business Office Manager was asked should the accounts be over $2200.00. The Business Office Manager stated, No .",2020-09-01
860,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2019-04-17,582,D,0,1,B3ST11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, Notice of Medicare Non-Coverage, and interview, the facility failed to provide an appropriate notice to the resident and/or legal representative in writing when skilled services were terminated for 1 of 4 (Resident #103) sampled residents reviewed. The findings include: 1. Medical record review revealed Resident #103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 2. The Notice of Medicare Non-Coverage documented, .Services Will End: 4/1/19 .Signature of Patient Representative .Date .4/10/19 . 3. An e-mail from the Business Office Manager to Resident #103's legal representative with a Notice of Medicare Non-Coverage attachment was dated 4/1/19. 4. Interview with Resident #103's legal representative on 4/15/19 at 11:11 AM, in Resident #103's room, Resident #103's legal representative was asked if she would be the person the facility would notify if there were changes in Resident #103's status. Resident #103's legal representative stated, .I have issues with the facility's communication .I got the notice my mother would be private pay the same day that services were completed and when I called the (Named Business Office Manager), she told me my mother would be private pay . Interview with the Business Office Manager on 4/17/19 at 9:35 AM, in the Business Office, the Business Office Manager was asked when was the Notice of Medicare Non-Coverage (NOMNC) sent to Resident #103's responsible party to advise of skilled services ending. The Business Office Manager stated, .April 1, 2019 . The Business Office Manager was asked when did Resident #103's skilled services end and when shoukld the NOMNC be given to the responsible party. The Business Office Manager stated, .I e-mailed the NOMNC form to (Named Responsible Party) on 4/1/19 per her request .the NOMNC is supposed to be given to the responsible party 24 hours prior to skilled services being discontinued .",2020-09-01
861,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2019-04-17,636,D,0,1,B3ST11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to complete a comprehensive assessment, using the Centers for Medicare & Medicaid Services-specific RAI process within the regulatory time frames for 3 of 39 (Resident #10, 101, and 200) sampled residents reviewed. The findings include: 1. The MDS 3.0 RAI Manual v (version) 1.16 (MONTH) 1, (YEAR) pages 2-20 through 2-22 documented, .The Admission assessment .must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 .The MDS completion date (Item Z500B) must be no later than day 14 .The annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days) .The ARD (Assessment Reference Date) (Item A2300) must be sent within 366 days after the ARD of the previous OBRA (Omnibus Budget Reconciliation Act) comprehensive assessment (ARD of previous assessment +366 calendar days) AND within 92 days since the ARD of the previous OBRA Quarterly .The MDS completion date (Item A0500B) must be no later than 14 days after the ARD . 2. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS with an ARD date of 3/25/19 revealed Item Z0500B was not complete. The annual MDS assessment should have been completed by 4/8/19 but had never been completed. 4. Medical record review revealed Resident #101 had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS with an ARD date 3/14/19 revealed Item Z0500B was incomplete. The admission MDS should have been completed on 3/27/19 but had never been completed. 6. Medical record review revealed Resident #200 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS with an ARD date of 3/26/19 revealed Item Z0500B was incomplete. The admission MDS should have been completed by 4/9/19 but had never been completed. 7. Interview with the Director of Clinical Reimbursement on 4/16/19 at 9:17 AM, in the Administrator Office, the Director of Clinical Reimbursement confirmed the MDS assessments for Resident #10, 101, and 200 were not completed timely.",2020-09-01
862,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2019-04-17,637,D,0,1,B3ST11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to complete a significant change assessment, using the Centers for Medicare & Medicaid Services-specific RAI process within the regulatory time frames for 1 of 39 (Resident #45) sampled residents reviewed. The findings include: 1. The MDS 3.0 RAI Manual v (version) 1.16 (MONTH) 1, (YEAR) page 2-24 documented, .The MDS completion date (Item Z0500B) must be no later than 14 days from the ARD (ARD + 14 calendar days) and no later than 14 days after the determination that the criteria for a SCSA were met. This date may be earlier than or the same as the CAA(s) completion date, but not later than . 2. Medical record review revealed Resident #45 had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the significant change MDS with an ARD date 3/24/19 revealed Item Z0500B was incomplete. The significant change MDS should have been completed by 4/7/19 but had never been completed. Interview with the Director of Clinical Reimbursement on 4/16/19 at 9:17 AM, in the Administrator Office, the Director of Clinical Reimbursement confirmed the MDS assessments for Resident #45 was not completed timely.",2020-09-01
863,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2019-04-17,638,D,0,1,B3ST11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to complete a quarterly assessment, using the Centers for Medicare & Medicaid Services-specific RAI process within the regulatory time frames for 4 of 39 (Resident #4, #6, #23, and #102) sampled residents reviewed. The findings include: 1. The MDS 3.0 RAI Manual v (version) 1.16 (MONTH) 1, (YEAR) page 2-33 documented, .The Quarterly assessment must be completed at least every 92 days following the previous OBRA (Omnibus Budget Reconciliation Act) assessment of any type .The ARD (Assessment Reference Date) (A2300) must be not more than 92 days after the ARD of the most recent OBRA assessment of any type .The MDS completion date (Item Z0500B) must be no later than 14 days after the ARD (ARD + 14 calendar days) . 2. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD date 3/19/19 revealed Item Z0500B was not completed. The quarterly MDS should have been completed by 4/2/19 but had never been completed. 3. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD date of 3/13/19 revealed Item Z0500B was not completed. The quarterly MDS should have been completed by 3/27/19 but had never been completed. 4. Medical record review revealed Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD date of 3/7/19 revealed Item Z0500B was not completed. The quarterly MDS should have been completed by 3/21/19 but had never been completed. 5. Medical record review revealed Resident #102 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD of 3/4/19 revealed Item Z0500B was not completed. The quarterly MDS should have been completed by 3/18/19 but had never been completed. 6. The Director of Clinical Reimbursement on 4/16/19 at 9:18 AM, in the Administrator Office, confirmed the MDS assessments for Resident #4, 6, 23, and 102 were not completed timely.",2020-09-01
864,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2019-04-17,657,D,0,1,B3ST11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident rights, policy review, medical record review, and interview, the facility failed to ensure each resident and/or resident's legal representative was involved in developing the care plan and making decisions about his or her care for 1 of 18 (Resident #103) sampled residents reviewed. The findings include: 1. The facility's Resident's Rights Under Federal Law documented, .The Resident has a right to participate in planning his or her care and treatment and treatment . The facility's Care Planning - Interdisciplinary Team policy dated (MONTH) 1, 2010 documented, .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 .Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family . 2. Medical record review revealed Resident #103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 3. Interview with Resident #103's legal representative on 4/15/19 at 11:07 AM, in Resident #103's room, Resident #103's legal representative was asked if she had been invited to a care plan meeting or had staff reviewed Resident #103's care plan with her. The legal representative stated, No, I have not received an invitation .it seems the facility is between social workers. Interview with the Assistant Director of Nursing (ADON) on 4/17/19 at 1:37 PM, in the Administrator Office, the ADON was asked what was the process for the initial care plan meeting. The ADON stated, .The normal process is to create and print the resident's care plan within the first 24 hours and then the Social Worker reviews the care plan with the resident's responsible party and has the responsible party sign the care plan . The ADON confirmed Resident #103's care plan had not been signed and could not verify the care plan had been reviewed with Resident #103's daughter.",2020-09-01
865,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2019-04-17,686,E,0,1,B3ST11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview the facility failed to provide care and services to promote healing of pressure ulcers for 2 of 3 (Resident #103 and #200) sampled residents reviewed for pressure ulcers. The findings include: 1. The facility's undated Pressure Ulcer Treatment policy documented, .The purpose of this procedure is to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers .The pressure ulcer treatment program should focus on the following strategies .Pressure ulcer care .The following information should be recorded in the resident's medical record, treatment sheet or designated wound form .The date .the dressing was changed . 2. Medical record review revealed Resident #103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Physician order [REDACTED].Clean, dry open area to buttock, apply small patch calcium alginate and cover c (with) padded dsg (dressing) q (every) day & (and) prn (as needed) . The Physician Telephone Order dated 3/25/19 documented, .Cleanse c WC (wound cleanser), pat dry, apply medi-honey & cover (symbol for with) drsg (dressing) QD (every day) & prn apply skin prep to Lt (left) inner heel q shift preventative . The Physician Telephone Order dated 4/12/19 documented, .Cleanse area to R (right) heel w (with) /NS (normal saline) pat dry, apply [MEDICATION NAME] & dry dressing q day . The Treatment Administration Record (TAR) did not document treatments were performed to the coccyx on 3/16/19, 3/21/19, 3/23/19, 3/28/19, and 4/8/19. The (MONTH) 2019 TAR for Resident #103 did not document skin prep was applied to left inner heel on the 6 PM-6 AM shift on 3/25/19, 3/26/19, 3/27/19, and both shifts on 3/28/19, and the 6 PM-6 AM shift on 3/29/19, 3/30/19, and 3/31/19. The (MONTH) 2019 TAR did not document skin prep was applied to the left inner heel on the 6 PM- 6 AM shift on 4/3/19, 4/5/19, 4/8/19, 4/9/19, 4/12/19, and 4/13/19. 3. Medical record review revealed Resident # 200 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The WOUND/SKIN HEALING RECORD dated 3/20/19 documented, DATE OF ONSET .3/20/19 .(R) (right) buttock .stage 3 .4.8 x (by) 4.2 x 0.3 cm (centimeters) . The WOUND/SKIN HEALING RECORD dated 3/20/19 documented, .DATE OF ONSET .3/20/19 .(L) (left) buttock .stage 3 .2.9 x 2.5 x 0.3 cm . The WOUND/SKIN HEALING RECORD dated 4/6/19 documented, .DATE OF ONSET .4/6/19 .ORIGINAL STAGE .SDTI (suspected deep tissue injury) .(L) heel .4.0 x 5.0 x na (Not Applicable) . The Physician order [REDACTED].Cleanse pressure ulcer c wound cleanser .pat dry apply alginate and cover c sacral foam dressing daily . Review of the (MONTH) 2019 TAR revealed these treatments were not performed on 4/3/19, 4/4/19, 4/7/19, 4/8/19, 4/9/19, 4/10/19, 4/11/19, 4/12/19, and 4/13/19. The Physician order [REDACTED].Skin prep L heel Q shift . Review of the (MONTH) 2019 TAR revealed these treatments were not performed on the 6 AM-6 PM shift on 4/7/19, 4/9/19, 4/10/19, 4/11/19, 4/12/19, 4/13/19, 4/15/19, and 4/16/19. These treatments were not performed on the 6 PM-6 AM shift on 4/12/19 and 4/13/19. The Physician order [REDACTED].Start- Cleanse sacral area w/ (with) NS (Normal Saline), apply Santyl, apply [MEDICATION NAME] dressing daily .Apply iodine to l heel daily . Review of the (MONTH) 2019 TAR revealed the Santyl treatment of [REDACTED]. The Iodine treatment to the left heel was not performed on 4/15/19 and 4/16/19. Interview with the Director of Nursing (DON) on 4/17/19 at 8:01 PM, in the Administrator Office, the DON confirmed the treatments were not done as prescribed.",2020-09-01
866,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2019-04-17,688,D,0,1,B3ST11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure interventions were in place to prevent further decrease in range of motion for 1 of 1 (Resident #102) sampled residents reviewed for range of motion. The findings include: 1. Medical record review revealed Resident #102 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] and a quarterly MDS dated [DATE] documented Resident #102 is rarely understood, had severe cognitive impairment, required extensive to total assistance with activities of daily living, and had functional limitations in range of motion with impairment in all extremities. The care plan dated 9/7/18 and revised 2/28/19 documented, .OT (Occupational Therapy) to eval (evaluate) and treat for orthotic management of bilateral hand contractures . The Restorative Referral dated 4/11/19 documented, .Comments: *Splint to (L) (left) leg x (for) 4 hours (R) (right) leg for 4 hours .Splinting to (R) hand x 4 hours .Splinting w (with) / carrot (L) hand x 4 hours . 2. Observations in Resident #102's room on 4/15/19 at 9:55 AM,12:06 PM, and 3:18 PM, and 4/16/19 at 5:05 PM, and 6:25 PM, revealed Resident #102 was observed in his bed. A carrot (type of splint) and hand splint was observed on the window sill at the foot of his bed. 3. Interview with Physical Therapy Assistant (PTA) on 4/16/19 at 1:07 PM, in the Therapy Room, the PTA was asked why Resident #102 was on therapy's case load. The PTA stated, .he (Resident #102) was seen for therapy for positioning and splinting .we discharged him from our case load on 4/11/19 . Interview with Certified Nursing Assistant (CNA) #2 on 4/16/19 at 5:13 PM, in room [ROOM NUMBER] (a vacant room), CNA #2 was asked whose responsibility it was to apply Resident #102's splints. CNA #2 stated, .mine .I'm still learning how to put the splints on his legs . CNA #2 was asked to explain why Resident #102's splints had not been applied the last two days. CNA #2 stated, .it's my responsibility to apply the splints and if I don't know how, it's my responsibility to ask for assistance and additional training . Interview with the Director of Nursing (DON) on 4/16/19 at 6:25 PM, at the Main Nurses' Desk, the DON was asked if she would expect the nursing staff to apply splints. The DON stated, Yes.",2020-09-01
867,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2019-04-17,690,E,0,1,B3ST11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services to maintain an indwelling urinary catheter when nursing failed to provide catheter care and failed to prevent the catheter tubing from touching the floor for 2 of 3 (Resident #23 and #103) sampled residents reviewed with catheters. The findings include: 1. The facility's undated Foley Catheter Care policy documented, .It is the policy of this facility that catheter care will be provided to all elders with indwelling catheters at least twice daily and more often as needed due to soiling with feces or when it is deemed necessary by the nurse . The facility's Catheter Care, Urinary policy dated (MONTH) 1, 2010 documented, .Maintain an accurate record of the resident's daily output, per facility policy and procedure .Be sure the catheter tubing and drainage bag are kept off the floor . 2. Medical record review revealed Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 9/11/18 documented, .cath (catheter) care as ordered . The (MONTH) 2019 Physician order [REDACTED]. The Hygiene and Bathing Roster did not document catheter care had been provided on 3/14/19, 3/15/19, 3/16/19, 3/18/19, 3/20/19, 3/22/19, 3/23/19, 3/24/19, 3/25/19, 3/26/19, 3/27/19, 3/28/19, and 3/29/19, The Hygiene and Bathing Roster did not document the 6 AM-6 PM shift provided catheter care on 3/13/19 , 3/17/19, 3/20/19, 3/21/19, and 3/30/19. The Hygiene and Bathing Roster did not document catheter had been provided on 4/2/19, 4/5/19, 4/7/19, 4/8/19, and 4/12/19. The Hygiene and Bathing Roster did not document catheter care had been provided on the 6 AM-6 PM shift on 4/6/19 and 4/9/19. The Hygiene and Bathing Roster did not document catheter care had been provided on the 6 PM-6 AM shift on 4/11/19. Observations in Resident #23's room on 4/16/19 at 7:30 AM, 8:15 AM, and 4/17/19 at 7:43 AM, revealed Resident #23's bedside drainage bag was on the floor. 3. Medical record review revealed Resident #103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Physician Telephone Order dated 3/7/19 documented, .Insert 16 F (French) foley catheter. Change drainage bag q (every) 2 weeks. Catheter care q shift and prn (as needed) change Foley catheter q month & prn . The (MONTH) 2019 Treatment Record (TAR) did not document Resident #103 received catheter care on 3/8/19, 3/11/19, 3/12/19, 3/15/19, 3/16/19, 3/17/19, 3/22/19, 3/24/19, 3/25/19, 3/26/19, 3/27/19, 3/29/19, 3/30/19, and 3/31/19. The (MONTH) 2019 TAR did not document Resident #103 had received any catheter care. Observations in the B Hall on 4/15/19 at 3:55 PM, revealed Resident #103 propelling herself down the hall with her foley bag under her wheelchair and the urinary catheter tubing was dragging on the floor. Interview with the the Director of Nursing (DON) on 4/17/19 at 11:05 AM, in the Administrator Office, the DON was asked if Resident #103's TAR's reflected that catheter care had been given as the physician ordered. The DON stated, .not according to the documentation . Interview with the DON on 4/17/19 at 12:54 PM, in the Administrator office, the DON was asked if she expected the staff to follow the physician orders [REDACTED]. The DON stated, Yes. Interview with the Assistant Director of Nursing (ADON) on 4/17/19 at 6:20 PM, in the DON Office, the ADON was asked if it was acceptable for urinary catheter tubing to be on the floor. The ADON stated, Oh, no.",2020-09-01
868,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2019-04-17,693,D,0,1,B3ST11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services to promote safe and effective nourishment by enteral tube feedings for 1 of 1 ( Resident #29) sampled residents reviewed for tube feedings. The findings include: The facility's undated Enteral Tube Feeding via Continuous Pump policy documented, .Documentation .The person performing this procedure should record the following information in the resident's medical record .Gastric residual volume .Report other information in accordance with facility policy and professional standards of practice . Medical record review revealed Resident #29 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The (MONTH) 2019 Physician order [REDACTED].@ (at) 65 CC/HR (cubic centimeters per hour) x (for) 22 HRS/DAY (hours per day) VIA TUBE . Review of the (MONTH) and (MONTH) 2019 Medication Administration Record [REDACTED]. Observations in Resident #29's room on 4/15/19 at 11:51 AM, and 4/16/19 at 4:04 PM, revealed the enteral feeding tubing was not dated. Interview with the Director of Nursing (DON) on 4/17/19 at 8:57 AM, in the Administrator Office, the DON was asked where tubing changes would be documented. The DON stated, I would on the TAR .I do not see it on here . Interview with the DON on 4/17/19 at 9:19 AM, in the Administrator Office, the DON was asked how often the enteral tube feeding residuals should be documented. The DON stated, Every shift. Interview with the DON on 4/17/19 at 9:47 AM, in the Administrator Office, the DON was asked if the residuals were documented every shift. The DON stated, No.",2020-09-01
869,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2019-04-17,812,F,0,1,B3ST11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by unsealed, unlabeled, and undated food items, a dirty drip pan, carbon build up, expired food, 3 of 6 (Dietary Manager, Cook #1 and Dietary Aide #1) staff members hair was not completely restrained, improper handwashing and glove use in the kitchen, a dented can, and 5 of 13 (Certified Nursing Assistant (CNA) #3, #4, #5, #10, and #6) staff members failed to perform hand hygiene during dining. The facility had a census of 55 residents, with 52 of those residents receiving a tray from the kitchen. The findings include: 1. The facility's Food Storage : Cold Foods policy revised ,[DATE] documented, .All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination . The facility's Equipment policy revised ,[DATE] documented, All food service equipment will be clean . The facility's Staff Attire policy revised ,[DATE] documented, All staff members will have hair .contained in a hair net or cap, and facial hair completely restrained . The facility's Food Preparation policy revised ,[DATE] documented, All staff will practice proper hand washing techniques and glove use . The facility's Receiving policy revised ,[DATE] documented,, .All canned goods will be appropriately inspected for dents .Damaged cans will be segregated and clearly identified for return to vendor or disposal, as appropriate . The facility's undated Hand Hygiene policy documented, .Indications for Hand-washing .Before and after having contact with inanimate objects .Before and after assisting an elder with eating .Indications for Hand-rubbing .Before and after assisting an elder with eating . 2. Observations in the Kitchen on [DATE] beginning at 9:45 AM, revealed the following: a. 1 container of danishes not sealed in the breakfast refrigerator b. 1 container pureed cake not dated or labeled in the reach in cooler c. A dirty drip pan on the stove d. 1 skillet with carbon on the inside and the bottom of the skillet e. 1 package of french fries not dated or labeled in the vegetable freezer f. 1 bag of corn not sealed in the vegetable freezer g. 1 box of carrots not sealed in the vegetable freezer h. 1 large bag of chicken strips not dated or labeled in the meat freezer i. 1 container of corn flakes dated [DATE] in the dry storage area Observations in the Dining Room on [DATE] at 3:40 PM, revealed 2 donated banana breads with an expiration date of [DATE] and [DATE] were given to residents playing bingo. Interview with the Activities Director on [DATE] at 5:50 PM, in the Administrator Office, the Activities Director confirmed the snacks were not checked for expiration dates and the snacks should not be served. Observations in the kitchen on [DATE] beginning at 5:05 PM, revealed the following: a. The Dietary Manager's hair was not completely restrained while performing the tray line temperatures b. Cook #1's hair was not completely restrained while serving food from the tray line c. Dietary Aide #1's facial hair was not completely covered while assisting with the tray line Observations in the kitchen on [DATE] at 5:10 PM, revealed Cook #1 placed a glove on one hand, then took a glove and placed it next to her mouth and blew into the glove, and placed the glove on her other hand, picked up a hamburger bun with her hands and placed lettuce and tomato on the hamburger bun and continued serving food from the tray line. Cook #1 then touched the potato wedges with her gloved hands and continued to serve food from the tray line. Cook #1 touched her clothing with her gloved hands, picked up an ink pen and documented on a piece of paper, then continued to serve food, touching the hamburger bun, lettuce and tomato with her gloved hands. Cook #1 placed a pan in the sink, then placed hamburgers in the puree machine, washed a pan in the sink, took the puree hamburger out of the machine and placed it on the serving line. Cook #1 continued to serve food from the serving line with the same pair of gloves. Observations in the Administrator office on [DATE] at 5:30 PM, revealed the following donated resident snacks: a. 20 undated oatmeal pies b. 12 undated packages of peanut butter and cheese crackers c. 6 undated package of sandwich cookies d. 3 undated packages of brownies e. 4 undated moon pies Observations in the kitchen on [DATE] at 2:20 PM, revealed the following: a. 1 dented can of re-fried beans sitting on the food preparation table b. The drip pan on the stove was dirty c. Cook #1's hair was not completely covered by a hair restraint Interview with the District Manager on [DATE] at 3:50 PM, in the Kitchen, the District Manager was asked should expired and undated snacks be stored in the Activities Department. The District Manager confirmed they should not be. Interview with the District Manager on [DATE] at 6:25 PM, in the Dining Room, the District Manager was asked if food should be completely sealed in the refrigerator or freezer. The District Manager stated, Yes, ma'am. The District Manager was asked if food should be dated and labeled. The District Manager stated, Yes, ma'am. The District Manager was asked if the drip pan should be dirty. The District Manager stated, No, ma'am. The District Manager was asked if carbon should be on the skillet. The District Manager stated, No, ma'am. The District Manager was asked if a container of corn flakes dated [DATE] was out of date. The District Manager stated, Yes . The District Manager was asked if hair and facial hair should be completely covered while serving food from the tray line. The District Manager stated, Yes, ma'am. The District Manager was asked if a dented can should be sitting in the food preparation area. The District Manager stated, No . The District Manager was asked if an employee should blow into a glove, place the glove on her hand, serve food from the food line, touch her clothing and other inanimate objects, and continue to serve food from the tray line with the same pair of gloves. The District Manager stated, No, ma'am, she should have washed her hands, discarded the gloves, and use new gloves between each task. 3. Observations in the Dining Room on [DATE] beginning at 12:05 PM, revealed the following: a. CNA #3 moved Resident #18's wheelchair twice and performed meal tray set up without performing hand hygiene. b. CNA #4 moved Resident #26's wheelchair and performed meal tray set up and fed Resident #26 without performing hand hygiene. c. CNA #5 moved Resident #36's wheel chair and performed tray set up without performing hand hygiene. Observations in the Dining Room on [DATE] beginning at 7:27 AM, revealed the following: a. CNA #10 moved Resident #26's wheelchair, locked the wheelchair brakes, moved a chair, performed tray set up, then fed Resident #26 without performing hand hygiene. b. CNA #6 touched the foot rest of Resident #28's recliner, moved the chair, touched the blanket with the edge of the blanket resting on the floor, moved a chair twice, then performed meal tray set up without performing hand hygiene. Interview with Director of Nursing (DON) on [DATE] at 6:20 PM, in the Administrator Office, the DON was asked if staff should touch items in the environment, then perform meal tray set up or feed residents. The DON stated, No, ma'am.",2020-09-01
870,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2019-04-17,865,F,0,1,B3ST11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, the Administrator job description, the Director of Nursing (DON) job description, medical record review, observation, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program that recognized and addressed ongoing concerns with resident's dignity, resident council grievances, resident trust funds, Minimum Data Sets (MDS) completed timely, care plans, provision of pressure ulcer treatments, proper care and treatment for [REDACTED]. The findings include: The facility's undated Quality Assurance and Performance Improvement (QAPI) Program policy documented, .The primary purpose of the Quality Assurance and Performance Improvement Program is to establish data-driven, facility-wide processes that improve the quality of care, quality of life and clinical outcomes of our residents .The program is ongoing and comprehensive .It involves the full range of services and departments in the facility .It covers all systems of care and management practices, with priority given to quality care, quality of life and resident choice .Input is sought from facility staff, residents, family members and individuals who are involved in the care of residents .Members of the facility leadership are accountable for QAPI efforts .Staff are encouraged to identify and report quality concerns as well as opportunities for improvement .Systems are in place to monitor care and services .Systems are designed to incorporate feedback .Establishing a zero tolerance policy for retaliation against individuals who appropriately report or communicate quality concerns .Gathering and using QAPI data in an organized and meaningful way. Areas that may be appropriate to monitor and evaluate include .pressure ulcers, infections .Complaints from residents and families .Staff turnover and assignments . The facility's Administrator job description signed and dated on 12/17/18 documented, .The primary purpose of your job position is to direct the day-to-day function of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times .Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the facility .Assist the Infection Control Coordinator .Assist in the development and implementation of policies and procedures governing the management and control of protected health information .Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies .Evaluate and implement recommendations from the facility's committee as necessary .Assist in the recruitment and selection of competent department directors, supervisors, facility non-licensed staff .Consult with department directors concerning the operation of their departments to assist in eliminating/correcting problem areas, and or improvement of services .Ensure that adequate supplies and equipment are on hand to meet the day-to-day operational needs of the facility and residents .Review resident complaints and grievances and make written reports of action taken .Ensure that resident funds maintained by the facility are managed in accordance with current federal and state regulations . The facility's Director of Nursing Services job description signed and dated 1/14/19 documented, The primary purpose of you job position is to plan organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility .to ensure that the highest degree of quality care is maintained at all times .Plan, develop, organize, implement, evaluate, and direct the nursing service department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the nursing care facilities .Make written and oral reports/recommendations to the Administrator .Develop, implement and maintain an ongoing quality assurance program for the nursing service department .Assist the Quality Assessment & (and) Assurance Committee in developing and implementing appropriate plans of action to correct identified deficiencies .Develop, implement and maintain a program for monitoring communicable and/or infectious diseases .Encourage the resident and his/her family to participate in the development and review of the resident's plan of care .Ensure that the resident assessment information is transmitted on a timely basis .Ensure that all nursing care is provided in privacy and that nursing service personnel knock before entering the resident's room .Review complaints and grievances made by the resident and make a written/oral report to the Administrator indicating what actions(s) were taken to resolve the complaint or grievance . Interview with the Administrator on 4/17/19 at 7:30 AM, in the Administrator Office, the Administrator was asked to provide documentation that Resident Council complaints or grievances had been resolved. That documentation was not provided. Interview with the Administrator on 4/17/19 at 8:31 PM, in the Conference Room, the Administrator was asked if pressure ulcer care was discussed in the 4/10/19 QAPI meeting. The Administrator stated, No. The Administrator was asked if the QAPI committee had discussed or was aware of complaints from the Resident Council pertaining to receiving ice routinely. The Administrator stated, That came up in resident council, yes. The Administrator was asked if it was brought up in the QAPI committee. The Administrator stated, It was brought up at that time. It was not deemed significant enough to PIP (performance improvement plan) . The Administrator was asked if the QAPI identified the problem of wound treatments not being done for residents with pressure ulcers. The Administrator stated, No ma'am. The Administrator was asked how the QAPI committee tracked and evaluated it's performance. The Administrator stated, With our audits. The Administrator was asked if there had been any audits about nursing concerns. The Administrator stated, No . The Administrator confirmed that he had been employed at the facility for 4 months. Review of the DON employee file revealed the DON was hired on 1/14/19. The Regional Nurse Consultant confirmed that she had been in the building for 2 days. The Administrator confirmed there was presently no Social Worker employed. The facility did not have a full time MDS Coordinator. 1. The QAPI Committee failed to identify and address concerns with resident dignity issues. Refer to F550. 2. The QAPI Committee failed to address resident grievances from the Resident Council. Refer to F565. 3. The QAPI Committee failed to maintain resident funds within regulated guidelines. Refer to F569. 4. The QAPI Committee failed ensure staff coded and transmitted Minimum Data Sets to the Centers of Medicare/Medicaid in a timely manner. Refer to F636, F637, and F638. 5. The QAPI Committee failed to ensure residents were encouraged to attend care plan meetings and be envolved with care planning. Refer to F657. 6. The QAPI Committee failed to ensure residents received prescribed medical treatments related to pressure ulcers. Refer to F686. 7. The QAPI Committee failed to ensure residents indwelling Foley catheters were maintained in an acceptable and sanitary manner. Refer to F690. 8. The QAPI Committee failed to ensure residents were provided safe and sanitary enteral tube feeding care. Refer to F693. 9. The QAPI Committee failed to ensure the kitchen was maintained in a safe and sanitary manner. This was a repeat deficiency from the previous annual survey. Refer to F812. 10. The QAPI Committee failed to ensure the facility provided an effective infection control program. This was a repeat deficiency from the previous annual survey. Refer to 880. 11. The QAPI Committee failed to ensure the facility provided an effective antibiotic stewardship program. Refer to 881. 12. The QAPI failed to ensure consistent and effective administrative staff.",2020-09-01
871,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2019-04-17,880,E,0,1,B3ST11,"Based on policy review, Monthly Infection List, Monthly Nosocomial Infection Site and Pathogen Grid, and Layout, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained by failing to track or trend facility's infections for 3 of 3 (January, February, and (MONTH) 2019) months reviewed. The findings include: 1. The facility's undated Infection Control policy documented, .The Infection Prevention and Control Program will follow accepted national standards and is based on facility assessment and includes prevention, identification, reporting, investigation and controlling infections and communicable disease for all residents, staff, volunteers, visitors and other individuals providing services . 2. Review of the Monthly Infection List, Monthly Nosocomial Infection Site and Pathogen Grid, and Layout revealed these forms were blank or incomplete. The facility was unable to provide tracking and trending for infections for the months of January, February, and (MONTH) 2019. 3. Interview with the Director of Nursing (DON) on 4/17/19 at 6:27 PM, in the Administrator Office, the DON was asked if January, February, and (MONTH) 2019 infection control tracking and trending was incomplete. The DON stated, Yes. The DON was asked how the facility was able to track and trend infections without actually completing the tracking and trending. The DON stated, You can't.",2020-09-01
872,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2019-04-17,881,F,0,1,B3ST11,"Based on policy review and interview, the facility failed to establish an antibiotic stewardship program to educate the staff and the community, failed to document the antibiotics used, and failed to track with diagnostics to ensure the correct antibiotic use, doses and duration for 55 of 55 residents currently listed on the census. The findings include: 1. The facility's undated Infection Control policy documented, .The facility is committed to follow an antibiotic stewardship program based on Center for Disease Control Antibiotic Stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use through the facility surveillance protocols . 2. The facility was unable to provide documentation of their Antibiotic Stewardship Program. 3. Interview with the Director of Nursing (DON) on 4/17/19 at 6:27 PM, in the Administrator Office, the DON was asked if the facility had an active Antibiotic Stewardship program. The DON stated, No .",2020-09-01
873,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2017-05-25,225,D,1,0,K3HH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, and interview, the facility failed to ensure a complete, thorough, and timely investigation was conducted for resident to resident altercations for 2 of 4 (Resident #3 and 6) sampled residents. The findings included: 1. The facility's Abuse, Neglect, Misappropriation of Resident Funds policy documented .Reporting of abuse, Neglect, or Misappropriation/Procedure 1. Any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the administrator or Director of Nursing (DON) .The names of any witnesses to the incident .7. Upon receiving information concerning a report of abuse, neglect, misappropriation, the Administrator or designee will investigate, obtain statements, and ensure the residents are safe and receive quality care . 2. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an incident documented, On 2/19 (2/19/17 at 10:40 AM) resident (Resident #3) was witnessed by other residents in the dining room running into the chair of resident (Resident #6). During this event resident (Resident #6)attempted to hit resident (Resident #3) causing a small scratch on lip. Residents were separated and monitored throughout the day. Mobile Crisis notified as was the DON (Director of Nursing) and Administrator . Review of the POS [REDACTED].Immediate Post-Incident Action: CNAs (Certified Nursing Assistant) informed to keep the 2 separated for today and to be [MEDICAL CONDITION] .Immediate actions Taken: Assessed for injuries, separated the 2 involved to different rooms, vital signs taken, asked him about what happened . 3. Medical record review revealed Resident #6 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of the POS [REDACTED].Narrative of incident: When in dining room, elder was hit in the face by another elder. No employees were present. 3 other elders were able to report the incident. Immediate Post-Incident action: Try to keep elders involved separated in the dining area. Assessed for injuries and separate to different rooms . Interview with the Assistant Director of Nursing (ADON) on 5/23/17 at 2:38 PM, in the DON's office, the ADON was asked to describe the incident between Resident #3 and Resident #6. The ADON stated, I do not know who the other 3 residents were that witnessed it and the nurse that filed the report is no longer here . Interview with the Administrator on 5/23/17 at 2:43 PM, in the DON's office, the Administrator was asked to describe the incident between Resident #38 and Resident #6, the investigation, and who were the 3 other residents that witnessed the incident. The Administrator stated, .I don't have a witness statement in there (looking through the investigation report) .I sure thought the statements were in there .I have had some renovation done to my office and they moved my desk around and may have slipped out of the file .I first put down that she was hit in the mouth but actually that was a growth on her lip area. She did not get hit in the mouth .the second altercation is when he hit her and I kept him in my office until the paramedics could come and get him out .when we have someone that has an altercation like that we separate them .make sure everyone is ok .get statements .monitor them .redirect them . Interview with the Administrator on 5/23/17 at 3:58 PM, in the DON's office, the Administrator was asked if he had statements from the witnesses. The Administrator stated, No .that is my fault for not following up on it .(the witnesses) they would have been able to tell you what happened right then but the next day they couldn't have told you . The facility failed to complete a thorough investigation of the incident that occurred between Resident #38 and 6.",2020-09-01
874,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2017-05-25,280,D,1,0,K3HH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation, and interview, the facility failed to revise the care plan to reflect current status for 3 of 20 (Resident #38, 6, and 42) sampled residents reviewed of the 33 residents included in stage 2. The findings included: 1. Review of the facility's CARE PLANS - COMPREHENSIVE policy documented, .Care plans are revised as changes in the resident's condition dictates. Reviews are made at least quarterly and upon change of condition . 2. Review of an incident documented, .On 2/19 (2/19/17 at 10:40 AM) resident #3289 (Resident #38) was witnessed by other residents in dining room running into chair of resident (Resident #6). During this event resident (Resident #38) attempted to hit resident (Resident #6) causing a small scratch on lip. Residents were separated and monitored throughout the day. Mobile Crisis notified as was the DON(Director of Nursing) and Administrator . 3. Medical record review revealed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #38's care plan dated 5/12/16 revealed no documentation of the altercation with Resident #6 that occurred on 2/19/17. 4. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6's care plan for behaviors dated 2/3/15 revealed no documentation of the altercation with Resident #3 that occurred on 2/19/17. Interview with the Interim Director of Nursing (IDON) on 5/23/17 at 4:53 PM, in the DON's office, the IDON was asked if she would expect the care plans to be updated to reflect the altercation that occurred on 5/9/17. The IDON stated, Yes. The IDON was asked if the care plans for Resident #38 and 6 had been updated to reflect the altercation that occurred on 2/19/17. The IDON stated, No. 5. Medical record review revealed Resident #42 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #42 had a fall on 5/19/17 at 9:51 AM while attempting to cross the threshold of the front entrance foyer when his wheelchair tipped over backwards resulting in a skin tear to his left forearm and the intervention included weights to be placed on the front of Resident #42's wheelchair and the furniture in front entrance foyer rearranged. Review of Resident #42's care plan dated 11/8/16 revealed no documentation of Resident #42's risk for falls or the fall that occurred on 5/19/17. Interview with the Minimum Data Set (MDS) Coordinator on 5/24/17 at 1:39 PM, in the Social Service's Office, the MDS Coordinator was asked if a resident who had a [DIAGNOSES REDACTED]. The MDS Coordinator stated, Yes. The MDS Coordinator was then asked if Resident #42 had a fall on 5/19/17 should the care plan have been updated to reflect that fall and the interventions that were put into place. The MDS Coordinator stated, Yes, it should .",2020-09-01
875,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2017-05-25,309,D,1,0,K3HH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to follow the physician's orders for laboratory tests for 1 of 20 (Resident #71) sampled residents reviewed of the 33 included in stage 2. The findings included: Medical record review revealed Resident #71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's telephone orders dated 10/7/16 documented, CBC (complete blood count), with Diff (differential), CMP (Comprehensive Metabolic Panel) D-Dimer, PT ([MEDICATION NAME] Time) /INR (International Normalized Ratio) (on) 10/11/16 . There were no laboratory results dated [DATE] for the CBC with Diff, CMP, D-Dimer, PT/INR found in the medical record. Interview with the Interim Director of Nursing (IDON) on 5/23/17 at 10:10 AM, in the hallway outside her office, the IDON stated she could not locate the laboratory results.",2020-09-01
876,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2018-06-13,576,E,0,1,C62611,"Based on policy review and interview, the facility failed to ensure that mail was delivered on Saturday to 9 of 46 (Resident #12, 13, 15, 24, 33, 34, 37, 44, and 48) sampled residents reviewed. The findings included: 1. Review of the facility's .Resident Rights Policy policy documented, .Every facility resident has the following minimum rights .To the delivery of their mail, unopened, on the business day it is received by the Facility . Interview with the Resident Council members on 6/13/18 at 2:45 PM, in the dining room, the resident council members were asked if they received mail on Saturdays. All members (Resident #12, 13, 15, 24, 33, 34, 37, 44, and 48) agreed they did not receive their mail on Saturdays. Interview with the Business Office Manager on 6/13/18 at 3:36 PM, in the business office, the Business Office Manager was asked if residents received their mail on Saturdays. The Business Office Manager stated, No, I'm not here . Interview with the Administrator on 6/13/18 at 10:08 PM, in the Administrator's office, the Administrator was asked if residents should receive mail on Saturdays. The Administrator stated, .Yes .",2020-09-01
877,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2018-06-13,679,E,0,1,C62611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to provide individualized activities based on resident preference for 2 of 3 (Resident #35 and 42) residents reviewed for activities. The findings included: 1. The facility's Activity Programs policy documented, .Activity programs designed to meet the needs of each resident are available on a daily basis .Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs .Individualized and group activities .offered at hours convienient to the residents, including evenings, holidays and weekends . The facility's Documentation .Quality of Life . policy documented, .The Activity Director/Coordinator is responsible for maintaining appropriate departmental documentation .The following records .are maintained by Activity Department personnel .Attendance records .The Activity Director/Coordinator is responsible for obtaining, charting, and filing required reports . The facility's Individual Activities and Room Visit policy documented, .Individual activities will be provided for those residents whose situation or condition prevents participation in other types of activites .Residents who choose not to attend group activities will maintain an independent program. It is the responsibility of the facility and the activity staff to make regular contacts and other supplies . 2. Medical record review revealed Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment, and participation in religious practices was very important to Resident #35. The care plan dated 10/18/16 and revised 5/1/18 documented, .OFFER ASSISTANCE TO AND FROM ACTIVITIES .AS NEEDED .NEIGHBOR MAY GO OFF UNIT FOR ACTIVITIES .STAFF TO SUPERVISE . Review of the Activities Attendance report for Resident #35, revealed there was no documentation that Resident #35 participated or refused activities 14 of 31 days for the month of (MONTH) (YEAR), 19 of 30 days for the month of (MONTH) (YEAR), and 19 of 31 days for the month of (MONTH) (YEAR). Observations in Resident #35's room on 6/11/18 at 10:48 AM, revealed Resident #35 resting in his bed on his back and staring at the ceiling. There was no interaction with staff or involvement in activities. Observations in Resident #35's room on 6/11/18 at 3:53 PM, revealed Resident #35 was seated on the side of his bed, with his hands folded, staring at the floor. There was no interaction with staff or involvement in activities. Observations in the secure unit on 6/12/18 at 10:45 AM, revealed Resident #35 was seated in an armchair in the hallway near the nurses station. Resident #31 stated to the Activity Director that he would like to go to the church service to hear some music. Observations in the main dining room on 6/12/18 at 10:52 AM, revealed a man singing hymns and playing the piano for several residents. A church volunteer confirmed the service started at 10:45 AM. Observations in the hall near the nurses station on 6/12/18 at 11:15 AM, revealed Resident #35 asked the Activity Director if she was going to take him to hear the church music. The Activity Director escorted Resident #35 to the dining room. Resident #35 arrived in the dining room at 11:20 AM. The church activity ended at 11:30 AM. Interview with the Activity Director on 6/13/18 at 1:49 PM, in the office of the Director of Nursing (DON), the Activity Director was asked if it was appropriate for a resident on the secure unit to arrive late to an activity they had requested to attend and miss most of the activity. The Activity Director stated, I wouldn't say it was appropriate. Interview with the Activity Director on 6/13/18 at 5:40 PM, in the conference room, the Activity Director reviewed the Activities Attendance report for Resident #35 and confirmed there was no documentation Resident #35 participated in activities 14 days in the month of March, 19 days in the month of (MONTH) and 19 days in month of May. 3. Medical record review revealed Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].May Participate in Activities as Tolerated . Review of the Activities Attendance report for Resident #42, revealed there was no documentation that Resident #42 participated or refused activities 18 of 31 days for the month of (MONTH) (YEAR), 20 of 30 days for the month of (MONTH) (YEAR), and 24 of 31 days for the month of (MONTH) (YEAR). Observations in Resident #42's room on 6/11/18 at 11:AM, 3:11 PM, and 6/12/18 at 8:10 AM, revealed Resident #42 lying in bed with her eyes closed, no interaction with staff or involvement in activities. Resident #42 was a non-verbal resident. Interview with the Activity Director on 6/13/18 at 6:40 PM, in the Conference Room, the Activity Director was asked who was responsible to document 1 to 1 visits. The Activity Director stated, I didn't know I was suppose to . The Activity Director reviewed the Activities Attendance report for Resident #42 and confirmed there was no documentation Resident #42 participated in activities 18 out of 31 days for the month of March, 20 out of 30 days for the month of (MONTH) and 24 out of 31 days for the month of May. Interview with the Administrator on 6/13/18 at 9:38 PM, in the conference room, the Administrator confirmed that activities were important for all residents, as well as residents in the secured unit.",2020-09-01
878,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2018-06-13,680,D,0,1,C62611,"Based on review of the Activity Director's job description, Activity Director's personnel file, and interview, the facility failed to ensure the position of 1 of 8 (Activity Director ) staff members was filled by a qualified staff member as evidenced by no documentation the Activity Director completed the required course. The facility had a census of 46 residents. The findings included: The Activity Director's job description documented, .is to plan, organize, develop, and direct the overall operation of the Activity Department in accordance with current state, and local standards, guidelines and regulations .must be knowledgeable of regulations governing activity services in nursing care facilities . Review of the Activity Director's personnel file revealed a hire date of 10/21/16 as a Certified Nursing Assistant. On 12/27/16 she acquired the position of Activity Director. Interview with the Activity Director on 6/13/18 at 5:55 PM, in the Conference room, the Activity Director confirmed she had taken the position of the Activity Director in (MONTH) (YEAR), and had not completed the required training for the Activity Director position. Interview with the Nursing Consultant on 6/13/18 at 7:55 PM, in the conference room, the Nursing Consultant confirmed the Activity Director had not completed the required training for the Activity Director position.",2020-09-01
879,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2018-06-13,698,D,0,1,C62611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to provide appropriate care and services for a resident receiving [MEDICAL TREATMENT] for 1 of 1 (Resident #33) sampled residents receiving [MEDICAL TREATMENT] by failing to accurately assess the resident's access site for [MEDICAL TREATMENT]. The findings included: 1. The facility's Post [MEDICAL TREATMENT] Care policy documented, .The post-[MEDICAL TREATMENT] nursing assessment, includes, but not limited to: Assessment of access site for bleeding Assessment of AV fistula/graft strength or thrill and bruit .Check & Monitor Shunt site appearance and bruit Once during the three 8 hour shifts to observe for any complications .Check Vascular Access Device and Dressing After [MEDICAL TREATMENT] To evaluate and monitor for any changes . 2. Medical record review revealed Resident #33 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] and the quarterly MDS dated [DATE] revealed Resident #33 had moderate cognitive deficits, required supervisory assistance with all activities of daily living, and received [MEDICAL TREATMENT]. The care plan dated 2/8/17 documented Resident #33 had interventions for complications related to [MEDICAL TREATMENT] including, .monitor placement of cath (catheter) as needed and notify MD (Medical Doctor)/[MEDICAL TREATMENT] immediately if any changes to site noted .monitor cath site for signs/symptoms of infection and notify MD/[MEDICAL TREATMENT] as needed . The General Nursing Notes did not document assessments of the access site were performed for the dates of: 3/2-4/18, 3/6/18, 3/9/18, 3/12-13/18, 3/15/18, 3/17/18, 3/18-24/18, 3/26-27/18, 4/10/18, 4/12/18, 4/15-20/18, 4/22-25/18, 5/1-3/18, 5/5-8/18, 5/17-20/18, 5/24-28/18, and 5/30-31/18. The [MEDICAL TREATMENT] Center Communication Form completed by the facility prior to the resident going to [MEDICAL TREATMENT] documented a Bruit/Thrill was present for the dates of 4/12/18, 4/14/18, 4/18/18, 4/21/18, 4/26/18, 4/28/18, 5/10/18, 5/12/18, 5/19/18, 5/24/18, 5/26/18, 6/5/18, 6/7/18, and 6/9/18. The Nurse's Note dated 4/27/18, 5/3/18, 5/4/18, 5/7/18, 5/9/18, and 5/11/18 documented resident was positive for a thrill and bruit. The Nurse's Note dated 4/27/18 and 5/11/18 documented Resident #33 had a shunt. Interview with the Director of Nursing (DON) on 6/13/18 at 1:40 PM, in the conference room, the DON was asked what type of [MEDICAL TREATMENT] access Resident #33 had. The DON stated, .a [MEDICAL TREATMENT] port . The DON was asked if a bruit/thrill should be assessed and documented. The DON stated, .Not for a [MEDICAL TREATMENT] port . The facility failed to provide documentation that assessments were completed for Resident #33's access site for [MEDICAL TREATMENT]. The facility also failed to assess the access site accurately by documenting Resident #33 had a shunt rather than a [MEDICAL TREATMENT] port and the staff was documenting a thrill/bruit was present. Interview with Resident #33 on 6/13/18 at 9:30 AM, in the dining room, Resident #33 was asked if the staff ever checked his shunt site. Resident #33 stated, .Naw, no .maybe every now and then . Interview with the DON on 6/13/18 1:45 PM, in the conference room, the DON stated, .the resident has a [MEDICAL TREATMENT] port and the charting is inaccurate . Interview with the Nursing Consultant on 6/13/18 at 4:40 PM, in the conference room, the Consultant was asked what she expected the staff to chart regarding a [MEDICAL TREATMENT] resident. The Consultant stated, .we are lacking in the documentation area and the sites should be assessed every shift .",2020-09-01
880,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2018-06-13,812,F,0,1,C62611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared and served in a sanitary manner when foods in the kitchen were found undated, the meat slicer had dried debris on the cutting surface, there was an unknown brown debris in the deep fryer, 3 of 6 (Certified Nursing Assistant (CNA) #1, 2 and 4) staff members failed to perform proper hand hygiene and 1 of 6 (CNA #4) staff members placed a dirty pitcher on a resident's over-bed table. The facility had a census of 46 with 45 of those residents receiving a meal tray from the kitchen. The findings included: 1. The facility's .Cold Foods policy documented, .5. All foods will be stored wrapped or in covered containers, labeled and dated . The facility's .Equipment policy documented, 3. All food contact equipment will be cleaned and sanitized after every use . The facility's .Handwashing/Hand Hygiene-Procedure . policy documented, .The purpose of this procedure is to provide guidelines for effective hand washing .To prevent and to control the spread of infectious diseases .handwashing with antimicrobial or non-antimicrobial soap and water must be performed under the following conditions .Before and after direct contact with residents .After contact with blood, body fluids, secretions, mucous membranes, or non-intact skin .After removing gloves .After handling items potentially contaminated with blood, body fluids, or secretions .Before eating . 2. Observations in the kitchen on 1 of 3 (6/11/18) days beginning at 10:50 AM, revealed the following: a. an open, undated bag of shredded cheese b. 6 plates of undated covered slices of watermelon c. pieces of dried debris on the base of the meat slicer Interview with the Dietary Manager (DM) on 6/11/18 at 10:55 AM, in the kitchen, the DM was asked if there should be an open date on the shredded cheese and watermelon slices. The DM stated, Yes, ma'am .anything that you open. The DM was shown the meat slicer and was asked if the meat slicer was clean. The DM stated, .no . Observations in the kitchen, on 6/13/18 at 1:45 PM, revealed a deep fryer with brown build up around the sides of the pan. Interview with the DM on 6/13/18 at 1:47 PM, in the kitchen, the DM was asked if the deep fryer was clean. The DM stated, .cooked fish Sunday .should have got cleaned . Interview with the Administrator on 6/13/18 at 3:40 PM, in the Administrator's office, the Administrator was asked if it was acceptable not to have open dates on food that had been opened. The Administrator stated, No . 3. Observations in the dining room on 6/11/18 at 11:21 AM, revealed CNA #2 prepared a resident's meal tray, touched her cell phone, obtained another tray from the cart, touched her clothes, placed the meal tray in front of the resident, placed a clothing protector on the resident, and prepared the meal tray without performing hand hygiene. CNA #2 then touched her clothes, obtained another meal tray from the cart, prepared the tray for the resident, touched her clothes, and proceeded to sit down and feed the resident without performing hand hygiene. Observations in Resident #19's room on 6/11/18 at 11:25 AM, revealed CNA #4 placed a tray on Resident #19's over-bed table. CNA #4 replaced the stop sign on the door, touched the trash can, touched the bed rail, repositioned Resident #19 in the bed, moved the over-bed table, and prepared the meal tray for Resident #19 and did not perform hand hygiene. CNA #4 obtained the next meal tray from the dining cart and entered Resident #4's room, set up the meal tray on the over-bed table, moved a chair closer to the resident's bed, sat down next to Resident #4 and began to feed Resident #4 without performing hand hygiene. Observations in Resident #25's room on 6/11/18 at 11:45 AM, revealed CNA #1 delivered Resident #25's meal tray. CNA #1 placed the resident's tray on the over-bed table. Resident #25 was seated on the side of the bed with his shoes off and on the floor beside his feet. There was an unknown brown substance on the floor next to the shoes. CNA #1 picked up the shoes with her hands to move them. CNA #1 then wiped her hands on her scrub pants. Resident #25 then stated, I think my ([MEDICAL CONDITION]) bag is off. CNA #1 lifted Resident #25's shirt and found the [MEDICAL CONDITION] bag was not attached to the resident's body. CNA #1 left the room and told another staff member to tell the nurse. CNA #1 did not perform hand hygiene prior to leaving Resident #25's room. CNA #1 then went to the meal cart and began to touch different trays and the cart itself. CNA #1 then took the cart to the A hall and delivered trays to Resident #43 and Resident #10 without performing hand hygiene. CNA #1 touched Resident #10's pillow, moved the chair and touched the tip of his straw and sat down to feed Resident #10 without performing hand hygiene. Observations in Resident #11 and #25's room on 6/12/18 beginning at 5:39 PM, revealed CNA #2 delivered their meal trays. CNA #2 washed her hands and turned the water faucet off with her clean, bare hands. Observations in Resident #31's room on 6/12/18 at 5:40 PM, revealed CNA #1 repositioned Resident #31 in the bed, used the bed control to raise the head of his bed, prepared the resident's meal tray, and touched the tip of Resident #31's straw while placing it in his drink. CNA #1 did not perform hand hygiene before preparing Resident #31's meal tray or before delivering Resident #22's tray. CNA #1 touched the tip of Resident #22's straw when placing it in his drink. Observations in Resident #19's room on 6/12/18 at 5:44 PM, revealed CNA #4 placed a supper tray on the over-bed table, donned clean gloves, touched the bed linens, elevated the head of the bed with the bed control, applied Resident #19's oxygen cannula to his nose, adjusted the over bed table, removed the gloves, donned another pair of clean gloves, took a sandwich out of a sack with her gloved hand, divided the sandwich into 4 pieces with her gloved hand and handed a piece to Resident #4. CNA #4 did not perform hand hygiene after removing the soiled gloves and donning the clean gloves. 4. Interview with CNA #4 on 6/11/18 at 11:40 AM, in Resident #4's room CNA #4 confirmed she had not performed hand hygiene between assisting Resident #19 and feeding Resident #4. Interview with CNA #2 on 6/12/18 at 5:59 PM, in the Conference room, CNA #2 was asked if she had washed her hands between serving meal trays or after touching her clothes and her cell phone. CNA #2 stated, .No. CNA #2 was asked if she should turn the water faucet off with her bare hands after washing her hands. CNA #2 stated, Should have turned it off with a paper towel . CNA #2 was asked what she should have done between glove changes and CNA #2 stated, .wash hands .in between glove changes . Interview with CNA #1 on 6/12/18 at 6:16 PM, in the Conference room, CNA #1 was asked what she did after placing Resident #25's tray down. CNA #1 stated, I asked him if he had his [MEDICAL CONDITION] bag on. He said that it fell off . CNA #1 was asked if she would consider her hands contaminated after lifting up the resident's shirt. CNA #1 stated, Yes, most definitely. CNA #1 was asked if she washed her hands when she left the room. CNA #1 stated No. CNA #1 was asked if she washed her hands before delivering the next 2 trays and assisting Resident #22 with his meal. CNA #1 stated, I don't remember. Interview with the Director of Nursing (DON) on 6/13/18 at 2:47 PM, in the Conference room, the DON was asked how she expected her staff to turn off the water faucet after they washed their hands. The DON stated, .with a dry paper towel .should be sanitizing between trays . The DON was asked if it was acceptable for staff to touch their clothes and cell phone and then deliver a meal tray. The DON stated, No. Interview with the DON on 6/13/18 at 3:16 PM, in the Conference Room, the DON was asked what she would expect a staff member to do after lifting a resident's shirt and finding the [MEDICAL CONDITION] bag had fallen off. The DON stated, Wash their hands . 5. Observations in Resident #6's room on 6/12/18 at 5:50 PM, revealed CNA #4 placed a supper tray on the over-bed table, moved the over-bed table. The water pitcher fell off the over-bed table and onto the floor. CNA #4 picked up the pitcher and placed it on the over-bed table next to Resident #6's dinner tray. Interview with CNA #5 on 6/12/18 at 6:12 PM,outside Resident #6's room. CNA #5 was asked if it was appropriate to pick up a water pitcher that had fallen on the floor and place it back on the over-bed table next to a resident's supper tray. CNA #5 stated, No, that needs to be put immediately in the sink. It shouldn't be put on the table once it hits floor that's contaminated . Interview with the DON on 6/12/18 at 6:24 PM, at the main nurse's station, the DON was asked what a CNA should do if a resident's pitcher falls on the floor. The DON stated, .it should be placed in the sink until it can be sent to the kitchen to be washed. The DON was asked what nursing staff should do between removing dirty gloves and donning clean gloves. The DON stated, Wash their hands.",2020-09-01
881,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2018-06-13,880,D,0,1,C62611,"**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 infection control practices were followed to prevent the spread of infection when 1 of 2 (Certified Nursing Assistant (CNA) #2) staff members did not perform proper hand hygiene during catheter care. The findings included: The facility's Handwashing/Hand Hygiene-Procedure policy documented, .The purpose of this procedure is to provide guidelines for effective hand washing and hygiene techniques that will aid in the prevention of the transmission of infection .a. Before and after direct contact with residents .d. after removing gloves . Medical record review revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #7's room on 6/12/18 at 1:50 PM, revealed CNA #2 and CNA #3 did not perform hand hygiene before providing catheter care for Resident #7. CNA #2 left the resident's room during care and returned to the room without performing hand hygiene. Interview with CNA #2 on 6/12/18 at 6:05 PM, in the Conference room, CNA #2 was asked what should be done after removing gloves and prior to applying new gloves. CNA #2 stated, Wash my hands . Interview with the Director of Nursing (DON) on 6/13/18 at 2:47 PM, in the Conference room, the DON was asked what should be done before performing catheter care. The DON stated, .wash hands as soon as they go in that door . The DON was asked what should be done after removing gloves and applying new gloves. The DON stated, .wash .",2020-09-01
882,AHC WEST TENNESSEE TRANSITIONAL CARE,445187,597 WEST FOREST AVENUE,JACKSON,TN,38301,2020-01-24,880,E,0,1,ZV0411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 3 of 4 nurses (Licensed Practical Nurse (LPN) #1, #2, and #3) failed to rinse nebulizer equipment after use, placed a contaminated bag of eye drops in the medication cart, administered oral medications with bare hands, and failed to place a soiled dressing in an appropriate receptacle for 3 of 6 sampled residents (Resident #12, #20, and #104) observed during medication administration and [MEDICAL CONDITION] (trach) care. The findings include: 1. Observation in the resident's room on 1/22/2020 at 7:35 AM, showed LPN #1 administered an oral inhalation treatment to Resident #104. After the treatment was completed, LPN #1 placed the nebulizer chamber back into the plastic storage bag. LPN #1 did not rinse or sanitize the nebulizer chamber before she placed it into the plastic bag. 2. Observation in the resident's room on 1/22/2020 at 1:30 PM, showed LPN #2 administered eye drops to Resident #20. An alarm sounded and LPN #2 entered another resident's room and dropped the plastic bag with the bottle of eye drops on the floor. LPN #2 picked up the bag of eye drops and placed the bag into the medication cart drawer. LPN #2 did not change or clean the plastic bag before placing the plastic bag with the eye drops back into the medication cart drawer. 3. The facility policy titled, [MEDICAL CONDITION] Care, dated 1/2017, documented, .Remove old dressing, discard in appropriate receptacle . 4. Observation in the resident's room on 1/22/2020 at 2:25 PM, showed LPN #1 [MEDICAL CONDITION] to Resident #104, removed [MEDICAL CONDITION] with a moderate amount of brownish colored drainage, and placed it on the top of the attached cover of the [MEDICAL CONDITION]. LPN #1 then used the saline from [MEDICAL CONDITION] to clean [MEDICAL CONDITION]. 5. Observation in the resident's room on 1/23/2020 at 7:10 AM, showed LPN #3 administered medications to Resident #12. LPN #3 picked up an [MEDICATION NAME] Coated Aspirin off of the resident's clothing with her bare hand and administered it to the resident. During an interview conducted on 1/24/2020 at 10:05 AM, the Director of Nursing (DON) was asked if staff should clean the chamber of a nebulizer after use. The DON confirmed it should be cleaned. The DON was asked if staff should pick up a pill with their bare hands and administer it to the resident. The DON stated No. The DON was asked if a [MEDICAL CONDITION] should be placed on the attached cover of a [MEDICAL CONDITION], and then use the saline from the kit to clean the trach. The DON stated, Not if still attached to [MEDICAL CONDITION] kit. During an interview conducted on 1/24/2020 at 10:25 AM, the DON was asked if a plastic bag of eye drops that had been dropped on the floor should be placed back into the medication cart drawer. The DON stated, .I would prefer they take the drops out of the that bag and put them in another bag.",2020-09-01
883,AHC WEST TENNESSEE TRANSITIONAL CARE,445187,597 WEST FOREST AVENUE,JACKSON,TN,38301,2019-03-13,561,D,0,1,SJSF11,"Based on policy review, observation, and interview, 1 of 13 (Certified Nursing Assistant (CNA) #1) staff members failed to offer food substitutes to Resident #16, #151, and #251 during dining observations. The findings include: The facility's Frequency of Meals policy documented, .Meals will also comply with resident needs, preferences, requests, and plan of care . Observation in Resident #251's room on 3/11/19 at 11:25 AM revealed CNA #1 served Resident #251 a meal tray. Resident #251 stated, I don't like noodles. CNA #1 failed to offer the resident an alternate selection of food. Observation in Resident #151's room on 3/11/19 at 11:30 AM revealed CNA #1 served Resident #151 a meal tray. Resident #151 stated, .I don't want green beans. CNA #1 failed to offer a food substitution for the green beans. Observation in Resident #16's room on 3/11/19 at 11:35 AM revealed CNA #1 served Resident #16 a meal tray. Resident #16 stated, Where is the milk? CNA failed to provide Resident #16 the milk requested. Interview with the Director of Nursing (DON) on 3/12/19 at 2:50 PM in the Conference Room, the DON was asked if a resident voiced a dislike for a food item, should a substitution be offered. The DON stated, Yes.",2020-09-01
884,AHC WEST TENNESSEE TRANSITIONAL CARE,445187,597 WEST FOREST AVENUE,JACKSON,TN,38301,2019-03-13,623,E,0,1,SJSF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to send the Ombudsman a notice of transfer for 3 of 3 (Resident #4, 21 and 52) sampled residents reviewed for transfer/discharge requirements. The findings include: 1. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The HOSPITAL TRANSFER FORM dated 1/12/19 documented, .Sent To: (Hospital) (Named Hospital) .Chest pain/[MEDICAL CONDITION] . The facility was unable to provide documentation that the Ombudsman had been notified of the resident's transfer to the emergency roiagnom on [DATE]. 2. Medical record review revealed Resident #21 was admitted on [DATE] with [DIAGNOSES REDACTED]. The HOSPITAL TRANSFER FORM dated 1/24/19 documented, .Sent To: (Hospital) (Named Hospital) .[MEDICAL CONDITION] Exacerbation . The HOSPITAL TRANSFER FORM dated 2/21/19 documented, .Sent To: (Hospital) (Named Hospital) .needing fluids . The facility was unable to provide documentation that the Ombudsman had been notified of the resident's transfer to the emergency roiagnom on [DATE] and 2/21/19. 3. Medical record review revealed Resident #52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The HOSPITAL TRANSFER FORM documented, .Date: 1/13/19 .Sent To: (Hospital) (Named Hospital) .Change in Mental Status . The facility was unable to provide documentation that the Ombudsman had been notified of the resident's transfer to the emergency roiagnom on [DATE]. Interview with the Administrator on 3/11/19 at 8:30 AM, in the Conference Room, the Administrator confirmed the Ombudsman had not been notified of emergency transfers to the hospital and stated, .thought we were exempt because we are short stay .",2020-09-01
885,AHC WEST TENNESSEE TRANSITIONAL CARE,445187,597 WEST FOREST AVENUE,JACKSON,TN,38301,2019-03-13,812,D,0,1,SJSF11,"Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared and served under sanitary conditions when 1 of 13 (Certified Nursing Assistant (CNA) #1) staff members failed to perform hand hygiene during dining observations for Residents ##8, #16, and #251, and the facility failed to properly handle thawed chicken in the kitchen. The facility had a census of 62 residents, with 2 of those residents receiving a meal tray with chicken served from the kitchen. The findings include: 1. The facility's Hand Hygiene policy dated 4/20/18 documented, .Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .Hand Hygiene Table .After handling contaminated objects . Observations in Resident #251's room on 3/11/19 at 11:25 AM revealed CNA #1 moved a wheelchair, placed the overbed table next to Resident #251, locked the wheelchair, replaced the overbed table, and then prepared the meal tray without performing hand hygiene. Observations in Resident #8's room on 3/11/19 at 11:27 AM revealed CNA #1 removed the knee rest from Resident #8's wheelchair, placed the call light next to the resident, then served Resident #8's meal tray without performing hand hygiene. Observations in Resident #16's room on 3/11/19 at 11:35AM revealed CNA #1 touched the hand rail and prepared the meal tray without performing hand hygiene. Observations in Resident #26's room on 3/12/19 at 7:16 AM revealed CNA #1 elevated the head of the bed, touched a cord in the wall, and then prepared the meal tray without performing hand hygiene. Interview with the Director of Nursing (DON) on 3/12/19 at 9:45 AM in the Conference Room, the DON was asked what staff should do during dining when objects in the environment were touched. The DON stated, They should sanitize. 2. The facility's PROPER THAWING TECHNIQUES policy dated (MONTH) 2014 documented, .Foods should be cooked promptly after thawing . 3. Observations in the Kitchen on 3/12/19 at 10:53 AM revealed 5 pieces of thawed chicken breast in the bottom of the sink. The chicken breasts were not completely submerged under cold running water. Interview with Dietary Staff #1 on 3/12/19 at 10:53 AM in the Kitchen, Dietary Staff #1 was if raw chicken breasts should be left in the sink. Dietary Staff #1 stated, No, ma'am .was there when I got here . Interview with the Certified Dietary Manger (CDM) on 3/13/19 at 7:51 AM in the Conference Room, the CDM was asked if raw chicken breasts should be left in the sink. The CDM stated, .was using it for the alternate and she had unthawed it .was running under cold water .I walked away .from that point on I don't know what happened .she forgot it is the only thing I can come up with .should have taken it out . Interview with the Registered Dietician (RD) on 3/13/19 at 10:48 AM in the Training Room, the RD was asked if thawed chicken breasts should be left in the sink. The RD stated, No.",2020-09-01
886,KIRBY PINES MANOR,445189,3535 KIRBY ROAD,MEMPHIS,TN,38115,2019-07-03,759,E,0,1,U8U611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of MED-PASS DIABETES: Injectable Medications provided by the American Society of Consultant Pharmacist, policy review, medical record review, observation, and interview, the facility failed to ensure 4 of 5 (Licensed Practical Nurse (LPN) #1 #3, #4, and #5) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 4 errors were observed out of 27 opportunities, resulting in an error rate of 14.81%. The findings include: 1. The MED-PASS DIABETES: Injectable Medications provided by the American Society of Consultant Pharmacist for typical dosing administration of insulin related to meals documented, .Humalog .Onset (In hours, unless noted) .15 min (minutes) TYPICAL ADMINISTRATION/COMMENTS .5 minutes prior to meals or immediately after eating . 2. The facility's Insulin Administration policy revised (MONTH) 2014 documented, .To provide guidelines for the safe administration of insulin to residents with diabetes .Type .Rapid-acting .Onset .10-(to)15 min . The facility's Administering Medications policy revised (MONTH) 2012 documented, .Medications must be administered in accordance with the orders, including any required time frame .Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified . 3. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Humalog .100 units/ml (milliliters) subcutaneous .Four Times a Day For TYPE 2 DM (Diabetes Mellitus) .201-250=(equal) 4 units . Observations in Resident #4's room on 7/1/19 at 11:45 AM, revealed LPN #1 administered 4 units of Humalog to Resident #4. At 12:12 PM, the resident received her lunch tray, 27 minutes after receiving the insulin. The failure of the nurse to provide a meal or substantial snack within 15 minutes of administration of the Humalog resulted in medication error #1. 4. Medical record review revealed Resident #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Calcium [MEDICATION NAME] 600 mg .1 tablet By Mouth Twice a Day . Observations in Resident #68's room on 7/1/19 at 3:58 PM, during medication administration, LPN #3 removed medications one by one from the medication cup with her gloved hand and administered medications to Resident #68. The plastic medication cup was noted to have a large amount of white creamy substance remaining. LPN #3 was asked what the white substance was. LPN #3 stated, I must have spilled water into the medication cup .that was the calcium pill that dissolved in the cup . LPN #3 tossed the medication cup containing the dissolved calcium pill into the trash can. LPN #3 did not administer the calcium as ordered, which resulted in medication error #2. 5. Medical record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] 325 mg (milligrams) 2 tablets By Mouth Four Times a Day For PAIN . Observations at medication cart #1 on 7/2/19 at 4:33 PM, LPN #4 stated the [MEDICATION NAME] (Tylenol) tablets were on hold. LPN #4 left the tablets on top of her computer and entered Resident #14's room and completed her medication administration. LPN #4 returned to the medication cart and placed the Tylenol tablets in the top drawer of the medication cart. LPN #4 did not administer the Tylenol as ordered, which resulted in medication error #3. 6. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's telephone orders dated 6/9/19 documented, .Humalog SSI (sliding scale insulin) .201-250=4 units . Observations in Resident #10's room on 7/3/19 at 5:32 AM, revealed LPN #5 administered 4 units of Humalog to Resident #10. At 7:37 AM, the resident received her breakfast tray, 2 hours and 5 minutes after receiving the insulin. The failure of the nurse to provide a meal or substantial snack within 15 minutes of administration of the Humalog resulted in medication error #4. Interview with the Unit Manager on 7/3/19 at 6:19 AM, at the Nurses' Station, the Unit Manager was asked should the nurse have given Resident #14's Tylenol. The Unit Manager stated, Yes, she should have . The Unit Manager was asked if a calcium pill dissolved in the medication cup during medication administration, should the nurse have ensured that Resident #68 received the correct dose of calcium. The Unit Manager stated, Yes, he should get the right dose. Interview with the Certified Pharmacy Technician on 7/3/19 at 8:32 AM, in the Senior Staffing Lounge, the Certified Pharmacy Technician was asked how soon should a resident receive a snack or meal after receiving Humalog insulin. The Certified Pharmacy Technician stated, .Within 15 minutes . Interview with the Director of Nursing (DON) on 7/3/19 at 9:37 AM, in the Administrator Office, the DON was asked should Resident #14 have received the Tylenol as ordered. The DON stated, Yes. The DON was asked should the nursing staff make sure the residents are getting their entire dose of medications as ordered. The DON stated, Yes.",2020-09-01
887,KIRBY PINES MANOR,445189,3535 KIRBY ROAD,MEMPHIS,TN,38115,2019-07-03,760,E,0,1,U8U611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of MED-PASS DIABETES: Injectable Medications provided by the American Society of Consultant Pharmacist, policy review, medical record review, observation, and interview, the facility failed to ensure residents were free of significant medication errors when 2 of 2 (Licensed Practical Nurse (LPN) #1 and #5) nurses failed to administer insulin correctly in correlation with meals. LPN #1 and #5 failed to administer insulin within the proper time frame related to food intake for Resident #4 and #10, which resulted in significant medication errors. The findings include: 1. The MED-PASS DIABETES: Injectable Medications provided by the American Society of Consultant Pharmacist for typical dosing administration of insulin related to meals documented, .Humalog .Onset (In hours, unless noted) .15 min (minutes) TYPICAL ADMINISTRATION/COMMENTS .5 minutes prior to meals or immediately after eating . 2. The facility's Insulin Administration policy revised (MONTH) 2014 documented, .To provide guidelines for the safe administration of insulin to residents with diabetes .Type .Rapid-acting .Onset .10-(to)15 min . 3. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Humalog .100 units/ml (milliliters) subcutaneous .Four Times a Day For TYPE 2 DM (Diabetes Mellitus) .201-250=(equal)4 units . Observations in Resident #4's room on 7/1/19 at 11:45 AM, revealed LPN #1 administered 4 units of Humalog to Resident #4. At 12:12 PM, the resident received her lunch tray, 27 minutes after receiving the insulin. The failure of the nurse to provide a meal or substantial snack within 15 minutes of administration of the Humalog resulted in a significant medication error. 4. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's telephone orders dated 6/9/19 documented, .Humalog SSI (sliding scale insulin) .201-250=4 units . Observations in Resident #10's room on 7/3/19 at 5:32 AM, revealed LPN #5 administered 4 units of Humalog to Resident #10. At 7:37 AM, the resident received her breakfast tray, 2 hours and 5 minutes after receiving the insulin. The failure of the nurse to provide a meal or substantial snack within 15 minutes of administration of the Humalog resulted in a significant medication error. Interview with LPN #5 on 7/3/19 at 7:37 AM, at the Nurses' Station, LPN #5 was asked when should a resident receive a snack or meal after receiving Humalog insulin. LPN #5 stated, Within 30 minutes. Interview with the Certified Pharmacy Technician on 7/3/19 at 8:32 AM, in the Senior Staffing Lounge, the Certified Pharmacy Technician was asked how soon should a resident receive a snack or meal after receiving Humalog insulin. The Certified Pharmacy Technician stated, .Within 15 minutes .",2020-09-01
888,KIRBY PINES MANOR,445189,3535 KIRBY ROAD,MEMPHIS,TN,38115,2019-07-03,761,D,0,1,U8U611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure medications were stored properly and safely in 1 of 5 (Medication Cart #1) medication storage areas and failed to ensure medications were stored securely when 1 of 5 (Licensed Practical Nurse (LPN) #4) nurses left medications unattended. The findings include: 1. The facility's Storage of Medications policy revised (MONTH) 2007 documented, .Drugs for external use, as well as poisons, shall be clearly marked as such, and shall be stored separately from other medication . The facility's Administering of Medications policy revised (MONTH) 2012 documented, .No medications are kept on top of the cart .The cart must be clearly visible to the personnel administering medications . 2. Observations in Medication Cart #1's drawer on 7/1/19 at 9:54 AM, revealed the following: a. 1 pack of Adult wipes b. 4 bottles of Polyethylenene [MEDICATION NAME] c. 1 bottle of [MEDICATION NAME] Syrup d. 1 bottle of Mucus & Chest Congestion e. 1 bottle of Pro Stat sugar free f. 1 bottle of [MEDICATION NAME] g. 1 bottle of Sore Throat spray h. 1 bottle of Acid Gas Relief tablets i. 1 box of Anti-Diarrheal tablets Interview with LPN #2 on 7/1/19 at 9:57 AM, at Medication Cart #1, LPN #2 was asked should adult wipes be stored in the same compartment with medications on the medication cart. LPN #2 stated, No, ma'am. Observations on 7/1/19 at 4:09 PM, outside of Residents #4's room, revealed LPN #4 placed a vial of [MEDICATION NAME] and a vial of Humalog on top of the medication cart. LPN #4 entered Resident #4's room, closed the door, and left the 2 vials of insulin on top of the medication cart unattended and out of sight. LPN #4 returned to the medication cart and drew up the insulin. LPN #4 returned to Resident #4's room, administered the insulin, and left the vials of insulin on the medication cart unattended and out sight of the nurse. Observations on 7/2/19 at 4:38 PM, outside of Resident #14's room, revealed LPN #4 placed 2 packaged Tylenol capsules on the medication cart and stated the Tylenol were on hold. LPN #4 left the Tylenol in their package on top of her computer key board, out of sight and unattended. LPN #4 entered Resident #14's room, closed the door, and completed her medication administration. Interview with LPN #4 on 7/2/19 at 4:48 PM, outside of Resident #14's room, LPN #4 was asked should medications be on top of the medication cart unattended and out of sight. LPN #4 stated, No. Interview with the Unit Manager on 7/3/19 at 6:19 AM, at the Nurses' Station, the Unit Manager was asked should the nursing staff leave medications on top of the medication cart unattended and out of sight. The Unit Manager stated, No. The Unit Manager was asked should the medication carts have internals and externals in the same compartment on the medication cart. The Unit Manager stated, No.",2020-09-01
889,KIRBY PINES MANOR,445189,3535 KIRBY ROAD,MEMPHIS,TN,38115,2019-07-03,812,F,0,1,U8U611,"Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by dark black and brown build-up on skillets, baking pans, convection ovens, deep fat fryers, and that chicken was thawed properly. The facility had a census of 23 residents with 23 of those residents receiving a tray from the kitchen. The findings include: 1. The facility's Sanitation policy revised (MONTH) 2008 documented, .The food service area shall be maintained in a clean and sanitary manner .All kitchens, kitchen areas .shall be kept clean .All equipment .shall be washed to remove or completely loosen soils . The facility's Food Preparation and Service policy revised (MONTH) 2019 documented, .Thawing Frozen Food .Thawing procedures include .Completely submerging the item in cold running water .that is running fast enough to agitate and remove loose ice particles . 2. Observations in the kitchen beginning on 7/1/19 at 9:32 AM, revealed the following: a. 8 skillets with a scratched coating and dark build-up b. 7 baking pans with black and brown build-up on the top and the bottom c. chicken breasts in both sides of a 2 compartment sink, submerged under water, without water running over them on 1 side of the sink, and only a slight drip of water on the other side of the sink Observations in the kitchen beginning on 7/2/19 at 8:50 AM, revealed the following: a. 2 convection ovens with food particles and a black and brown build-up inside b. 3 deep fat fryers with loose particles on the top sides and a thick brown build-up around the sides Interview with the Culinary Director on 7/3/19 at 10:03 AM, in the Harmony Room, the Culinary Director was asked should skillets have a scratched coating and a black and brown build-up. The Culinary Director stated, That's not a standard of practice. The Culinary Director was asked should chicken breasts be thawing in the sink submerged under water without water running over them. The Culinary Director stated, That's not our standard of practice . The Culinary Director was asked should the convection ovens be dirty with food particles and black and brown build-up inside. The Culinary Director stated, That is not a standard of practice. The Culinary Director was asked should the deep fat fryers have crumbs and a thick brown build-up around the side. The Culinary Director stated, That is not the standard of practice.",2020-09-01
890,KIRBY PINES MANOR,445189,3535 KIRBY ROAD,MEMPHIS,TN,38115,2019-07-03,880,E,0,1,U8U611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, 5 of 6 (Wound Care Nurse, Licensed Practical Nurse (LPN #1, #3, #4, and #5) nurses failed to ensure the practices to prevent the potential spread of infection were followed during wound care and medication administration observations. The findings include: 1. The facility's HANDWASHING/HAND HYGIENE policy revised on (MONTH) (YEAR), documented, .This facility considers hand hygiene the primary means to prevent the spread of infections .Use an alcohol-based hand rub containing at least 62% alcohol; or, alternately, soap (antimicrobial or non-antimicrobial) with water for the following situations .Before handling clean or soiled dressings, gauze pads .Before moving from a contaminated body site to a clean body site during resident care .After removing gloves .turn off faucets with a clean, dry paper towel . 2. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #5's room on 7/2/19 at 10:47 AM, revealed the Wound Care Nurse washed his hands then turned off the faucet with his bare hands. Interview with the Wound Care Nurse on 7/3/19 at 7:43 AM, in the Senior Staff Lounge, the Wound Care Nurse was asked how should the faucet be turned off after washing hands. The Wound Care Nurse stated, With a clean paper towel. Medical record review revealed Resident #117 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #117's room on 7/2/19 at 3:01 PM, revealed the Wound Care Nurse gathered the wound care supplies, turned the resident to the right side, removed the old dressing, removed his gloves, applied new gloves, and did not perform hand hygiene. The Wound Care Nurse helped Resident #117 turn to the right side and then measured and cleaned the wound with the same gloves on. He assisted the resident to her back and placed a pillow behind her. He then removed the gloves and did not perform hand hygiene. Interview with the Director of Nursing (DON) on 7/3/19 at 10:33 AM, in the DON Office, the DON was asked what would she expect staff to do after they remove gloves and before they don new gloves. The DON stated, .wash hands before and after . The DON was asked after performing wound care, would she expect staff to keep the same gloves on and have contact with the resident. The DON stated, No, should have taken off their gloves and washed hands before contact .that's our practice . 3. Observations on 7/1/19 at 11:31 AM, in Resident #4's bathroom, revealed LPN #1 washed her hands and turned off the faucet with the same wet paper towel. Observations on 7/1/19 at 3:58 PM, in Resident #68's room, revealed LPN #3 entered the room to administer medications. LPN #3 dropped the [MEDICATION NAME] capsule between the folds of Resident #68's blanket, picked up the capsule, and placed it in the resident's mouth. Observations on 7/1/19 at 4:24 PM, in Resident #4's bathroom, revealed LPN #4 washed her hands and used the same wet paper towel to turn off the faucet. Observations on 7/2/19 at 11:57 AM, in Resident #11's bathroom, revealed LPN #1 washed her hands and used the same wet paper towel to turn off the faucet. Observations on 7/3/19 at 5:07 AM, in Resident #10's bathroom, revealed LPN #5 washed her hands and used the same wet paper towel to turn off the faucet. LPN #5 then used the same wet paper towel to wipe around the sink. Interview with LPN #5 on 7/03/19 at 5:48 AM, at the Nurses' Station, LPN #5 was asked how should the faucet be turned off after washing hands. LPN #5 stated, With a dry paper towel. Interview with the Director of Nursing (DON) on 7/3/19 at 9:37 AM, in the Administrator Office, the DON was asked how should the staff members turn off the faucet after hand washing. The DON stated, With a clean paper towel. The DON was asked should the nursing staff turn off the faucet with their bare hands. The DON stated, No. The DON was asked should the nurse have picked up the pill from the resident's blanket and then gave the medication to the resident. The DON stated, No, she should not have done that .",2020-09-01
891,KIRBY PINES MANOR,445189,3535 KIRBY ROAD,MEMPHIS,TN,38115,2018-09-18,695,E,0,1,CU8L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to follow the physician orders for oxygen and a breathing treatment for 3 of 3 (Resident #12, 15, and 19) sampled residents reviewed for respiratory services. The findings included: 1. The facility's Oxygen Administration policy dated (MONTH) 2010 documented, .Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration .Steps in the Procedure .10. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered .Documentation .3. The rate of oxygen flow, route, and rationale . 2. Medical record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Plan dated 8/19/18 documented, .at risk for complications related to [MEDICAL CONDITIONS] on continuous O2 (oxygen) .Provide oxygen as ordered . The physician's order dated 9/17/18 documented, .Oxygen - 2L (liters) Nasal Continuous . Observations in Residents #12's room on 9/16/18 at 11:05 AM and in the Rehab Dining room on 9/17/18 at 8:27 AM and 9:44 AM, revealed Resident #12 was receiving oxygen via nasal cannula at a flow rate of 3 liters/minute. Interview with Registered Nurse (RN) #1 on 9/17/18 at 10:16 AM, in the Rehab Nurses' station, RN #1 was asked if Resident #12 had an order for [REDACTED].#1 was asked to confirm Resident #12's oxygen rate. RN#1 confirmed the oxygen was on 3 liters and turned the oxygen down to 2 liters. RN #1 was asked if the flow rate of the oxygen was correct. RN #1 stated, No it was incorrect. Interview with the Director of Nursing (DON) on 9/17/18 at 1:55 PM in the Senior Staff lounge, the DON was asked if it acceptable for a resident to be on 3 liters of oxygen if the order was for 2 liters. The DON stated, No, it should have been on 2 liters . 3. Medical record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The STANDING ORDERS (YEAR) documented,DYSPNEA OR SHORTNESS OF BREATH .OXYGEN AT 2L BNC (binasal cannula) . The Interdisciplinary Notes dated 9/8/18 documented, .O2 @ (at) 3L BNC in use . Observations in Resident #15's room on 9/16/18 at 11:00 AM, revealed Resident #15 was lying in the bed with O2 on at 3L by nasal cannula. Interview with the DON on 9/17/18 at 10:30 AM, in the Senior Staff lounge, the DON confirmed the standing orders documented O2 to be at 2L BNC. 4. Medical record review revealed Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The PHYSICIAN TELEPHONE ORDER dated 9/12/18 documented, .[MEDICATION NAME] (a breathing treatment) BID (twice a day) indefinitely . Review of the (MONTH) (YEAR) Medication Record revealed no documentation that the [MEDICATION NAME] had been given twice a day as ordered. Observations in the Rehab lounge area on 9/16/18 at 11:19 AM, revealed Resident #43 was seated in a wheelchair with audible wheezing. Interview with RN #1 on 9/17/18 at 11:03 AM, in the Rehab (Rehabilitation) Nurses' station, RN #1 was asked if Resident #19 had been receiving [MEDICATION NAME] twice a day as ordered. RN #1 stated, It does not appear she has .didn't transcribe the order correctly . RN #1 was asked since 9/12/18 the number of [MEDICATION NAME] treatments Resident #19 had received . RN #1 stated, .none on the 12th, 13th, 14th, 15th .the order said continuously . Interview with the DON on 9/18/18 at 8:00 AM, in the Rehab Nurses' station, the DON was asked if the breathing treatments should have been on the medication record. The DON stated, .should have been transcribed on the MAR (Medication Administration Record) .",2020-09-01
892,KIRBY PINES MANOR,445189,3535 KIRBY ROAD,MEMPHIS,TN,38115,2018-09-18,880,D,0,1,CU8L11,"**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 appropriate infection control practices were followed when signage for isolation was not posted for 1 of 1 (Resident #226) sampled residents observed in isolation and when 1 of 3 (Licensed Practical Nurse (LPN ) #1) nurses did not perform hand hygiene between glove use during medication administration observations. The findings included: 1. The facility's Isolation - Categories of Transmission-Based Precautions policy revised (MONTH) 2012 documented, .Contact Precautions 1. In addition to Standard Precautions, Implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with resident or indirect contact with environmental surfaces or resident-care items in the resident's environment .8. Signs - The facility will implement a system to alert staff to the type of precaution resident requires . Medical record review revealed Resident #226 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. The Interdisciplinary Notes dated 9/14/18 documented, .Today noted to have several loose slimy stools every attends change/4-5x (times). Medical Team alerted; will place on Contact isolation . Observations in Resident #226's room on 9/16/18 at 10:30 AM, 3:01 PM, 9/17/18 at 7:57 AM, 10:16 AM, 1:55 PM, and 9/18/18 at 8:08 AM, revealed a cart with personal protective equipment. There was no sign on the door indicating the resident was in isolation. Interview with LPN #1 on 9/17/18 at 1:45 PM at the Rehab Nurses' station, LPN #1 was asked if a resident was in contact isolation should there be a sign to be on the door to alert staff and visitors. LPN #1 stated, Yes. 2. The facility's Personal Protective Equipment (PPE) - Using Gloves policy revised (MONTH) 2010 documented, .Purpose To guide the use of gloves .Objectives 1. To prevent the spread of infection .3. To protect hands from potentially infectious material .Miscellaneous .5. Wash hands after removing gloves. (Note: Gloves do not replace handwashing.) . The facility's Handwashing/Hand Hygiene policy revised (MONTH) (YEAR) documented, .Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation .7 .m. After removing gloves .9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections . Observations in front of the Rehab Nurses' station on 9/17/18 at 9:50 AM revealed LPN #1 washed her hands, applied gloves, prepared the medications for Resident #226, removed the gloves, entered Resident #226's room, applied PPE and gloves without performing hand hygiene, and administered eye drops to this resident. LPN #1 removed her gloves and applied new gloves without performing hand hygiene, checked gastrostomy tube placement, and administered medications through the gastrostomy tube. LPN #1 then removed the PPE and gloves and washed her hands. LPN #1 went to the medication cart, applied gloves, cleaned the bag containing the eye drops with a bleach wipe, removed her gloves, and obtained the next set of eye drops to administer to the resident. LPN #1 entered Resident #226's room, applied PPE and gloves without performing hand hygiene, and administered eye drops to the resident. Interview with the Director of Nursing (DON) on 9/18/18 at 10:35 AM, in the Senior Staff lounge, the DON was asked what nurses should be do after the removal of gloves and application of new gloves. The DON stated, Wash hands.",2020-09-01
893,"CAMBRIDGE HOUSE, THE",445190,250 BELLEBROOK RD,BRISTOL,TN,37620,2017-03-02,159,D,0,1,2UZT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide access to resident personal funds after regular business hours and on weekends for 2 residents (#23, #13) of 32 residents with personal funds accounts. The findings included: Medical record review revealed Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9, indicating the resident was moderately cognitively impaired for daily decision making. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, indicating the resident was cognitively intact for daily decision making. Interview with Resident #23 on 2/27/17 at 12:14 PM, in the resident's room revealed money from Resident #23's personal funds account was not available on weekends. Interview with Resident #13 on 2/27/17 at 3:18 PM, in the resident's room revealed money from Resident #13's personal funds account was not available on weekends and was not available after 5:00 PM on weekdays. Interview with the Business Office Manager on 3/1/17 at 12:00 PM, in the Business Office Managers Office, confirmed the facility failed to provide access to resident personal funds after regular business hours on weekdays and on weekends.",2020-09-01
894,"CAMBRIDGE HOUSE, THE",445190,250 BELLEBROOK RD,BRISTOL,TN,37620,2017-03-02,278,J,0,1,2UZT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, review of Incident/Accident reports, and interviews, the facility failed to accurately assess the wandering risk for two residents (#58, #10) of three residents reviewed with a known risk of wandering and elopement, of 29 residents reviewed. The facility's failure resulted in Resident #58 eloping from the facility, sustaining an open fracture (if the bone breaks in such a way that bone fragments stick out through the skin or a wound penetrates down to the broken bone, the fracture is called an open or compound fracture) in her right arm requiring surgical repair, and placing Resident #58 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 Administrator (NHA) was informed of the Immediate Jeopardy on 3/1/17 at 1:25 PM in her office. The findings included: Medical record review revealed Resident #58 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an annual Minimum Data Set (MDS) assessment for Resident #58, dated 2/8/16, revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating Resident #58 had a severe cognitive impairment. Further review revealed . Wandering - Presence & Frequency .Behaviors not exhibited . (Per the MDS 3.0 Manual, wandering is the act of moving from place to place with or without a specific course or known direction. The wandering resident may be oblivious to his or her physical or safety needs.) Review of a facility Incident/Accident Report dated 2/23/16 revealed Resident #58 had eloped from the facility at 2:15 PM. Resident #58 was found outside the facility and was confused. Medical record review of the Wandering and Elopement assessment dated [DATE] revealed Resident #58 was assessed as a wandering and elopement risk. Review of a facility Incident/Accident Report dated 3/16/16 revealed Resident #58 had eloped from the facility at 8:45 PM. Resident #58 was found outside the front doors in the parking lot and was confused. Medical record review of the MDS assessment dated [DATE] revealed Resident #58 had severe cognitive impairment and . Wandering - Presence & Frequency .Behaviors not exhibited . Review of a facility Incident/Accident Report dated 5/10/16 revealed Resident #58 had eloped from the facility at 4:10 PM. Resident #58 was found outside the facility by the 500 hallway exit door and had intermittent confusion. Review of a Psychiatric visit note dated 6/30/16, revealed one of the chief complaints for the visit was Resident #58's exit seeking behaviors. Medical record review of a quarterly MDS assessment dated [DATE], revealed Resident #58 had severe cognitive impairment and .Wandering - Presence & Frequency .Behaviors not exhibited . Medical record review of an Activity Progress Note dated 7/14/16 revealed .She likes to go outside a lot + (and) frequently seeks ways to get outside . Review of a Psychiatric visit note dated 7/19/16, revealed one of the chief complaints for the visit was exit seeking behaviors. Continued review revealed the resident .continues with wandering . Medical record review of a quarterly MDS assessment dated [DATE], revealed Resident #58 had severe cognitive impairment and .Wandering - Presence & Frequency .Behaviors not exhibited . Medical record review of an annual MDS assessment dated [DATE] revealed the resident had severe cognitive impairment and .Wandering - Presence & Frequency .Behaviors not exhibited . Review of a facility Incident/Accident Report dated 1/17/17 revealed Resident #58 had eloped from the facility at 9:00 PM. Resident #58 was found outside the 400 hallway exit. Review of the resident was found lying outside on her stomach with her wheelchair beside her and had abrasions to her face and a swollen wrist. Medical record review of hospital records revealed the resident was transported to the hospital on [DATE] and had a surgical repair for an open right wrist fracture. Medical record review of a 14 day MDS assessment dated [DATE] revealed Resident #58 had severe cognitive impairment and .Wandering - Presence & Frequency .Behaviors not exhibited . Observation of Resident #58 on 2/16/17 at 10:00 AM, revealed the resident in her wheelchair, using her feet and left hand to move the wheelchair around the facility, with no end destination. Interview with Social Worker #1 on 2/16/17 at 10:30 AM, in the conference room, revealed Resident #58 did exhibit exit seeking behaviors and .had eloped from the facility before . Interview with Licensed Practical Nurse (LPN) #4 on 2/16/17 at 12:45 PM, in the conference room, revealed Resident #58 .still wanders over the building . Observation of Resident #58 on 2/16/17 between 10:00 AM and 1:30 PM, revealed the resident repeatedly propelling the hallways of the facility, except when she was in the dining room for lunch. Interview with Social Worker #1 on 2/17/17 at 9:15 AM, in the conference room, confirmed the MDS assessments for Resident #58 did not accurately reflect the resident's wandering status. Interview with the Administrator and Director of Nursing (DON) on 2/17/17 at 9:55 AM, in the conference room, confirmed the MDS assessments dated 2/8/16, 4/25/16, 7/8/16, 9/27/16, 12/14/16 and 2/6/17 for Resident #58 were inaccurate. Continued interview confirmed Resident #58 displayed wandering behaviors daily. Medical record review revealed Resident #10 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the annual MDS assessment dated [DATE], revealed Resident #10's BIMS was 4 out of a possible 15, showing severe cognitive impairment, and .Wandering - Presence & Frequency .Behaviors not exhibited . Medical record review of Resident #10's care plan dated 2/9/17 revealed .at risk for wandering and elopement r/t (related to) hx (history) of wandering . Observation of Resident #10 on 2/16/17 at 1:30 PM, revealed the resident was propelling himself around the facility in his wheelchair. Continued observation revealed he would go from his room to the front door, and repeat the process. Interview with LPN #4 on 2/16/17 at 3:00 PM by the 400 hallway exit door revealed Resident #10 propels himself in his wheelchair to the front entrance and back to his room repeatedly when his wife is not at the facility. Observation on 2/16/17, at various times throughout the day, revealed Resident #10 repeatedly wandered from his room to the front door, when his wife was not present. Interview with Social Worker #1 on 2/17/17 at 9:15 AM, in the conference room, confirmed the MDS assessment for Resident #10 did not accurately reflect the wandering behavior. Interview with the Administrator and Director of Nursing (DON) on 2/17/17 at 9:55 AM, in the conference room, confirmed the MDS assessment dated [DATE] for Resident #10 was inaccurate. Continued interview confirmed Resident #10 had been coded as non-wanderer, but displayed wandering behaviors daily. The Immediate Jeopardy was effective from 1/17/17 through 3/1/17. An acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received on 3/2/17, and corrective actions were validated through review of documents, observation, and staff interviews. The surveyors verified the allegation of compliance by: 1. Reviewing the facility's in-service records to validate the two MDS Coordinators responsible for development of the MDS's were in-serviced on 3/1/17. 2. Conducted interviews with the two MDS Coordinators on 3/2/17 in the conference room, to determine the level of comprehension gained through the in-service education conducted on the morning of 3/1/17 regarding correctly coding the MDS's for wandering behaviors of the residents. 3. Reviewing the MDS assessment of all residents (Residents #58, #10, and #68) assessed at risk for wandering and elopement developed on 3/1/17. The review was to ensure the development of a corrected MDS to aid in the development of a Comprehensive Care Plan to prevent unsafe wandering and elopement. 4. Review of Resident #58's 30 day MDS assessment dated [DATE] revealed it had been corrected to show wandering behaviors occurred daily. Noncompliance continues at a scope and severity of D for monitoring the effectiveness of corrective actions and evaluation of monitoring by the Quality Assurance (QA) Committee. The facility is required to submit a plan of correction. Refer to F-323 J",2020-09-01
895,"CAMBRIDGE HOUSE, THE",445190,250 BELLEBROOK RD,BRISTOL,TN,37620,2017-03-02,280,J,0,1,2UZT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, observation, review of facility Incident/Accident reports and interviews, the facility failed to revise the care plan after each elopement attempt for 1 Resident (#58) of 3 residents reviewed for wandering and elopement, of 29 residents reviewed. The facility's failure resulted in Resident #58 eloping from the facility, sustaining an open (if the bone breaks in such a way that bone fragments stick out through the skin or a wound penetrates down to the broken bone, the fracture is called an open or compound fracture) fracture to her arm requiring surgical repair, placing Resident #58 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 Administrator (NHA) was informed of the Immediate Jeopardy on 3/1/17 at 1:25 PM in her office. The findings included: Review of the facility's policy Wandering and Elopement revised 8/4/03, revealed .Purpose: To provide specific guidelines regarding assessment and care of the resident with the potential to wander and/or elope .The facility will provide preventative interventions as necessary for the safety of the resident .A care plan will be developed and implemented for each resident that is identified as at risk for wandering and/or elopement .Resident discovered missing from the facility .Upon return to the facility, the charge nurse should .Implement interventions to prevent further elopement .update the resident's care plan with elopement precautions . Medical record review revealed Resident #58 was admitted on [DATE]. Her [DIAGNOSES REDACTED]. Review of a Brief Interview for Mental Status (BIMS) dated 2/8/16 revealed a score of 3, indicating Resident #58 had a severe cognitive impairment. Medical record review of Review of Resident #58's care plan revealed an intervention for wandering and elopement .Problem/Need .Problem Onset: 2/9/16 .At risk for wandering and elopement r/t (related to) hx (history) of wanderin .monitor q (every) 15 min's (minutes) and redirect as needed .mental health eval (evaluation) + (and) review meds (medications) . Review of a facility Incident/Accident Report dated 2/23/16 revealed Resident #58 had eloped from the facility at 2:15 PM. Resident #58 was found outside the 500 hallway door. Review of the accident report revealed .door alarm sounding, resident went out the 500 hall door to the outside of the building, brought back in by .(Certified Nursing Assistant(CNA) #2) . and .(CNA #3) . Resident was alert but confused and had no injuries. Review of the care plan problem onset date 2/9/16 At risk for wandering and elopement revealed the intervention added for 2/23/16 elopement was .above interventions in place . referring to the interventions that were already on the care plan dated 2/9/16. The care plan was not revised with any new interventions to prevent elopement. Review of the facility Incident/Accident Report dated 3/16/16 revealed Resident #58 had eloped from the facility at 8:45 PM. Resident #58 was found outside the front doors in the parking lot. Review of the accident report revealed .resident went out front door + (and) made her way to front parking lot. found by nursing staff + (and) brought back into building . Resident was alert but confused and had no injuries. Review of the care plan problem dated 2/9/16 revealed the intervention added for 3/16/16 elopement was .continue above interventions . No new interventions to prevent the resident from exiting the building were implemented on the care plan. Review of a facility Incident/Accident Report dated 5/10/16 revealed Resident #58 had eloped from the facility at 4:10 PM. Resident #58 was found outside the 500 hallway. Review of the accident report revealed .resident observed by CNA outside 500 hall rolling down the sidewalk . The report indicated the resident was alert with intermittent confusion and had no injuries. Review of the care plan revealed the intervention added for 5/10/16 elopement was .continue above interventions . The care plan was not revised to reflect any new interventions implemented to prevent the resident from eloping. Review of the facility Incident/Accident Report dated 1/17/17 revealed Resident #58 had eloped from the facility at 9:00 PM. Resident #58 was found outside the 400 hallway exit. Review of the accident report revealed .called to eastwing by CNA's + (and) hospitality aide, found resident lying outside, at bottom of 400 exit hall ramp w/c (wheelchair) beside her on stomach . Continued review revealed injuries sustained were .abraision/ skin tear nose, wrist swollen . Cognitive status was marked as alert and confused. Emergency Medical Services were called and transported Resident #58 to the hospital for admission and surgical repair of an open fracture to the right arm. Review of the care plan dated 2/3/17 revealed At risk for wandering and elopement and revealed the intervention for the elopement was .continue above interventions . referring to the same interventions since 2/9/16. The care plan was not revised with new interventions to prevent the resident from exiting the facility after the elopement on 1/17/17 which resulted in injuries. Observation of Resident #58 on 2/16/17 at 10:00 AM, revealed the resident in her wheelchair, using her feet and left hand to move the wheelchair around the facility. Interview with Social Worker #1 on 2/16/17 at 10:30 AM in the conference room, revealed Resident #58 did exhibit exit seeking behaviors, and .had eloped from the facility before . Interview with Director of Nursing (DON) on 2/16/17 at 12:30 PM in the conference room, confirmed the facility failed to revise the care plan with new interventions to prevent further elopement after each elopement attempt. Observation of Resident #58 on 2/16/17 at 1:30 PM, revealed the resident in her wheelchair, using her feet and left hand to move the wheelchair around the facility. Interview with the Administrator on 2/16/17 at 9:45 PM in the conference room, confirmed the facility failed to revise the care plan with new interventions to prevent further elopement. The Immediate Jeopardy was effective from 1/17/17 to 3/1/17. The facility presented an acceptable Allegation of Compliance and implementation of the A[NAME] was validated by interviews conducted by the surveyors to validate the staff were in-serviced on the following policies: Wandering and Elopement Wandering, Unsafe Resident 1. Conducted interviews beginning on 3/2/17 with staff to include the Administrator, 8 Registered Nurses, Director of Nursing, 6 Licensed Practical Nurses, 20 Certified Nursing Assistants, 3 Housekeeping and Laundry staff, 4 Dietary, 2 Medical Record staff, 1 Maintenance Director, 2 Business Office staff 2 Rehab staff, 1 Receptionist for a total of 50 employees. This was to determine the level of comprehension gained through in-service education regarding the facility's policies, changes to the Wandering and Elopement policy, implementation of the policy Wandering, Unsafe Resident, and the effect these policies had on staffing levels. 2. Observation of Residents #58, #10, and #68 on 3/2/17 at 2:00 PM revealed them all to have their wander guard bracelets in place. These three residents were assessed as wanderers. 3. Review of medical record and care plans for Residents #58, #10, and #68, on 3/2/17 at 2:30 PM revealed their care plans had been updated to reflect changes. Continued review revealed .if .exit seeking or is displaying other high risk behaviors .s/he will be placed on 1:1 monitoring until exit seeking .abated .the Director of Nursing will be notified . Continued review of care plan revealed .2/23/17 Wanderguard placed on Resident .check Wanderguard q (every) shift by door accuracy . Noncompliance continues at a scope and severity of D for monitoring the effectiveness of corrective actions and evaluation of monitoring by the Quality Assurance (QA) Committee. The facility is required to submit a plan of correction. Refer to F-323 J",2020-09-01
896,"CAMBRIDGE HOUSE, THE",445190,250 BELLEBROOK RD,BRISTOL,TN,37620,2017-03-02,323,J,0,1,2UZT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, review of facility Incident/Accident Reports, observations and interview, the facility failed to provide adequate supervision to prevent unsafe wandering and elopement from the facility for 1 Resident (#58) of 3 residents reviewed for elopement risk, of 29 residents reviewed. The facility's failure resulted in Resident #58 eloping from the facility, sustaining an open fracture (if the bone breaks in such a way that bone fragments stick out through the skin or a wound penetrates down to the broken bone, the fracture is called an open or compound fracture) in her right arm requiring surgical repair, and abrasions and contusions to her face, placing Resident #58 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 Administrator (NHA) was informed of the Immediate Jeopardy on 3/1/17 at 1:25 PM in her office. F-323 resulted in Substandard Quality of Care. The findings included: Review of the facility's policy Wandering and Elopement, revised 8/4/03, revealed .Purpose: To provide specific guidelines regarding assessment and care of the resident with the potential to wander and/or elope .The facility will provide preventative interventions as necessary for the safety of the resident .If the resident is identified as being at risk for elopement, the resident will be placed on q 15-minute (every 15 minutes) visual monitoring .The q 15-minute visual monitoring will be recorded on the 'Wandering Resident Monitor' tool .Re-evaluation of resident for continuing q-15 minute checks will be done after 72 hours. Decision of IDT (Interdisciplinary Team) and Physician will be made at that point as to continue or discontinue based on behaviors demonstrated and documented while on q-15 minute checks .The facility will ensure any monitoring devices such as door alarms or sensor bracelets are operational 24 hours a day .The nurse/designee will check each door alarm q shift and record on 'Door Alarm Maintenance Checklist' .If there is a problem noted with the door alarm, the facility will post a staff member at the exit door until door alarm is functional .All personnel are to report any resident attempting to leave the premises to the charge nurse as soon as possible .Resident discovered missing from the facility .Upon return to the facility, the charge nurse should .Implement interventions to prevent further elopement . Medical record review revealed Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 3, indicating the resident had a severe cognitive impairment. Review of the care plan dated 2/9/16 revealed a problem area of wandering and elopement for Resident #58. Review of a facility Incident/Accident Report dated 2/23/16 revealed Resident #58 had eloped from the facility at 2:15 PM. Resident #58 was found outside the facility by the 500 hallway exit door. Continued review of the accident report revealed .door alarm sounding, resident went out the 500 hall door to the outside of the building, brought back in by .(Certified Nursing Assistant (CNA) #2) . and .(CNA #3) . Resident with .no apparent . injuries noted. Level of consciousness was marked as .alert with confusion . Review of the care plan problem area wandering and elopement, revised 2/23/16 revealed above interventions in place, and no new interventions were implemented. Review of a visual observation form revealed the staff charted every 15 minute visual observation of Resident #58 for 72 hours after her elopement on 2/23/16. Review of the Wandering and Elopement assessment dated [DATE] revealed Resident #58 was assessed as a wandering and elopement risk. Review of a facility Incident/Accident Report dated 3/16/16 revealed Resident #58 had eloped from the facility at 8:45 PM. Resident #58 was found outside the front doors in the parking lot. Continued review of the accident report revealed .resident went out front door + (and) made her way to front parking lot. found by nursing staff + (and) brought back into building . Resident with .no apparent .injuries noted. Level of consciousness was marked as .alert/confused . Review of the care plan dated 3/16/16 revealed cont (continue) above interventions and no new interventions were implemented. Review of a visual observation form revealed the staff charted every 15 minute visual observations of Resident #58 for 72 hours after her elopement on 3/16/16. Review of the quarterly MDS assessment dated [DATE] revealed a Brief Interview for Mental Status score of 3, indicating the resident had a severe cognitive impairment. Review of Wandering and Elopement Assessment review dated 4/26/16 revealed Resident #58 with .no further episodes of wandering noted . Review of a facility Incident/Accident Report dated 5/10/16 revealed Resident #58 had eloped from the facility at 4:10 PM. Resident #58 was found outside the facility by the 500 hallway exit door. Continued review of the accident report revealed .resident observed by CNA outside 500 hall rolling down the sidewalk . Resident with .no apparent . injuries noted. Level of consciousness was marked as .alert with intermit (intermittent) confusion . Review of the care plan problem area wandering and elopement, dated 5/10/16 revealed cont (continue) above interventions and no new interventions were implemented. Review of a visual observation form revealed the staff charted every 15 minute visual observations of Resident #58 for 72 hours after her elopement on 5/10/16. Review of the annual MDS assessment dated [DATE] revealed a Brief Interview for Mental Status score of 3, indicating the resident had a severe cognitive impairment. Review of a nurse's note dated 1/17/17 revealed: at 8:00 PM .caught resident trying to open outside door next to her room .at 8:30 PM CNA brought resident back .from around door at room 509 . Review of a nurse's note dated 1/17/17 revealed at 8:15 PM, .I saw (Resident #58) . about 8:15 on T hall trying to go out that door .followed me down the 500 hall wanting to go out that door . Review of a facility Incident/Accident Report dated 1/17/17 revealed Resident #58 had eloped from the facility at 9:00 PM. Resident #58 was found outside the 400 hallway exit. Review of the accident report revealed .called to eastwing by CNA's + (and) hospitality aide, found resident lying outside, at bottom of 400 exit hall ramp w/c (wheelchair) beside her) on stomach . Continued review revealed injuries sustained were .abraision/ skin tear nose, wrist swollen . Cognitive status was masked as alert and confused. Emergency Medical Services were called and transported Resident #58 to the hospital for admission. Review of the hospital Emergency Department history & (and) physical, dated 1/17/17, revealed .the patient is confused and history is provided by her daughter .tonight the patient went out the door in her wheelchair, slid down a sidewalk where she turned over and tried to catch herself with her right arm .states .has not been ambulatory in 3 years and is wheelchair bound .the patient has significant bruising to her face and open right wrist fracture . Review of the hospital discharge Summaries, dated 1/24/17, revealed .open right distal radius and ulnar fracture, S/P (status [REDACTED].Acute blood-loss anemia . Medical record review revealed Resident #58 returned to the facility on [DATE]. Review of a Wandering and Elopement Risk assessment dated [DATE] revealed Resident #58 to be assessed as a wandering and elopement risk. Review of a visual observation form revealed the staff charted every 15 minute visual observation of Resident #58 for 72 hours after her return from the hospital on [DATE]. Review of the care plan revealed 1/17/17 episodes of wandering and cont (continue) above interventions and no new interventions were implemented. Observation of Resident #58 on 2/16/17 at 10:00 AM, revealed the resident in her wheelchair, using her feet and left hand to move the wheelchair around the facility. Interview with the Hospitality Aid on 2/16/17 at 12:00 PM per telephone, confirmed she found Resident #58 outside, on the ground at the 400 Exit Hall door, at the bottom of a concrete ramp on 1/17/17 at 9:00 PM after seeing her on the ground from another resident's room window. Observation of Resident #58 on 2/16/17 at 1:30 PM, revealed the resident was in her wheelchair, using her feet and left hand to move the wheelchair around the facility. Interview with Licensed Practical Nurse (LPN) #1 on 2/16/17 at 8:50 PM in the conference room, revealed she was aware Resident #58 was an elopement risk and had attempted three times to elope on 1/17/17 after 8:00 PM, prior to her getting out of the building on 1/17/17 at 9:00 PM. Continued interview revealed there was not enough staff on the evening of 1/17/17 to provide supervision to ensure Resident #58 did not leave the building. She also confirmed the resident had a noticeable change in her behavior and demeanor when she was going to try and elope. The noticeable behaviors exhibited by Resident #58 to indicate she might elope were increased wandering in her wheelchair and going to the exit doors and looking outside. Resident #58 would not try to exit seek every time but would look outside. The LPN confirmed staff did not provide supervision to prevent Resident#58 from eloping. Interview with CNA #1 on 2/16/17 at 9:00 PM in the conference room, confirmed Resident #58 was a known elopement risk and had attempted three times to elope at 8:00 PM, 8:15 PM, and 8:30 PM on 1/17/17 prior to her elopement at 9:00 PM. Continued interview revealed there was not enough staff on the evening 1/17/17 to provide supervision to prevent Resident #58 from leaving the building. Continued interview revealed the resident had a noticeable change in her behavior and demeanor when she was going to try and elope. The behaviors exhibited by Resident #58 were increased wandering in her wheelchair and going to the exit doors and looking outside. Resident #58 would not try to exit seek every time but would look outside. Interview with the Administrator on 2/16/17 at 9:30 PM, at the 400 Hall Exit door, confirmed the door alarm did not sound on 1/17/17, when Resident #58 exited the building, because it had a dead battery. Observation of the 400 Exit Hall door on 2/16/17 at 9:30 PM, revealed a concrete ramp approximately12 feet long, leading from the door to a sidewalk, edged with a metal railing at the bottom of the ramp and on one side. Interview with the Family Nurse Practitioner, (FNP), on 2/17/17 at 7:30 AM in the conference room, revealed he did not remember their practice being notified about Resident #58's elopements on 2/23/16, 3/16/16 and 5/10/16. Continued interview revealed that when someone has as many elopements as Resident #58, they start looking for a secure unit for the resident to ensure their safety. Interview with the Medical Director on 2/17/17 at 10:40 AM per telephone, revealed he did not remember being told about Resident #58's elopements that occurred on 2/23/16, 3/16/16, and 5/10/16. The Medical Director stated he signed the incident reports regarding these days but did not read them. Continued interview revealed the Medical Director would have looked at transferring Resident #58 to another facility that had a secure unit for her safety, had he known about the number of elopements. The Immediate Jeopardy was effective from 1/17/17 through 3/1/17. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated through review of documents, observation, and staff interviews conducted onsite on 3/2/17. The surveyor verified the allegation of compliance by: 1. Observing the main entrance egress doors for signage of Notice to Visitors (not to let residents out of the facility without staff notification), and proper functioning of anti-elopement system on the following doors: [NAME] Main entrance egress doors B. Sun room egress doors C. 400 Hall/Conference room fire exit door D. 500 Hall fire exit door E. 300 Hall fire exit door F. Dining room egress door [NAME] 100/200 Hall ambulance entrance door All egress doors had (1) a 15 seconds delayed mag lock with key pad implemented after the elopements on 2/9/17; (2) a wanderguard alarm system (if a resident with a wanderguard bracelet attempts to exit the doors lock, alarms sound, and the door will not open until the resident with the wanderguard is removed from the door area. The wanderguard bracelet system was installed and working on 2/21/17. Observation of Residents #58, #10, and #68 on 3/2/17 at 2:00 PM revealed them all to have their wander guard bracelets in place. These three residents were assessed as wanderers. 2. All audible door alarms placed on the Fire and Egress doors will continuously emit an audible alarm until the staff respond to the specific alarm and manually deactivate it. 3. Observed the staff response to all the alarmed doors when triggered by the surveyor on 3/2/17 between 1:05 PM and 1:25 PM. 4. Interviewed 6 visitors on 3/2/16 between 8:00 AM and 12:00 PM regarding their knowledge about not letting residents out of the building without notifying the nursing staff first, and how to properly sign out a resident from the facility. 5. Reviewed the facility's in-service records to validate the facility staff was in-serviced on the alarm system on the exit doors and the following policies: Wandering and Elopement Wandering, Unsafe Resident 6. Conducted interviews beginning on 3/2/17 at 12:44 PM with staff to include the Administrator, 8 Registered Nurses, Director of Nursing, 6 Licensed Practical Nurses, 20 Certified Nursing Assistants, 3 Housekeeping and Laundry staff, 4 Dietary, 2 Medical Record staff, 1 Maintenance Director, 2 Business Office staff 2 Rehab staff, 1 Receptionist for a total of 50 employees. This was to determine the level of comprehension gained through in-service education regarding the facility's policies, changes to the Wandering and Elopement policy, and implementation of the policy Wandering, Unsafe Resident. Noncompliance continues at a scope and severity of D for monitoring the effectiveness of corrective actions and evaluation of monitoring by the Quality Assurance (QA) Committee. The facility is required to submit a plan of correction.",2020-09-01
897,"CAMBRIDGE HOUSE, THE",445190,250 BELLEBROOK RD,BRISTOL,TN,37620,2017-03-02,353,J,0,1,2UZT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the monthly staffing schedule, medical record review, observation, review of facility Incident/Accident Reports and interview the facility failed to be adequately staffed to provide supervision to prevent an elopement from the facility for 1 resident (#58) of 3 residents reviewed for wandering and elopement risk, of 29 residents reviewed. The facility's failure resulted in Resident #58 eloping from the facility sustaining an open fracture (if the bone breaks in such a way that bone fragments stick out through the skin or a wound penetrates down to the broken bone, the fracture is called an open or compound fracture) in her right arm requiring surgical repair, placing Resident #58 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 Administrator (NHA) was informed of the Immediate Jeopardy on 3/1/17 at 1:25 PM in her office. The findings included: Review of the (MONTH) (YEAR) Staffing Schedule for the evening/night shift (7 PM to 7AM) revealed staffing of I Registered Nurse (RN) supervisor, 2 Licensed Practical Nurses (LPN), 5 Certified Nursing Assistants (CNA), and I Hospitality Aide on the evening shift only. Medical Record review revealed Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of care plan dated 2/9/16 revealed a problem area of wandering and elopement for Resident #58. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 3, indicating the resident had a severe cognitive impairment. Review of a Wandering and Elopement assessment dated [DATE] revealed Resident #58 was a wandering and elopement risk. Review of the facility Incident/Accident Report dated 1/17/17 revealed Resident #58 had eloped from the facility at 9:00 PM. Resident #58 was found outside the 400 hallway exit. Review of the accident report revealed .called to eastwing by CNA's + (and) hospitality aide, found resident lying outside, at bottom of 400 exit hall ramp w/c (wheelchair) beside her on stomach . Continued review revealed injuries sustained were .abraision/ skin tear nose, wrist swollen . Cognitive status was marked as alert and confused. Emergency Medical Services were called and transported Resident #58 to the hospital for admission. Review of the hospital Emergency Department history & (and) physical, dated 1/17/17, revealed .tonight the patient went out the door in her wheelchair, slid down a sidewalk where she turned over and tried to catch herself with her right arm .the patient has significant bruising to her face and open right wrist fracture . Review of a nurse's note dated 1/17/17 revealed: at 8:00 PM, .caught resident trying to open outside door next to her room .at 8:30 PM CNA brought resident back .from around door at room [ROOM NUMBER] . Review of a nurse's note dated 1/17/17 revealed: at 8:15 PM, revealed .I saw . about 8:15 on T hall trying to go out that door .followed me down the 500 hall wanting to go out that door . Interview with RN #1 on 2/16/17 at 11:45 AM, in the conference room revealed there was no staff member assigned to Resident #58 to provide increased supervision after the elopement attempts. Continued interview revealed I was too busy admitting residents, when asked if one on one supervision had been implemented for Resident #58. Interview with the Hospitality Aid on 2/16/17 at 12:00 PM per telephone, confirmed she found Resident #58 outside on the ground on 1/17/17 at 9:00 PM after seeing her on the ground from another resident's room window. Interview with Licensed Practical Nurse (LPN) #1 on 2/16/17 at 8:50 PM in the conference room, revealed she was aware Resident #58 was an elopement risk and had attempted three times to elope on 1/17/17 after 8:00 PM, prior to her getting out of the building on 1/17/17 at 9:00 PM. Continued interview revealed there was not enough staff on the evening of 1/17/17 to provide supervision to ensure Resident #58 did not leave the building. She also confirmed the resident had a noticeable change in her behavior and demeanor when she was going to try and elope. The noticeable behaviors exhibited by Resident #58 to indicate she might elope were increased wandering in her wheelchair and going to the exit doors and looking outside. Resident #58 would not try to exit seek every time but would look outside. Continued interview revealed staff did not provide supervision to prevent Resident #58 from eloping, they would redirect her but did not provide increased supervision. Interview with CNA #1 on 2/16/17 at 9:00 PM in the conference room, confirmed Resident #58 was a known elopement risk and had attempted three times to elope at 8:00 PM, 8:15 PM, and 8:30 PM on 1/17/17 prior to her elopement at 9:00 PM. Continued interview revealed there was not enough staff on the evening 1/17/17 to provide supervision to prevent Resident #58 from leaving the building. Continued interview revealed the resident had a noticeable change in her behavior and demeanor when she was going to try and elope. The behaviors exhibited by Resident #58 were increased wandering in her wheelchair and going to the exit doors and looking outside. Resident #58 would not try to exit seek every time but would look outside. Continued interview revealed staff would redirect Resident #58, but did not have staff to provide increased supervision as they were busy putting people to bed. The Immediate Jeopardy was effective from 1/17/17 through 3/1/17. An Acceptable Allegation of Compliance, was received on 3/2/17 which removed the immediacy of the jeopardy, was received and corrective actions were validated through review of documents, observation, and staff interviews conducted onsite on 3/2/17. The surveyor verified the allegation of compliance by: 1. All audible door alarms placed on the Fire and Egress doors will continuously emit an audible alarm until the staff respond to the specific alarm and manually deactivate it. 2. Observed the staff response to all the alarmed doors when triggered by the surveyor on 3/2/17 between 1:05 PM and 1:25 PM. 3. Reviewed the facilities in-service records from 2/17/17 to 2/22/17 to validate the facility staff was in-serviced on the alarm system on the exit doors and the following policies: Wandering and Elopement Wandering, Unsafe Resident 4. Conducted interviews beginning on 3/2/17 at 12:44 PM with staff to include the Administrator, 8 Registered Nurses, Director of Nursing, 6 Licensed Practical Nurses, 20 Certified Nursing Assistants, 3 Housekeeping and Laundry staff, 4 Dietary, 2 Medical Record staff, 1 Maintenance Director, 2 Business Office staff 2 Rehab staff, 1 Receptionist for a total of 50 employees. This was to determine the level of comprehension gained through in-service education regarding the facility's policies, changes to the Wandering and Elopement policy, implementation of the policy Wandering: Unsafe Resident, and making sure unsafe wandering residents are made 1:1 observation with notification of the Director of Nursing for staff replacement and supervision. Noncompliance continues at a scope and severity of D for monitoring the effectiveness of corrective actions and evaluation of monitoring by the Quality Assurance (QA) Committee. The facility is required to submit a plan of correction. Refer to F-323 J",2020-09-01
898,"CAMBRIDGE HOUSE, THE",445190,250 BELLEBROOK RD,BRISTOL,TN,37620,2017-03-02,501,J,0,1,2UZT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Medical Director Agreement, review of medical records, review of facility Incident/Accident Reports, and interview, the medical director failed to coordinate medical care after signing 4 of 4 elopement reports for 1 Resident (#58) of 3 residents reviewed for wandering and elopement of 29 residents reviewed. The facility's failure resulted in Resident #58 sustaining an open fracture (if the bone breaks in such a way that bone fragments stick out through the skin or a wound penetrates down to the broken bone, the fracture is called an open or compound fracture) requiring surgical repair and placing Resident #58 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 Administrator (NHA) was informed of the Immediate Jeopardy on 3/1/17 at 1:25 PM in her office. The findings included: Medical record review revealed Resident #58 was admitted on [DATE]. Her [DIAGNOSES REDACTED]. Review of the Medical Director Agreement effective date 1/1/2002, revealed under the Medical Director Duties .Medical Director shall evaluate resident care provided in the Facility, and shall advise the Administrator in writing of any discrepancies or inadequacies in connection therewith . Review of Resident #58's care plan dated 2/9/16, revealed .Problem/Need .Problem Onset: 2/9/16 .At risk for wandering and elopement r/t (related to) hx (history) of wandering . Review of a facility Incident/Accident Report dated 2/23/16 revealed Resident #58 had eloped from the facility at 2:15 PM. Resident #58 was found outside the 500 hallway door. Review of the accident report revealed .door alarm sounding, resident went out the 500 hall door to the outside of the building, brought back in by .(Certified Nurse Assistant (CNA) #2) . and .(CNA #3) . Continued review confirmed the Medical Director signed the form 2/26/16. Review of a facility Incident/Accident Report dated 3/16/16 revealed Resident #58 had eloped from the facility at 8:45 PM. Resident #58 was found outside the front doors in the parking lot. Review of the accident report revealed .resident went out front door + (and) made her way to front parking lot. found by nursing staff + (and) brought back into building . Continued review revealed the Medical Director signed the form on 4/1/16 Review of a facility Incident/Accident Report dated 5/10/16 revealed Resident #58 had eloped from the facility at 4:10 PM. Resident #58 was found outside the 500 hallway. Review of the accident report revealed .resident observed by CNA outside 500 hall rolling down the sidewalk . Continued review revealed the Medical Director signed the form on 8/6/16, 3 months after the elopement. Continued review of a facility Incident/Accident Report dated 1/17/17 revealed Resident #58 had eloped from the facility at 9:00 PM. Resident #58 was found outside the 400 hallway exit. Review of the accident report revealed .called to eastwing by CNA's + (and) hospitality aide, found resident lying outside, at bottom of 400 exit hall ramp w/c (wheelchair) beside her on stomach . Continued review revealed injuries sustained were .abraision/ skin tear nose, wrist swollen . Continued review revealed the Medical Director signed the form on 1/23/17. Interview with the Medical Director on 2/17/17 at 10:40 AM per telephone, revealed he did not remember being told about Resident #58's elopements that occurred on 2/23/16, 3/16/16, and 5/10/16. The Medical Director confirmed he signed the incident reports regarding these days but did not read them. The Medical Director stated that if he would have known about the number of elopements that Resident #58 had he would have looked at transferring her to another facility that had a secure unit for her safety. Interview with the Administrator on 2/28/17 at 4:00 PM in her office, revealed the Administrator expected the Medical Director to read the incident reports, and not just sign them. The Immediate Jeopardy was effective from 1/17/17 through 3/1/17. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy was received on 3/2/17, and corrective actions were validated through review of documents, observation, and staff interviews conducted onsite on 3/2/17. The surveyor verified the allegation of compliance by: 1. Interview with the Administrator on 3/2/17 at 10:30 AM in her office, confirmed she and the Quality Assurance (QA) Coordinator were monitoring the Medical Director for compliance in reading the incident reports prior to signing them. 2. Interview with the QA Coordinator on 3/2/17 at 11:00 AM in her office, confirmed she was to monitor the Medical Director reading and signing the facility's Incident/Accident Reports on an ongoing basis. The QA Coordinator will maintain all Incident/Accident Reports reviewed and signed by the Medical Director. 3. Interview with the Medical Director on 3/2/17 at 2:15 PM, in the conference room, confirmed he was informed to fulfill his contractual agreement with the facility he was to read all Incident/Accident Reports prior to signing them. This will allow him to better coordinate medical care for residents in the facility. Noncompliance continues at a scope and severity of D for monitoring the effectiveness of corrective actions and evaluation of monitoring by the Quality Assurance (QA) Committee. The facility is required to submit a plan of correction. Refer to F-323 J",2020-09-01
899,"CAMBRIDGE HOUSE, THE",445190,250 BELLEBROOK RD,BRISTOL,TN,37620,2017-03-02,520,J,0,1,2UZT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility Incident/Accident Reports and interview, the facility's Quality Assurance (QA) Committee failed to ensure development of a plan to provide adequate supervision to prevent unsafe wandering and elopement from the facility, to ensure Minimum Data Set Assessments and care plans were completed accurately, to ensure sufficient nurse staffing for 1 resident (#58) with known for wandering and elopement, of 29 residents reviewed. The facility's failure resulted in Resident #58 sustaining an open fracture (if the bone breaks in such a way that bone fragments stick out through the skin or a wound penetrates down to the broken bone, the fracture is called an open or compound fracture) requiring surgical repair, and abrasions and contusions to her face, placing Resident #58 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 Administrator (NHA) was informed of the Immediate Jeopardy on 3/1/17 at 1:25 PM in her office. The findings included: Medical record review revealed Resident #58 was admitted on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #58's care plan dated 2/9/16, revealed .Problem/Need .Problem Onset: 2/9/16 .At risk for wandering and elopement r/t (related to) hx (history) of wandering . Medical record review and review of facility Incident/Accident reports revealed Resident #58 had been found outside the facility, after exiting the building (eloping) on three occasions, 2/23/16, 3/16/16, and 5/10/16. After each elopement, the facility monitored the resident with every 15 minute observations for 72 hours. The facility did not implement any new interventions or revise the resident's care plan to prevent the resident from eloping again. Medical record review of the resident's MDS assessments revealed the resident was not identified as having wandering behaviors. Medical record review and review of facility Incident/Accident reports revealed the resident attempted to exit the building on 1/17/17 at 8:00 PM, 8:15 PM, and 8:30 PM, and was found outside of the building, lying on the ground with her wheelchair overturned, at 9:00 PM. The resident sustained [REDACTED]. Interview with the Medical Director on 2/17/17 at 10:40 AM, revealed the Medical Director was a member of the QA Committee and attended the QA meetings. Continued interview revealed he did not remember being informed about Resident #58's elopements that occurred on 2/23/16, 3/16/16, and 5/10/16. The Medical Director stated that he was unaware of the resident's constant wandering and multiple attempts at elopement from the facility. Further interview revealed the Medical Director was unaware of any issues with residents wandering or elopements prior to the 1/31/17 QA meeting. Interview with Registered Nurse (RN) #3, the QA Coordinator, on 2/28/17 at 4:15 PM, in the conference room, confirmed the only time that elopements and wanderings had been discussed in QA during the past year was on 1/31/17. This was after Resident #58 eloped from the facility and fell outside, breaking her right arm. Interview with the Administrator on 3/1/17 at 12:30 PM, in the Administrator's office, confirmed the QA Committee had not identified the elopements as an area to be discussed for development of a QA the QA meeting on 1/31/17. The Immediate Jeopardy was effective from 1/17/17 through 3/1/17. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received on 3/2/17 and corrective actions were validated through review of documents, observation, and staff interviews. The surveyor verified the allegation of compliance by: 1. Observing the main entrance egress doors for signage of Notice to Visitors (not to let residents out of the facility without staff notification), and proper functioning of anti-elopement system on the following doors: [NAME] Main entrance egress doors B. Sun room egress doors C. 400 Hall/Conference room fire exit door D. 500 Hall fire exit door E. 300 Hall fire exit door F. Dining room egress door [NAME] 100/200 Hall ambulance entrance door All egress doors had (1) a 15 seconds delayed magnetic lock with key pad implemented on 2/9/17; (2) a Wanderguard alarm system (if a resident with a Wanderguard bracelet attempted to exit, the doors lock, alarms sound, and the door will not open until the resident with the Wanderguard is removed from the door area). The Wanderguard bracelet was installed and working on 2/21/17. 2. All audible door alarms placed on the Fire and Egress doors continuously emit an audible alarm until the staff respond to the specific alarm and manually deactivate it. 3. Observed the staff response time to all the alarmed doors when triggered by the surveyor on 3/2/17 between 1:05 PM and 1:25 PM. 4. Interviewed 6 visitors on 3/2/17 between 8:00 AM and 12:00 PM, regarding their knowledge about not letting residents out of the building without notifying the nursing staff first, and how to properly sign out a resident from the facility. 5. Reviewed the facility's in-service records to validate the facility staff was in-serviced on the alarm system on the exit doors and the following policies: Wandering and Elopement Wandering, Unsafe Resident 6. Conducted interviews on 3/2/17 with staff to include the Administrator, 8 Registered Nurses, Director of Nursing, 6 Licensed Practical Nurses, 20 Certified Nursing Assistants, 3 Housekeeping and Laundry staff, 4 Dietary staff, 2 Medical Record staff, 1 Maintenance Director, 2 Business Office staff, 2 Rehab staff, and 1 Receptionist, for a total of 50 employees. This was to determine the level of comprehension gained through in-service education regarding the facility's policies, changes to the Wandering and Elopement policy, and implementation of the policy Wandering, Unsafe Resident. Noncompliance continues at a scope and severity of D for monitoring the effectiveness of corrective actions and evaluation of monitoring by the Quality Assurance (QA) Committee. The facility is required to submit a plan of correction. Refer to F-278 J Refer to F-280 J Refer to F-323 J Refer to F-353 J Refer to F-501 J",2020-09-01
900,"CAMBRIDGE HOUSE, THE",445190,250 BELLEBROOK RD,BRISTOL,TN,37620,2018-03-21,609,D,1,0,ZD9T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review and interviews, the facility failed to report to the state agency allegations of abuse to include an injury of unknown origin for one resident (#4) of five sampled residents reviewed for allegations of abuse. The findings included: Review of the facility policy Abuse, Neglect, Mistreatment and Misappropriation of Resident Property dated 12/4/2017, revealed allegations of abuse are to be reported to the Administrator, State Agency, law enforcement, the physician, and the resident and/or Power of Attorney. Review of the medical record revealed the facility admitted Resident #4 on 5/3/17 with [DIAGNOSES REDACTED]. Review of the medical record revealed Resident #4 had a chest x-ray on 1/2/2018 due to a cough. Review of the medical record revealed KUB (Kidney, Ureters, and Bladder) x-rays were done on 1/29/18, 1/30/18, and 2/1/18. These x-rays reported a metallic screw over the right upper quadrant of the abdomen. Review of the medical record revealed the physician was notified of the KUB x-ray results on 1/29/18, 1/30/18 and 2/1/18. Review of the nurse's note dated 2/1/18 revealed the POA agreed with the doctor for Resident #4 to be admitted to the hospital on [DATE] for evaluation of the screw in the abdomen. Review of the Op Note (surgical note) dated 2/1/18 revealed the screw was removed from the resident's duodenum (upper part of the small intestine) with a scope inserted down the resident's throat. Resident #4 tolerated the procedure well and returned to the facility on [DATE]. Interview with Resident #4 was attempted on 3/19/18 at 1:00 PM, on in the 300-500-unit dining room, and Resident #4 was unable to answer any questions. Interview with the Medical Director, who was also the attending physician, on 3/20/18 at 1:30 PM, at the nurses' station on the 300-500 units, revealed, Later when I looked at the chest x-ray films, I thought I saw a foreign body on the films even though the chest x-ray report did not mention it so I ordered the KUB x-ray. I have no idea where the screw came from. The screw showed up on a chest x-ray so I ordered a KUB (x-ray of the abdomen) three times to verify that this was a screw and not an artifact. The resident had no pain or vomiting or change in bowel habits. Once I verified that it was a screw I admitted her to the hospital under the care of a [MEDICATION NAME]. The screw was removed without any adverse effect to the resident. The Medical Director stated Resident #4 had no prior history of putting non-food items in her mouth. Interview with the Director of Nursing (DON) on 3/20/18 at 11:30 AM, in the DON's office, revealed the incident of Resident #4 having a screw in her abdomen was not reported. The DON stated a screw in the abdomen is an unusual finding and we should have reported it. Since she (Resident #4) didn't have any outcome we just didn't think to report it.",2020-09-01
901,"CAMBRIDGE HOUSE, THE",445190,250 BELLEBROOK RD,BRISTOL,TN,37620,2018-03-21,610,D,1,0,ZD9T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, and interviews, the facility failed to investigate an injury of unknown origin for one resident (#4) of five sampled residents reviewed for abuse. The findings included: Review of the Abuse, Neglect, Mistreatment and Misappropriation of Resident Property dated 12/4/2017, revealed allegations of abuse are to be investigated. Review of the medical record revealed the facility admitted Resident #4 on 5/3/17 with [DIAGNOSES REDACTED]. Review of the medical record revealed Resident #4 had a chest x-ray on 1/2/2018 due to a cough. Review of the medical record revealed KUB (Kidney, Ureters, and Bladder) x-rays were done on 1/29/18, 1/30/18, and 2/1/18. These x-rays reported a metallic screw over the right upper quadrant of the abdomen. Review of the medical record revealed the physician was notified of the KUB x-ray results on 1/29/18, 1/30/18 and 2/1/18. Review of the nurse's note dated 2/1/18 revealed the POA agreed with the doctor for Resident #4 to be admitted to the hospital on [DATE] for evaluation of the screw in the abdomen. Review of the Op Note (surgical note) dated 2/1/18 revealed the screw was removed from the resident's duodenum (upper part of the small intestine) with a scope inserted down the resident's throat. Resident #4 tolerated the procedure well and returned to the facility on [DATE]. Interview with Resident #4 was attempted on 3/19/18 at 1:00 PM, on in the 300-500-unit dining room, and Resident #4 was unable to answer any questions. Interview with the Director of Nursing (DON) on 3/20/18 at 11:30 AM, in the DON's office, revealed no formal investigation had been done or documented. The DON stated the family was interviewed about Resident #4 possibly swallowing a screw prior to admission to the facility, staff were interviewed if Resident #4 had displayed any behavior of putting non-food items in her mouth, and the physician was interviewed. The DON stated the resident had no change in condition related to swallowing, pain or bowel movements. It (the screw) was discovered as a fluke on an x-ray. Interview with the Medical Director on 3/20/18 at 1:30 PM, at the nurses' station on the 300-500 units, revealed he had no idea where the screw came from. The screw showed up on a chest x-ray so I ordered a KUB three times to verify that this was a screw and not an artifact. Once verified, I admitted the resident to the hospital under a [MEDICATION NAME] (physician specializing in the throat, stomach, and intestinal tract). The screw was removed without adverse effect to the resident. I had the staff check the resident's room and wheel chair for missing screws. None were found. Interview with the DON on 3/21/18 at 9:45 AM, in the conference room, confirmed, We did not write up an investigation.",2020-09-01
902,"CAMBRIDGE HOUSE, THE",445190,250 BELLEBROOK RD,BRISTOL,TN,37620,2019-04-26,578,J,0,1,48RJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to follow policy and procedures to obtain and honor a resident's wishes to refuse resuscitative treatment for 1 resident (#364), failed to obtain a physician's signature on a Physician Orders for Scope of Treatment (POST) form for 1 resident (#18), and failed to obtain a physician's order for code status for 1 resident (#53) of 18 sampled residents. The facility's failure to honor a resident's wishes to refuse resuscitative treatment for [REDACTED]. The Administrator was informed of the Immediate Jeopardy in the Administrator's office on [DATE] at 1:39 PM. An extended survey was conducted on [DATE] - [DATE]. The Immediate Jeopardy was removed on [DATE] and was effective from [DATE] - [DATE]. The findings include: Review of the facility policy Do Not Resuscitate Order revised ,[DATE] revealed .Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect .A Do Not Resuscitate (DNR) order form must be completed and signed by the Attending Physician and resident (or resident's legal surrogate, as permitted by State law) and placed in the front of the resident's medical record . Medical record review revealed Resident #364 was admitted to the facility on [DATE] and was discharged home on [DATE]. The resident was again admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #364's Physician Discharge Orders dated [DATE] from a local hospital revealed the resident's code status was Do Not Resuscitate (DNR). Medical record review of a Physician's Telephone Order written by Registered Nurse (RN) #1 and dated [DATE] revealed .accept this patient and all orders . indicating the DNR order was to be an admitting order. Continued review revealed the telephone order had been reviewed and signed by the Nurse Practitioner on [DATE]. Medical record review of the resident's Baseline Care Plan dated [DATE] revealed the resident's cognitive status was alert and oriented. Further review revealed .DNR . indicating the resident's code status was DNR. Medical record review of a POST form placed in front of Resident #364's chart dated [DATE], revealed .Resuscitate (CPR) (Cardio [MEDICAL CONDITION] Resuscitation) . Further review revealed this form was dated with the resident's previous admission date of [DATE], not the current admission date of [DATE]. Medical record review of a nurse's note dated [DATE] revealed .no heartbeat heard O (no) B/P (blood pressure) no respirations .Code blue (a page indicating resident was unresponsive) called overhead. CPR started: 911 called-CPR continued for 15 minutes and EMTs (emergency medical technicians) arrived .resident (#364) was transported out with pulse and respirations . Medical record review of Emergency Medical Services (EMS) records dated [DATE] revealed Resident #364 received [MEDICATION NAME] (medication used to treat sudden [MEDICAL CONDITION] and regain heart beat), [MEDICATION NAME] (medication used to increase heart rate during [MEDICAL CONDITION]), and was intubated (tube placed through mouth and into airway to assist with breathing during CPR). Further review of the EMS records revealed .Patient was noted to .be in a wide complex bradycardic (heart rate less than 60 beats per minute) rhythm with a pulse . Medical record review of emergency room (ER) records dated [DATE] revealed .Bystander CPR was started. EMS continued Advanced Cardiac Life Support (ACLS) protocol he was intubated prior to arrival. Patient had a brief return of spontaneous circulation just prior to arrival. He however lost a pulse shortly after arriving in the emergency department. Continuing resuscitative efforts were unsuccessful . During interview with the Admissions Coordinator on [DATE] at 12:55 PM, in the Admissions office, the Admissions Coordinator stated she had talked with Resident #364's family member on the [DATE] admitted and instructed him .get with the nurse and fill out a new POST form . Interview with RN #1 on [DATE] at 12:55 PM, in the Admissions office, revealed RN #1 completed Resident #364's admission assessment to the facility on [DATE]. Continued interview revealed RN #1 asked the resident if his heart stopped would he want to have CPR (Cardio [MEDICAL CONDITION] Resuscitation) initiated. Further interview revealed the resident said yes at first then said no, .he was confused, I think . Continued interview revealed RN #1 did not ensure the resident's wishes for resuscitation were clarified with the resident or the resident's representative upon admission to the facility on [DATE]. Telephone interview with Resident #364's family member on [DATE] at 4:40 PM, revealed Resident #364's wishes were for a DNR code status. Continued interview revealed .he (Resident #364) 100% did not want CPR performed on him . Further interview revealed the family member stated the facility did not discuss a POST form with the family or instruct the family member to complete a POST form. The family member stated the facility did not ask what the resident's wishes were regarding code status. Interview with RN #1 on [DATE] at 4:52 PM, in the conference room, revealed RN #1 was the admitting nurse for Resident #364. Continued interview revealed .I try to get the POST form filled out when I do the admission. If family member is not available, I normally would call and have two nurses present and take a verbal order for the code status . Further interview confirmed .the truth of the matter is I screwed up. I should have gotten it (POST) signed . Interview with the Director of Nursing (DON) on [DATE] at 8:10 AM, in the DON's office, confirmed a POST form for Resident #364 had not been completed upon admission to the facility on [DATE] by the resident or resident's representative in order to document the resident's wishes for resuscitative measures. Continued interview confirmed there was a DNR code status on the admission orders [REDACTED]. Continued interview confirmed the facility failed to honor the resident's wishes to be a DNR and not have resuscitative interventions. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed a POST form was signed and dated by the resident's Power of Attorney on of [DATE]. Further review revealed the resident wished for a DNR status. Continued review revealed the POST form had not been signed by the attending Physician. Interview with Licensed Practical Nurse (LPN) #2 on [DATE] at 2:22 PM, in the conference room, revealed a new POST form should be completed upon each admission .nurse admitting the resident goes back and talks to family and the family decides . Interview with LPN #4 on [DATE] at 2:35 PM, in the conference room, revealed a new POST form should be completed upon each admission . RN doing the admission places the form on the chart, any nurse can ask resident or family about POST form . Continued interview revealed when determining whether or not to implement resuscitative measures, she would look in the front of the resident's chart at the POST form to confirm code status. Further interview revealed if the POST form had not been signed by the physician, the resident was considered a full code, even if the form stated DNR. Interview with Minimum Data Set (MDS) Coordinator on [DATE] at 3:12 PM, at the nurse's station, revealed if a POST form was in a resident's chart and it had not been signed by the physician, she would abide by the family and or resident wishes for code status. Continued interview revealed a new POST form should be completed upon each admission .the nurse on floor who does the admission is responsible for the POST form .if family not available and resident is unable to sign the nurse on next shift is responsible for completing the POST form . Interview with the Staff Development Coordinator on [DATE] at 3:23 PM, in the conference room, revealed resident wishes for code status were placed on a POST form in front of the resident's chart. Further interview revealed the POST form was not legal until the physician signed the form. Continued interview revealed if the POST form had not been signed by the physician, she would initiate CPR regardless of the actual Physician's order or code status on the form. Interview with LPN #5 on [DATE] at 7:04 PM, in the conference room, revealed resident POST forms were located in the front of the resident's chart. Further interview revealed if the POST form had not been signed by the physician the resident was considered a full code no matter what the actual physician's order indicated. Interview with RN #1 on [DATE] at 7:16 PM, in the conference room, revealed a resident was considered full code until a physician signed the POST form, even if there was a physician's order in place for the code status. Further interview revealed .the form is not legal until it had been signed by a Physician . Interview with RN #3 on [DATE] at 7:30 AM, in the 500 hallway, revealed if a POST form had not been signed by a physician she would go by resident's wishes for code status. Interview with LPN #1 on [DATE] at 7:40 AM, in the conference room, revealed if a POST form had not been signed by the physician, the resident was considered a full code. Interview with the DON on [DATE] at 9:15 AM, in the hallway outside the conference room, confirmed the facility failed to obtain a physician's signature on the POST form for Resident #18. In summary, interviews with multiple licensed nurses over various shifts revealed inconsistent knowledge of the facility's policy and procedures related to code status when the POST form had not been signed by the physician. Medical record review revealed Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #53's Care Plan dated [DATE] revealed .Request for full code status . Medical record review of an Admission MDS assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating Resident #53 had moderately impaired cognition. Medical record Review of the POS [REDACTED].Resuscitate (CPR) .Full Treatment . indicating Resident #53 had requested full code status. Medical record review of the Physician's Orders dated [DATE] - [DATE] revealed a Physician's order had not been obtained for Resident #53's full code status. Interview with RN #1 on [DATE] at 8:04 AM, at the nurse's station, confirmed the facility failed to obtain a Physician's order for Resident #53's full code status. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the jeopardy, was received [DATE] at 4:50 PM, and the corrective actions were validated on-site by the surveyors on [DATE] through review of documents, observations, in-service training logs, review of facility policies, and staff interviews. The A[NAME] presented to the survey team by the facility documented the following immediate corrective action measures implemented. On [DATE] - [DATE] the facility's leadership consisting of the Administrator and the DON provided oversight and training to all licensed nurses, the Social Services Director, the Admissions Coordinator, and the Medical Records Clerk. The oversight and training included: 1. Facility's policy and procedures for Advance Directives to include the new process to identify code status. 2. How to transcribe Physician orders. 3. The facility's policy on baseline care plans to include resident's code status. On [DATE]-[DATE] the facility's leadership consisting of the Administrator and the DON conducted a comprehensive review of all current resident medical records to verify they were complete and accurate, that included a completed POST form with a physician's signature, to verify a physician's order had been obtained for the code status, and to verify the care plan had been updated to include code status. The surveyors review of the facility's A[NAME], facility training materials, interviews, and in-service logs dated [DATE]-[DATE] verified all (12) licensed nurses, the Social Services Director, the Admissions Coordinator, and the Medical Records Clerk had completed the following training as of [DATE]: 1. Facility's policy and procedures for Advance Directives to include the new process to identify code status. 2. How to transcribe Physician orders. 3. The facility's policy on baseline care plans to include resident's code status. Review verified 10 of 12 licensed nurses, Social Services Director, Admissions Coordinator, and the Medical Records Clerk employed at the facility had completed training on maintaining an accurate/complete medical record to include Advanced Directives, POST forms, code status, physician's orders, and baseline care plans. The 2 remaining licensed nurses will be in-serviced before their next scheduled shift and there were no identified concerns. The surveyors interviewed 2 Registered Nurses (RN's), 4 Licensed Practical Nurses (LPN'S) on all shifts, the Social Services Director, the Admissions Coordinator, and the Medical Records Clerk on [DATE]. These interviews revealed they had received new training on the facility's policy and procedures for Advance Directives to include the new process to identify code status and how to transcribe Physician orders. Continued interview revealed they had received new education on Baseline Care Plans and how to maintain an accurate and complete medical record. These interviews confirmed the staff was knowledgeable and able to verbalize the facility's policy and procedures for Advance Directives to include the new process to identify code status, how to transcribe Physician orders, Baseline Care Plans, and how to maintain an accurate and complete medical record, and there were no identified concerns. The surveyors reviewed the A[NAME] and verified 25 current resident medical records were complete and accurate and included a completed POST form with a physician's signature, a physician's order had been obtained for the code status, and the care plan had been updated to include code status. Noncompliance at F578 continues at a scope and severity of D for monitoring of the effectiveness of corrective actions to ensure sustained compliance.",2020-09-01
903,"CAMBRIDGE HOUSE, THE",445190,250 BELLEBROOK RD,BRISTOL,TN,37620,2019-04-26,655,J,0,1,48RJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to implement a Baseline Care Plan to honor a Do Not Resuscitate (DNR) code status for 1 resident (#364) of 18 sampled residents. This facility's failure to implement the baseline care plan resulted in the resident receiving Cardio [MEDICAL CONDITION] Resuscitation (CPR) and other life-saving measures against his wishes. The facility's failure to implement Resident #364's baseline care plan placed the resident 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 Administrator was informed of the Immediate Jeopardy in the Administrator's office on [DATE] at 1:39 PM. An extended survey was conducted on [DATE] - [DATE]. The Immediate Jeopardy was removed [DATE] and was effective from [DATE] - [DATE]. The findings include: Medical record review revealed Resident #364 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physician Discharge Order from a local hospital dated [DATE] revealed an order for [REDACTED].>Medical record review of Resident #364's Baseline Care Plan dated [DATE] revealed the resident was care planned for DNR code status. Medical record review of a nurse's note dated [DATE] revealed .no heartbeat heard O (no) B/P (blood pressure) no respirations .Code blue (a page indicating resident was unresponsive) called overhead. CPR started: 911 called-CPR continued for 15 minutes and EMTs (emergency medical technicians) arrived .resident (#364) was transported out with pulse and respirations . Medical record review of Emergency Medical Services (EMS) records dated [DATE] revealed Resident #364 received [MEDICATION NAME] (medication used to treat sudden [MEDICAL CONDITION] and regain heart beat), [MEDICATION NAME] (medication used to increase heart rate during [MEDICAL CONDITION]), and was intubated (tube placed through mouth and into airway to assist with breathing during CPR). Further review of the EMS records revealed .Patient was noted to .be in a wide complex bradycardic (heart rate less than 60 beats per minute) rhythm with a pulse . Medical record review of emergency room (ER) records dated [DATE] revealed .Bystander CPR was started. EMS continued Advanced Cardiac Life Support (ACLS) protocol he was intubated prior to arrival. Patient had a brief return of spontaneous circulation just prior to arrival. He however lost a pulse shortly after arriving in the emergency department. Continuing resuscitative efforts were unsuccessful . Interview with the Minimum Data Set (MDS) Coordinator on [DATE] at 3:12 PM, in the conference room, revealed when she entered Resident #364's room to assist, the resident was unresponsive. Continued interview confirmed the MDS Coordinator did not refer to the resident's care plan, but remembered from reviewing the medical record earlier, that the resident was a full code. Further interview revealed the MDS Coordinator informed Registered Nurse (RN) # 1 to initiate CPR. Interview with Registered Nurse (RN) #1 on [DATE] at 4:52 PM, in the conference room, confirmed RN #1 had completed the Baseline Care Plan on [DATE], which included a DNR code status for Resident #364. Continued interview confirmed the facility initiated CPR and did not implement Resident #364's Baseline Care Plan of DNR code status. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the jeopardy, was received [DATE] at 4:50 PM, and the corrective actions were validated on-site by the surveyors on [DATE] through review of documents, observations, in-service training logs, review of facility policies, and staff interviews. The A[NAME] presented to the survey team by the facility documented the following immediate corrective action measures implemented. On [DATE] - [DATE] the facility's leadership consisting of the Administrator and the DON provided oversight and training to all licensed nurses, the Social Services Director, the Admissions Coordinator, and the Medical Records Clerk. The oversight and training included: 1. Facility's policy and procedures for Advance Directives to include the new process to identify code status. 2. How to transcribe Physician orders. 3. The facility's policy on baseline care plans to include resident's code status. On [DATE]-[DATE] the facility's leadership consisting of the Administrator and the DON conducted a comprehensive review of all current resident medical records to verify they were complete and accurate, that included a completed POST form with a physician's signature, to verify a physician's orders [REDACTED]. The surveyors review of the facility's A[NAME], facility training materials, interviews, and in-service logs dated [DATE]-[DATE] verified all (12) licensed nurses, the Social Services Director, the Admissions Coordinator, and the Medical Records Clerk had completed the following training as of [DATE]: 1. Facility's policy and procedures for Advance Directives to include the new process to identify code status. 2. How to transcribe Physician orders. 3. The facility's policy on baseline care plans to include resident's code status. Review verified 10 of 12 licensed nurses, Social Services Director, Admissions Coordinator, and the Medical Records Clerk employed at the facility had completed training on maintaining an accurate/complete medical record to include Advanced Directives, POST forms, code status, physician's orders [REDACTED]. The 2 remaining licensed nurses will be in-serviced before their next scheduled shift and there were no identified concerns. The surveyors interviewed 2 Registered Nurses (RN's), 4 Licensed Practical Nurses (LPN'S) on all shifts, the Social Services Director, the Admissions Coordinator, and the Medical Records Clerk on [DATE]. These interviews revealed they had received new training on the facility's policy and procedures for Advance Directives to include the new process to identify code status and how to transcribe Physician orders. Continued interview revealed they had received new education on Baseline Care Plans and how to maintain an accurate and complete medical record. These interviews confirmed the staff was knowledgeable and able to verbalize the facility's policy and procedures for Advance Directives to include the new process to identify code status, how to transcribe Physician orders, Baseline Care Plans, and how to maintain an accurate and complete medical record, and there were no identified concerns. The surveyors reviewed the A[NAME] and verified 25 current resident medical records were complete and accurate and included a completed POST form with a physician's signature, a physician's orders [REDACTED]. Noncompliance at F655 continues at a scope and severity of D for monitoring of the effectiveness of corrective actions to ensure sustained compliance.",2020-09-01
904,"CAMBRIDGE HOUSE, THE",445190,250 BELLEBROOK RD,BRISTOL,TN,37620,2019-04-26,684,J,0,1,48RJ11,"**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 follow a Physician's order for Do Not Resuscitate (DNR) code status for 1 resident (#364) of 3 residents reviewed for code status, and failed to follow a Physician's order for wound care for 1 resident (#39) of 18 sampled residents. The facility's failure to follow a physician's order for DNR resulted in Resident #364 receiving Cardiopulmonary Resuscitation (CPR) and other life-saving treatments against his wishes. The facility's failure to follow the physician's order for DNR placed Resident #364 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 Administrator was informed of the Immediate Jeopardy in the Administrator's office on [DATE] at 1:39 PM. An extended survey was conducted on [DATE] - [DATE]. The Immediate Jeopardy was removed [DATE] and was effective from [DATE] - [DATE]. Substandard Quality of Care was cited under F-684 at a scope and severity of [NAME] The findings include: Review of the facility policy Do Not Resuscitate Order, revised ,[DATE], revealed .Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect .A Do Not Resuscitate order form must be completed and signed by the Attending Physician .and placed in front of the resident's medical record . Medical record review revealed Resident #364 was admitted to the facility on [DATE] and was discharged home on [DATE]. Continued review revealed the resident was again admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physician's Order for Scope of Treatment (POST) form dated [DATE] (from previous admission) was located in the front of Resident #364's medical record. Continued review of the medical record revealed a POST form from the resident's admission to the facility on [DATE] was not in the chart. Medical record review of a Physician Discharge Order dated [DATE] from a local hospital revealed Resident #364 was a DNR code status. Medical record review of a Physician Telephone Order dated [DATE] revealed .accept this patient and all orders . indicating the DNR order from the hospital was to continue in the nursing home. Continued review revealed the telephone order was signed by the Nurse Practitioner on [DATE]. Medical record review of Resident #364's Baseline Care Plan dated [DATE] revealed DNR code status. Medical record review of a nurse's note dated [DATE] revealed .no heartbeat heard O (no) B/P (blood pressure) no respirations .Code blue (a page indicating resident was unresponsive) called overhead. CPR started: 911 called-CPR continued for 15 minutes and EMTs (emergency medical technicians) arrived .resident (#364) was transported out with pulse and respirations . Medical record review of Emergency Medical Services (EMS) records dated [DATE] revealed Resident #364 received [MEDICATION NAME] (medication used to treat sudden [MEDICAL CONDITION] and regain heart beat), [MEDICATION NAME] (medication used to increase heart rate during [MEDICAL CONDITION]), and was intubated (tube placed through mouth and into airway to assist with breathing during CPR). Further review of the EMS records revealed .Patient was noted to .be in a wide complex bradycardic (heart rate less than 60 beats per minute) rhythm with a pulse . Medical record review of emergency room (ER) records dated [DATE] revealed .Bystander CPR was started. EMS continued Advanced Cardiac Life Support (ACLS) protocol he was intubated prior to arrival. Patient had a brief return of spontaneous circulation just prior to arrival. He however lost a pulse shortly after arriving in the emergency department. Continuing resuscitative efforts were unsuccessful . Interview with Registered Nurse (RN) #1 on [DATE] at 12:45 PM, in the admissions office, confirmed Resident #364 went into [MEDICAL CONDITION] on [DATE] and CPR was initiated. Further interview revealed the MDS Coordinator initiated the chest compressions while RN #1 initiated the ambu bag (artificial ventilation for someone not breathing). Interview with Licensed Practical Nurse (LPN) #6 on [DATE] at 1:08 PM, in the 300 hallway, revealed Resident #364 went into [MEDICAL CONDITION] on [DATE] and the resident was a full code according to the POST form in the front of the resident's chart (dated [DATE] from previous admission). Further interview revealed LPN #6 called the emergency room and gave a report on the resident's condition, and informed them the resident was a full code. Interview with Certified Nursing Assistant (CNA) #2 on [DATE] at 2:45 PM, in the conference room, revealed he had assisted Resident #364 to his bed from the bathroom. Further interview revealed he left the resident sitting on the side of the bed and went to assist another resident. Continued interview revealed when CNA #2 was coming back up the hall, Resident #364's roommate called out for help, and when the CNA entered the room, Resident #364 was lying back in the bed with his legs off the bed. Further interview revealed the CNA notified RN #1. Interview with CNA #1 on [DATE] at 2:50 PM, in the conference room, revealed she had assisted Resident #364 to the bathroom and informed CNA #2 the resident would be calling out for assistance back to bed, then she went to lunch. A few minutes later she heard code blue (page indicating resident was unresponsive) called out and went to Resident #364's room. Continued interview revealed the Minimum Data Set (MDS) Coordinator was performing chest compressions and CNA #1 took over the chest compressions. Interview with the MDS Coordinator on [DATE] at 3:12 PM, in the conference room, revealed she had gone to Resident #364's room on [DATE] when she had overheard a CNA request an oxygen mask from the nurse. Further interview revealed she went to help and when she entered the room, the resident was unresponsive. She checked for a radial pulse and RN #1 checked for a carotid pulse (at neck). Continued interview revealed the MDS Coordinator did not verify Resident #364's code status and stated she had reviewed the chart earlier on [DATE] and remembered he was a full code. Further interview confirmed she had informed RN #1 to initiate CPR and the MDS Coordinator initiated chest compressions while RN #1 started using the ambu bag. Continued interview confirmed the POST form in Resident #364's medical record was dated [DATE] from the previous admission. Interview with the Staff Development Coordinator (SDC) on [DATE] at 3:23 PM, in the conference room, revealed she heard a code blue paged to Resident #364's room. Further interview revealed when she entered the room, CPR was in progress. Continued interview revealed the MDS Coordinator was performing chest compressions and CNA #1 took over the chest compressions to relieve the MDS Coordinator. Continued interview revealed the SDC took over the ambu bag from RN #1. Interview with the Director of Nursing (DON) on [DATE] at 8:10 AM, in the DON's office, confirmed the facility did not complete an updated POST form when Resident #364 was readmitted to the facility on [DATE]. Continued interview confirmed Resident #364 was admitted to the facility with a DNR order from the hospital. Further interview confirmed there was a physician's order for the resident to be DNR, however the facility failed to ensure the physician's order was followed. Interview with the Medical Director on [DATE] at 2:10 PM, in the conference room, confirmed the DNR order from the hospital was a valid admission order, and it was her expectation for the facility to verify the code status with the resident or the resident's representative. Medical record review revealed Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Podiatry Order form dated [DATE] revealed .1. Apply [MEDICATION NAME] to L (left) great toe cover with a dry .dressing. 2. Change daily for two weeks. 3. Then apply only a dry .gauze dressing during the day. Open to air at night for one week . Medical record review of Resident #39's Treatment Record dated [DATE] - [DATE] revealed the treatment order had not been transcribed to the Treatment Record until [DATE] (4 days after the Physician's order had been written). Continued review revealed Resident #39 had not received the wound care as ordered on [DATE], [DATE], [DATE] and [DATE]. Interview with LPN #6 on [DATE] at 11:36 AM, at the nurse's station, confirmed Resident #39 had been evaluated by the Podiatrist on [DATE]. Further interview confirmed wound care had been ordered on [DATE] and the treatment had not been transcribed to the (MONTH) 2019 Treatment Record until [DATE]. Observation on [DATE] at 10:51 AM, in the resident's room with LPN #6, revealed no dressing observed to the left great toe. Further observation revealed the left great toe had dried blood and redness with no drainage observed. Telephone interview with the Nurse Practitioner on [DATE] at 4:30 PM, revealed he had completed an assessment of the resident on [DATE]. Further interview revealed he ordered a uric acid (a laboratory test to determine gout) level because the resident had a history of [REDACTED]. Continued interview revealed he did not think the resident had any active infection in the left great toe and the redness and inflammation was from a flare up of gout. Interview with LPN #6 on [DATE] at 3:30 PM, in the conference room, confirmed the facility failed to transcribe wound care orders timely and failed to provide treatment for 4 days for Resident #39. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the jeopardy, was received [DATE] at 4:50 PM, and the corrective actions were validated on-site by the surveyors on [DATE] through review of documents, observations, in-service training logs, review of facility policies, and staff interviews. The A[NAME] presented to the survey team by the facility documented the following immediate corrective action measures implemented. On [DATE] - [DATE] the facility's leadership consisting of the Administrator and the DON provided oversight and training to all licensed nurses, the Social Services Director, the Admissions Coordinator, and the Medical Records Clerk. The oversight and training included: 1. Facility's policy and procedures for Advance Directives to include the new process to identify code status. 2. How to transcribe Physician orders. 3. The facility's policy on baseline care plans to include resident's code status. On [DATE]-[DATE] the facility's leadership consisting of the Administrator and the DON conducted a comprehensive review of all current resident medical records to verify they were complete and accurate, that included a completed POST form with a physician's signature, to verify a physician's order had been obtained for the code status, and to verify the care plan had been updated to include code status. The surveyors review of the facility's A[NAME], facility training materials, interviews, and in-service logs dated [DATE]-[DATE] verified all (12) licensed nurses, the Social Services Director, the Admissions Coordinator, and the Medical Records Clerk had completed the following training as of [DATE]: 1. Facility's policy and procedures for Advance Directives to include the new process to identify code status. 2. How to transcribe Physician orders. 3. The facility's policy on baseline care plans to include resident's code status. Review verified 10 of 12 licensed nurses, Social Services Director, Admissions Coordinator, and the Medical Records Clerk employed at the facility had completed training on maintaining an accurate/complete medical record to include Advanced Directives, POST forms, code status, physician's orders, and baseline care plans. The 2 remaining licensed nurses will be in-serviced before their next scheduled shift and there were no identified concerns. The surveyors interviewed 2 Registered Nurses (RN's), 4 Licensed Practical Nurses (LPN'S) on all shifts, the Social Services Director, the Admissions Coordinator, and the Medical Records Clerk on [DATE]. These interviews revealed they had received new training on the facility's policy and procedures for Advance Directives to include the new process to identify code status and how to transcribe Physician orders. Continued interview revealed they had received new education on Baseline Care Plans and how to maintain an accurate and complete medical record. These interviews confirmed the staff was knowledgeable and able to verbalize the facility's policy and procedures for Advance Directives to include the new process to identify code status, how to transcribe Physician orders, Baseline Care Plans, and how to maintain an accurate and complete medical record, and there were no identified concerns. The surveyors reviewed the A[NAME] and verified 25 current resident medical records were complete and accurate and included a completed POST form with a physician's signature, a physician's order had been obtained for the code status, and the care plan had been updated to include code status. Noncompliance at F684 continues at a scope and severity of D for monitoring of the effectiveness of corrective actions to ensure sustained compliance.",2020-09-01
905,"CAMBRIDGE HOUSE, THE",445190,250 BELLEBROOK RD,BRISTOL,TN,37620,2019-04-26,760,E,0,1,48RJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, interview, and review of the pharmacy delivery manifest, the facility failed to ensure 1 resident (#413) was free from significant medication errors of 3 residents observed for medication administration. The findings include: Review of the facility policy Administering Medications, revised 12/2012, revealed .Medications shall be administered in a safe and timely manner, and as prescribed .must be administered in accordance with the orders, including any required time frame . Review of the facility policy ORDERING AND RECEIVING MEDICATIONS FROM PHARMACY, undated, revealed .Medication orders are phoned or faxed to the pharmacy as soon as the order is received from the prescriber .Reorder medication 3-4 days in advance of need .Use the emergency kit when the resident needs a medication prior to pharmacy delivery .The nurse verifies medications received and directions for use with the medication order and receipt record .omissions are reported promptly to the issuing pharmacy and the charge nurse/supervisor . Medical record review revealed Resident #413 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician's Order dated 4/1/19 - 4/30/19 for Resident #413 revealed, .[MEDICATION NAME] (medication used to treat nerve pain) CAP (capsule) 100MG (MILLIGRAM) 1 CAPSULE BY MOUTH at bedtime (REORDER 3 DAYS BEFORE NEEDED) Start: 1/29/19 . Further review of the Physician's Order revealed, .[MEDICATION NAME] (antidepressant) TAB 100MG 1 TABLET BY MOUTH at bedtime FOR [MEDICAL CONDITION] .Start: 1/23/19 . Medical record review of the Medication Record for 1/19-4/19 revealed it was documented Resident #413 was administered [MEDICATION NAME] 100 mg daily at bedtime from 1/23/19 - 4/22/19. Medical record review of the Medication Record dated 4/2019 revealed it was documented Resident #413 was administered [MEDICATION NAME] 100 mg daily at bedtime from 4/1/19 - 4/22/19. Medical record review of the Controlled Drug Receipt Record revealed Registered Nurse (RN) #2 administered the last dose of [MEDICATION NAME] on 4/17/19 at 9:00 PM. Interview with Resident #413 on 4/22/19 at 12:01 PM, in the resident's room revealed .I was awake all night because I haven't been sleeping very good . Further interview revealed Resident #413 was concerned she had not received all of her medications. Interview with Licensed Practical Nurse (LPN) #2 and observation of the 400 hall medication cart on 4/23/19 at 3:23 PM, revealed Resident #413 did not have any [MEDICATION NAME] or [MEDICATION NAME] available in the medication drawer. Continued interview confirmed the [MEDICATION NAME] had not been available for administration since 1/26/19. Further interview confirmed the [MEDICATION NAME] had not been available for administration since 4/17/19. Interview with the Medical Director on 4/23/19 at 3:42 PM, at the nurses station, revealed, .I would expect the nurses to call me so I could have adequately assessed the resident who had not received their prescribed medication . Continued interview confirmed .omitting [MEDICATION NAME] and [MEDICATION NAME] for that many days would be a medication error . Telephone interview with the Pharmacy Technician on 4/23/19 at 3:49 PM, confirmed the supply of [MEDICATION NAME] for Resident #413 ended on 4/17/19. Further interview confirmed the pharmacy had not received a refill request from the facility for the [MEDICATION NAME] 100 mg. Continued interview confirmed the supply of [MEDICATION NAME] for Resident #413 ended on 1/26/19. Interview with RN #2 on 4/23/19 at 5:36 PM, in the 400 hallway, confirmed the [MEDICATION NAME] and [MEDICATION NAME] were not available in the medication cart for administration to Resident #413. Interview and observation with RN #2 on 4/23/19 at 5:48 PM, of the east wing emergency medication night box, confirmed both [MEDICATION NAME] 100 mg and [MEDICATION NAME] 50 mg were available in the emergency box. Continued interview confirmed there was no record the emergency box had been utilized to obtain the [MEDICATION NAME] and [MEDICATION NAME] for Resident #413. Review of the pharmacy delivery manifest dated 4/23/19 at 8:29 PM revealed, .[MEDICATION NAME] TAB 100 MG .[MEDICATION NAME] CAP 100 MG DELIVERED 4/23/19 . Telephone interview with the Pharmacist on 4/24/19 at 11:28 AM, revealed, .a fax was sent from our pharmacy to the facility on [DATE] at 11:40 AM for a new order of [MEDICATION NAME] and we (the pharmacy) did not receive a new order until yesterday (4/23/19) . Further interview revealed, .the initial order for [MEDICATION NAME] was received by the pharmacy on 1/23/19 and the facility received four tablets .the rest of the medications should then be in her weekly medication rolls .I'm not sure why the facility did not receive the medications or why they were not sent from our pharmacy .if the facility did not receive medications that were ordered I would expect that the facility would call our pharmacy and let us know that they did not receive something .then our courier would deliver this medication .our pharmacy did not receive any emergency box notification request for [MEDICATION NAME] or [MEDICATION NAME] on (Resident #413) . Continued interview confirmed, .the medications were not available to administer to the resident .the last time [MEDICATION NAME] would have been available for administration would have been 1/26/19 at 9:00 PM (a total of 88 omitted doses) .[MEDICATION NAME] last dose available was on 4/17/19 at 9:00 PM (a total of 5 omitted doses) . In summary, interview the Pharmacist sent a fax to the facility on [DATE] to obtain a new order for [MEDICATION NAME] and the pharmacy did not receive a new order for the [MEDICATION NAME] until 4/23/19. The initial order for [MEDICATION NAME] was received on 1/23/19 and four tablets were sent to the facility at that time. Interview with LPN #2 and RN #2 confirmed the [MEDICATION NAME] had not been available for administration since 1/26/19 and the [MEDICATION NAME] had not been available for administration since 4/17/19. Resident #413 missed 88 doses of [MEDICATION NAME] and 5 doses of [MEDICATION NAME].",2020-09-01
906,"CAMBRIDGE HOUSE, THE",445190,250 BELLEBROOK RD,BRISTOL,TN,37620,2019-04-26,770,D,0,1,48RJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to obtain physician's ordered laboratory services for 1 resident (#60) of 6 residents reviewed for laboratory services of 18 sampled residents. The findings include: Medical record review revealed Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician's Orders dated 4/1/19 - 4/30/19 revealed .Atorvastatin (medication to treat high cholesterol) .Levetiraceta (anticonvulsant) .[MEDICATION NAME] (antihypertensive) .[MEDICATION NAME] Sodium (nonsteroidal anti-[MEDICAL CONDITION] pain medication) .[MEDICATION NAME] (antidepressant) . Medical record review of the comprehensive care plan dated 10/4/18 and updated 1/10/19 and 4/11/19 revealed the resident had a potential for complications related to MS, HTN, and [MEDICAL CONDITION] with the approach .Monitor labs as ordered by physician . Medical record review of a Physician's Telephone Order dated 3/8/19 revealed laboratory (lab) orders for a complete blood count (CBC) and basic metabolic panel (BMP) .once . Medical record review revealed the CBC and BMP lab results for 3/8/19 were not on the resident's chart. Interview with the Registered Nurse (RN) #1 on 4/23/19 at 6:10 PM, at the nurse's station, confirmed the resident's CBC and BMP ordered on [DATE] was not obtained. Interview with the Director of Nursing (DON) on 4/24/19 at 12:10 PM, at the nurse's station, confirmed the facility failed to obtain the ordered lab services for Resident #60.",2020-09-01
907,"CAMBRIDGE HOUSE, THE",445190,250 BELLEBROOK RD,BRISTOL,TN,37620,2019-04-26,804,E,0,1,48RJ11,"Based on facility policy review, observation, and interview, the facility failed to serve milk and other cold food items at a safe and appetizing temperature on 12 meal trays of 16 meal trays observed with milk or cold food items. The findings include: Review of the facility policy Food Temperatures updated 9/2011, revealed .Foods should be served at proper temperature to insure (ensure) food safety and palatability .Milk, juice . Observation on 4/22/19 at 12:40 PM, of the east wing lunch meal, revealed 9 meal trays remained on the open rolling rack to be served at 1:45 PM, 1 hour and 5 minutes after being delivered to the wing. Observation of the east wing lunch meal trays and interview with the Certified Dietary Manager (CDM) and the Dietary Supervisor on 4/22/19 at 1:45 PM, revealed the temperature of 1 of the half pints of milk was 48.6 degrees F, and the ice cream was melted on 2 of the 9 remaining trays. Continued interview with the CDM confirmed the ice cream was melted and the milk temperature was 7.6 degrees F above the required serving temperature for milk. Observation on 4/23/19 at 7:58 AM, of the east wing breakfast meal, revealed 6 meal trays remained on the open rolling rack at 8:45 AM, 47 minutes after being delivered to the wing. Observation of the east wing breakfast meal trays on the open rolling rack and interview with the CDM and the Dietary Supervisor on 4/23/19 at 8:55 AM, revealed 1 of the 1/2 pints of milk, on 1 of the 3 remaining meal trays, was 46.9 degrees F. Continued interview with the CDM confirmed the milk temperature was 5.9 degrees F above the required serving temperature for milk. Interview with the CDM on 4/24/19 at 5:00 PM, outside the kitchen door, revealed the meal service trays for lunch on 4/22/19 and breakfast on 4/23/19 were to be served within 30 minutes of delivery. Continued interview confirmed the meal trays were not served in a timely manner, resulting in the temperatures of the ice cream and milk not being maintained or served at the required temperature.",2020-09-01
908,"CAMBRIDGE HOUSE, THE",445190,250 BELLEBROOK RD,BRISTOL,TN,37620,2019-04-26,842,J,0,1,48RJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview, and review of the pharmacy deliver manifest, the facility failed to maintain an accurate and complete medical record for 2 residents (#364, #413) of 18 sampled residents. The facility's failure to ensure a complete and accurate medical record resulted in Resident #364 receiving cardiopulmonary resuscitation (CPR) against the resident's wishes, and placed Resident #364 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). An extended survey was conducted on [DATE] - [DATE]. The Administrator was informed of the Immediate Jeopardy in the Administrator's office on [DATE] at 1:39 PM. The Immediate Jeopardy was removed [DATE] and was effective from [DATE] - [DATE]. The findings include: Medical record review revealed Resident #364 was admitted to the facility on [DATE] and was discharged home on [DATE]. The resident was readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physician order [REDACTED]. indicating Resident #364 had requested to receive CPR if he had no pulse and was not breathing. Further review revealed no POST form had been completed upon Resident #364's readmission on [DATE], and the POST form for the resident's [DATE] admission had been placed on the chart. Medical record review of Resident #364's Physician Discharge Orders dated [DATE] from a local hospital revealed Do Not Resuscitate (DNR) code status, indicating the resident no longer wished to receive CPR. Medical record review of Resident #364's Baseline Care Plan dated [DATE] revealed DNR code status. Medical record review of a nurse's note dated [DATE] revealed .no heartbeat heard O (no) B/P (blood pressure) no respirations .Code blue (a page indicating resident was unresponsive) called overhead. CPR started: 911 called-CPR continued for 15 minutes and EMTs (emergency medical technicians) arrived .resident (#364) was transported out with pulse and respirations . Medical record review of Emergency Medical Services (EMS) records dated [DATE] revealed Resident #364 received [MEDICATION NAME] (medication used to treat sudden [MEDICAL CONDITION] and regain a heartbeat), [MEDICATION NAME] (medication used to increase heart rate during [MEDICAL CONDITION]), and was intubated (tube placed through mouth and into airway to assist with breathing during CPR). Further review of the EMS records revealed .Patient was noted to .be in a wide complex bradycardic (heart rate less than 60 beats per minute) rhythm with a pulse . Medical record review of emergency room (ER) records dated [DATE] revealed .Bystander CPR was started. EMS continued Advanced Cardiac Life Support (ACLS) protocol he was intubated prior to arrival. Patient had a brief return of spontaneous circulation just prior to arrival. He however lost a pulse shortly after arriving in the emergency department. Continuing resuscitative efforts were unsuccessful . Interview with Registered Nurse (RN) #1 on [DATE] at 4:52 PM, in the conference room, revealed a new POST form should have been completed upon Resident #364's re-admission on [DATE] .I did not place the old post form onto the chart .I don't know how it got there . Further interview confirmed an inaccurate POST form from the resident's previous admission on [DATE] had been placed on the resident's current medical record. Interview with the Director of Nursing (DON) on [DATE] at 8:10 AM, in the DON's office, confirmed an inaccurate POST form from the resident's previous admission on [DATE] had been placed on the resident's current medical record. In summary, the facility's failure to maintain a complete and accurate medical record for Resident #364 resulted in the resident receiving CPR against his DNR code status wishes. Medical record review revealed Resident #413 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED].#413 revealed, .[MEDICATION NAME] (medication used to treat nerve pain) CAP (capsule) 100MG (MILLIGRAM) 1 CAPSULE BY MOUTH at bedtime (REORDER 3 DAYS BEFORE NEEDED) Start: [DATE] . Further review of the physician's orders [REDACTED].Start: [DATE] . Medical record review of the Medication Record for ,[DATE]-,[DATE] revealed it was documented Resident #413 was administered [MEDICATION NAME] 100 mg daily at bedtime from [DATE] - [DATE]. Medical record review of the Medication Record dated ,[DATE] revealed it was documented Resident #413 was administered [MEDICATION NAME] 100 mg daily at bedtime for [DATE] - [DATE]. Medical record review of the Controlled Drug Receipt Record revealed RN #2 administered the last dose of [MEDICATION NAME] on [DATE] at 9:00 PM. Facility record review of the pharmacy delivery manifest dated [DATE] at 8:29 PM revealed, .[MEDICATION NAME] TAB 100 MG .[MEDICATION NAME] CAP 100 MG DELIVERED [DATE] . Interview with Licensed Practical Nurse (LPN) #2 on [DATE] at 3:23 PM, at the 400 hall medication cart, revealed Resident #413 did not have any [MEDICATION NAME] or [MEDICATION NAME] available in the medication drawer. Continued interview confirmed the [MEDICATION NAME] had not been available for administration since [DATE]. Further interview confirmed the [MEDICATION NAME] had not been available for administration since [DATE]. Interview with RN #2 on [DATE] at 5:36 PM, in the 400 hallway, confirmed the [MEDICATION NAME] and [MEDICATION NAME] were not available in the medication cart for administration to Resident #413. Telephone interview with the Pharmacist on [DATE] at 11:28 AM, revealed, .a fax was sent from our pharmacy to the facility on [DATE] at 11:40 AM for a new order of [MEDICATION NAME] and we (the pharmacy) did not receive a new order until yesterday ([DATE]) . Further interview revealed, .the initial order for [MEDICATION NAME] was received by the pharmacy on [DATE] and the facility received four tablets . Continued interview confirmed, .the medications were not available to administer to the resident .the last time [MEDICATION NAME] would have been available for administration would have been [DATE] at 9:00 PM (a total of 88 omitted doses) .[MEDICATION NAME] last dose available was on [DATE] at 9:00 PM (a total of 5 omitted doses) . In summary, Resident #413 had been ordered [MEDICATION NAME] 100mg to be administered at 9:00 PM daily and [MEDICATION NAME] 100mg to be administered at 9:00 PM daily. Review of the Medication Record revealed it was documented Resident #413 had been administered her medications as ordered. Interview with LPN #2 confirmed the [MEDICATION NAME] had not been available for administration since [DATE] and the [MEDICATION NAME] had not been available for administration since [DATE]. Interview with RN #2 confirmed the [MEDICATION NAME] and [MEDICATION NAME] were not available in the medication cart for administration to Resident #413. Interview with the Pharmacist confirmed .the last time [MEDICATION NAME] dose would have been available for administration would have been [DATE] at 9:00 PM (a total of 88 omitted doses) .[MEDICATION NAME] last dose available was on [DATE] at 9:00 PM (a total of 5 omitted doses) . An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the jeopardy, was received [DATE] at 4:50 PM, and the corrective actions were validated on-site by the surveyors on [DATE] through review of documents, observations, in-service training logs, facility policies, and staff interviews. The facility's A[NAME] included: On [DATE] - [DATE] the facility's leadership consisting of the Administrator and the DON provided oversight and training to all licensed nurses, the Social Services Director, the Admissions Coordinator, and the Medical Records Clerk. The oversight and training included: 1. Facility's policy and procedures for Advance Directives to include the new process to identify code status. 2. How to transcribe Physician orders. 3. The facility's policy on baseline care plans to include resident's code status. On [DATE]-[DATE] the facility's leadership consisting of the Administrator and the DON conducted a comprehensive review of all current resident medical records to verify they were complete and accurate that included a completed POST form with a physician's signature, to verify a physician's orders [REDACTED]. The surveyors review of the facility's A[NAME], facility training materials, interviews, and in-service logs dated [DATE]-[DATE] verified all (12) licensed nurses, the Social Services Director, the Admissions Coordinator, and the Medical Records Clerk had completed the following training as of [DATE]: 1. Facility's policy and procedures for Advance Directives to include the new process to identify code status. 2. How to transcribe Physician orders. 3. The facility's policy on baseline care plans to include resident's code status. Continued review verified 10 of 12 licensed nurses, Social Services Director, Admissions Coordinator, and the Medical Records Clerk employed at the facility had completed training on maintaining an accurate/complete medical record to include Advanced Directives, POST forms, code status, physician's orders [REDACTED]. The 2 remaining licensed nurses will be in-serviced before their next scheduled shift and there were no identified concerns. The surveyors interviewed 2 Registered Nurses (RN's), 4 Licensed Practical Nurses (LPN'S) on all shifts, the Social Services Director, the Admissions Coordinator, and the Medical Records Clerk on [DATE]. These interviews revealed they had received new training on the facility's policy and procedures for Advance Directives to include the new process to identify code status and how to transcribe Physician orders. Continued interview revealed they had received new education on Baseline Care Plans and how to maintain an accurate and complete medical record. These interviews confirmed the staff was knowledgeable and able to verbalize the facility's policy and procedures for Advance Directives to include the new process to identify code status, how to transcribe Physician orders, Baseline Care Plans, and how to maintain an accurate and complete medical record and there were no identified concerns. The surveyors reviewed the A[NAME] and verified 25 current resident medical records were complete and accurate that included a completed POST form with a physician's signature, to verify a physician's orders [REDACTED]. Noncompliance at F842 continues at a scope and severity of D for monitoring of the effectiveness of corrective actions to ensure sustained compliance.",2020-09-01
909,"CAMBRIDGE HOUSE, THE",445190,250 BELLEBROOK RD,BRISTOL,TN,37620,2018-05-16,604,D,0,1,VPQ611,"**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 1 resident (#57) prior to the use of a physical restraint, and failed to assess 1 resident (#63) for restraint reduction of 3 residents reviewed for physical restraints. The findings included: Review of the facility policy, Use of Restraints, revised (MONTH) 2007, revealed .Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints .Restrained individuals shall be reviewed regularly to determine whether they are candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination . Medical record review revealed Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed no documentation the restraint assessment had been completed prior to the use of bilateral 3/4 length side rails. Observation of the resident on 5/14/18 at 8:00 AM, in the resident's room, revealed the resident lying in bed with both 3/4 side rails in the up position. Observation of the resident on 5/14/18 at 12:00 PM, in the resident's room, revealed the resident sitting on the left side of the bed (with the left 3/4 length side rail down) eating lunch and the right side 3/4 rail was in the up position. Observation of the resident on 5/14/18 at 3:30 PM, in the resident's room, revealed the resident lying in the bed with both 3/4 side rails in the up position. Interview with the Registered Nurse (RN) Unit Manager #1 on 5/15/18 at 2:15 PM, in the resident's room, revealed the facility does not code side rails as restraints. Further interview revealed the resident was unable to transfer out of the bed or sit on the side of the bed due to the side rails. Further interview revealed the resident was able change positions from lying to sitting with no assistance. Further interview revealed the side rails were in place to keep the resident in the bed to prevent falls. Interview with the Director of Nursing on 5/15/18 at 3:15 PM, in the conference room, confirmed the side rails were used as a restraint and a restraint assessment had not been completed. She stated she was unaware that 3/4 side rails were being used in the facility. Medical record review revealed Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physical Restraint Elimination assessment dated [DATE] and 5/15/18 revealed the resident was a good candidate for restraint reduction/elimination. Review of the Resident's Physical Restraint assessment dated [DATE] and reviewed on 5/15/18 revealed to continue with the .lap buddy ( a soft, cushion-type device that fits over the lap and may be secured in different ways depending on the manufacturer) due to decreased safety awareness. Resident with extreme decreased safety awareness - tolerating lap buddy well. Resident with history of Dementia, Depression, Mood Disorder . Continued review revealed the resident was a good candidate for restraint reduction or elimination. Review of Resident #63's care plan dated 11/10/17 and updated on 1/31/18 and 4/20/18 revealed the resident was to use a lap buddy while up in the wheelchair to stop unassisted ambulation. The care plan stated reassess for elimination of restraint or for change to less restrictive option routinely. The care plan stated the resident needed the lap buddy restraint due to poor safety awareness. Observation of Resident #63 on 5/14/18 on several occasions from 10:00 AM until 4:00 PM revealed the resident was up in the hallways and day room with the lap buddy in place. Observation of the resident on 5/15/18 on several occasions from 7:30 AM until 4:15 PM revealed the resident was up in the hallways and day room with the lap buddy in place. Interview with the Director of Nurses on 5/15/18 at 3:15 PM, in the conference room, confirmed no interventions to reduce the resident's use of a restraint had been attempted in quite a while.",2020-09-01
910,"CAMBRIDGE HOUSE, THE",445190,250 BELLEBROOK RD,BRISTOL,TN,37620,2018-05-16,656,G,1,1,VPQ611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of the facility's investigation, observation, and interview, the facility failed to implement the care plan for appropriate use of the mechanical lift for transfers for 1 resident (#18) resulting in Harm, and failed to develop comprehensive care plans for the use of oxygen for 2 residents (#6, #71) of 21 sampled residents. The findings included: Review of the facility policy, Safe Lifting and Movement of Residents, revised (MONTH) (YEAR), revealed, .In order to protect the safety and well-being of .residents .this facility uses appropriate techniques and devices to lift and move residents .Resident safety .will be incorporated into goals and decisions regarding the safe lifting and moving of residents .Nursing staff .shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include .Resident's mobility (degree of dependency) .All equipment design and use will meet or exceed guidelines and regulations concerning resident safety .Safe lifting and movement of residents is part of an overall facility employee health and safety program . Review of the facility policy, Fall Prevention Program, dated (MONTH) 2001, revealed, .It is the policy of this facility to identify residents at risk for falls, develop plans of care that address the risk and implement procedures to assist in preventing falls .Maintain equipment and assistive devices in safe working order . Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #18 was cognitively intact. Further review revealed Resident #18 was totally dependent on 2 or more person physical assist for bed mobility, and transfers, and had impaired mobility in upper and lower extremities. Medical record review of Resident #18's comprehensive care plan dated 2/28/18 revealed, .potential for falls r/t (related to) dependent on staff for transfers via mechanical lift and 4 person assist . Further review revealed, .transfer (Resident #18) via mechanical lift and 4 person assist . Medical record review of the Physician Recapitulation Orders dated 5/1/18 - 5/31/18 revealed, .Mech (mechanical) lift for transfers . Medical record review of the Nurse's Notes dated 5/2/18 at 5:00 AM revealed, .called to room by CNA (Certified Nurse Aide #1). Rsd (resident) in floor .(No) injuries voiced. Rsd (resident) lowered to floor by CNA .assessed .assisted back to bed . Medical record review of the Nurse's Notes dated 5/2/18 at 11:30 AM revealed, .NP (Nurse Practitioner) saw resident r/t (related to) .(increased) pain. New order .(right) ankle xray . Medical record review of the Radiology Interpretation dated 5/2/18, revealed, .Impression: Acute bony avulsion (when a tendon or ligament comes away from the bone often pulling a small piece of bone with it) to the medial malleolus (the round bony prominence on inner side of the ankle joint) . Medical record review of the Physician's Telephone Orders dated 5/2/18 at 4:20 PM revealed, .send to (named hospital) ER (emergency room ) for eval (evaluation) (and) tx (treat) for (right) ankle X-Ray . Medical record review of the Radiology Report of the X-Ray of the Right Ankle - 3 View, performed at the Emergency Department on 5/2/18 revealed, .lucency (technical term for an area that lets X-rays through the tissue and as a result appears darker on the picture) noted through the posterior aspect of the calcaneus (heel bone) on lateral projection raising the possibility of fracture .Impression: Questionable calcaneal (heel bone) fracture . Medical record review of the Emergency Department Physician's Report dated 5/2/18 revealed, .patient is a [AGE] year-old female who presents with right foot and ankle pain. Patient is non-ambulatory, had a fall while being transferred (at) the nursing home. Patient has swelling noted to her foot, diffuse (spread over a wide area) dorsal (upper side) tenderness, and lateral malleolus (bony prominence on the outside of the ankle) tenderness. X-rays today show evidence of definitive acute fracture. Patient will be placed [MEDICATION NAME] in a boot, she is given instructions follow up close with her primary care physician. She will be discharge with strict return precautions for worsening symptoms or other concerns . Medical record review of the Nurse's Notes dated 5/2/18 at 11:15 PM revealed, .returned from ER (emergency room ) .(No) new orders ntd (noted). MD (Medical Doctor) to see Rsd (resident) in 2 days. Rsd (Resident) (with) brace on to wore ( be worn) 6 weeks . Medical record review of the Nurse Practitioner Progress Note dated 5/2/18 revealed, .(right) ankle avulsion fx (fracture) s/p (status [REDACTED].(with) orthoboot . Review of the facility investigation dated 5/2/18 revealed at approximately 5:00 AM on 5/2/18 Certified Nursing Aide (CNA) #1 was transferring Resident #18 with a mechanical lift. Further review revealed during transfer the left rear wheel .locked up . and the lift tilted forward. Continued review revealed CNA #1 was unable to return the lift to an upright position and Resident #18 was lowered to the floor. Further review revealed as the day progressed Resident #18 complained of pain and at that time an X-ray was performed of the resident's right ankle which showed an avulsion fracture. Interview with Resident #18 on 5/14/18 at 12:15 PM, and again at 4:09 PM, in the resident's room, confirmed on the day of the incident (5/2/18) only 1 staff member (CNA #1) assisted with the transfer using the mechanical lift, and since the fall it has been 4 staff members every time. Continued interview revealed prior to the fall, it was usually 1 person. Interview with the Director of Nursing (DON) on 5/14/18 at 3:57 PM, in the DON's office revealed Resident #18's care plan, dated 2/28/18, was accurate, and Resident #18 required assistance of 4 staff for transfers with the mechanical lift. Further interview confirmed at the time of the fall on 5/2/18 the facility failed to follow Resident #18's care plan for transferring the resident using the mechanical lift and assistance of 4 persons. Interview with the Medical Director on 5/15/18 at 9:59 AM, in the conference room, confirmed his expectation was for staff to follow the plan of care while providing care to all residents, and the facility's failure to follow the plan of care while transferring Resident #18 with a mechanical lift resulted in an ankle fracture (actual physical harm.) Interview with CNA #1 via phone on 5/15/18, at 4:40 PM, confirmed she was aware Resident #18 required 4 staff for transfers but stated the rest of the staff was really busy. Continued interview confirmed she knew now not to transfer her alone and received training following the incident. Review of a facility policy, Care Plans, Comprehensive Person - Centered, revised (MONTH) (YEAR), revealed .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented .Describe the services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being . Review of a facility policy, Oxygen Administration, revised (MONTH) 2010, revealed .Review the care plan to assess for any special needs of the resident . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly MDS dated [DATE] revealed Resident #6 received oxygen therapy. Medical record review of a Physician's Recapitulation Orders dated 5/1/18 - 5/31/18, revealed .O2 (oxygen) @ (at) 2 lpm (liters per minute) to keep O2 Sats (saturation - amount of oxygen in bloodstream) 90% (percent) or above .Change humidifier bottle every month and PRN (as needed) . Medical record review of Resident #6's care plan dated 11/13/17 revealed no documentation indicating Resident #6 received oxygen. Observation of Resident #6 on 5/15/18 at 12:30 PM, in the resident's room, revealed the resident with oxygen applied via nasal cannula (a device used to deliver oxygen through the nares of the nose). Interview with the MDS Coordinator on 5/16/18 at 1:20 PM in the MDS office confirmed the care plan had not been individualized to address the resident's O2 therapy. Medical record review revealed Resident #71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed, a Brief Interview for Mental Status (BIMS) score of 9 indicating the resident's cognition was moderately impaired. Further review revealed the resident received oxygen therapy, and experienced shortness of breath or trouble breathing with exertion. Medical record review of Resident #71's care plan dated 2/7/18 revealed no documentation indicating Resident #71 received oxygen. Medical record review of the Physician's Recapitulation Orders dated 5/1/18 - 5/31/18 revealed .O2 (oxygen) @ 6 lpm VIA (by) NC (nasal cannula) CONT (continuous) .Check O2 sats every shift and PRN (as needed) .Change humidifier every month and PRN . Medical record review of the weekly nurse's note dated 5/4/18 revealed, .O2 .3 L/min . Continued review of the nurse's note dated 5/5/18 revealed .O2 .3L/min .continuous . Multiple observations of Resident #71 on 5/15/18 from 8:50 AM to 1:34 PM, in the resident's room, revealed the resident lying in bed with the O2 concentrator and nasal cannula at the bedside, not in use. Interview with the MDS coordinator on 5/16/18 at 1:29 PM, in the MDS office, confirmed the facility failed to develop a comprehensive care plan for the use of oxygen for Resident #71.",2020-09-01
911,"CAMBRIDGE HOUSE, THE",445190,250 BELLEBROOK RD,BRISTOL,TN,37620,2018-05-16,657,D,0,1,VPQ611,"**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 revise the care plan for 2 residents (#37, #39) of 21 residents reviewed. The findings included: Review of the facility's policy, Care Planning - Interdisciplinary Team, revised (MONTH) 2013, revealed .Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition changes . Medical record review revealed Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED].oxygen at 2 liters per minute, via nasal cannula (device used to administer oxygen through the nares of the nose) continuously . Review of the care plan dated 7/14/17 and updated 5/16/18, revealed the resident had a potential ineffective breathing pattern. Further review revealed the care plan had not been updated for the resident's refusal to wear the oxygen in the dining room. Observation of the Resident #37 on 5/16/18, at 8:00 AM, in the dining room, revealed the resident was up in a wheel chair without oxygen. Interview with the Registered Nurse (RN) Unit Manager #1 on 5/16/18, at 8:15 AM, in the dining room, confirmed the resident refused to wear the oxygen during meal times. Interview with the RN Unit Manager #1 on 5/16/18 at 8:30 AM, at the nurse's station, confirmed Resident #37 was not using the oxygen in the dining room, and the care plan had not been updated with the resident's refusal to use oxygen in the dining room. Medical record review revealed Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Observation of the resident on 5/16/18 at 9:00 AM, in the resident's room, revealed the resident was lying in the bed and the oxygen concentrator was next to the bed and turned off. Interview with the Registered Nurse (RN) Unit Manager #2 on 5/16/18, at 9:15 AM, in the resident's room, confirmed Resident #39's oxygen concentrator was not on and stated the resident was non-compliant with the oxygen use. Review of the care plan dated 3/6/18 and updated on 5/16/18 revealed the resident had a potential for an ineffective breathing pattern. Further review revealed the care plan had not been updated for the resident's non-compliance with oxygen use. Interview with the RN Unit Manager on 5/16/18, at at 9:30 AM, at the nurse's station, confirmed Resident #39's care plan had not been updated with the resident's non-compliance with oxygen.",2020-09-01
912,"CAMBRIDGE HOUSE, THE",445190,250 BELLEBROOK RD,BRISTOL,TN,37620,2018-05-16,689,G,1,1,VPQ611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, review of the manufacturer's mechanical lift operation manual, medical record review, review of the facility investigation, observation and interview, the facility failed to implement interventions for safe transfers with an assistive device to prevent accidents for 1 resident (Resident #18) of 3 residents reviewed for accidents. The facility's failure resulted in actual physical harm for Resident #18. The findings included: Review of the facility policy, Safe Lifting and Movement of Residents, revised (MONTH) (YEAR), revealed, .In order to protect the safety and well-being of .residents .this facility uses appropriate techniques and devices to lift and move residents .Resident safety .will be incorporated into goals and decisions regarding the safe lifting and moving of residents .Nursing staff .shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include .Resident's mobility (degree of dependency) .All equipment design and use will meet or exceed guidelines and regulations concerning resident safety .Safe lifting and movement of residents is part of an overall facility employee health and safety program . Review of the facility policy, Fall Prevention Program, dated (MONTH) 2001, revealed, .It is the policy of this facility to identify residents at risk for falls, develop plans of care that address the risk and implement procedures to assist in preventing falls .Maintain equipment and assistive devices in safe working order . Review of the manufacturer's mechanical lift operation manual, not dated, revealed, .before each patient transfer, it is important for staff to inspect the (named mechanical lift) to make sure no parts are missing or overly worn and that all parts work correctly .Transport Procedure .the required number of staff members must be present .certain patients or situation require the help of one or more additional staff members .The presence of more than one staff member increases safety .additional staff to hold onto sling handles .prevents the patient from swaying thereby decreasing the possibility of tipping the (named mechanical lift) .transporting patients in a (named mechanical lift) .requires at least two staff members . Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #18 was cognitively intact. Further review revealed Resident #18 was totally dependent on 2 or more person physical assist for bed mobility, and transfers, and had impaired mobility in upper and lower extremities. Medical record review of Resident #18's comprehensive care plan dated 2/28/18 revealed, .potential for falls r/t (related to) dependent on staff for transfers via mechanical lift and 4 person assist . Further review revealed, .transfer (Resident #18) via mechanical lift and 4 person assist . Medical record review of the Physician Recapitulation Orders dated 5/1/18 - 5/31/18 revealed, .Mech (mechanical) lift for transfers . Medical record review of the Nurse's Notes dated 5/2/18 at 5:00 AM revealed, .called to room by CNA (Certified Nurse Aide #1). Rsd (resident) in floor .(No) injuries voiced. Rsd (resident) lowered to floor by CNA .assessed .assisted back to bed . Medical record review of the Nurse's Notes dated 5/2/18 at 11:30 AM revealed, .NP (Nurse Practitioner) saw resident r/t (related to) .(increased) pain. New order .(right) ankle xray . Medical record review of the Radiology Interpretation dated 5/2/18, revealed, .Impression: Acute bony avulsion (when a tendon or ligament comes away from the bone often pulling a small piece of bone with it) to the medial malleolus (the round bony prominence on inner side of the ankle joint) . Medical record review of the Nurse's Notes dated 5/2/18 at 4:20 PM, revealed, .Received X-Ray. Call placed to N.P. (Nurse Practitioner). New order received . Medical record review of the Physician's Telephone Orders dated 5/2/18 at 4:20 PM revealed, .send to (named hospital) ER (emergency room ) for eval (evaluation) (and) tx (treat) for (right) ankle X-Ray . Medical record review of the Radiology Report of the X-Ray of the Right Ankle - 3 View, performed at the Emergency Department on 5/2/18 revealed, .lucency (technical term for an area that lets X-rays through the tissue and as a result appears darker on the picture) noted through the posterior aspect of the calcaneus (heel bone) on lateral projection raising the possibility of fracture .Impression: Questionable calcaneal (heel bone) fracture . Medical record review of the Emergency Department Physician's Report dated 5/2/18 revealed, .patient is a [AGE] year-old female who presents with right foot and ankle pain. Patient is non-ambulatory, had a fall while being transferred (at) the nursing home. Patient has swelling noted to her foot, diffuse (spread over a wide area) dorsal (upper side) tenderness, and lateral malleolus (bony prominence on the outside of the ankle) tenderness. X-rays today show evidence of definitive acute fracture. Patient will be placed [MEDICATION NAME] in a boot, she is given instructions follow up close with her primary care physician. She will be discharge with strict return precautions for worsening symptoms or other concerns . Medical record review of the Nurse's Notes dated 5/2/18 at 11:15 PM revealed, .returned from ER (emergency room ) .(No) new orders ntd (noted). MD (Medical Doctor) to see Rsd (resident) in 2 days. Rsd (Resident) (with) brace on to wore ( be worn) 6 weeks . Medical record review of the Nurse Practitioner Progress Note dated 5/2/18 revealed, .(right) ankle avulsion fx (fracture) s/p (status [REDACTED].(with) orthoboot . Review of the facility investigation dated 5/2/18 revealed at approximately 5:00 AM on 5/2/18 CNA #1 was transferring Resident #18 with a mechanical lift. Further review revealed during transfer the left rear wheel .locked up . and the lift tilted forward. Continued review revealed CNA #1 was unable to return the lift to an upright position and Resident #18 was lowered to the floor. Further review revealed as the day progressed Resident #18 complained of increase pain and at that time an X-ray was performed of the resident's right ankle which showed an avulsion fracture. Interview with Resident #18 on 5/14/18 at 12:15 PM, in the resident's room, confirmed on the day of the incident (5/2/18) only 1 staff member (CNA #1) assisted with the transfer using the mechanical lift. Interview with the Director of Nursing (DON) on 5/14/18 at 3:57 PM, in the DON's office revealed Resident #18's care plan, dated 2/28/18, was accurate, and Resident #18 required assistance of 4 staff for transfers with the mechanical lift. Further interview confirmed at the time of the fall on 5/2/18 the facility failed to follow Resident #18's care plan for transferring the resident using the mechanical lift and assistance of 4 persons. Interview with the Medical Director on 5/15/18 at 9:59 AM, in the conference room, confirmed his expectation was for staff to follow the plan of care while providing care to all residents, and the facility's failure to follow the plan of care while transferring Resident #18 with a mechanical lift resulted in an ankle fracture (actual physical harm.) Interview with CNA #1 via phone on 5/15/18, at 4:40 PM, confirmed she was aware Resident #18 required 4 staff for transfers but stated the rest of the staff was really busy. Continued interview confirmed she knew now not to transfer her alone and received training following the incident. Interview with CNA #1 via phone on 5/16/18 at 7:27 AM, confirmed she had not completed a competency with return demonstration on the proper use of transferring residents with a mechanical lift.",2020-09-01
913,"CAMBRIDGE HOUSE, THE",445190,250 BELLEBROOK RD,BRISTOL,TN,37620,2018-05-16,695,E,0,1,VPQ611,"**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 administer oxygen per Physician's Order for 5 residents (#11, #13, #37, #39, and #71), failed to change oxygen tubing per Physician's Order for 1 resident (#24), and failed to replace humidifier bottles for 2 residents (#6, #71) of 21 residents reviewed for respiratory care and services. The findings included: Review of the facility policy, Oxygen Administration, revised (MONTH) 2010, revealed, .Review the physician's order .Unless otherwise ordered, start oxygen at the rate of 2 to 3 liters per minute .Place appropriate oxygen device on the resident .Check the .humidifying jar (water bottle), etc., to be sure they are in working order .Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through .Periodically re-check water level in humidifying jar .Documentation .The rate of oxygen flow .If the resident refused the procedure, the reason why and the intervention taken .Notify the supervisor if the resident refuses the procedure .Report other information in accordance with the facility policy and professional standards of practice . Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physician Recapitulation Orders for (MONTH) (YEAR), revealed an order for [REDACTED]. Observation of Resident #11 on 5/16/18 at 7:45 AM, in the day room, revealed the resident was wearing oxygen at 3 LPM via nasal cannula. Interview with the Registered Nurse (RN) Unit Manager #1 on 5/16/18 at 8:00 AM, in the day room, confirmed Resident #11's oxygen amount was not correct, and the Physician's Order had not been followed. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of Resident #13 on 5/16/18 at 7:45 AM, in the resident's room, revealed the resident was receiving oxygen at 2 1/2 LPM via nasal cannula. Medical record review of the Physician's Order dated 5/1/18 revealed an order for [REDACTED]. Interview with the RN Unit Manager #1 on 5/16/18 at 7:45 AM, in the resident's room, confirmed Resident #13's oxygen was not set at 4 liters per minute as ordered by the Physician. Medical record review revealed Resident #37 was admitted to the facility on [DATE] with Pneumonia and Heart Failure. Observation of the resident on 5/16/18 at 8:00 AM, in the dining room, revealed the resident was up in a wheel chair without oxygen. Medical record review of the Physician's Order dated 3/27/17 revealed an order for [REDACTED]. Interview with RN Unit Manager #1 on 5/16/18 at 8:15 AM, in the dining room, revealed Resident #37 refused to wear the oxygen during meal times. Interview with RN Unit Manager #1 on 5/16/18 at 8:30 AM, at the nurse's station, confirmed Resident #37 was not using the oxygen in the dining room. Medical record review revealed resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of the resident on 5/16/18 at 8:00 AM, in the resident's room, revealed the resident lying in the bed with eyes closed. Further observation revealed the oxygen concentrator was located next to the bed and was turned off. Medical record review of a Physician's Order dated 2/28/18 revealed an order for [REDACTED]. Interview with RN Unit Manager #2 on 5/16/18 at 8:05 AM, in the resident's room, confirmed Resident #39's oxygen was not on the resident due to the resident's refusal to use the oxygen. Medical record review of the care plan dated 2/28/18 revealed the care plan had not been updated with Resident #39's refusal to use the oxygen. Interview with RN Unit Manager #2 on 5/16/18 at 8:15 AM, at the nurse's station, confirmed the care plan had not been updated with Resident #39's refusal to use the oxygen. Medical record review revealed resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of the resident on 5/14/18 at 10:00 AM, in the resident's room revealed the oxygen tubing was changed on 4/10/18. Medical record review of the Physician's Recapitulation Orders dated 5/1/18 - 5/31/18 revealed the facility was to change the oxygen tubing every week and as needed. Interview with RN Unit Manager #1 on 5/15/18 at 1:30 PM, in the resident's room, confirmed Resident #24's oxygen tubing had not been changed as ordered by the Physician. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician Recapitulation Orders dated 5/1/18 - 5/31/18 revealed .O2 (oxygen) @ (at) 2 lpm to keep O2 Sats (saturation - amount of oxygen in bloodstream) 90% (percent) or above .Change humidifier bottle every month and PRN (as needed) . Observation on 5/15/18 at 12:30 PM, in Resident #6's room, revealed an oxygen concentrator humidifier water bottle dated 4/9/18. Interview with Licensed Practical Nurse #1 on 5/15/18 at 12:52 PM, in Resident #6's room, confirmed the humidifier bottle had not been changed monthly as ordered by the Physician. Medical record review revealed Resident #71 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 for Mental status (BIMS) score of 9 indicating the resident's cognition was moderately impaired. Further review revealed oxygen therapy and shortness of breath/trouble breathing with exertion were coded as present. Medical record review of the Physician's Recapitulation Order dated 5/1/18 - 5/31/18 revealed .O2 @ (at) 6 lpm VIA (by) NC (nasal cannula, device used to deliver oxygen) CONT (continuous) .Check O2 sats every shift and PRN (as needed) .Change humidifier every month and PRN . Medical record review of the weekly Nurse's Note dated 5/12/18 revealed documentation of the use of oxygen, further review of the weekly nurses note dated 5/5/18 revealed .O2 .3 L/min .continuous . Continued review of the weekly nurses note dated 5/4/18 revealed, .O2 .3 L/min . Observation of Resident #71 on 5/14/18 at 2:54 PM, in the resident's room, revealed O2 in use via nasal cannula with the O2 concentrator at the bedside, and the humidifier bottle was dated 4/9/18. Observation of Resident #71 on 5/15/18 at 7:40 AM, in the resident's room, revealed the resident lying in bed with O2 in use, the O2 concentrator was at the bedside with no visible water in the humidifier bottle, and the humidifier bottle was dated 4/9/18. Observation of Resident #71 on 5/15/18 at 8:50 AM, in the resident's room, revealed the resident lying in bed; the O2 concentrator was at the bedside; the O2 nasal cannula was in the floor at the bedside. Observation of Resident #71 on 5/15/18 at 11:13 AM, in the resident's room, revealed the resident lying in the bed, the O2 nasal cannula was laying in the floor, the O2 concentrator was at the bedside with no visible water in the humidifier bottle, and the humidifier bottle was dated 4/9/18. Observation of Resident #71 on 5/15/18 at 1:34 PM, in the resident's room, revealed the resident lying in the bed with O2 nasal cannula was on the floor. Interview with Licensed Practical Nurse (LPN) #1 on 5/15/18 at 11:16 AM, in the resident's room, confirmed the O2 humidifier bottle was dated for 4/9/18, there was no water in the humidifier bottle, and the O2 nasal cannula was laying in the floor not in use by the resident. Further interview confirmed .it should have been changed .on the MAR (medication administration record) for night shift to change them out . Interview with LPN #1 on 5/15/18 at 2:01 PM, in the resident's room, confirmed the oxygen concentrator was turned off. LPN turned concentrator on and stated .She's always been on 3 (liters) .I'm putting it on 3 . Further interview, at the east wing nurses station, confirmed the MAR indicated [REDACTED].continuous . Continued interview confirmed the facility failed to administer oxygen therapy and failed to replace the humidifier bottle per the Physician's Order.",2020-09-01
914,"CAMBRIDGE HOUSE, THE",445190,250 BELLEBROOK RD,BRISTOL,TN,37620,2018-05-16,726,G,1,1,VPQ611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of the manufacturer's mechanical lift operation manual, review of employee education files, and interview the facility failed to ensure nursing staff were competent in the proper use and technique for transferring residents with a mechanical lift which resulted in a fall with injury for 1 resident (#18) causing actual physical Harm for Resident #18. The findings included: Review of the facility policy, Safe Lifting and Movement of Residents, dated (MONTH) (YEAR), revealed, .In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents .resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents .staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices .only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents .staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques . Review of the manufacturer's mechanical lift operation manual, not dated, revealed, .Before using the (named mechanical lift) to transfer patients, all staff must be trained and authorized to use the (named mechanical lift) .Only staff members who have been trained according to the procedures in this manual, by a manufacturer's representative or by a nurse or professional rehabilitation staff member designated as your facility's mechanical lift trainer, may be allowed to use the (named mechanical lift) . Review of the facility's policy, Staff Training/Education and Competencies, not dated, revealed, .During new hire orientation, all employees are educated on .General Safety Precautions, Accident Prevention and Safety Awareness .Fall Prevention Program .Safe Lifting Techniques .During orientation on the floor, licensed nurses and certified nursing assistants complete a checklist of various skills that is required to perform their job description . Review of Registered Nurse (RN) Unit Manager #1's employee education file revealed a hire date of 3/7/18 (2 months) with no documentation RN Unit Manager #1 had completed a competency on the proper use and technique on transferring a resident with a mechanical lift. Review of RN Unit Manager #2's employee education file revealed a hire date of 11/7/03 ([AGE] years) with no documentation RN Unit Manager #2 had completed a competency on the proper use and technique on transferring a resident with a mechanical lift. Review of Licensed Practical Nurse (LPN) #1's employee education file revealed a hire date of 4/9/90 ([AGE] years) with no documentation LPN #1 had completed a competency on the proper use and technique on transferring a resident with a mechanical lift. Review of LPN #2's employee education file revealed a hire date of 9/12/06 ([AGE] years) with no documentation LPN #2 had completed a competency on the proper use and technique on transferring a resident with a mechanical lift. Review of LPN #4's employee education file revealed a hire date of 12/4/96 ([AGE] years) with no documentation LPN #4 had completed a competency on the proper use and technique on transferring a resident with a mechanical lift. Review of LPN #5's employee education file revealed a hire date of 11/14/00 ([AGE] years) with no documentation LPN #5 had completed a competency on the proper use and technique on transferring a resident with a mechanical lift. Review of Certified Nurse Aide (CNA) #1's employee education file revealed a hire date of 12/7/09 (9 years) with no documentation CNA #1 had completed a competency on the proper use and technique on transferring a resident with a mechanical lift. Review of CNA #2's employee education file revealed a hire date of 2/16/18 (3 months) with no documentation CNA #2 had completed a competency on the proper use and technique on transferring a resident with a mechanical lift. Review of CNA #3's employee education file revealed a hire date of 6/5/14 (4 years) with no documentation CNA #3 had completed a competency on the proper use and technique on transferring a resident with a mechanical lift. Review of CNA #4's employee education file revealed a hire date of 3/21/17 (1 year) with no documentation CNA #4 had completed a competency on the proper use and technique on transferring a resident with a mechanical lift. Review of CNA #5's employee education file revealed a hire date of 2/12/16 (2 years) with no documentation CNA #5 had completed a competency on the proper use and technique on transferring a resident with a mechanical lift. Review of CNA #6's employee education file revealed a hire date of 4/16/10 (8 years) with no documentation CNA #6 had completed a competency on the proper use and technique on transferring a resident with a mechanical lift. Review of CNA #7's employee education file revealed a hire date of 11/22/16 (2 years) with no documentation CNA #7 had completed a competency on the proper use and technique on transferring a resident with a mechanical lift. Review of CNA #8's employee education file revealed a hire date of 2/16/18 (3 months) with no documentation CNA #8 had completed a competency on the proper use and technique on transferring a resident with a mechanical lift. Review of CNA #9's employee education file revealed a hire date of 7/12/93 ([AGE] years) with no documentation CNA #9 had completed a competency on the proper use and technique on transferring a resident with a mechanical lift. Review of CNA #10's employee education file revealed a hire date of 8/3/12 (6 years) with no documentation CNA #10 had completed a competency on the proper use and technique on transferring a resident with a mechanical lift. Review of CNA #11's employee education file revealed a hire date of 1/14/14 (4 years) with no documentation CNA #11 had completed a competency on the proper use and technique on transferring a resident with a mechanical lift. Interview with the Staff Development Coordinator (SDC) on 5/15/18 at 3:39 PM, in the SDC's office, confirmed competencies on the proper use and technique on transferring a resident with a mechanical lift had not been completed with the facility's nursing staff. Interview with CNA #1 via phone on 5/16/18 at 7:27 AM, confirmed she had not completed a competency with return demonstration on the proper use of transferring residents with a mechanical lift. Interview with RN Unit Manager #1 on 5/16/18 at 7:30 AM, in the 500 hallway, confirmed she had not completed a return demonstration to prove competence on the proper use and technique for the transferring residents with a mechanical lift. Interview with CNA #8 on 5/16/18 at 7:59 AM, in the 400 hallway, confirmed she had not completed a competency on the proper use and technique for transferring residents with a mechanical lift. Interview with CNA #9 on 5/16/18 at 8:02 AM, in the dining room, confirmed she had not completed a competency on the proper use and technique for transferring a resident with a mechanical lift. Interview with CNA #7 on 5/16/18 at 8:05 AM, in the 200 hallway, confirmed she had not completed a demonstration for competency on the proper use and technique of transferring residents with a mechanical lift. Interview with LPN #4 on 5/16/18 at 8:37 AM, in the 100 hallway, confirmed she had not completed a competency demonstration on the proper use and technique for transferring residents with a mechanical lift. Interview with LPN #3 on 5/16/18 at 8:39 AM, in the 100 hallway, confirmed she had not completed a competency with return demonstration on the proper use and technique for transferring residents with a mechanical lift. Interview with CNA #2 on 5/16/18 at 8:40 AM, in the 200 hallway, confirmed she had not completed a demonstration for competence of the proper use and technique for transferring residents with a mechanical lift. Interview with LPN #2 on 5/16/18 at 8:45 AM, at the 200 nurse's station, confirmed she had not completed a competency that includes return demonstration for the proper use and technique for transferring residents with a mechanical lift. Interview with the Director of Nursing (DON) on 5/16/18 at 1:37 PM, in the conference room, confirmed the facility failed to ensure nursing staff had completed competency evaluations in the proper use and technique of transferring residents using a mechanical lift. Further interview confirmed the facility's failure to ensure nursing staff were competent in the proper use and technique of transferring residents using a mechanical lift was a .contributing factor . that resulted in a fall with injury causing actual physical harm for Resident #18. Refer to F689",2020-09-01
915,"CAMBRIDGE HOUSE, THE",445190,250 BELLEBROOK RD,BRISTOL,TN,37620,2018-05-16,759,D,0,1,VPQ611,"**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 administer the correct dose of medication for 1 resident (#68). The facility had a total of 4 medication errors in 31 opportunities resulting in a medication error rate of 10%. The findings included: Review of the facility's policy, Administrating Medications, revised (MONTH) 2012, revealed .the individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication . Medical record review revealed Resident #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of a medication pass with Licensed Practical Nurse (LPN) #3 on 5/15/18 at 8:05 AM, in the 300 hallway revealed the LPN prepared Resident #68's medication for administration. Continued observation revealed the LPN did not check the prepackage medications with the Medication Administration Record. Further observation revealed the LPN removed medications from the packet and placed the medications into a cup. Continued observation revealed the LPN placed pudding into the cup and carried the cup to the door of the resident's room. At this time, the surveyor stopped the LPN before she administered the medications and obtained the Registered Nurse (RN) Unit Manager #1 to check the medications about to be administered. LPN #3 had placed the 8:00 AM dose for 5/15/18 and the 8:00 AM dose for 5/16/18 of the [MEDICATION NAME] XL (a diabetic medication) 2.5 milligram (mg) into the cup (1 extra dose). Further observation revealed the LPN had placed the 5/15/18 - 8:00 AM and 8:00 PM dose and the 5/16/18 - 8:00 AM dose of the [MEDICATION NAME] (a blood pressure medication) 50 mg into the cup (2 extra doses). Continued observation revealed the LPN had placed the Tamulosin (relaxes the muscle in the bladder) 0.4 mg capsule in the cup which was due on 5/15/18 at 8:00 PM. Medical record review of the Physician Recapitulation Orders dated 5/1/18 - 5/31/18 revealed the resident was ordered the following medications: [REDACTED]. Interview with LPN #3 and RN Unit Manager #1 on 5/15/18 at 8:15 AM, in the 300 hallway confirmed LPN #3 had failed to check the medications against the resident's Medication Administration Record [REDACTED].",2020-09-01
916,"CAMBRIDGE HOUSE, THE",445190,250 BELLEBROOK RD,BRISTOL,TN,37620,2018-05-16,812,F,0,1,VPQ611,"Based on review of facility policy, observation, and interview the facility failed to maintain a sanitary kitchen evidenced by undated, unlabeled, and opened to air food items in 1 of 1 stand alone refrigerator, 1 of 1 ice cream freezers, and 1 of 1 walk-in freezers in the kitchen area, effecting 69 of 70 residents in the facility. The finding included: Review of the facility policy, Food Receiving and Storage, with a revised date of (MONTH) 2008, revealed .All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) . Observation with the Dietary Manager and the Kitchen Supervisor on 5/14/18 at 11:05 AM, of the stand alone refrigerator, in the kitchen, revealed; approximately a 1/2 pound of sliced ham wrapped loosely in aluminum foil, open to air, undated, unlabeled, and available for resident consumption. Observation with the Dietary Manager and Kitchen Supervisor on 5/14/18 at 11:08 AM, of the ice cream freezer, in the kitchen, revealed 100 pancakes in plastic bag, open to air, undated, and available for resident consumption. Observation with the Dietary Manager and Kitchen Supervisor on 5/14/18 at 11:12 AM, of the walk in freezer, in the kitchen, revealed approximately a 10 pound bag of mixed vegetables, in a large plastic bag, in a cardboard box, open to air, undated, and available for resident consumption. Interview with the Dietary Manager on 5/14/18 at 11:18 AM, in the kitchen, confirmed the facility failed to maintain a sanitary kitchen with open to air, undated, and unlabeled food items stored in the stand alone refrigerator, ice cream freezer, and the walk in freezer, which were available for resident consumption.",2020-09-01
917,"CAMBRIDGE HOUSE, THE",445190,250 BELLEBROOK RD,BRISTOL,TN,37620,2018-05-16,880,E,0,1,VPQ611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Centers for Disease Control and Prevention (CDC) Frequently Asked Questions about [MEDICAL CONDITION] for Healthcare Providers, medical record review, observation and interview, the facility failed to ensure staff adhered to appropriate infection control isolation practices and appropriate hand hygiene practice for 1 resident (#172) of 5 residents reviewed on isolation precautions, and failed to use appropriate infection control hand hygiene practice during medication administration in 1 of 3 medication administration observations. The findings included: Review of the CDC Frequently Asked Questions about [MEDICAL CONDITION] for Healthcare Providers dated 3/6/12 revealed, .Use Contact Precautions for patients with known or suspected [MEDICAL CONDITION] infection .Place these patients in private rooms .these patients can be placed in rooms with other patients with [MEDICAL CONDITION] infection .Perform Hand Hygiene after removing gloves .Because alcohol does not kill [MEDICAL CONDITION] spores, use of soap and water is more efficacious than alcohol based hand rubs . Review of the facility policy, Administering Medications, dated (MONTH) 2012 revealed, .staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications . Review of the facility policy, Handwashing/Hand Hygiene, dated (MONTH) (YEAR) revealed, .all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .Use an alcohol-based hand rub .soap (antimicrobial or non-antimicrobial) and water for the following .before and after direct contact with residents .after contact with a resident's intact skin .after removing gloves .Hand hygiene is the final step after removing and disposing of personal protective equipment .The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections . Medical record review revealed Resident #172 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a hospital lab result with a release date of 4/23/18, revealed Resident #172 had a stool culture (Stool specimen tested for toxin) positive for [MEDICAL CONDITION] (infectious bacteria that can cause symptoms ranging from diarrhea to life threatening inflammation of the colon). Medical record review of Resident #172's care plan dated 5/11/18 revealed the resident required assistance of 1 person for bathing, dressing, ambulation, transfers, repositioning, and bed mobility. Continued review revealed Resident #172 was incontinent of bowel and bladder and was on a check and change incontinence management program. Continued review revealed the resident was care planned for contact isolation precautions related to [DIAGNOSES REDACTED]. Medical record review of a Physician's Order clarification dated 5/14/18, revealed an order for [REDACTED].>Observation of Resident #172's room on 5/14/18 at 11:33 AM, revealed a contact precautions sign located outside of the resident's door. Continued observation revealed personal protective equipment of gowns, gloves, and masks located on a cart outside of the resident's door. Further observation revealed signage outside of the resident's room on the door instructing visitors to please check at the nursing station before entering the resident's room. Observation of Resident #172 with Licensed Practical Nurse (LPN) #2 on 5/14/18 at 11:35 AM, in the common lounge area, near the 200 hall nursing station, revealed Resident #172 seated in the lounge area with 7 other residents seated at various tables and in wheelchairs. Interview with Licensed Practical Nurse (LPN) #2 on 5/14/18 at 12:08 PM, on the 200 hall, confirmed Resident #172 was on contact isolation for [MEDICAL CONDITION] and should not have been in the lounge common area with other peers. Interview with the Director of Nursing (DON) on 5/14/18 at 3:01 PM, in the conference room, confirmed Resident #172 was on contact isolation for [MEDICAL CONDITION] and the facility failed maintain appropriate contact isolation practice for Resident #172. Observation of Resident #172 on 5/14/18, at 12:54 PM, in resident's room, during dining observation, on the 200 hallway, revealed Certified Nurse Aide (CNA) #2 entered the resident's room wearing a gown and gloves. Continued observation revealed CNA #2 set up Resident #172's meal tray. Further observation revealed prior to exiting the resident's room CNA #2 removed her gown and gloves and then used hand sanitizer off the wall to sanitize her hands. Interview with CNA #2 on 5/14/18, at 12:54 PM, in the 200 hallway, confirmed the CNA failed to use soap and water to sanitize her hands prior to exiting Resident #172's room. Continued interview confirmed the CNA failed to follow CDC guidelines for hand washing for a resident with [MEDICAL CONDITION] on contact isolation. Interview with the DON on 5/15/18, at 12:42 PM, in the DON's office, confirmed the facility failed to follow CDC guidelines for hand washing with soap and water prior to exiting a resident's room with [MEDICAL CONDITION] on contact isolation. Continued interview confirmed the facility failed to use appropriate hand hygiene and infection control practices for Resident #172. Observation of medication administration on 5/15/18, at 7:52 AM, on the 400 Hallway with LPN #1 revealed LPN #1 prepared medications for administration at the medication cart on the 400 Wing Hallway. Continued observation revealed LPN #1 entered a resident's room, raised the resident's shirt, lowered the waist of their pants, administered a subcutaneous medication, removed gloves, and exited the resident's room without performing hand hygiene. Further observation revealed upon exiting the resident's room LPN #1 returned to the medication cart, opened the Medication Administration Record [REDACTED]. Interview with LPN #1 on 5/15/18, at 7:54 AM, on the 400 Hallway confirmed she had not performed proper hand hygiene during medication administration. Interview with the Director of Nursing on 5/15/18, at 8:42 AM, in the conference room confirmed the facility failed to follow their policies on hand hygiene and medication administration and failed to maintain proper hand hygiene during medication administration.",2020-09-01
918,"NHC HEALTHCARE, HENDERSONVILLE",445191,370 OLD SHACKLE ISLAND RD,HENDERSONVILLE,TN,37075,2017-06-28,155,D,1,1,QJYC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on patient rights review, medical record review, and interview, the facility failed to allow 1 Resident (#59) of 32 residents reviewed the right to refuse dental services. The findings included: Review of the Patient Rights handbook provided to each resident in the facility revealed, .You have the right to accept or refuse any medication or treatment .You are entitled to explore various options available to you and to choose the treatment option you prefer . Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].>Telephone interview with Resident #59's family conservator on 6/28/17 at 12:53 PM revealed she had revoked her consent for dental care in (YEAR). Continued interview revealed she had verbalized this to the Social Worker (SW) who stated she would call the dental office and tell them to take the resident off the list to be seen at the facility. Continued interview revealed the family conservator learned the resident received dental services on 1/5/17 after receiving a bill from the dental clinic. She called the facility and spoke with the SW and was told she would call the dental clinic again and make sure the resident was no longer on the list for cleanings or any further dental care. Medical record review revealed a Dental Progress Note dated 1/5/17 indicating that a dental exam, cleaning, and x-rays had been completed by the dental clinic for Resident #59. Interview with the SW on 6/28/17 at 2:05 PM in the classroom confirmed the family conservator had requested no dental services to be performed for the resident. Continued interview revealed the resident was placed on the exam list by the dental clinic in error, and the resident did receive dental services on 1/5/17. The SW stated, I just overlooked her being on the list when he showed it to me. The SW confirmed the facility failed to honor the resident's right to refuse dental services.",2020-09-01
919,"NHC HEALTHCARE, HENDERSONVILLE",445191,370 OLD SHACKLE ISLAND RD,HENDERSONVILLE,TN,37075,2017-06-28,164,D,0,1,QJYC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation, and interview, the facility failed to provide privacy for 2 residents (#127, #154) of 8 residents observed during blood glucose monitoring and medication administration. The findings included: Review of facility policy, Preparation and General Guidelines IIA2: Medication Administration-General Guidelines, dated 6/2016 revealed .16) The privacy of the resident is maintained as needed during the administration of medications . Medical record review revealed Resident #127 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation and interview on 6/26/17 at 5:00 PM in room [ROOM NUMBER] revealed Licensed Practical Nurse (LPN) #1 performing blood glucose monitoring for Resident #127. Continued observation of the resident revealed the resident sitting in a wheelchair in the middle of her private room angled toward the door. The LPN performed the blood glucose monitoring while the door was still open to the hallway. Interview with the LPN when asked if she usually closed the door or provided privacy, revealed I usually do. Continued interview revealed when asked if she should provide privacy to residents during procedures revealed yes. LPN #1 confirmed she did not provide privacy for Resident #127 while performing blood glucose monitoring. Medical record review revealed Resident #154 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation and interview on 6/27/17 at 8:56 AM in room [ROOM NUMBER] B revealed Registered Nurse (RN) #1 administering medications via feeding tube to Resident #154. Continued observation revealed the door and the privacy curtain between A and B bed were open. The resident in A bed was in the room in her wheelchair. Further observation revealed the RN exposed the resident's abdomen and when asked if the privacy curtain should be pulled stated yes it should. The RN confirmed she did not provide privacy to Resident #154 prior to exposing the resident. Interview with the Director of Nursing (DON) on 6/28/17 at 11:47 AM in the classroom revealed when asked if she expected nursing staff to provide privacy during procedures and medication administration stated yes. Continued interview with the DON confirmed staff was to provide privacy to residents during procedures and medication administration. Further interview confirmed the facility failed to provide privacy during blood glucose monitoring and medication administration.",2020-09-01
920,"NHC HEALTHCARE, HENDERSONVILLE",445191,370 OLD SHACKLE ISLAND RD,HENDERSONVILLE,TN,37075,2017-06-28,241,D,0,1,QJYC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, observation, and interview, the facility staff failed to treat 2 residents (#94, #131) of 11 residents observed with dignity by standing over the two residents while assisting them to eat. The findings included: Review of facility policy, Assistance with meals, revised (MONTH) 2013 revealed .Residents who cannot feed themselves will be fed with attention to .dignity, for example: (1) Not standing over residents while assisting them with meals . Medical record review revealed Resident #94 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #94's cognitive patterns could not be assessed because the resident was rarely or never understood. Review of the Activities of Daily Living (ADL) care plan dated 3/1/17 and updated 5/16/17 revealed Resident #94 required assistance with ADLs with an intervention to assist the resident with meals as needed. Observation on 6/26/17 at 12:50 PM in the 100/200 hall assisted dining room revealed Licensed Practical Nurse (LPN) #3 was standing over Resident #94 while assisting the resident with dining. Interview with LPN #3 at 12:50 PM in the 100/200 hall assisted dining room revealed it was not the facility's practice for staff to stand while assisting residents with dining. Continued interview with the LPN confirmed the facility failed to treat Resident #94 with dignity when the staff member stood over the resident while assisting the resident with dining. Medical record review revealed Resident #131 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly MDS dated [DATE] revealed the resident required extensive assistance with meals. Observation of the lunch service on 6/26/17 at 1:03 PM in the assisted dining room on the 300 and 400 hall revealed LPN #2 standing while assisting Resident #131 with dining. Interview with LPN #2 at 3:00 PM at the 400 hall medication cart revealed when asked if he normally stood to assist residents with meals stated, I was just there for a few minutes to help out. Continued interview revealed when asked if it was an appropriate procedure to stand while assisting residents with meals, the LPN stated no. LPN #2 confirmed he failed to treat the resident with dignity while standing to assist the resident with dining.",2020-09-01
921,"NHC HEALTHCARE, HENDERSONVILLE",445191,370 OLD SHACKLE ISLAND RD,HENDERSONVILLE,TN,37075,2017-06-28,278,D,0,1,QJYC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide an accurate Minimum Data Set (MDS) assessment for 2 residents (#59, #79) of 32 residents reviewed in the stage 2 sample. The findings included: Medical record review revealed Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed a physician's orders [REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was not assessed to receive hospice services. Interview with the MDS Coordinator on 6/28/17 at 4:00 PM in the MDS office confirmed the facility failed to accurately assess Resident #59's status for hospice services. Medical record review revealed Resident #71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 6/26/17 at 2:40 PM in Resident #71's room revealed the resident's top dentures moved up and down as she talked. Medical record review of the Annual MDS dated [DATE] revealed the oral/dental status section was coded as none of the above were present indicating the resident had no dental concerns. Telephone interview with Resident #71's daughter on 6/26/17 at 4:00 PM revealed she was aware her mother's dentures were too big due to weight loss. Continued interview revealed her mother was on end of life care and did not want to put her through having to have another denture fitting. Interview with the 300-400 hall Unit Manager on 6/28/17 at 9:49 AM in room [ROOM NUMBER] confirmed staff knew of the resident's loosely fitting dentures. Interview with the MDS Coordinator on 6/28/17 at 4:10 PM in the MDS office confirned she was aware of the resident's loosely fitting dentures. Continued interview revealed the MDS coordinator confirmed the facility failed to accurately assess the resident's loose fitting dentures on the Annual MDS dated [DATE].",2020-09-01
922,"NHC HEALTHCARE, HENDERSONVILLE",445191,370 OLD SHACKLE ISLAND RD,HENDERSONVILLE,TN,37075,2017-06-28,282,D,0,1,QJYC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to update the care plan and follow interventions for 1 Resident (#25) of 32 residents reviewed in the stage 2 sample. The findings included: Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #25 had non-injury falls to occur on 4/1/17, 4/21/17, 4/25/17, 4/30/17, and 5/2/17. Medical record review of the care plan updated 5/16/17 revealed no interventions were initiated after the 4/21/17, 4/25/17, 4/30/17, and 5/2/17 falls. Medical record review of the care plan updated on 5/26/17 revealed the resident was to have assistance of 2 with transfers, a gait belt and a bathroom door alarm. Review of the facility Fall Investigation dated 5/2/17 revealed .Pt was toileted by CNA (certified nursing assistant) and after pt (patient) was placed back in w/c (wheelchair) and alarms were not turned back on. CNA was written up and all interventions were in place . Medical record review of the care plan updated 5/16/17 revealed no interventions were initiated after the 5/2/17 fall. Medical record review of the care plan updated 5/26/17 revealed the resident was to have assistance of 2 with transfers and a gait belt, and a bathroom door alarm. Observation and interview with CNA #1 on 6/28/17 at 4:54 PM at the door to the resident's room revealed when asked about a bathroom door alarm, explained there is one on the door, but it is never on. Continued observation with the CNA present revealed the bathroom door alarm was in the off position. Continued interview revealed the CNA stated We don't turn it on because we have to take her to the bathroom. When asked if she had ever seen the bathroom alarm on she stated No. That's not for these residents. Interview with Licensed Practical Nurse (LPN) #1 on 6/28/17 at 4:58 PM in room [ROOM NUMBER] revealed when asked about the bathroom door alarm LPN #1 stated there was a bathroom door alarm on the bathroom door but it is not on. I'm not sure why it's there. LPN #1 confirmed the bathroom door alarm was not in the working position and the facility failed to follow the care plan. Interview with CNA #1 on 6/28/17 at 5:40 PM in the split between 100-200 halls revealed she had just gotten the resident up and assisted her with the meal. The CNA was asked how much assist the resident required, she replied I do her by myself. Continued interview revealed she could get her up, transfer, toilet, and bathe the resident by herself. Interview with the Director of Nursing (DON) on 6/28/17 at 6:38 PM at the 100-200 hall nurse's station revealed when the DON was asked if the current interventions on the care plan should be in place, the DON stated yes, if it is on the current care plan it should be done. Continued interview revealed when asked about the bathroom door alarm, and assist of 2 for the resident, the DON confirmed those interventions should be done. Continued interview revealed when the DON was asked if the care plan should be updated after each fall the DON stated yes. Interview with the DON confirmed the facility failed to update the care plan after each of the resident's falls and failed to follow the care plan interventions.",2020-09-01
923,"NHC HEALTHCARE, HENDERSONVILLE",445191,370 OLD SHACKLE ISLAND RD,HENDERSONVILLE,TN,37075,2017-06-28,323,G,1,1,QJYC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to ensure safety devices were in place and functioning for 3 residents (#105, #25, #68) of 6 residents reviewed for falls. This failure resulted in Harm to 1 resident (#105) who sustained a fall with a femur fracture. The findings included: Review of facility policy, Falls Prevention Program, revised [DATE] revealed The incidence of hip fractures increase with age .Each center has a Falls Committee which monitors falls and utilizes data to systematically address falls which is a subcommittee of the Quality Assurance and Performance Improvement (QAPI) Committee. The Falls Committee takes direction from and reports to the center QAPI (Quality Assurance Performance Improvement) Committee . Medical record review revealed Resident #105 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #105 scored 4 on the Brief Interview for Mental Status (BIMS), indicating she was moderately impaired cognitively. Continued MDS review revealed Resident #105 required extensive assistance of 2 people for transfers; extensive assistance of 1 person for dressing, toileting, and grooming; was dependent on 2 people for bathing; and was always incontinent of bowel and bladder. Medical record review of a Falls Investigation dated [DATE] revealed Resident #105 was found on her right side beside the bed. Continued review revealed Resident #105 had a seat belt which was found beside the chair, broken in half. Further review revealed the resident had a contusion to her head and complained of right thigh pain. Medical record review revealed Resident #105 was transported to the hospital where x-rays showed she had suffered a .comminuted intertrochanteric femoral fracture of the right side (unstable hip fracture) . The resident underwent [REDACTED]. Further medical record review revealed Resident #105 was sent out to the hospital on [DATE] and admitted with [DIAGNOSES REDACTED]. Continued medical record review revealed the resident was placed on hospice care on [DATE] and expired on [DATE]. Interview with the Director of Nursing (DON) on [DATE] at 12:20 PM in the classroom revealed Resident #105 fell ; complained of leg pain; and hit her head in the fall. Continued interview revealed no one was sure whether she was trying to go to bed or to the bathroom. Further interview revealed the seatbelt Resident #105 was used for pelvic support. Continued interview revealed Resident #105 was [DIAGNOSES REDACTED] and could not stand or walk. Further interview with the DON revealed the zip tie must have come loose from where it was tied to the posts of the wheelchair. Continued interview revealed it is the responsibility of the Certified Nurse Aide (CNA) caring for the resident to check the seat belt and connections before using the wheelchair for a resident. Further interview with the DON confirmed this check was probably not completed if the zip tie broke. Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Post Falls Nursing assessment dated [DATE] at 9:30 AM revealed Resident # 25 was found lying on floor mat bedside bed with no injury noted. Medical record review of the Post Falls Nursing assessment dated [DATE] at 6:16 PM revealed staff heard alarms sounding and found Resident #25 sitting on her buttocks by her door in her room and no injury noted. Medical record review of the Post Falls Nursing assessment dated [DATE] at 11:15 AM revealed upon entering room Resident #25 was found sitting on the floor beside the bed without injury. Medical record review of the Post Falls Nursing assessment dated [DATE] revealed .CNA was walking by room and saw patient's feet on the floor. Exiting wheelchair. Entered room and saw patient lying on the floor next to bed .Additional Comments: Alarms were not sounding and staff was educated and reprimanded for safety needs not being met . Continued review revealed the document was signed by Licensed Practical Nurse (LPN) #1. Review of Supervisory Adverse Action Notice dated [DATE] revealed .Supervisor's Statement of Incident: Employee failed to turn alarms back on patient after toileting which resulted in patient falling . Continued review revealed the document was signed by CNA #1 and LPN #1. Review of the Fall Investigation dated [DATE] revealed .Pt (Patient) was toileted by CNA and after pt (patient) was placed back in w/c (wheelchair) the alarms were not turned back on. CNA was written up and all interventions were in place . Medical record review of the care plan updated [DATE] revealed no interventions were initiated after the [DATE], [DATE], [DATE], and the [DATE] falls. Observation on [DATE] at 8:57 AM revealed Resident #25 had a seatbelt in place going across her lower abdomen through the arms of the wheelchair, around the back of and attached to the back frame of the wheelchair on the right and left sides with a zip tie wrapped around several times and secured Observation on [DATE] at 4:57 PM in Resident #25's room revealed a bathroom door alarm on the bathroom door, in the off position. Interview with CNA #1 on [DATE] at 4:54 PM at the door to Resident #25's room revealed when asked about a bathroom door alarm, she explained there was one on the door, but it was never on. We don't turn it on because we have to take her to the bathroom. When asked if she had ever seen the bathroom alarm on she stated No. That's not for these residents. Interview with LPN #1 on [DATE] at 4:58 PM in room 101 revealed the resident had multiple falls in the last couple of months. Continued interview revealed when asked about the bathroom door alarm she stated there was a bathroom door alarm on the bathroom door but it is not on. I'm not sure why it's there. Continued interview revealed she was asked about the fall on [DATE]. The LPN explained a CNA had recently toileted the resident and after transferring the resident back to the wheelchair, the Aide had forgot to put the alarm back on. Continued interview revealed the resident then fell out of her wheelchair. Continued interview with the LPN revealed it had been determined the fall was due to the alarm not being turned back on. The LPN confirmed the facility failed to prevent the resident's fall. Medical record review revealed Resident #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Falls Investigation dated [DATE], revealed Resident #68 was found sitting on the floor near the head of the bed. His call light was on but his alarms were not in place. Resident #68 stated he was trying to go get his nurse. The resident did not sustain any injuries as a result of the fall. Review of the falls investigation revealed a Supervisory Adverse Action Notice dated [DATE] stating the patient alarms were not in place at the time of the fall and were set in place after the resident was placed in bed. Interview with the DON on [DATE] at 4:30 PM in the classroom, confirmed the report stated the resident's alarms were not in place at the time of the fall and confirmed the staff would not have been alerted to the resident's fall.",2020-09-01
924,"NHC HEALTHCARE, HENDERSONVILLE",445191,370 OLD SHACKLE ISLAND RD,HENDERSONVILLE,TN,37075,2017-06-28,441,D,0,1,QJYC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation, and interview, the facility failed to wash or sanitize the hands and don gloves prior to entering 1 contact isolation room (#102) while delivering meal trays, and failed to wash or sanitize the hands while exiting the room for 14 meal trays observed on the 100 hall. The findings included: Review of facility policy, Transmission Based Procedures, revised 10/1/08 revealed, .use Contact precautions for patients known or suspected to be infected or colonized with epidemiologically significant microorganisms that can be transmitted by direct contact with the patient or indirect contact with the environmental surfaces .In addition to wearing gloves .remove gloves before leaving room and wash hands immediately with an antimicrobial agent . Observation on 6/26/17 at 12:17 PM on the 100 hall revealed Certified Nurse Aide (CNA) #2 entering room [ROOM NUMBER] carrying disposable meal containers. Isolation personal protective equipment was noted hanging on the outside of the door to the room. Continued observation revealed the CNA did not wash or sanitize the hands or don gloves prior to entering the room. Continued observation revealed the CNA moved items on the resident's over bed table and placed the disposable meal containers on the over bed table and exited the room without washing or sanitizing the hands. Interview with CNA #2 on 6/26/17 at 12:18 PM in the 100 hall when asked if the resident in room [ROOM NUMBER] was on contact isolation stated, Yes, he has MRSA (bacterial infection that is resistant to numerous antibiotics). Continued interview with the CNA revealed when asked why she did not wash or sanitize her hands or don gloves upon entering the room or wash her hands prior to exiting the room stated, I forgot. Interview with the Director of Nursing (DON) on 6/26/17 at 4:00 PM in the hallway by the ADON's (Assistant DON's) office confirmed washing hands, and donning gloves before and after entering an isolation room was the expectation of all staff. The DON confirmed the facility failed to follow standard infection control practices for handwashing.",2020-09-01
925,"NHC HEALTHCARE, HENDERSONVILLE",445191,370 OLD SHACKLE ISLAND RD,HENDERSONVILLE,TN,37075,2019-07-11,638,D,0,1,YQNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to complete a Quarterly Minimum Data Set (MDS) for 1 (#1) of 38 residents reviewed. The findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #1 had a Quarterly MDS completed on 3/19/19. Further medical record review revealed no Quarterly MDS was completed in (MONTH) 2019. Interview on 7/9/19 with Registered Nurse (RN) #1, MDS Coordinator at 4:43 PM in her office revealed Resident #1 had not had a Quarterly MDS completed since (MONTH) 2019. When asked when the MDS assessment was due for Resident #1 the MDS Coordinator confirmed, The Quarterly MDS was due on (MONTH) 19, 2019 and I missed it.",2020-09-01
926,"NHC HEALTHCARE, HENDERSONVILLE",445191,370 OLD SHACKLE ISLAND RD,HENDERSONVILLE,TN,37075,2019-07-11,657,D,0,1,YQNG11,"**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 revise/update care plans for 2 (#55 and #237) of 38 residents reviewed. The findings include: Review of the facility policy, Care Plan Development, revised 7/3/08 revealed .Care Plans are updated as needed, but are reviewed completely by the interdisciplinary team on a quarterly basis within 7 days of completion .New problems are handled as they arise, and are to be added to the current care plan even if the change in condition is not considered significant enough for a complete revision . Medical record review revealed Resident #55 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Discharge Minimum Data Set ((MDS) dated [DATE] revealed Resident #55 was always incontinent of bladder and bowel. Medical record review of the Admission Observation dated 7/2/19 revealed Resident #55 was admitted with an indwelling catheter. Observation on 7/8/19, 7/9/19, and 7/10/19 in Resident #55's room revealed the resident's catheter bag was in a dignity bag on the side of the bed. Interview with Registered Nurse #5 (RN) on 7/10/19 at 11:50 AM at the nurse station revealed the staff nurses, MDS coordinator and Unit Managers could update the care plans. Continued interview revealed when asked what the date on the care plan was RN #5 responded .7/10/19 . Continued interview revealed when asked when it would be appropriate to update the care plan she replied .If I see a new care order I would update the care plan . Interview with the Director of Nursing (DON) on 7/10/19 at 6:10 PM in the conference room revealed care plans are completed on admission. Continued interview revealed the MDS coordinator completed the comprehensive care plan after the 1st Resident Assessment Instrument (RAI) assessment. Interview with the MDS Coordinator on 7/10/19 at 6:23 PM in her office revealed the care plan was not updated until after an assessment. Continued interview revealed nurses were responsible for updating the care plan when a resident was admitted to the facility. Interview with LPN #6 also known as the Unit Manager on 7/10/19 at 6:30 PM in the conference room confirmed .Normally it (catheter) should be put on admission. I don't know why it was missed . Interview with the DON on 7/10/19 at 6:44 PM in the hall by the conference room when asked to review Resident #55's care plan she confirmed .I will be honest with you, if it's (catheter) not there we forgot to do it . Medical record review revealed Resident #237 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #237's Admission MDS dated [DATE] revealed the resident had no venous or arterial ulcers. Medical record review of Resident #237's 14 day MDS dated [DATE] revealed the resident had 1 venous and arterial ulcer present. Medical record review of the Physician Orders for Resident #237 revealed .5/1/19 .Right LAT.(Lateral) ANKLE - (SCAB REMOVAL FROM ABRASION) .CLEANSE WITH WOUND WASH &(And) PAT DRY .APPLY SKIN PREP COVER WITH MEDIUM ALLEVYN-DAILY .5/6/19 RIGHT LATERAL ANKLE - (ARTERIAL ULCER) .CLEANSE WITH WOUND WASH & PAT DRY .APPLY SKIN PREP TO PERI-WOUND .APPLY SANTYL TO WOUND BED .COVER WITH MEDIUM ALLEVYN .CHANGE DRESSING EVERY MON (Monday)/WED (Wednesday)/FRI (Friday) .5/10/19 RIGHT LATERAL ANKLE - (ARTERIAL ULCER) .CLEANSE WITH WOUND WASH & PAT DRY .APPLY SKIN PREP TO PERI-WOUND .APPLY BIOSTEP TO WOUND BED .COVER WITH MEDIUM ALLEVYN .CHANGE DRESSING DAILY .RIGHT LATERAL ANKLE - (ARTERIAL ULCER) .PRN (As needed) .CLEANSE WITH WOUND WASH & PAT DRY. APPLY SKIN PREP TO PERI-WOUND .APPLY SANTYL TO WOUND BED .COVER WITH MEDIUM ALLEVYN .CHANGE DRESSING AS NEEDED DUE TO ACCIDENTAL REMOVAL/LOOSE/SOILED .6/18/19 RIGHT LATERAL ANKLE - (ARTERIAL ULCER) .CLEANSE WITH WOUND WASH & PAT DRY .APPLY SKIN PREP TO PERI-WOUND .APPLY ZINC OINTMENT TO PERI-WOUND .APPLY THICK LAYER OF SANTYL TO WOUND BED .LARGE [MEDICATION NAME] .CHANGE DRESSING - EACH SHIFT .Day 7:00 AM .Night 7:00 PM .FLOAT ANKLES/HEELS . Medical Record Review of Resident #237's comprehensive care plan dated 3/29/2019 - 7/10/2019 revealed .alteration in/potential for alteration in skin integrity R/T (related to)[MEDICAL CONDITION] with right sided weakness . Continued review revealed the resident had no wounds to the right lateral ankle. Interview with the DON on 7/11/19 at 11:51 AM in the conference room when asked to look at the care plans for Resident #237, she stated There's nothing in here that addresses the ankle. Continued interview with the DON confirmed Resident #237's care plan was not updated, she stated any nurse receiving orders should update the care plan with what the orders reflect and (named resident) was not.",2020-09-01
927,"NHC HEALTHCARE, HENDERSONVILLE",445191,370 OLD SHACKLE ISLAND RD,HENDERSONVILLE,TN,37075,2019-07-11,690,D,0,1,YQNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview, the facility failed to obtain physician orders timely for placement of an indwelling catheter for 1 (#55) of 38 residents reviewed. The findings include: Review of the facility policy, Medication Orders, dated 6/2016 revealed .Medications are administered only upon an order from a person lawfully authorized to prescribe . Medical record review revealed Resident #55 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the History of Present Illness dated 6/28/19 revealed .had evidence of a acute kidney injury .was found to have acute [MEDICAL CONDITION] by bladder scan .Foley catheter was placed with 1200 ml (milliter) of urine returned . Medical record review of the Physician Orders for Resident #55 dated 7/5/19 revealed .Change Indwelling Catheter every 30 days once a day on the 1st month .Catheter Care Once per shift and document . Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #55 required an indwelling catheter. Interview with Licensed Practical Nurse #6 also known as the Unit Manager on 7/11/19 at 11:55 AM in his office revealed .normally the staff nurses would put the orders in on admission . Interview with the Director of Nursing on 7/11/19 at 12:32 PM in the conference room revealed it was a night shift admission and the information did not get relayed appropriately. Continued interview confirmed .any of the nurses could have gotten an order and put it in. It should have been in place .",2020-09-01
928,"NHC HEALTHCARE, HENDERSONVILLE",445191,370 OLD SHACKLE ISLAND RD,HENDERSONVILLE,TN,37075,2019-07-11,695,D,0,1,YQNG11,"**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 label and date oxygen and nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) tubing and humidified canisters for 1 (#71) of 20 residents reviewed receiving respiratory treatments. The findings include: Facility policy review, Supplemental Oxygen, dated 1/2005, revealed .the purpose of delivering oxygen by nasal cannula is to: correct [MEDICAL CONDITION] (low oxygen) by increasing available alveolar oxygen .Diminish the [MEDICAL CONDITION] (heart) work load by correcting hypoxemia (low level of oxygen in the blood) .decrease in breathing efforts to maintain adequate oxygenation .infection can occur if equipment is not changed and cleaned properly .change tubing and cannula every 7 days .label each tubing with date, and your initial .change humidifier when empty or at least weekly and date . Facility policy review, Aerosol Therapy, revised 7/2014, revealed .intermittent Aerosol with Medication Administration with medication is used to deliver fine particles of liquid and medication in the [MEDICATION NAME] tree .this means of medication administration is quick and has few systemic side effects .Intermittent aerosol with medication administration is indicated for [MEDICAL CONDITION] such as asthma or [MEDICAL CONDITION] .be sure nebulizer and tubing are labeled with the date and initial .nebulizer can become contaminated resulting in an infection .change nebulizer and tubing every 7 days . Medical record review revealed Resident #71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #71's Significant Change Minimum Data Set ((MDS) dated [DATE] revealed the resident received oxygen therapy. Medical record review of Resident #71's physician orders [REDACTED].oxygen (02) 2 liters per minute via nasal cannula continuous .6/14/19 [MEDICATION NAME] (a medication used to open the airway) solution for nebulization 0.5 milligram (mg) - 3 mg (2.5 mg base)/3 milliliter (ml) 1 inhalation every 6 hours (hr) as needed .[MEDICAL CONDITIONS] . Medical record review of Resident #71's comprehensive care plan dated 6/26/19 revealed .Respiratory complications: at risk for R/T (related to) [MEDICAL CONDITION] 02 dependent .Administer 02 at [MEDICAL CONDITION] (positive air pressure machine to treat sleep apnea) at hour of sleep as ordered neb (nebulizer) treatments as ordered 02 as ordered .administer [MEDICATION NAME][MEDICATION NAME] . Observation on 07/08/19 at 10:56 AM and at 4:22 PM in Resident #71's room revealed the resident receiving 02 via (by) nasal cannula at 2 liters per minute. Continued observation revealed a nebulizer machine (a machine used to deliver aerosol treatments) on the resident's bedside table not in use. Continued observation revealed the oxygen tubing, humidified water bottle and the nebulizer tubing were dated 6/27/19. Interview with the Central Supply Nursing Assistant on 7/8/19 at 4:38 PM in her office revealed she was responsible for changing the residents' oxygen tubing, humidified water bottles and nebulizer tubing. Continued interview revealed oxygen tubing, nebulizer tubing and humidified water were changed weekly. Observation and interview with the Central Supply Nursing Assistant on 7/8/19 at 4:40 PM in Resident #71's room when asked to look at the resident's tubings and humidified water bottle she confirmed the tubings and bottle were dated 6/27/19. Continued interview she stated I thought I changed these Friday (July 5 2019); I did not do (named resident), (named resident) was the last one, (named resident) was in the shower; I meant to go back and change them and I did not. Observation and interview with the Director of Nursing on 7/8/19 at 4:58 PM in the Resident #71's room confirmed the resident's oxygen tubing, nebulizer tubing and humidified water bottle were dated 6/27/19. Continued interview she stated the bottle and tubings were to be changed weekly by the Central Supply Nursing Assistant.",2020-09-01
929,"NHC HEALTHCARE, HENDERSONVILLE",445191,370 OLD SHACKLE ISLAND RD,HENDERSONVILLE,TN,37075,2019-07-11,711,D,0,1,YQNG11,"**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 the attending physician visit included an evaluation of the resident's total program of care including medications, treatments and a decision about continued appropriateness for current medical regimen for 1 (#237) of 12 residents reviewed. The findings include: Facility policy review, Medical Services, revised 2/2018, revealed .The physician delegated option does not relieve the physician of the obligation to visit a patient when the patient's medical condition makes that visit necessary or from performing services or procedures prohibited under state law from being delegated .reviews medications, patient program of care, and diagnoses, at regular intervals .supports efforts to assure that patients have indicated laboratory and X-ray or other procedures . Medical record review revealed Resident #237 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Resident #237's physician visit note dated 4/1/19 revealed, .No Ulcer/Rash/Petechia/Purpura/Masses/or other [MEDICAL CONDITION] . Medical record review of Resident #237 Resident Progress Notes by the NP (Nurse Practitioner) dated 4/4/19 revealed, .Ext (Extremities): No [MEDICAL CONDITION] . Medical record review of Resident #237's Resident Progress Notes by the NP dated 4/11/19 revealed, .Skin: No rashes, [MEDICAL CONDITION] or ulcers . Medical record review of Resident#237's Reesident Progress Notes by the NP dated 4/18/19 revealed, .Ext: No [MEDICAL CONDITION] . Medical record review of Resident #237's Resident Progress Notes by the NP dated 4/25/19 revealed, .Skin: see nursing notes . Medical record review of Resident #237's Resident Progress Notes by the PA (Physician's Assistant) dated 4/30/19 revealed, .Skin: warm and dry . Medical record review of Resident #237's physician visit note dated 5/27/19 revealed skin assessment not performed. Medical record review of Resident #237's Resident Progress Notes by the NP dated 6/13/19 revealed, .wound care following skin break down on penis .skin: see wound care notes . Medical record review of Resident #237's Resident Progress Notes by the PA dated 6/21/19 revealed, .Skin: No rashes, [MEDICAL CONDITION] or ulcers . Interview with the Medical director, also Resident #237's attending physician on 7/9/19 at 5:29 PM in the conference room revealed the resident did not have a [DIAGNOSES REDACTED]. Continued interview when asked if Resident's #237's right [MEDICAL CONDITION] could have been prevented he stated, It's hard to tell; possibly if the resident had a Doppler done of the extremity (named resident) could have went to a vascular surgeon for an angioplasty. Further interview when asked if he had assessed Resident #237's wound he confirmed, I never saw the resident. Interview with the Administrator with the Director of Nursing present on 7/10/19 at 7:20 PM in the conference room revealed when asked if Resident #237's attending physician assessed Resident #237's wound during his visit he stated, He signed the orders, I leave the assessments to the nursing department and the Director of Nursing.",2020-09-01
930,"NHC HEALTHCARE, HENDERSONVILLE",445191,370 OLD SHACKLE ISLAND RD,HENDERSONVILLE,TN,37075,2019-07-11,712,D,0,1,YQNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Medical record review, facility policy review and interview the facility failed to ensure timely physician visits were performed for 1 (#237) of 12 residents reviewed. The findings include: Facility policy review, Medical Services, revised 2/2018, revealed .The physician delegated option does not relieve the physician of the obligation to visit a patient when the patient's medical condition makes that visit necessary or from performing services or procedures prohibited under state law from being delegated .reviews medications, patient program of care, and diagnoses, at regular intervals .supports efforts to assure that patients have indicated laboratory and X-ray or other procedures . Medical record review revealed Resident #237 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #237's physician visit notes dated 4/1/19 revealed the resident was seen by the physician. Medical record review of Resident #237's physician visit notes dated 5/27/19 revealed the resident was seen by the physician. Interview with the Medical director, also Resident #237's attending physician on 7/9/19 at 5:29 PM in the conference room revealed when asked if he had assessed Resident #237 he confirmed, I never saw the resident.",2020-09-01
931,"NHC HEALTHCARE, HENDERSONVILLE",445191,370 OLD SHACKLE ISLAND RD,HENDERSONVILLE,TN,37075,2018-07-18,584,D,0,1,B25G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to replace and repair the baseboards for 1 of 14 rooms (room [ROOM NUMBER]) on the 400 hall reviewed. Findings include: Observation on 7/16/18 at 9:30 AM, 7/17/18 at 10:36 AM, and 7/18/18 at 8:08 AM, in room [ROOM NUMBER] on the 400 hall revealed the baseboard on the left side entrance to the bathroom was missing. Further observation revealed the baseboard adjacent to the bathroom on the left side was separated from the wall. Observation on 7/18/18 at 5:09 PM, with the Director of Nursing (DON), in room [ROOM NUMBER] revealed the baseboard on the left side entrance to the bathroom was missing. Further observation revealed the baseboard adjacent to the bathroom on the left side was separated from the wall. Interview with the DON on 7/18/18 at 5:44 PM in room [ROOM NUMBER] confirmed the facility failed to replace and repair the baseboards in room [ROOM NUMBER].",2020-09-01
932,"NHC HEALTHCARE, HENDERSONVILLE",445191,370 OLD SHACKLE ISLAND RD,HENDERSONVILLE,TN,37075,2018-07-18,676,D,0,1,B25G11,"**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 ensure 1 of 34 residents (Resident #294) reviewed, had clean and groomed finger nails. Findings include: Review of facility policy Fingernails, Cleaning and Trimming, undated, revealed .Designated partner will care for patients nails daily and PRN (as needed) .clean around and under the nails . Medical record review revealed Resident #294 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #294's comprehensive care plan dated 7/12/18 revealed the resident required assistance with activities of daily living. Continued review of the care plan revealed .Check, clean, and trim nails as needed and to keep nails short . Observations of Resident #294 on 7/16/18 at 11:16 AM, 12:47 PM, and 4:41 PM in the residents room revealed the resident's fingernails were long, chipped, and had brown debris under the nails on both hands. Interview with the Director of Nursing (DON) on 7/16/18 at 4:41 PM in Resident #294's room confirmed the resident's nails were uncleaned and ungroomed. The DON looked at Resident #294's nails and stated You're in need of a trim. Further interview with DON revealed resident nail care was to be performed during showers and as needed.",2020-09-01
933,"NHC HEALTHCARE, HENDERSONVILLE",445191,370 OLD SHACKLE ISLAND RD,HENDERSONVILLE,TN,37075,2018-07-18,800,F,0,1,B25G11,"Based on observation and interview, the facility dietary department failed to maintain and serve hot food at or greater than 135 degrees Fahrenheit (F) for 1 of 6 meal services observed. Findings included: Observation on 7/16/18 at 11:48 AM in the dietary department, with the Registered Dietitian (RD) present, revealed the resident mid-day meal trayline service was in progress. Further observation revealed residents in the main dining room and the 300 hall had been served their meal. Observation of the dietary department trayline revealed the dietary server obtaining food temperatures. Further observation revealed the broccoli was 115 degrees F and the baked pureed fish was 126 degrees F. Further observation revealed the server continued to serve the broccoli after the temperatures were obtained. Interview with the dietary server and the RD on 7/18/18 at 11:55 AM in the dietary department at the trayline confirmed the facility failed to maintain and serve hot food at or greater than 135 degrees F.",2020-09-01
934,"QUINCE NURSING AND REHABILITATION CENTER, L L C",445197,6733 QUINCE ROAD,MEMPHIS,TN,38119,2020-02-21,640,D,0,1,R6M911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility to complete and transmit an MDS assessment within 14 days of the completion date for 1 of 38 sampled residents (Resident #2) reviewed for Resident Assessment and transmission. The finding include: Review of the MDS 3.0 RAI Manual v (version) 1.16 (MONTH) 1, (YEAR) page 664, showed, .Assessment Transmission .MDS assessments must be submitted within 14 days of the MDS Completion Date . Review of the medical record, showed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS assessment, showed the assessment had an Assessment Reference Date of 1/10/2020 and a completion date of 1/24/2020. The annual assessment should have been transmitted by 2/7/2020, but had not been transmitted. During an interview conducted on 2/20/2020 at 6:55 PM, MDS Coordinator #1 stated, .(Resident #2's MDS) didn't get transmitted .got over looked .",2020-09-01
935,"QUINCE NURSING AND REHABILITATION CENTER, L L C",445197,6733 QUINCE ROAD,MEMPHIS,TN,38119,2020-02-21,641,D,0,1,R6M911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to accurately assess residents for bladder and bowel continence, activities of daily living, cognition, and the use of antipsychotics for 4 of 38 sampled residents (Resident #10, #62, #87, and #104) reviewed. The findings include: 1. Review of the medical record, showed Resident #10 had [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE], showed Resident #10 was frequently incontinent of bladder and bowel. Review of the annual MDS dated [DATE], showed Resident #10 was always incontinent of bladder and bowel. Review of the Care Plan dated 11/25/2019, showed, .(Named Resident #10) is incontinent of bowel and bladder r/t (related to) impaired mobility and cognitive deficit . During an interview conducted on 2/20/2020 at 2:13 PM, MDS Coordinator #2 confirmed the MDS dated [DATE] was coded incorrectly for bladder and bowel, and stated, .she (Resident #10) is always incontinent . 2. Review of the medical record, showed Resident #62 had [DIAGNOSES REDACTED]. Review of the Care Plan dated 8/19/16 and revised 10/8/2019 showed, .I am at risk for alteration of ADL's (Activities of Daily Living) r/t limited mobility .[MEDICAL CONDITION] r/[MEDICAL CONDITION] .Transfer (Named) Lift and large sling .Staff performs all ADL's . Review of the quarterly MDS dated [DATE] showed, Resident #62 was extensive assist for bed mobility. During an interview conducted on 2/20/2020 at 2:23 PM, MDS Coordinator #3 confirmed the MDS dated [DATE] was coded incorrectly for bed mobility, and stated, .she (Resident #62) has always been total care . 3. Review of the medical record, showed Resident #87 had [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE], showed Section C (Cognitive Patterns) was not completed. During an interview conducted on 2/20/2020 at 6:48 PM, MDS Coordinator #1 confirmed Section C, Cognitive Patterns had not been completed. 4. Review of the medical record, showed Resident #104 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the (MONTH) 2019 and (MONTH) 2019 Medication Administration Record [REDACTED]. Review of the quarterly MDS dated [DATE], showed in Section N0410A that antipsychotic medications were received for the last 7 days and in Section N0450A that antipsychotic medications were not received. During an interview conducted on 2/20/2020 at 2:43 PM, MDS Coordinator #2 confirmed the MDS dated [DATE] was coded incorrectly for antipsychotics, and stated, That's a contradiction.",2020-09-01
936,"QUINCE NURSING AND REHABILITATION CENTER, L L C",445197,6733 QUINCE ROAD,MEMPHIS,TN,38119,2020-02-21,689,D,0,1,R6M911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to implement fall interventions for 2 of 5 sampled residents (Resident #71 and #135) reviewed for falls. The findings include: 1. Review of the medical record, showed Resident #71 had [DIAGNOSES REDACTED]. Review of the Care Plan revised 1/15/2020, showed, .Problem .has the potential for falls and fall related injuries r/t (related to) poor safety awareness .Approaches .1/15/20 (2020) .dycem (cushion that prevents sliding) to w/c (wheelchair) . Observation in the resident's room on 2/20/2020 at 3:50 PM, showed there was no dycem in Resident #71's wheelchair. During an interview conducted on 2/20/2020 at 3:50 PM, Licensed Practical Nurse (LPN) #1 confirmed there was no dycem in Resident #71's wheelchair. 2. Review of the medical record, showed Resident #71 had [DIAGNOSES REDACTED]. Review of the Care Plan revised 12/14/2019, showed, .Problem .is at risk for falls .Approaches .12/14/2019 .Landing mat to Left side of bed . Observation in the resident's room on 2/18/2020 at 3:50 PM, 2/19/2020 at 7:55 AM and 5:04 PM, 2/20/2020 at 7:44 AM and 10:11 AM, and 2/21/2020 at 7:57 AM, showed there was no landing mat on the floor to the left side of Resident #71's bed. During an interview conducted on 2/21/2020 at 8:45 AM, LPN #2 confirmed there was no landing mat in his room. LPN #2 was asked if interventions on the Care Plan should be followed. LPN #2 stated, Yes, suppose to follow interventions on the Care Plan .",2020-09-01
937,"QUINCE NURSING AND REHABILITATION CENTER, L L C",445197,6733 QUINCE ROAD,MEMPHIS,TN,38119,2020-02-21,690,D,0,1,R6M911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide care and services to maintain an indwelling urinary catheter for 1 of 2 sampled residents (Resident #103) reviewed for the use of an indwelling urinary catheters. The findings include: Review of the medical record, showed Resident #103 had [DIAGNOSES REDACTED]. Review of the (MONTH) 2020 Physician Orders, showed, .MAINTAIN PATENCY AND PLACEMENT OF #18FR (FRENCH) / 10CC (CUBIC CENTIMETERS) BULB INDWELLING FOLEY CATHETER EVERY SHIFT .FOLEY CATHETER CARE WITH SOAP AND WATER EVERY SHIFT . Review of the (MONTH) 2020 Medication Administration Record [REDACTED]. Review of the (MONTH) 2020 MAR, showed no documentation for catheter care for an indwelling urinary catheter from 2/8/2020 to 2/20/2020 on the 7:00 AM to 7:00 PM shift and on 2/12/2020, 2/13/2020, 2/14/2020, 2/16/2020, 2/17/2020, and 2/19/2020 on the 7:00 PM to 7:00 AM shift. Observation in the resident's room on 2/18/2020 at 4:37 PM, 2/19/2020 at 4:56 PM, and 2/20/2020 at 7:48 AM, showed Resident #103 had an indwelling urinary catheter. During an interview conducted on 2/21/2020 at 2:45 PM, the Interim Director of Nursing (DON) confirmed that nursing staff should have documented maintenance and placement for the use of an indwelling urinary catheter and should have documented indwelling urinary catheter care every shift as ordered.",2020-09-01
938,"QUINCE NURSING AND REHABILITATION CENTER, L L C",445197,6733 QUINCE ROAD,MEMPHIS,TN,38119,2020-02-21,732,E,0,1,R6M911,"Based on document review and interview, the facility failed to document the total number of actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care on every shift on the staffing postings and failed to have staffing postings completed and available for 24 of 76 days of staffing postings (12/2/2019, 12/3/2019, 12/4/2019, 12/5/2019, 12/6/2019, 12/7/2019, 12/8/2019, 12/9/2019, 12/12/2019, 12/14/2019, 12/15/2019, 12/25/2019, 1/7/2020, 1/8/2020, 2/1/2020, 2/2/2020, 2/3/2020, 2/4/2020, 2/10/2020, 2/11/2020, 2/12/2020, 2/13/2020, 2/14/2020, and 2/17/2020) reviewed. The findings include: Review of the staffing postings between 12/1/19 and 2/18/2020, showed the facility did not document actual Registered Nurse hours worked on 12/2/2019, 12/3/2019, 12/4/2019, 12/6/2019, 12/7/2019, 12/8/2019, 12/25/2019, 1/7/2020, 1/8/2020, 2/3/2020, 2/4/2020, 2/11/2020, 2/12/2020, 2/13/2020, 2/14/2020, and 2/17/2020. Review of the staffing postings between 12/1/2019 and 2/18/2020, showed the facility did not document actual Licensed Practical Nurse and Certified Nursing Assistant hours worked on 12/2/2019, 12/3/2019, 12/5/2019, 12/6/2019, 12/7/2019, 12/8/2019, 12/9/2019, 12/12/2019, 1/7/2020, 1/8/2020, 2/10/2020, 2/11/2020, 2/12/2020, 2/13/2020, and 2/14/2020. The facility was unable to provide staffing postings for 12/14/2019, 12/15/2019, 2/1/2020, and 2/2/2020. During an interview conducted on 2/20/2020 at 6:13 PM, the Director of Nursing confirmed the staffing postings were inaccurate.",2020-09-01
939,"QUINCE NURSING AND REHABILITATION CENTER, L L C",445197,6733 QUINCE ROAD,MEMPHIS,TN,38119,2020-02-21,758,E,0,1,R6M911,"**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 residents who received [MEDICAL CONDITION] medications were appropriately monitored for side effects and behaviors for 5 of 7 sampled residents (Resident #27, #100, #104, #111, and #283) reviewed for unnecessary medications. The findings include: Review of the facility's policy titled, SUBJECT: Behavior Management and Psycho-pharmological Medication Monitoring Protocol, dated 3/2018, showed that medication side effects and resident behaviors should be monitored for residents receiving antipsychotic, anti-depressant, sedative/hypnotic, or anti-anxiety ([MEDICAL CONDITION]) medications. 1. Review of the medical record showed, Resident #27 had a [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED].[MEDICATION NAME] HCL ([MEDICATION NAME]) (an antidepressant) 100 MG (milligrams) .TWO .TABLETS .BY MOUTH EVERY EVENING . Review of the (MONTH) 2019, (MONTH) 2020, and (MONTH) 2020 Medication Administration Record [REDACTED]. 2. Review of the medical record showed, Resident #100 had a [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED].[MEDICATION NAME] HCL (an antianxiety medication) 10MG TABLET ONE (1) TABLET BY MOUTH TWICE DAILY .[MEDICATION NAME] HCL (an antidepressant medication) 40MG TABLET ONE TABLET BY MOUTH . Review of the (MONTH) 2019, (MONTH) 2020, and (MONTH) 2020 Medication Administration Record [REDACTED]. During an interview conducted on 2/21/2020 at 9:41 AM, the Interim Infection Control Preventionist confirmed that Resident #27 and Resident #100 did not have behavior or side-effects monitoring for the use of a [MEDICAL CONDITION] medication. 3. Review of the medical record, showed Resident #104 had [DIAGNOSES REDACTED]. The Physician order [REDACTED].[MEDICATION NAME] (an antianxiety medication) 0.5 MG .ONE .TABLET BY MOUTH TWICE DAILY .[MEDICATION NAME] (an antianxiety medication) .250 MG .ONE .TABLE BY MOUTH THREE TIMES DAILY . The Physician order [REDACTED].ONE .TABLET BY MOUTH TWICE DAILY . Review of the (MONTH) 2019, (MONTH) 2019, (MONTH) 2020, and (MONTH) 2020 MAR, showed no documentation of medication side effects and behavior monitoring for the use of a [MEDICAL CONDITION] medication. During an interview conducted on 2/21/2020 at 9:20 AM, the Interim Staff Development Coordinator confirmed medication side effects and behavior monitoring were not documented every shift for Resident #104. 4. Review of the medical record showed, Resident #111 had [DIAGNOSES REDACTED]. The Physician order [REDACTED].[MEDICATION NAME] (an antipsychotic medication) 50 MG .TAKE ONE TABLET BY MOUTH TWICE DAILY . The Physician order [REDACTED].[MEDICATION NAME] (an antidepressant medication) .7.5 MG .TAKE ONE TABLET BY MOUTH DAILY AT BEDTIME . Review of the (MONTH) 2019, (MONTH) 2019, (MONTH) 2020, and (MONTH) 2020 MAR, showed no documentation of medication side effects and behavior monitoring for the use of a [MEDICAL CONDITION] medication. During an interview conducted on 2/21/2020 at 9:22 AM, the Interim Staff Development Coordinator confirmed medication side effects and behavior monitoring were not documented every shift for Resident #111. 5. Review of the medical record showed, Resident #283 had a [DIAGNOSES REDACTED]. The Physician order [REDACTED].[MEDICATION NAME] (an antipsychotic medication) 5 MG .TAKE ONE TABLET BY MOUTH DAILY .ANXIETY DISORDER .[MEDICATION NAME] (an antidepressant medication) 20 MG .TAKE ONE TABLET BY MOUTH DAILY . Review of the (MONTH) 2020 MAR, showed no documentation of medication side effects and behavior monitoring for the use of a [MEDICAL CONDITION] medication. During an interview conducted on 2/21/2020 at 9:25 AM, the Interim Staff Development Coordinator confirmed medication side effects and behavior monitoring were not documented every shift for Resident #283.",2020-09-01
940,"QUINCE NURSING AND REHABILITATION CENTER, L L C",445197,6733 QUINCE ROAD,MEMPHIS,TN,38119,2020-02-21,880,E,0,1,R6M911,"**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 in 2 of 3 isolation rooms (Resident #107 and #163) and failed to maintain infection control practices when 2 of 6 nurses (Licensed Practical Nurse (LPN) #3 and #4) failed to perform proper hand hygiene, failed to clean a stethoscope, and failed to protect the feeding tube tip from being contaminated for 2 of 7 sampled residents (Resident #45 and #88) reviewed during medication administration observations. The findings include: Review of the facility's policy titled, .CONTACT PRECAUTIONS, dated 9/2019, showed that a door sign that reads Contact Precautions or Visitors Must See Nurse Before Entering must be on the door, a cart must be placed outside the room that contains a covered supply of personal protective equipment such as gowns, gloves, masks, and plastic bags, and personal protective equipment should be worn prior to entering the room. 1. Review of the medical record showed, Resident #107 had [DIAGNOSES REDACTED]. A Physician order [REDACTED].Isolation for ESBL (Extended Spectrum Beta-Lactamase) . Observation outside of the resident's room on 2/18/2020 at 12:39 PM, showed Certified Nursing Assistant (CNA) #1 entered Resident #107's room without donning personal protective equipment. CNA #1 came out of Resident #107's room and immediately entered another resident's room. Observation outside of the resident's room on 2/18/2020 at 12:48 PM, showed CNA #1 entered Resident #107's room without donning personal protective equipment, sat down beside his bed. CNA #1's clothing came in contact with the the bed linens as she began to assist Resident #107 to eat lunch. During an interview conducted on 2/21/2020 at 9:50 AM, the Interim Infection Control Preventionist confirmed all staff should don personal protective equipment any time they enter an isolation room, and it should be removed before they leave the room. 2. Review of the medical record showed, Resident #163 had [DIAGNOSES REDACTED]. A Physician order [REDACTED].CONTACT ISOLATION .VRE ([MEDICATION NAME] Resistant [MEDICATION NAME]) ABDOMINAL WOUND ABSCESS . Observation outside of Resident #163's room on 2/18/2020 at 9:45 AM, 12:39 PM, and 3:49 PM, showed an isolation cart was beside the door and there was no sign on the door. During an interview conducted on 2/21/2020 at 9:55 AM, the interim Infection Control Preventionist confirmed when a resident is in isolation there should be a sign on the door the entire time the resident is in isolation. 3. Observation in the resident's room on 2/19/2020 at 5:05 PM, showed LPN #3 was preparing to administer Resident #88's medication. LPN #3 washed her hands, donned gloves, removed her gloves, picked up a tissue off of the floor, handled the bed remote, and raised the head of the bed. LPN #3 administered medications to Resident #88 and went back to the medication cart. LPN #3 failed to perform hand hygiene between glove changes and after handling items in the room with the same gloves. Observation in the resident's room on 2/19/2020 at 5:45 PM, showed LPN #4 was preparing to administer Resident #45's medication via a Percutaneous Endoscopic Gastrostomy (PEG) tube. LPN #4 washed her hands, donned gloves, placed the pump on hold, raised the head of the bed with the remote, reached into her pocket with the syringe/plunger in her hand, pulled out an alcohol pad, cleaned her stethoscope, and placed it back around her neck. LPN #4 disconnected the tubing and the tip was hanging down, touching the feeding pump. LPN #4 then checked for PEG placement with the stethoscope and administered the PEG medications. LPN #4 did not clean the stethoscope after use. During an interview conducted on 2/20/2020 at 10:13 AM, the Director of Nursing (DON) confirmed equipment should be cleaned before and after each use. During an interview conducted on 2/21/2020 at 3:50 PM, the Interim DON confirmed hands should be washed in between glove changes and after handling items in the environment. The Interim DON confirmed stethoscopes should not be placed around the neck prior to use and the stethoscope should be cleaned prior to and after use. The Interim DON confirmed the PEG tubing tip should be protected from contamination while administering PEG medications.",2020-09-01
941,"QUINCE NURSING AND REHABILITATION CENTER, L L C",445197,6733 QUINCE ROAD,MEMPHIS,TN,38119,2019-04-03,636,E,0,1,VQY911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to complete a comprehensive assessment, using the Centers for Medicare & Medicaid Services-specified RAI process within the regulatory time frames for 9 of 53 (Resident #1, 14, 16, 19, 21, 27, 38, 48, and 386) sampled residents reviewed. The findings include: 1. The MDS 3.0 RAI Manual v (version) 1.16 (MONTH) 1, (YEAR) pages 2-20 through 2-22 documented, .The Admission assessment .must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 .The MDS completion date (Item Z0500B) must be no later than day 14 .The Annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days) .The ARD (Assessment Reference Date) (Item A2300) must be set within 366 days after the ARD of the previous OBRA comprehensive assessment (ARD of previous comprehensive assessment + 366 calendar days) AND within 92 days since the ARD of the previous OBRA Quarterly .The MDS completion date (Item Z0500B) must be no later than 14 days after the ARD . 2. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS with an ARD of 3/15/19 revealed Item Z0500B was not completed. The admission MDS assessment should have been completed by 4/2/19 but had never been completed. 3. Medical record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS with an ARD of 2/14/19 revealed Item Z0500B was not completed. The annual MDS assessment should have been completed by 2/28/19 but had never been completed. 4. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS with an ARD of 2/17/19 revealed Item Z0500B was not completed. The annual MDS assessment should have been completed by 3/3/19 but had never been completed. 5. Medical record review revealed Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS with an ARD of 2/17/19 revealed Item Z0500B was not completed. The annual MDS assessment should have been completed by 3/3/19 but had never been completed. 6. Medical record review revealed Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS with an ARD of 2/19/19 revealed Item Z0500B was not completed. The annual MDS assessment should have been completed by 3/5/19 but had never been completed. 7. Medical record review revealed Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS with an ARD of 2/24/19 revealed Item Z0500B was not completed. The annual MDS assessment should have been completed by 3/10/19 but had never been completed. 8. Medical record review revealed Resident #38 was admitted to the facility on [DATE] with readmission on 2/20/19 with [DIAGNOSES REDACTED]. Review of the annual MDS dated [DATE] revealed Item Z0500B was not completed. The annual MDS assessment was due to be completed by 3/14/19 but had never been completed. 9. Medical record review revealed Resident #48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS with an ARD of 3/18/19 revealed Item Z0500B was not completed. The annual MDS assessment should have been completed by 4/1/19 but was never completed. 10. Medical record review revealed Resident #386 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS with an ARD of 3/20/19 revealed Item Z0500B had not been completed. The admission MDS assessment should have been completed by 3/25/19 but had never been completed. Interview with MDS Coordinator #1 on 4/03/19 at 12:59 PM, in the MDS Office, MDS Coordinator #1 confirmed Resident #1's admission assessment was not completed timely. Interview with MDS Coordinator #2 on 4/3/19 at 4:08 PM, in the MDS Office, MDS Coordinator #2 confirmed the MDS assessments for Resident #14, 16, 19, 21, and 27 were not completed timely. Interview with the Director of Nursing (DON) on 4/3/19 at 4:50 PM, in the Conference Room, the DON was asked do you expect MDS assessments to be completed timely. The DON stated, I do.",2020-09-01
942,"QUINCE NURSING AND REHABILITATION CENTER, L L C",445197,6733 QUINCE ROAD,MEMPHIS,TN,38119,2019-04-03,638,E,0,1,VQY911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to complete quarterly assessments, using the Centers for Medicare & Medicaid Services-specified RAI process within the regulatory time frames for 19 of 53 (Resident #7, 8, 9, 10, 11, 12, 15, 17, 20, 22, 23, 24, 25, 26, 28, 29, 42, 45 and 144) sampled residents reviewed. The findings include: 1. The MDS 3.0 RAI Manual v (version) 1.16 (MONTH) 1, (YEAR) page 2-33 documented, .The Quarterly assessment must be completed at least every 92 days following the previous OBRA assessment of any type .The ARD (Assessment Reference Date) (A2300) must be not more than 92 days after the ARD of the most recent OBRA assessment of any type . The MDS completion date (Item Z0500B) must be no later than 14 days after the ARD (ARD + 14 calendar days) . 2. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD of 2/5/19 revealed Item Z0500B was not completed. The quarterly MDS assessment should have been completed by 2/19/19, but was never completed. 3. Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD of 2/7/19 revealed Item Z0500B was not completed. The quarterly MDS assessment should have been completed by 2/21/19 but had never been completed. 4. Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD of 2/10/19 revealed Item Z500B was not completed. The quarterly MDS assessment should have been completed by 2/24/19 but had never been completed. 5. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD of 2/7/19 revealed Item Z500B was not completed. The quarterly MDS assessment should have been completed by 2/21/19 but had never been completed. 6. Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD of 2/10/19 revealed Item Z500B was not completed. The quarterly MDS assessment should have been completed by 2/24/19 but had never been completed. 7. Medical record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD of 2/10/19 revealed Item Z500B was not completed. The quarterly MDS assessment should have been completed by 2/24/19 but had never been completed. Interview with MDS Coordinator #1 on 4/3/19 at 4:03 PM, in the MDS Office, MDS Coordinator #1 confirmed Resident #12's 2/10/19 MDS was not completed. 8. Medical record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD of 2/12/19 revealed Item Z500B was not completed. The quarter;y MDS assessment should have been completed by 2/26/19 but had never been completed. 9. Medical record review revealed Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD of 2/14/19 revealed Item Z500B was not completed. The quarterly MDS assessment should have been completed by 2/28/19 but had never been completed. 10. Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD of 2/17/19 revealed Item Z500B was not completed. The quarterly MDS assessment should have been completed by 3/3/19 but had never been completed. 11. Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD of 2/14/19 revealed Item Z500B was not completed. The quarterly MDS assessment should have been completed by 2/28/19 but had never been completed. 12. Medical record review revealed Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD of 2/12/19 revealed Item Z500B was not completed. The quarterly MDS assessment should have been completed by 2/26/19 but had never been completed. 13. Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD of 2/12/19 revealed Item Z500B was not completed. The quarterly MDS assessment should have been completed by 2/26/19 but had never been completed. 14. Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD of 2/20/19, which should have been completed by 3/5/19, and was not completed until 4/3/19. The quarterly MDS assessment was not completed timely. Interview with MDS Coordinator #2 on 4/3/19 at 4:06 PM, in the MDS Office, MDS Coordinator #2 confirmed Resident #25's 3/5/19 MDS was not completed timely. 15. Medical record review revealed Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD of 2/27/19 revealed Item Z500B was not completed. The quarterly MDS assessment should have been completed by 3/13/19 but had never been completed. 16. Medical record review revealed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD of 2/24/19 revealed Item Z500B was not completed. The quarterly MDS assessment should have been completed by 3/10/19 but had never been completed. 17. Medical record review revealed Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD of 2/19/19 revealed Item Z500B was not completed. The quarterly MDS assessment should have been completed by 3/5/19 but had never been completed. 18. Medical record review revealed Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS assessment that should have been completed in (MONTH) (YEAR) was never scheduled to be completed. 19. Medical record review revealed Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD of 3/7/19 revealed Item Z500B was not completed. The quarterly MDS assessment should have been completed by 3/21/19 but had never been completed. 20. Medical record review revealed Resident #144 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS assessment should have been completed in (MONTH) 2019. The facility failed to schedule the assessment to be completed. Interview with MDS Coordinator #2 on 4/3/19 at 4:05 PM, in the MDS Office, MDS Coordinator #2 was asked if Resident #144 should have had a quarterly MDS completed. MDS Coordinator #2 stated, Should have had one in March. Interview with MDS Coordinator #2 on 4/3/19 at 4:08 PM, in the MDS Office, MDS Coordinator #2 confirmed the MDS assessments for Resident #7, 8, 9, 10, 11, 15, 17, 20, 23, 24, 26, 28, and 45 were incomplete not completed timely. Interview with the Director of Nursing (DON) on 4/3/19 at 4:50 PM, in the Conference Room, the DON was asked if she expected MDS assessments to be completed timely. The DON stated, I do.",2020-09-01
943,"QUINCE NURSING AND REHABILITATION CENTER, L L C",445197,6733 QUINCE ROAD,MEMPHIS,TN,38119,2019-04-03,640,D,0,1,VQY911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to complete and transmit MDS assessments timely for 2 of 53 (Resident #4 and 6) residents reviewed for Resident Assessment and transmission. The finding include: 1. The MDS 3.0 RAI Manual v (version) 1.16 (MONTH) 1, (YEAR) page 664 documented, . Assessment Transmission .MDS assessments must be submitted within 14 days of the MDS Completion Date . 2. Medical record review revealed Resident #4 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Resident #4 had a discharge MDS assessment with an ARD of 11/1/18 and a completion date of 11/7/18. The discharge MDS assessment should have been transmitted by 11/21/18 but had not been transmitted. 3. Medical record review revealed Resident #6 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Resident #6 had a discharge MDS assessment with an ARD of 11/21/18 and a completion date of 12/5/18. The discharge assessment should have been transmitted by 12/19/19 but had not been transmitted. Interview with MDS Coordinator #1 on 4/3/19 at 4:05 PM, in the MDS Office, MDS Coordinator #1 was asked if the Discharge assessment dated [DATE] for Resident #6 should have been transmitted. MDS Coordinator #1 stated, I don't know why it wasn't. MDS Coordinator #1 was asked if the Discharge assessment dated [DATE] on Resident #4 should have been transmitted. MDS Coordinator #1 stated, Yes. Interview with the Director of Nursing (DON) on 4/3/19 at 4:50 PM, in the Conference Room, the DON was asked if she expected the MDS to be completed and transmitted timely. The DON stated, I do.",2020-09-01
944,"QUINCE NURSING AND REHABILITATION CENTER, L L C",445197,6733 QUINCE ROAD,MEMPHIS,TN,38119,2019-04-03,656,D,0,1,VQY911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, policy review, medical record review, and interview, the facility failed to complete a comprehensive care plan for 1 of 33 (Resident #171) sampled residents reviewed. The findings include: The MDS 3.0 RAI Manual v (version) 1.16 (MONTH) 1, (YEAR) page 43-44 documented, .The Admission assessment is a comprehensive assessment .that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 .The MDS completion date (Item Z0500B) must be no later than day 14 .The CAA (Care Area Assessment)(s) completion date (Item V0200B2) must be no later than day 14 .The care plan completion date (Item V0200C2) must be no later than 7 calendar days after the CAA(s) completion date (Item V0200B2) (CAA(s) completion date + 7 calendar days) . The facility's Comprehensive Person Centered Care Plans policy documented, .The Comprehensive Person Centered Care Plan shall be fully developed within 7 days after completion of the Admission MDS Assessment . Medical record review revealed Resident #171 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A comprehensive care plan should have been developed by 2/12/19. The facility was unable to provide a comprehensive care plan for Resident #171. Interview with Licensed Practical Nurse (LPN) #1 on 4/3/19 at 5:30 PM, LPN #1 was asked if Resident #171 had a comprehensive care plan. LPN #1 stated, No.",2020-09-01
945,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2018-01-22,758,D,0,1,JYC211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to determine a stop date for PRN (as needed) [MEDICAL CONDITION] medications for 1 of 5 sampled residents (Resident #64) reviewed prescribed [MEDICAL CONDITION] medications. Findings include: Medical record review revealed Resident #64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physician order [REDACTED]. Continued review revealed an order dated 11/2/17 for [MEDICATION NAME] (antidepressant also used for [MEDICAL CONDITION]) 50 mg by mouth at bedtime PRN for depression, (sleeplessness) with no stop date. Interview with the Director of Nursing on 1/22/18 at 12:00 PM in the conference room confirmed the facility failed to determine a stop date for PRN [MEDICAL CONDITION] medications for Resident #64.",2020-09-01
946,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2018-01-22,812,D,0,1,JYC211,"Based on facility policy review, observation and interview, the facility failed to maintain 2 of 4 resident refrigerators and 2 of 3 ice machines in a sanitary manner. The findings included: Review of facility policy, unnamed, dated 9/2016 revealed, .Refrigerators in the Nursing Stations will be kept clean, free of debris, and mopped with sanitizing solution on a weekly basis and more often as necessary . Observation and interview on 1/18/18 at 12:26 AM in the 2nd Floor Nourishment Room with the Registered Nurse (RN) #1/Unit Manager present revealed brown dried debri on the shelves and door of the resident refrigerator. Continued observation of the ice machine on the interior upper portion revealed black debri. Interview with the Unit Manager confirmed the facility failed to maintain the resident refrigerator and the ice machine in a sanitary manner. Observation and interview on 1/18/18 at 12:29 PM in the 3rd Floor Nourishment Room with the RN #1/Unit Manager present revealed dried brown liquid on the shelves of the resident refrigerator. Further observation of the ice machine on the interior upper portion revealed black debri. Interview with the Unit Manager confirmed the facility failed to maintain the resident refrigerator and the ice machine in a sanitary manner.",2020-09-01
947,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2018-01-22,880,E,0,1,JYC211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation and interview the facility failed to clean resident care equipment in a sanitary manner for 1 of 17 sampled residents (Resident #56) reviewed. Findings Include: Review of Cleaning and Disinfection of Resident-Care Items and Equipment dated 9/1/10 and revised 11/2011 revealed, .Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC (Centers for Disease Control and Prevention) recommendations for disinfection and the OSHA (Occupational Safety and Health Administration) Bloodborne Pathogens Standard .Patients can be exposed to potentially pathogenic organisms in several ways, including .Improper glove use (e.g., utilizing a single pair of gloves for multiple tasks or multiple patients) . Medical record review revealed Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident was placed on isolation precautions on 12/11/17 for VRE ([MEDICATION NAME]-Resistant [MEDICATION NAME]; type of bacterial infection) in the sputum and urine. Observation on 1/18/18 at 8:45 AM in Resident #56 room revealed Licensed Practical Nurse (LPN) #1 donned a mask, gloves and disposable gown as the resident was on isolation. Continued observation revealed the LPN took a rolling vital sign machine into the room to check the resident's vital signs and placed the blood pressure cuff on the residents left arm. Continued observation revealed after the LPN obtained the vital signs he rolled the machine to the doorway of the room and proceeded to clean the machine, blood pressure cuff and tubing with a bleach sani-wipe without changing into clean gloves or sanitizing his hands. Further observation revealed after the LPN cleaned the vital sign machine with dirty gloves he placed it in the hallway for resident use. Interview with LPN #1 on 1/18/18 at 8:53 AM on the 2 West hall confirmed he failed to change gloves, sanitize his hands, and don clean gloves prior to disinfecting reusable resident care equipment.",2020-09-01
948,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2019-01-30,812,F,0,1,V3LN11,"Based on observation and interview, the facility dietary department failed to maintain dietary equipment in a sanitary manner in 1 of 4 observations of the dietary department. The findings include: Observation on 1/28/19 at 5:10 AM in the dietary department revealed the reach-in refrigerator next to the trayline had red dried spattered debris on the bottom interior surface. Observation on 1/28/19 at 7:00 AM in the dietary department revealed the 6 gas burner range top foil lined spill pan had a heavy accumulation of dried food debris. Further observation revealed all the hood filters over the production equipment, including fryer, range top, steamer, convection oven, grill and range top combination, had an accumulation of blackened debris and grease accumulation in the filters in the hood. Observation of the interior and exterior of the convection oven doors revealed a sticky brown accumulation of debris. Observation of the corners of the grill revealed a heavy accumulation of blackened debris. Observation of the 2 gas burner range, attached to the grill, revealed the foil lined spill pan had a heavy accumulation of dried food debris. Observation revealed the reach-in refrigerator next to the trayline had red dried spattered debris on the bottom interior surface. Observation on 1/28/19 at 9:55 AM in the dietary department dishroom, with the Director of Dietary Services present, revealed the dish machine was in operation and dishes were being stored in the clean areas. Further observation revealed a wall mounted fan in operation and directed at the clean dishes. Further observation revealed the fan grate, the blades and the wall surrounding the fan had a blackened accumulation of debris and could contaminate the cleaned dishes. Observation and interview, with the Director of Dietary Services, on 1/28/19 at 10:00 AM in the dietary department confirmed the dietary equipment, including the reach-in refrigerator by the trayline, the 6 and 2 burner range top spill pans, the grill, the filters in the hood, the convection oven doors, and the wall mounted fan in the dishroom, had not been maintained in a sanitary manner.",2020-09-01
949,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2019-01-30,880,D,0,1,V3LN11,"**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 have appropriate signage for transmission-based precautions for 1 (#9) of 21 residents reviewed on transmission-based precautions. The findings include: Review of the facility policy, Isolation, dated 10/2016 revealed .Transmission-Based Precautions shall be used when caring for resident who are documented or suspected to have communicable diseases .Signs--use coded signs and/or other measures to alert staff of the implementation of Isolation or Droplet Precautions .place a sign at the doorway . Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #9 had an infection requiring transmission based precautions. Medical record review of a comprehensive care plan dated 1/24/19 revealed Resident #9 was monitored and assessed for transmission based precautions both contact and droplet. Continued review revealed the transmission based precautions were for[DIAGNOSES REDACTED] and CRPA, respectively. Observation of Resident #9's doorway on 1/28/19 at 5:37 AM and 3:10 PM on the 3rd floor west hall revealed no signage identifying transmission based precautions required. Interview with Licensed Practical Nurse (LPN) #1 on 1/28/19 at 5:37 AM at the 3rd floor west hall medication cart confirmed Resident #9 was on contact and droplet transmission based precautions for[DIAGNOSES REDACTED] and CRPA respectively. Interview with LPN #4 and Registered Nurse (RN) #1 on 1/28/19 at 3:10 PM in the 3rd floor west hall confirmed no signage to indicate transmission based precautions was present on Resident #9's doorway.",2020-09-01
950,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2017-09-20,221,D,1,0,SMVC11,"**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 1 resident (#4) of 11 residents reviewed was free of a physical restraint unless it was needed to treat an assessed medical symptom. Resident #4 was restrained in bed through the use of 4 side rails. The restraint was used without assessment for its need, without less restrictive measures attempted prior to its use, without a medical symptom justifying the use of the restraint, and without a physician's orders [REDACTED]. The findings included: Review of facility policy, Restraint Management, revealed Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff conveniences or for the prevention of falls. Physical restraints include, but are not limited to .side rails. Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including: Using side rails that keep a resident from voluntarily getting out of bed. Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention AND a restraint is required to: a. Treat the medical symptom; b. Protect the resident's safety; and c. Help the resident attain the highest level of his/her physical or psychological well being. Prior to applying a restraint, one must have an order for [REDACTED]. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review of the MDS revealed Resident #4 required extensive assistance from staff with bed mobility, transfers, and locomotion, and had no restraints. Review of the medical record revealed no evidence of Physician Orders, Assessment, or Consent for the use of a restraint. Continued review revealed no evidence of an assessment for the use of side rails. Review of the current care plan, with a goal date of 10/17/17, revealed conflicting information about the use of side rails. Review of the Care Plan revealed Self Care Deficit, with approaches including, 7/4/17 .1/4 (one quarter) length side rails up times 2 when in bed to enable participation with bed mobility. However, review of the Care Plan for Fall Risk revealed an approach dated 7/26/17 Staff to ensure placement and raising of lower bedrail to amputation side of the bed in order to assist with safety during sleep. Note: (Resident #4) will still be able to get OOB (out of bed) to her strong side. Observation on 9/18/17 at 8:35 AM and 1:49 PM revealed Resident #4 was asleep in bed. She had 2 one half side rails raised on each side of the bed. The use of these 4 partial rails resulted in the effect of 2 full side rails which blocked normal egress from the bed. Interview on 9/18/17 at 1:52 PM with Certified Nurse Aide (CNA) #3, in the hallway outside the resident's room, confirmed the resident had 4 side rails up while she was asleep in bed. CNA #3 stated she always used all 4 side rails when Resident #4 was in bed. She stated the resident had a leg amputation earlier this year, and After she came back from the hospital, we was (were) told to use all 4 side rails with her because she's a fall risk. Further interview with CNA #3 revealed the use of the 4 side rails restricted the resident's normal movement of exit/entry from the bed, as she stated, Just last week, I found her sliding out the end of the bed when all 4 side rails were raised. Interview on 9/18/17 at 1:55 PM with Licensed Practical Nurse (LPN) #1, in the hallway outside the resident's room, revealed staff were only supposed to use 2 side rails, because if they used all 4 side rails, It would be a restraint. CNA #3, who was present during this interview, confirmed all 4 side rails would constitute a restraint, saying, That's right. However, CNA #3 added, I was told to use all 4 because she's a fall risk. Interview with the Director of Nursing (DON) on 9/18/17 at 2:10 PM, in the first floor administrative wing confirmed, We have not historically done any assessment for side rails. She stated the facility was in the process of adding this to the admission packet, but confirmed no side rail or restraint assessments had been completed for Resident #4. The DON stated 4 side rails constituted a restraint for Resident #4, based on her physical condition. Further interview with the DON revealed she was unaware staff were using all 4 side rails when the resident was in bed, and the resident had no medical symptom to justify the use of a restraint.",2020-09-01
951,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2017-09-20,223,D,1,0,SMVC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility investigation, observation, review of a Tek-Care Report and interview, the facility failed to prevent Verbal Abuse for 1 resident (#5) and Neglect for 1 resident (#6) of 7 residents reviewed for abuse. The findings included: Review of facility policy, Abuse Prevention, revised 4/1/17 revealed, .Abuse .will not be tolerated by anyone, including staff .Neglect occurs when facility staff fails to monitor and/or supervise the delivery of patient care and services to assure the care is provided as needed for the resident .Verbal Abuse: The use of oral .language that willfully includes disparaging and derogatory terms to the residents .or within hearing distance . Medical record review revealed Resident #5 was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was cognitively intact, bed bound, and required extensive assistance from 2 or more people for bed mobility; extensive assistance from 1 person for dressing, eating, and hygiene; was totally dependent with 2 or more people needed for bathing and toileting. Continued review revealed the resident was always incontinent of bladder and frequently incontinent of bowel. Review of a facility investigation dated 6/27/17 at 2:45 PM revealed Certified Nurse Aide (CNA) #6 was providing incontinence care to Resident #5 when 2 Licensed Practical Nurses (LPNs) and another CNA entered the resident's room and CNA #6 told them she was not catering to her ass, the resident got on her nerves, and she had been on the call light all day. Continued review of a handwritten statement from LPN #5 dated 6/27/17 revealed, .walked into (Resident #5's) room and (CNA #6) was changing her. I overheard her say to (Resident #5) .she doesn't have time for this[***]and I'm not catering to her ass. She gets on my nerves, she's been on the call light all day .(CNA #6) said 'f*** this[***] packed up the dirty linen and left .(Resident #5) was in tears . Continued review revealed handwritten statements from LPN #6 and CNA #8 dated 6/27/17 corroborated the same details. Further review of a statement from Resident #5 taken by the Director of Nursing (DON) on 6/28/17 revealed the resident stated, .(CNA #6) kept yelling at her and saying she cannot keep coming in there and change her .when other staff named (LPN #6, LPN #5, and CNA #8) were in the room that (CNA #6) stated she didn't have time to cater to her ass . Observation and interview of Resident #5 on 9/19/17 at 8:55 AM in the resident's room revealed the resident was awake, alert, oriented, on the ventilator and unable to speak out loud. Continued observation revealed the resident was able to nod yes or no and mouthed words when spoken to. Interview with the resident revealed she was able to confirm the facts were the same as written by LPN #5. Interview with LPN #5 on 9/18/17 at 10:30 AM in the conference room revealed, .(Resident #5) was crying and (CNA #6) was cleaning her up and telling her she wasn't catering to her ass .asked her (CNA #6) to leave because she was being aggressive and she said 'F*** this[***] and left .(Resident #5) was still crying and pointed to the door and mouthed 'I don't want her back in my room . Continued interview confirmed the interaction between the resident and CNA #6 was reported immediately to the DON and LPN #5 wrote a statement of the event. Interview with the DON on 9/19/17 at 10:50 AM in the conference room confirmed allegations of verbal abuse to Resident #5 from CNA #6 were substantiated by the facility and CNA #6 was terminated. Continued interview revealed the DON confirmed the facility failed to prevent verbal abuse to Resident #5. Medical record review revealed Resident #6 was admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a 30 day MDS dated [DATE] revealed Resident #6 was cognitively intact with modified independence, and altered level of consciousness that fluctuated; was bed bound and was dependent with assistance of 1 person required for bed mobility, dressing, eating, hygiene, bathing and toileting. Continued review revealed the resident had bilateral upper extremity impairments and received services from Respiratory Therapy for oxygen, suctioning, [MEDICAL CONDITION] care and ventilator care. Review of a facility investigation dated 7/26/17 revealed Resident #6 pushed his call light between 8:00 AM and 8:30 AM and told CNA #5 he needed Respiratory Therapy. The CNA told Respiratory Therapist (RT) #1 the resident requested him and he said OK. The resident pushed his call light a 2nd time and CNA #8 answered the call light and was told he needed respiratory because he couldn't breathe. The CNA informed RT #1 and he said OK, thanks. Approximately 5 minutes later the call light went off a 3rd time and CNA #8 answered it and the resident again stated he needed respiratory and he couldn't breathe. The CNA asked if RT #1 had made it in yet and the resident said No. The CNA said she would let him know again and found RT #1 sitting at a table in the hallway charting. CNA #8 told him Resident #6 still needed him because he said he couldn't breathe, and the RT smiled and said OK, thanks. The resident pushed his call light a 4th time and CNA #5 and LPN #7 entered the resident's room and he asked to be transferred out of the facility because he didn't feel safe. Review of handwritten statements in the facility investigation from CNA #5, and CNA #8 dated 7/26/17 corroborated the allegations above. Continued review of LPN #7's written statement revealed, .Resident requested to be 'sent out' .asked what was going on Resident stated, 'I don't feel safe here' .asked why he felt unsafe and who made him feel unsafe .(RT #1) .made him feel uneasy .Resident stated, 'I couldn't breathe and the alarm was going off.' The tech entered the room and resident asked for (RT #1) and he never came. A 2nd tech came and resident requested to see (RT #1) and he finally came. Resident stated, '(RT #1) chewed me out. He told me it was the same people everyday and he wasn't dealing with this crap today.' He turned off the alarm and walked out.' The resident stated, 'I'd rather die than feel the way he makes me feel' . Interview with the RT Director on 9/20/17 at 1:20 PM in the 2nd floor dining room stated she took over RT #1's assignment the morning of 7/26/17. Continued interview revealed the Nurse Practitioner asked her to assess Resident #6's respiratory status as she had heard wheezes in his lungs. Continued interview confirmed the resident had coarse wheezes and the RT Director gave him a PRN (as needed) breathing treatment per the physician's orders [REDACTED].#6 to be believable, she stated, Yes, I do with this situation. Interview with CNA #5 on 9/20/17 at 1:35 PM in the 2nd floor dining room confirmed she had answered the call light of Resident #6 on 7/26/17 between 8:00 AM and 8:30 AM the first time and told RT #1 the resident needed him. Continued review revealed CNA #5 and CNA #8 were working together in another resident's room and CNA #5 was able to confirm CNA #8 answered the resident's call light 2 more times and reported to RT #1 the resident needed him both times. Further interview revealed when the resident's call light went off a 4th time both she and LPN #7 entered the resident's room together and the CNA heard the resident say I want to be moved out, I don't feel safe here. Continued interview revealed LPN #7 asked the resident what was the problem, and the resident said (RT #1) said I'm not dealing with this crap today and turned off my alarms and left. Review of a Tek-Care Report dated 7/31/17 revealed the ventilator alarm for Resident #6 went off on 7/26/17 at 8:49:42 AM and alarmed for 5 minutes, 18 seconds. Continued review revealed the oxygen saturation alarm went off on 7/26/17 at 8:49:53 AM and alarmed for 3 minutes, 44 seconds. Interview with the DON on 9/20/17 at 3:36 PM in the conference room revealed RT #1 was terminated. Continued interview confirmed the DON found the written statements dated 7/26/17 by facility staff regarding events occurring to Resident #6 to be truthful. Continued interview confirmed the facility failed to respond to ventilator and oxygen saturation alarms timely, and failed to provide care and assistance to Resident #6 as requested resulting in neglect to the resident.",2020-09-01
952,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2017-09-20,225,E,1,0,SMVC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of facility investigation, and interview, the facility failed to report timely, thoroughly investigate, and/or report investigative findings within 5 working days to the State Agency for an injury of unknown origin for 2 residents (#4, #7) and allegations of abuse for 1 resident (#5) of 7 residents reviewed for abuse. The findings included: Medical record review revealed Resident #4's Admission notes revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review admission Minimum Data Set (MDS), dated [DATE] revealed the resident was cognitively impaired, and required limited assistance with bed mobility, transfers and walking in her room. The resident had no functional limitations to range of motion, but was not steady in transfers, and was only able to stabilize herself during transfers with staff assistance. She was assessed as at risk for falls. Review of Resident #4's Progress Notes dated 5/14/17 revealed the resident complained of pain to her left leg. No falls were documented in the record, and the Progress Notes included there was no visible injury. Continued review of the Progress Notes dated 5/15/17 revealed the resident was sent out to the hospital for evaluation when the pain worsened. She returned from the hospital the same day with changes to her [MEDICATION NAME] order and a [DIAGNOSES REDACTED]. Review of Resident #4's Progress Notes dated 5/18/17 revealed on 5/17/17 the resident continued to have pain in the left leg. The nurse Noted visual quivering of thigh muscle left. Pt (patient) reports increased pain with muscle spasms. Review of Resident #4's Progress Notes dated 5/19/17 revealed, the resident was sent to the ER (emergency room ) for eval (evaluation) and TX (treatment) r/t (related to) recent x-ray of the left hip. Review of the x-ray report dated 5/19/17 revealed the resident had increased pain, decreased mobility, and the x-ray showed an acute [MEDICAL CONDITION] femoral neck. Review of the Progress Notes the resident was hospitalized from [DATE] - 5/24/17 when she was readmitted to the facility with new [DIAGNOSES REDACTED]. Review of Resident #4's clinical record revealed no evidence as to how the left [MEDICAL CONDITION] occurred. Review of the facility's investigation revealed an investigation was started on 5/19/17 when the x-ray indicated a [MEDICAL CONDITION] and there was no known etiology. The allegation of injury of unknown origin was not reported to the State Survey Agency (SSA) until 3 days later, on 5/22/17. Further review of the facility investigation by the survey team on 9/18/17 revealed no evidence the investigation was completed or that the facility had made a determination as to abuse/neglect which was not reported to the SSA within 5 working days. The investigation was not thorough and did not provide sufficient information to make a determination as to whether abuse/neglect occurred. The investigation contained no evidence of any interviews with staff to determine if they might have knowledge of how the fracture happened. The only interview documented was with the resident. There was no evidence the facility came to a conclusion about the injury of unknown origin, reported the results to the SSA or took action to prevent the potential for further abuse/neglect of the resident. Interview with the Director of Nursing (DON) on 9/18/17 at 2:27 PM verified the packet of information provided to the survey team was the complete investigation into Resident #4's injury of unknown origin. The DON stated the facility became aware of the injury of unknown origin on 5/19/17; however, it was not reported to the SSA until 5/22/17. When asked why the allegation of injury of unknown origin was not immediately reported to the SSA, the DON stated, I think I was trying to figure out what happened. The DON stated, at the time of Resident #4's injury, My understanding was that we had 24 hours (to report). The DON stated she believed the regulation is going to 2 hours in (MONTH) (2018), so we're doing that now. Further interview with the DON revealed she was unaware the changes regarding time frames for reporting had been in effect since (MONTH) 8, (YEAR), and the allegation of injury of unknown origin resulted in serious harm was required to be reported within 2 hours. The DON stated the facility was currently only submitting a follow-up to the SSA within 5 working days if the initial allegation included a named perpetrator of abuse or neglect. She stated she was unaware the 5-day follow-up report was required for all allegations, including injuries of unknown origin, that were reported to the SS[NAME] Further interview with the DON revealed staff should have been interviewed and witness statements should have been completed as part of a thorough investigation. She confirmed there were none present in the investigation file, and stated she could not explain why these were not done. The DON, who stated she was the abuse coordinator, stated, That's my frustration, I've not been shown how to complete an investigation. Interview with the DON on 9/18/17 at 2:35 PM revealed she had additional information about why the allegation of injury of unknown origin had not been reported timely. She stated staff learned of the fracture of unknown source on 5/19/17, which was a Friday. The DON stated the nurse who received the x-ray did not report the fracture to her, and she was unaware of the incident until she returned to work on Monday, 5/22/17. The DON stated when the nurse received the x-ray results indicating a fracture with no known origin, she should have called the DON, Quality Assurance (QA) Nurse, Administrator, or Social Worker. The DON stated any of these 4 staff could have reported the allegation to the SS[NAME] However, No one called and the administrative staff were not aware until the following Monday, when they then reported the allegation to the SS[NAME] Review of facility policy, Abuse Prevention, revised 4/1/17 revealed it did not include correct time frames for reporting abuse. This policy indicated, Any alleged incident of abuse or neglect will be reported immediately to the Administrator/Assistant Administrator and to other officials in accordance with State Law within 5 working days of the event. Further review of this policy revealed Any patient event that is reported to any staff .will be considered as possible abuse if it meets any of the following criteria .Any indication of possible willful infliction of injury to include unexplained bruising. Any partner having any knowledge .is required to report either verbally or in writing to their supervisor, to the facility social worker, the Director of Nursing/ADON (Assistant Director of Nursing) or the Administrator/Assistant Administrator. On 9/19/17 at 10:00 AM, the DON provided a second policy, titled, Abuse, Neglect, Misappropriation Protocol, revised 2/17. Interview with the DON revealed this was the correct abuse policy for the facility, and the policy dated 4/1/17 had been provided in error. Review of the second policy provided by the facility revealed To help with recognition of incidents of abuse, the following definitions of abuse are provided .Injury of unknown source is defined as an injury that meets both following conditions: a. source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and b. The injury is suspicious because of: i. the extent of the injury; or ii. the location of the injury (e.g. the injury is located in an area not generally vulnerable to trauma. The first policy provided time frames for the reporting of reasonable suspicion of a crime, depending on the seriousness of the event that leads to the reasonable suspicion, review of the second policy revealed it did not address time frames for reporting allegations of abuse and neglect to the SS[NAME] Further review of the second policy revealed, The individual conducting the investigation will, as a minimum .Interview staff members on all shifts who have had contact with the resident during the period of the alleged incident; Interview the resident's roommate, family members, and visitors .Witness reports will be reduced to writing, Witnesses will be required to sign and date such reports. Note: A copy of such reports must be attached to the Resident Abuse Investigation Report .The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, and the local police department, if necessary, and other as may be required within five (5) working days of the reported incident. Medical record review revealed Resident #5 was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a facility investigation dated 6/27/17 at 2:45 PM revealed Certified Nurse Aide (CNA) #6 was providing incontinence care to Resident #5 when 2 Licensed Practical Nurses (LPN's) and another CNA entered the resident's room and CNA #6 told them she was not catering to her ass, the resident got on her nerves, and she had been on the call light all day. Continued review of a handwritten statement from LPN #5 dated 6/27/17 revealed, .walked into (Resident #5's) room and (CNA #6) was changing her. I overheard her say to (Resident #5) .she doesn't have time for this[***]and I'm not catering to her ass. She gets on my nerves, she's been on the call light all day .(CNA #6) said 'f*** this[***] packed up the dirty linen and left .(Resident #5) was in tears . Continued review revealed handwritten statements from LPN #6 and CNA #8 dated 6/27/17 corroborated the same details. Further review of a statement from Resident #5 taken by the DON on 6/28/17 revealed the resident stated, .(CNA #6) kept yelling at her and saying she cannot keep coming in there and change her .when other staff named (LPN #6, LPN #5, and CNA #8) were in the room that (CNA #6) stated she didn't have time to cater to her ass . Interview with the DON on 9/20/17 at 3:36 PM in the conference room when asked what time the above allegation of abuse was reported to the State Agency, the DON stated, I reported it on 6/27/17 at 6:29 PM. Continued interview confirmed the facility failed to timely report allegations of abuse for Resident #5. Medical record review revealed Resident #7's [DIAGNOSES REDACTED]. Review of the resident's most recent quarterly assessment, dated 8/23/17, revealed the resident was moderately cognitively impaired and totally dependent on staff for transfers and required extensive staff assistance for bed mobility. Medical record review of the Progress Notes revealed on 8/5/17, the resident was noted to have a large brised (bruised) area to right upper chest that was dark in coloration. Unknown etiology, patient is unable to recall. On 8/6/17, the Progress Notes indicated the bruise to the Rt (right) shoulder, upper arm and chest area has gotten worse. The Physician was contacted and ordered x-rays D/T (due to) bruising and [MEDICAL CONDITION] (swelling) and pain. Review of the Progress Notes on 8/7/17 revealed the x-rays were negative for fractures; however, the bruising continues to spread down her rt arm and side. Staff continued to monitor and document the bruising was still present as of 9/18/17. Further review of Resident #7's medical record revealed no evidence the origin of this injury had been identified. Review of the facility investigation revealed no evidence this injury of unknown origin was immediately reported to the SSA when the bruising was identified on 8/4/17 at 7:30 PM. In addition to the failure to immediately make the initial notification of an injury of unknown origin to the SSA as required, the facility also failed to complete and report the findings of an investigation to the SSA within 5 days. Review of the facility's investigation revealed it was not completed within 5 days of its initiation. There was no evidence of any investigative activity after 9/3/17 until 9/18/17 (after intervention by the survey team) when a handwritten note was added to the investigation form that read ecchymosis (discoloration of the skin resulting frombleeding underneath typically caused by bruising) discussed with nursing director - not related to abuse/neglect by facility. Further review of the investigation revealed it was not thorough. Review of Progress Notes dated 8/16/17 indicated the bruising was s/p (status [REDACTED]. The investigation form was marked Yes to indicate Employee statements completed and reviewed. However, review of the investigation reports provided by the facility revealed there were no employee statements documented. Interview with the DON on 9/18/17 at 1:13 PM revealed she was the facility's abuse coordinator. When asked about Resident #7's injury of unknown origin, she stated, It didn't ring a bell and she would have to investigate further. She confirmed she had provided all investigations completed and reported to the SSA since the last standard survey in (MONTH) (YEAR), and Resident #7's injury of unknown origin was not included in them. Additional interview with the DON on 9/18/17 at 2:50 PM confirmed the injury of unknown origin had never been reported to the SSA, and there had been no investigation into the cause of the bruising to Resident #7's chest. At 2:52 PM, the DON then provided different information, by stating the facility's QA Nurse had an open investigation into the injury of unknown origin, and That's why it wasn't reported. At this time, she provided the investigation report. Additional interview with the DON on 9/18/17 at 3:00 PM confirmed the investigation was not thorough or complete. She stated the QA nurse did not have witness statements, saying, She just talked to staff. Further interview with the DON revealed the facility had not reported the allegation because it was still open, there was no evidence of any action being taken to investigate the injury of unknown origin from 9/3/17 until 9/18/17, when the survey team asked for the record. Observation during an assessment on 9/18/17 at 3:00 PM revealed Resident #7 had bruising across her chest. The resident, who had a right [PR[NAME]EDURE], had purple-grey bruising across this area and the tissue was very firm. The bruising then extended from the right breast area, across the midline to the areola of the left breast. From the sternum to the left breast, the area was yellow-green (indicative of old bruising) that was soft-feeling. In addition, there was one dime-sized area by the areola that was dark purple in color. A Nurse Practitioner (NP), who was present during this assessment, palpated the area and stated it felt like there had been a hematoma (a solid swelling of clotted blood within the tissue) that had bled and was now healing. An attempt was made to interview the resident during the assessment; however, she answered nonsensical words to various questions which were asked and could not tell how the bruising had occurred. An additional attempt to interview the resident on 9/18/17 at 5:06 PM was also unsuccessful, as the resident mumbled inaudible words in response to questions. Interview with the QA Nurse on 9/18/17 at 3:05 PM revealed whenever a resident had a bruise, skin tear or other injury, the nurse on the unit would start the investigation paperwork. It would then be reviewed by the Unit Manager, who would, in turn, send it to the QA nurse and Then I look at it. If the nurse can determine what caused them, then I don't have to do an investigation. However, she continued, Resident #7 was completely different. She stated the bruise just showed up out of nowhere and We didn't know how it happened. She stated the facility knew the bruise was not related to a fall because the resident could not get up off the floor without staff assistance and no falls had been reported. The QA Nurse stated she had not documented any interviews with staff. When asked why, she stated if the resident had said someone had been mean, I would have gotten written statements. But I didn't think it was abuse so I didn't. I just get it (written statements) when there is abuse. Further interview with the QA nurse revealed she did not know how the injury occurred and stated, Maybe when they (staff) were turning her - she is prone to bruising. Further interview with the QA Nurse on 9/18/17 at 3:05 PM confirmed she had never reported the injury of unknown origin to the SS[NAME] When asked why, she stated, I hadn't concluded my investigation so it had not yet been reported. The QA Nurse could not provide an explanation as to why the investigation had not been completed in the 46 days since the bruising was first identified. The QA Nurse could also provide no rationale as to why, if it was still being investigated, there had been no action taken from 9/03 - 9/18/17. During this interview, the QA nurse stated, I'll be honest - I did not know what the time frame was for reporting when the investigation was initiated. She added, I do now - we have 2 hours to report. I found that out about 2 weeks ago.",2020-09-01
953,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2017-09-20,226,D,1,0,SMVC11,"> Based on facility policy review and interview, the facility failed to develop a current Abuse Policy containing accurate information related to 2 components, Reporting and Training, of the 7 mandatory requirements maintained in an Abuse Policy, and failed to include and define Exploitation in the facility Abuse Policy. The findings included: Review of facility policy, Abuse Prevention, with an effective date of 11/1/10 and a revised dated of 4/1/17, provided by the Director of Nursing (DON) on 9/18/17 at 9:05 AM revealed, .Any alleged incident of abuse or neglect will be reported immediately to the Administrator .and to other officials in accordance with State Law within 5 working days of the event . Interview with the DON on 9/18/17 at 6:00 PM in the conference room revealed she did not know the 7 components required in the facility Abuse Policy, but would have to check. Continued interview confirmed the DON was the Abuse Coordinator. Further interview revealed the DON and the Social Services Director were responsible for drafting facility policy's with the Administrator signing off on them. Review of facility policy, Abuse, Neglect, Misappropriation Protocol, with an effective date of 1/17/2001 and revised 2/2017 provided by the DON on 9/19/17 at 10:00 AM revealed, .Elder Abuse Act .crime has occurred against a resident .from this facility, he/she MUST notify BOTH .The State Survey Agency (SSA) .A Local Law Enforcement Entity .The facility has identified the .(named city) Police Department to notify if abuse occurs .Reporting of Abuse, Neglect, or Misappropriation/Protection .Reports must be within 24 hours (if there is not serious bodily injury) after forming your reasonable suspicion. Within 2 hours (if there is serious bodily injury) .Serious Bodily Injury - 2 Hour Limit: If the events that cause the reasonable suspicion result in serious bodily injury to a resident, the facility shall report the suspicion immediately, but not later than 2 hours after forming the suspicion .All Others - Within 24 Hours: If the events that cause the reasonable suspicion do not result in serious bodily injury to a resident, the facility shall report the suspicion not later than 24 hours after forming the suspicion .Training .All new employees will be trained as part of General Orientation, departmental Orientation, and ongoing training sessions to include .Definition of abuse, neglect, involuntary seclusion and misappropriation of resident property . Continued review of the Abuse, Neglect, Misappropriation Protocol policy revealed the local Police Department identified to notify if abuse occurred was not a local Police Department, not located in the same county as the facility, and was 100 miles away from the facility. Continued review revealed it did not include allegations of abuse in the 2 hour time frame for reporting to the State Agency. Further review revealed the training component did not include annual training for abuse. Further review revealed neither policy included exploitation as a form of resident abuse. Interview with the DON on 9/19/17 at 9:50 AM in the conference room confirmed the Abuse Prevention Policy was not up to date with current federal guidelines for reporting allegations of Abuse within 2 hours. Further interview confirmed the Abuse, Neglect, Misappropriation Protocol did not contain accurate information, and did not accurately reflect the Reporting and Training components required. The DON confirmed the facility failed to maintain an updated Abuse Policy.",2020-09-01
954,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2017-09-20,279,D,1,0,SMVC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, review of facility policy,and interview, the facility failed to revise the care plan to reflect the resident's current status for 2 residents (#4, #7) of 11 residents reviewed. The facility failed to update care plans for 2 residents (#4, #7) when previous approaches were no longer appropriate and/or new interventions were needed to prevent accidents. The findings included: Review of the facility's undated policy, Care Plans Comprehensive, revealed: The Care Planning/Interdisciplinary Team is responsible for the periodic review and updating of Care Plans: When there has been a significant change in the resident's condition .At least quarterly. Observation on 9/18/17 at 11:40 AM revealed Resident #4 was sitting in a wheelchair. The resident was observed to have an amputation of the left leg below the knee and was using a stabilizer to hold the stump of her leg in place. Review of Resident #4's clinical record revealed the resident was readmitted to the facility on [DATE], after a [MEDICAL CONDITION] (BKA) of the left leg due to a gangrenous toe. Review of a comprehensive assessment, dated 7/10/17, was completed based on the changes in the resident's condition due to the amputation. Review of her Comprehensive Care Plan revealed the last care conference was held on 7/19/17 and the Care Plan showed a goal date of 10/17/17. Review of Resident #4's Care Plan revealed approaches were not revised to reflect the resident's current status. For example, the Care Plan noted the resident was at risk for infection r/t Left BK[NAME] Approaches to meet the goal of remaining free of infection revealed the resident was to have Shoes on only during therapy r/t L (left) heel blister. The Care Plan also noted the resident is a fall risk r/t S/P (Status/Post) BK[NAME] Approaches to meet the goal of no avoidable falls included Therapy states that she is able to ambulate herself to and from the bathroom. Observation on 9/18/17 at 8:35 AM revealed Resident #4 was asleep in bed with 4 side rails raised. The bed was not in a low position. No fall mats were in use on either side of the bed. Additional observation on 9/18/17 at 1:49 PM. revealed the resident was asleep in bed. Although the bed was now in a low position, no fall mats were in use and all 4 side rails were raised. Review of Resident #4's Physician order [REDACTED]. Further review of Resident #4's Comprehensive Care Plan revealed, although the Care Plan identified the resident was at risk for falls, neither of these Physician ordered interventions had been added to the Care Plan. Interview on 9/19/17 at 9:12 AM with Minimum Data Set (MDS) Coordinator #1, in the first floor administrative wing, revealed the facility currently had a Care Plan Nurse. He stated, although the facility's system was changing in (MONTH) (YEAR), the Care Plan Nurse was currently responsible for developing Care Plans from required assessments, as well as making any needed revisions, including new approaches identified during falls meeting. Interview on 9/19/17 at 9:30 AM with the Care Plan Nurse, in his office revealed it depended on the type of Care Plan revision as to who was responsible for updating the Care Plan. He stated if the resident had a fall, the floor nurse should update both the comprehensive Care Plan and the summarized Care Plan used by direct staff with new interventions to prevent further accidents. The Care Plan Nurse stated he then completed the Care Plan reviews that were required after each quarterly or comprehensive MDS. He stated, When I review, I try to make sure what's in Matrix (the facility's electronic health system used for comprehensive care plans) jibes with what's in the closet (where the summary care plans used by direct care staff are stored.) The Care Plan Nurse confirmed the resident's Care Plan should have been updated, saying, The obvious answer is yes. He stated the approaches of shoes and walking to the bathroom were no longer appropriate for Resident #4, and the Care Plan should have been revised, as the resident had completely different needs after the amputation of her leg. Further interview with the Care Plan Nurse revealed he did not know the reason for the delay in revising the Care Plan with new interventions. He stated he was not alerted when every new order was received, and the nurse on the unit who was aware of the order should have revised the Care Plan if needed. Medical record review of Resident #7's revealed [DIAGNOSES REDACTED]. Medical record review of Resident #7's Comprehensive Care Plan with a review date of 9/7/17, revealed the resident was an elopement risk r/t (related to) dementia. Review of the approaches for this problem revealed they included, Apply wander alert safety bracelet to resident, if ambulatory, and w/c (wheelchair) if chair bound. Observation on 9/18/17 at 5:06 PM revealed the resident was seated in a wheelchair in her room. Additional observations on 9/19/17 at 8:10 AM and 3:15 PM, revealed the resident was seated in her wheelchair in the third floor dining/day room. No wander alert bracelet was applied to the wheelchair and none was visible on the resident during any of these observations. Interview on 9/19/17 at 8:10 AM with Certified Nursing Assistant (CNA) #1, in the third floor dining/day room, confirmed the resident did not have a wander alert bracelet on either her body or her wheelchair. Interview on 9/19/17 at 3:15 PM with Licensed Practical Nurse (LPN) #1, in the third floor dining/day room, confirmed the resident did not currently use a wander alert bracelet. Interview on 9/19/17 at 3:22 PM with Unit Manager (UM) #1, in his office, revealed Resident #7 doesn't need or use a wander alert bracelet anymore. He stated the facility had used one when the resident was ambulatory, but it was no longer needed because she was no longer at risk for elopement and used a wheelchair for locomotion. Interview with UM #2, who was also present during the interview on 9/19/17 at 3:22 PM, confirmed Resident #7 had not used a wander alert bracelet since at least (YEAR). Interview with UM #1 revealed the care plan should have been revised when the wander alert bracelet was discontinued. He stated any nurse in the building could update Care Plans, and the need for revision could have also been identified when required quarterly care plan reviews were completed.",2020-09-01
955,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2017-09-20,280,D,1,0,SMVC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, observation, medical record review, and interview, the facility failed to revise the Care Plan to reflect the resident's current status for 3 of 11 sampled residents (#4, #5, #7). The facility failed to update Care Plans for Resident #4 and Resident #7 when previous approaches were no longer appropriate and/or new interventions were needed to prevent accidents. The facility failed to update the Care Plan for Resident #4 to reflect a new intervention for a skin tear. The findings included: Review of facility policy, Care Plans - Comprehensive, undated revealed The Care Planning/Interdisciplinary Team is responsible for the periodic review and updating of care plans: When there has been a significant change in the resident's condition .At least quarterly. Medical record review revealed Resident #4's clinical record revealed the resident was admitted on [DATE] and readmitted to the facility on [DATE], after a [MEDICAL CONDITION] (BKA) of the left leg due to a gangrenous toe. A comprehensive assessment dated [DATE], was completed, based on the changes in the resident's condition due to the amputation. Review of her Comprehensive Care Plan revealed the last care conference was held on 7/19/17 and the Care Plan showed a goal date of 10/17/17. Review of Resident #4's Care Plan revealed approaches were not revised to reflect the resident's current status. Medical record review revealed the Care Plan noted the resident was at risk for infection r/t (related to) Left BK[NAME] Approaches to meet the goal of remaining free of infection revealed the resident was to have Shoes on only during therapy r/t L (left) heel blister. The care plan also noted the resident is a fall risk r/t S/P (Status/Post) BK[NAME] Approaches to meet the goal of no avoidable falls included Therapy states that she is able to ambulate herself to and from the bathroom. Review of Resident #4's Physician order [REDACTED]. Further review of Resident #4's Comprehensive Care Plan revealed although the Care Plan identified the resident was at risk for falls, neither of these Physician Ordered interventions had been added to the Care Plan. Observation on 9/18/17 at 11:40 AM revealed Resident #4 was sitting in a wheelchair. The resident was observed to have an amputation of the left leg below the knee and was using a stabilizer to hold the stump of her leg in place. Observation on 9/18/17 at 8:35 AM revealed Resident #4 was asleep in bed with 4 side rails raised. The bed was not in a low position. No fall mats were in use on either side of the bed. Additional observation on 9/18/17 at 1:49 PM revealed the resident was asleep in bed. Although the bed was now in a low position, no fall mats were in use and all 4 side rails were raised. Interview on 9/19/17 at 9:12 AM with the Minimum Data Set (MDS) Coordinator #1 revealed the facility currently had a Care Plan Nurse. He stated, although the facility's system was changing in (MONTH) (YEAR), the Care Plan Nurse was currently responsible for developing Care Plans from required assessments, as well as making any needed revisions, including new approaches identified during falls meeting. Interview on 9/19/17 at 9:30 AM with the Care Plan Nurse revealed that it depended on the type of Care Plan revision as to who was responsible for updating the Care Plan. He stated if the resident had a fall, the floor nurse should update both the comprehensive Care Plan and the summarized Care Plan used by direct staff with new interventions to prevent further accidents. The Care Plan Nurse stated he then completed the Care Plan reviews that were required after each quarterly or Comprehensive MDS. He stated, When I review, I try to make sure what's in Matrix (the facility's electronic health system used for comprehensive Care Plans) jibes with what's in the closet (where the summary Care Plans used by direct care staff are stored.) The Care Plan Nurse confirmed the resident's Care Plan should have been updated, saying, The obvious answer is yes. He stated the approaches of shoes and walking to the bathroom were no longer appropriate for Resident #4, and the Care Plan should have been revised, as the resident had completely different needs after the amputation of her leg. Further interview with the Care Plan Nurse revealed he did not know the reason for the delay in revising the Care Plan with new interventions. He stated he was not alerted when every new order was received, and the nurse on the unit who was aware of the order should have revised the Care Plan if needed. Medical record review revealed Resident #5 was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a facility Event Report dated 6/18/17 revealed Resident #5 was found with a skin tear to her right inner thigh as a result from scratching herself. Continued review revealed new orders related to the incident was a referral to the Wound Care Nurse. Continued review documented the Care Plan was updated on 6/18/17 at 7:42 PM. Medical record review of the Comprehensive Care Plan dated 2/23/17 revealed a problem of impaired skin integrity. Continued review revealed the approaches were dated 2/23/17 and no new approaches related to the skin tear were present. Interview with the Director of Nursing (DON) on 9/20/17 at 3:36 PM in the Conference Room confirmed the facility failed to revise Resident #5's Care Plan to reflect approaches related to a skin tear on 6/18/17. Medical record review revealed Resident #7's [DIAGNOSES REDACTED]. Review of Resident #7's Comprehensive Care Plan, review date of 9/7/17, revealed the resident was an elopement risk r/t dementia. Review of the approaches for this problem revealed they included, Apply wander alert safety bracelet to resident, if ambulatory, and w/c (wheelchair) if chair bound. Observation on 9/18/17 at 5:06 PM, and 9/19/17 at 8:10 AM and 3:15 PM, revealed the resident was seated in her wheelchair. No wander alert bracelet was applied to the wheelchair and none was visible on the resident. Interview on 9/19/17 at 8:10 AM with Certified Nurse Aide (CNA) #1 confirmed the resident did not have a wander alert bracelet on either her body or her wheelchair. Interview on 9/19/17 at 3:15 PM with Licensed Practical Nurse (LPN) #1 confirmed the resident did not currently use a wander alert bracelet. Interview on 9/19/17 at 3:22 with Unit Manager (UM) #1 revealed Resident #7 doesn't need or use a wander alert bracelet anymore. He stated the facility had used one when the resident was ambulatory, but it was no longer needed because she was no longer at risk for elopement and used a wheelchair for locomotion. Interview with UM #2, who was also present during the interview on 9/19/17 at 3:22 PM, confirmed Resident #7 had not used a wander alert bracelet since at least (YEAR). Interview with UM #1 revealed the Care Plan should have been revised when the wander alert bracelet was discontinued. He stated any nurse in the building could update Care Plans, and the need for revision could have also been identified when required quarterly Care Plan reviews were completed.",2020-09-01
956,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2017-09-20,282,G,1,0,SMVC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of Event Report, interview, and observation, the facility failed to ensure Care Plans were followed for 5 residents (#2, #6, #7, #8, #9) of 11 residents reviewed. Resident #2 sustained HARM (laceration to head which required stitches) during a fall when staff failed to follow his Care Plan for using 2 staff to provide care. In addition, the facility failed to follow other Care Plan interventions designed to prevent accidents, such as low bed, fall mats, and call light in reach for Resident #8; failed to provide respiratory care for Resident #6 and #9; and failed to use geri-sleeves to prevent skin tears for Resident #7. The findings included: Medical record review revealed Resident #2 was admitted to the facility on [DATE]. The resident had a [MEDICAL CONDITION] and was dependent on supplemental oxygen. The resident's [DIAGNOSES REDACTED]. Review of an Event Report dated 1/1/16 revealed the resident was lowered to floor. Review of the investigation notes revealed, while she was giving him a bed bath, resident coughed violently multiple times that had him leaning off bed. For safety, resident was lowered to floor to keep from falling off bed .Care Plan to reflect x2 (2 staff) assist for all care. Continued review revealed the staff were educated to use x2 assist for Activities of Daily Living (ADLs) and turning. Review of the 11/16/16 Minimum Data Set (MDS) revealed Resident #2 continued to require total assistance of 2 staff for ADLs, as noted on his Care Plan, which indicated the resident was at risk for falls r/t (related to) impaired mobility, need for 2 staff members with ADL assistance. Review of an Event Report dated 12/4/16 revealed at 6:00 AM, Resident #2 sustained a fall when staff failed to follow the Care Plan and provided only 1 staff during ADL care. Per the resident, the 1 Certified Nurse Aide (CNA) had resident turned twards (towards) herself as she was providing incontinent (incontinence) care. Resident began to forcefully cough multiple times. Resident's body came off the bed and (staff) was unable to stop him from falling due to weight. The Event Report noted the resident had a 2-inch gash above the right eye. The resident was transferred to the hospital, where stitches were applied to the laceration above the resident's eye. In addition, review of the hospital report revealed a computerized tomography (CT) scan of the resident's head was conducted and found a small amount of new intraventricular hemorrhage within the atria of both lateral ventricles, greatest on the left. Interview with the Quality Assurance (QA) Nurse on 9/19/17 at 11:04 AM on the first floor administration wing revealed she had been responsible for the investigation of the incident. She stated the fall with injury occurred when the resident's Care Plan was not followed. The QA Nurse confirmed the Care Plan called for 2 staff to be present whenever ADL care was given; however, only one staff was present to give care when the fall occurred. The QA Nurse stated the CNA, who no longer worked at the facility, was aware of the resident's Care Plan, stating the CNA knew that there were supposed to be 2 people in the room, but she was in a hurry. She made a big mistake resulting in a fall from the bed requiring stitches to a laceration on the forehead (Harm). Medical record review revealed Resident #6 was admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a 30 day MDS dated [DATE] revealed the resident was cognitively intact with modified independence, and altered level of consciousness that fluctuated; was bed bound and was dependent with assistance of 1 person for bed mobility, dressing, eating, hygiene, bathing and toileting. Continued review revealed the resident had bilateral upper extremity impairments and received services from Respiratory Therapy for oxygen, suctioning, [MEDICAL CONDITION] care and ventilator care. Review of a facility investigation dated 7/26/17 revealed Resident #6 pushed his call light between 8:00 AM and 8:30 AM and told CNA #5 he needed respiratory therapy. The CNA told Respiratory Therapist (RT) #1 the resident requested him and he said OK. The RT was caring for another resident at that time. The resident pushed his call light a 2nd time and CNA #8 answered the call light and was told he needed respiratory because he couldn't breathe. The CNA informed RT #1 who was caring for another resident, stated OK, thanks. Approximately 5 minutes later the call light went off a 3rd time and CNA #8 answered it and the resident again stated he needed respiratory and he couldn't breathe. The CNA asked if RT #1 had made it in yet and the resident said No. The CNA said she would let him know again and found RT #1 sitting at a table in the hallway charting. CNA #8 told him Resident #6 still needed him because he said he couldn't breathe, and the RT smiled and said OK, thanks. The resident pushed his call light a 4th time and CNA #5 and Licensed Practical Nurse (LPN #7) entered the resident's room and he asked to be transferred out of the facility because he didn't feel safe. Medical record review of the Comprehensive Care Plan dated 6/2/17 revealed a problem of Impaired Gas Exchange-Ventilation with approaches to Perform Ventilator Checks every 4 hours and as needed.; a problem of Impaired Gas Exchange-Oxygenation with an approach to initiate SP02 (peripheral capillary oxygen saturation - an amount of oxygen in the blood) monitoring; a problem of Airway Patency and [MEDICAL CONDITION] Hygiene with approaches to Administer [MEDICATION NAME][MEDICATION NAME] via Nebulizer per orders, Tracheal Suctioning as needed. Review of a Tek-Care Report dated 7/31/17 revealed the ventilator alarm for Resident #6 went off on 7/26/17 at 8:49:42 AM and alarmed for 5 minutes, 18 seconds. Continued review revealed the oxygen saturation alarm went off on 7/26/17 at 8:49:53 AM and alarmed for 3 minutes, 44 seconds. Medical record review of the Respiratory Treatment Flo Administration History dated 7/1/17-7/31/17 revealed End Tidal Capnography every 4 hours (checks carbon [MEDICATION NAME] level) was scheduled to be checked at 8:00 AM on 7/26/17. RT #1 documented it was checked at 9:50 AM. Continued review revealed Resident #6 received his breathing treatment scheduled at 8:00 AM and 9:50 AM by RT #1. Continued review revealed Resident #6 was suctioned by RT #1 at 9:50 AM on 7/26/17 and received a moderate amount of thick pale yellow secretions. Interview with the Director of Nursing (DON) on 9/20/17 at 3:36 PM in the conference room confirmed the facility failed to respond to ventilator and oxygen saturation alarms timely, failed to provide care and assistance to Resident #6 timely, and failed to follow the Comprehensive Care Plan. Medical record review revealed Resident #7 was admitted with [DIAGNOSES REDACTED]. Review of a quarterly MDS dated [DATE], revealed the resident was moderately cognitively impaired, totally dependent on staff for transfer, and required extensive assistance with bed mobility. The resident did not walk and required either supervision or limited assistance from staff with locomotion in her wheelchair. Review of Resident #7's Progress Notes revealed the resident had a history of [REDACTED]. Review of Resident #7's Comprehensive Care Plan, dated 9/7/17, revealed the resident has impaired/potential for impaired skin integrity r/t impaired mobility, incontinence of bowel and bladder, age related skin changes, ASA (aspirin) in use. [MEDICAL CONDITION], chronic [MEDICAL CONDITION]. Approaches to help the resident meet the goal of avoidable skin breakdown included 8/21/16 - Geri-sleeves to be in place. Review of the Safety Care Plan used by direct care staff and posted in the resident's closet also revealed the instructions: Geri-sleeves to be in place at all times d/t (due to) frequent STs (skin tears) - 8/21/16. Observation of Resident #7 on 9/18/17 at 8:48 AM, 3:00 PM., 5:06 PM., and on 9/19/17 at 8:10 AM., 8:26 AM, and 3:15 PM, revealed the resident was not wearing geri-sleeves. Bruising was noted on the resident's right hand, which extended from the index finger to the thumb, across the back of the hand. Interview on 9/19/17 at 8:26 AM with CNA #1 in the third floor dining/dayroom confirmed the resident was not wearing geri-sleeves at that time, and her arms were bare from below her elbow. CNA #1 stated, No, she doesn't use them. Interview with CNA #1 revealed she used the Care Plans posted in each resident's closet to know what care needed to be provided. After a review of the Care Plan posted in Resident #7's closet, CNA #1 confirmed it called for the use of geri-sleeves at all times, and she stated she had not known this intervention was listed on the Care Plan. Interview on 9/19/17 at 3:15 PM with LPN #1 in the third floor dining/dayroom, confirmed Resident #7 was not wearing geri sleeves. She stated the facility had geri-sleeves available, and they should be in place if the Care Plan called for their use. Interview on 9/19/17 at 3:22 PM with Unit Manager (UM) #1 in his office also confirmed the facility had geri-sleeves available for the resident's use and stated, If it's on the Care Plan, they should have been used. Review of Resident #8's Comprehensive Care Plan, initiated 11/10/16, was reviewed on 9/18/17. The Care Plan indicated the resident is at risk for falls r/t dependent on staff for ADLs, limited mobility, antihypertensive and [MEDICAL CONDITION] medications in use. To meet the goal of no avoidable falls, interventions since 12/20/16 included Floor mats at bedside. Interview on 9/18/17 at 1:52 PM with CNA #3 on the third floor hallway revealed the facility posted Care Plans in each resident's closet so direct care staff knew what care the resident needed. She stated the Care Plans included the amount of ADL assistance the resident needed, as well as any special devices or equipment that were to be used. Observation on 9/18/17 at 5:34 PM revealed Resident #8 was in his bed, which was in a high position. A fall mat was observed on the left side of the bed. However, no fall mat was present on the right side of the bed. Observation in Resident #8's closet revealed there was no Care Plan posted to provide information on the resident-specific approaches to be implemented. Review of Resident #9's Admission MDS, dated [DATE], revealed the resident was moderately cognitively impaired, was bedfast, had a [MEDICAL CONDITION], and was totally dependent on staff for all care, including transfers and bed mobility. Review of an Event Report revealed, on 9/17/17 at 2:20 AM, the resident had a fall from the bed and was found on the floor between the two beds in the room. The Event Report noted injuries from the fall, as the resident was decannulated ([MEDICAL CONDITION] came out), complained of pain after the fall, and had to have a [MEDICAL CONDITION]. In response to this fall, Resident #9's Care Plan for fall risk, initiated 8/23/17, was revised on 9/17/17 to include a Low bed when unattended. Observation on 9/18/17 at 5:24 PM, revealed the resident was asleep in bed, with his [MEDICAL CONDITION] in place, and nutrition infusing via gastrostomy tube. No staff were present in the room. The resident's bed was not in a low position and was higher than that of his roommate in the next bed. Interview on 9/19/17 at 3:22 PM with UM #1 in his office revealed if an intervention was listed on the Care Plan, it should have been used.",2020-09-01
957,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2017-09-20,323,G,1,0,SMVC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of Event Report, review of hospital record, interview, and observation, the facility failed to provide an environment free of accident hazards and the supervision needed to prevent accidents for 5 residents (#2, #4, #7, #8, #9) of 11 residents reviewed. Resident #2 sustained HARM (laceration to head which required stitches) during a fall when the facility failed to follow his care plan by using 2 staff to provide care. In addition, the facility failed to provide assistive devices such as low beds, fall mats, and call lights in reach to prevent falls for 4 residents (#4, #7, #8, #9). The facility failed to ensure devices to prevent accidents, such as geri-sleeves to prevent skin tears, were provided for Resident #7. The facility failed to ensure interventions resulting from an investigation were acted upon for 4 residents (#2, #4, #7, #9). The facility failed to ensure the environment was free of accident hazards such as side rails for which there was no assessment and were a factor in Resident #4's fall from the bed. The findings included: Review of facility policy, Fall Risk Reduction and Management, revised 9/16 revealed .A 'fall' is when a resident comes to rest unintentionally on the floor. An intercepted fall is a fall. A fall without injury is a fall. When a resident is found on the floor, the conclusion is that a fall has occurred. If a resident rolls or 'scoots' off a bed or mattress on the floor, this is a fall .Complete side rail assessment at time of admission, quarterly, at time of significant change Interventions appropriate to individual resident and their risk for falls will be implemented based on recognized standards of practice .MDS (Minimum Data Set)/Care Plan Coordinator is responsible for updating care plan related to fall risks, interventions and/or injury related to falls .Interdisciplinary staff will make suggestions for appropriate interventions to decrease likelihood of recurrent fall/fall with injury .The MDS/Care Plan Coordinator will be responsible for making sure that the care plan is updated accordingly .If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant .If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable . Review of a facility policy, Incident/Accident, revised 9/10/16, revealed .Incidents, accidents, or injury of unknown origin will be investigated and appropriate interventions taken as needed .Residents are assessed through the routine assessment and care planning process for factors that may place them at risk for incidents or accidents. Interventions will be implemented based on the assessment findings .The facility will investigate the incident, accident or injury to identify potential contributing factors .Based on investigative findings, the care plan will be reviewed and revised to include preventative interventions to decrease potential for recurrence . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident had a tracheostomy and was dependent on supplemental oxygen. Review of an Event Report dated 1/1/16 revealed the resident was lowered to floor. Review of the facility investigation revealed staff stated while she was giving him a bed bath, resident coughed violently multiple times that had him leaning off bed. For safety, resident was lowered to floor to keep from falling off bed .Care Plan to reflect x2 (2 person) assist for all care. Continued review of the note, staff were educated to use x2 assist for ADLs (Activities of Daily Living) and turning. Review of hospital records dated 11/2/16, revealed the resident was admitted to the hospital with [REDACTED]. Review of Progress Notes revealed the resident was readmitted to the facility on [DATE]. Review of an admission Fall Risk assessment completed on 11/9/16 revealed the resident was at risk for falls based on factors including decreased muscular coordination, impaired mobility, continent, medication use, length of stay, and his neuromuscular/functional status. Review of an Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 continued to require total assistance of 2 staff for ADLs including bed mobility, transfer, dressing and toilet use. Continued review of the assessment revealed the resident was bedfast, severely cognitively impaired, and had no recent falls. Review of Resident #2's fall risk Care Plan last updated on 12/4/16, revealed upon his return to the facility, the documentation remained the resident at risk for falls r/t (related to) impaired mobility, need for 2 staff members with ADL assistance. Review of an Event Report dated 12/4/16 revealed at 6:00 AM staff had resident turned twards (towards) herself as she was providing incontinent (incontinence) care. Resident began to forcefully cough multiple times. Resident's body came off the bed and (staff) was unable to stop him from falling due to weight. The Event Report noted the resident had a 2-inch gash above the right eye. Review of the Progress Notes attached to the facility investigation revealed swelling was present to the area and neurochecks were started due to suspected head trauma. Review of the fall investigation revealed the resident was transferred to the hospital at approximately 9:15 AM, at the sister's request. Review of the 12/4/16 hospital record revealed the resident had stitches applied to the laceration above his right eye. Continued review of a computerized tomography (CT) scan of the resident's head revealed there was a small amount of new intraventricular hemorrhage within the atria of both lateral ventricles, greatest on the left. Review of the 12/4/16 Progress Notes dated 12/4/16 revealed the resident returned from the Emergency Department at approximately 2:30 PM. Review of Progress Notes on 12/5/16, revealed the resident continues to have edema (swelling) to right side of face and eye (the same side of the head as the craniectomy). Continued review of the Progress Notes revealed the Resident is noted to have blood present in trachea and is present when being suctioned, that was initially noted after returning from hospital. Review of a CNA (Certified Nurse Aide) Observation form dated 12/4/16 and a witness statement from the CNA that was present at the time of the fall revealed, I was turning (Resident #2) towards the window .to reposition him and change him. (Resident) coughed and coughed very hard two - 3 times. He threw himself out of the bed and I was unable to catch him. He fell out and had hurt himself. Review of her statement revealed that she had marked Yes to the question, Were all intervention(s) in place? Interview with the Director of Nursing (DON) on 9/19/17 at 10:48 AM on the first floor administrative wing revealed the Quality Assurance (QA) Nurse completed the investigation of this fall with injury, and she would be able to answer questions about it. The DON related the CNA involved in the incident had been disciplined for failing to follow the resident's Care Plan a second time in (MONTH) (YEAR), and no longer worked at the facility. Interview with the QA Nurse on 9/19/17 at 11:04 AM revealed the CNA's witness statement was not accurate. She stated all interventions were not in place, as the Care Plan called for 2 staff to be present whenever ADL care was given. The QA Nurse confirmed There were supposed to be 2 staff present at the time of the fall. She stated the CNA was aware of the resident's Care Plan and knew that there were supposed to be 2 people in the room but she was in a hurry. She made a big mistake. Medical record review revealed Resident #4's was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed the resident was cognitively impaired and required limited assistance with bed mobility, transfers and walking in her room. Continued review revealed the resident had no functional limitations to range of motion, but was not steady in transfers and was only able to stabilize herself during transfers with staff assistance. She was assessed as at risk for falls and the problem was Care Planned. Review of Resident #4's clinical record revealed no Physician Orders for any type of restraints, including side rails. Review of x-ray results dated 5/19/17 revealed Resident #4 was diagnosed with [REDACTED]. Review of Progress Notes dated 5/19/17 revealed the resident required hospitalization and a hip replacement. Review of the facility investigation revealed the facility was unable to determine the etiology of this fracture. Resident #4 returned to the facility on [DATE] and remained at risk for falls and the problem continued to be Care Planned. Fall 1 - Review of an Event Report dated 6/20/17 revealed at 11:00 PM the resident had an unwitnessed fall, and was found sitting next to bed on floor. Patient still had blankets on. Continued review of the Event Report revealed bilateral hip and sacral x-rays were ordered on [DATE] due to the resident's increased pain after the fall; however, no new fractures were found. The Probable Cause of the fall was listed as resident attempted to ambulate without assistance. Review of the Event Report revealed the Care Plan was updated; however, review of the Care Plan, initiated on 4/19/17, revealed no interventions were added to the Care Plan. Review of hospital records revealed the resident was hospitalized from [DATE] - 7/3/17, when she required a below the knee amputation (BKA) of her left leg due to a gangrenous great toe. Resident #4 returned to the facility on [DATE]. The resident's Comprehensive Care Plan continued to indicate she was at risk for falls. Medical record review of a comprehensive assessment dated [DATE], was completed for a significant change in the resident's condition. After the amputation, the resident no longer walked, and needed extensive staff assistance with bed mobility and transfers. After completion of the Comprehensive Assessment, the resident's Comprehensive Care Plan was updated and a Care Conference was held on 7/19/17. Review of Resident #4's Care Plan revealed approaches were not revised to reflect the resident's current status. Review of the Care Plan revealed the resident was at risk for infection r/t Left BK[NAME] Approaches to meet the goal of remaining free of infection revealed the resident was to have Shoes on only during therapy r/t L (left) heel blister. The care plan also noted the resident is a fall risk r/t S/P (status [REDACTED]. Both of these approaches had previously been on the resident's Care Plan and were not revised/deleted after the amputation of the resident's leg. Fall 2 - Review of an Event Report dated 7/13/17 revealed the resident's next fall occurred on 7/13/17 at 1:35 AM. The resident was found by staff Sitting on floor at bedside with legs extended in front of her. Resident stated she slid out of bed once her leg went over the side. Medical record review of a x-ray Report of the resident's left hip (which was previously fractured and replaced) revealed no new fractures. Review of Physician Orders attached to the Event Report revealed, on 7/13/17, the Physician gave new orders for Fall mats beside pt's (patient's) bed. Bed in lowest position at ALL times. Continued review of the Event Report revealed the resident's Care Plan was updated in response to the fall on 7/13/17. Further review of the Care Plan revealed the approach of the bed in the lowest position was not added to the Care Plan until 8/1/17. Continued review of the Care Plan revealed, as of 9/18/17, the approach of fall mats at the bedside had never been added to Resident #4's Care Plan. Fall 3 - Review of an Event Report dated 8/1/17 revealed, at approximately 4:30 PM, the resident was found sitting on the floor .When asked what happened, the resident stated, I just wanted to get in the chair. Continued review of the Event Report revealed the Probable cause of the fall was the Resident has intermittent confusion, is a fall risk, and doesn't always remember to use call light. Although the investigation identified the resident's [DIAGNOSES REDACTED]. Fall 4 - Review of an Event Report dated 8/25/17 revealed at 4:15 PM, the resident attempted to transfer herself from the chair to the bed without assistance and fell , did not call and ask for help. The root cause was described as transferring without assistance, not using call light. The Care Plan was updated on 8/25/17 with an intervention for, Remind resident to use the call light for assistance. Continued review revealed there was no evidence of identification that the use of the call light was already on the Care Plan and was not successful in preventing this fall. Further review revealed there was no evidence of an investigation as to why the previous intervention of the call light was not successful, and the facility did not assess factors such as whether the call light was out of reach, or if the resident could not remember to use it due to cognitive function. Fall 5 - Review of an Event Report dated 9/11/17 revealed at 11:20 AM, staff walked into resident's room to find resident at the end of bed with legs hanging off bed touching floor. Resident began to slide, (staff) assisted resident to floor. Review of the Probable Cause was listed as resident scooted to foot of bed and lost her balance and fell off bed. Continued review revealed there was no evidence the facility assessed the root cause of why the resident scooted to the foot of the bed. Medical record review of the resident's Care Plan revealed, since 7/26/17, the resident was to have a lower bedrail raised on the amputation side (left side) of the bed. Further review of the Care Plan revealed with the use of the one lower side rail, the resident will still be able to get OOB (out of bed) to her strong side. Review revealed there was no evidence the facility investigated whether one (or more) side rails were in use at the time of this fall and whether their use restricted normal exit from the bed, forcing the resident to scoot to the end to try and get out of bed. Although the Event Report indicated there were no injuries noted from this fall, review of the facility investigation revealed the resident complained of pain to the left leg stump on 9/12/17 and 9/13/17, as well as knee pain on 9/14/17. Fall 6 - Review of Progress Notes dated 9/17/17 revealed at approximately 5:30 AM the resident was found sitting on floor on knee/stump, claims she forgot she only has one leg. Medical record review revealed the resident's stump was bleeding and she had a small bruise to the right knee. Continued medical record review revealed at 7:16 PM, the resident was complaining of pain in her right ankle from the fall and the nurse observed bruising across the top of the ankle. X-rays were obtained on 9/18/17, and no fracture was identified. Observation on 9/18/17 at 8:35 AM revealed Resident #4 was asleep in bed. The resident's Physician Orders for fall mats and the bed to be in the lowest position were not followed. Observation revealed the resident's bed was not lowered and the fall mats were not in use. The resident's Care Plan called for one lower side rail to be up when the resident was in bed. However,observation revealed all 4 one-half side rails were raised, creating the effect of 2 full side rails which restrained the resident in bed. Although the Care Plan called for the resident to use her call light to prevent falls, observation revealed the call light cord was looped through the middle bar of the top side rail, and was dangling under the bed, out of the resident's reach. Further observation on 9/18/17 at 1:49 PM revealed the resident was asleep in bed with the bed in the lowest position closest to the floor with no fall mats in use and the 4 side rails raised. Observation on 9/19/17 at 8:08 AM revealed Resident #4's right foot was bruised and purple-grey in color. The bruising extended over the top of the resident's foot from the ankle to the toe and around the back and side of the ankle. The resident was moaning, and when Licensed Practical Nurse (LPN) #1 asked Resident #4 if her foot hurt, she responded, Yes. Interview with CNA #3 on 9/18/17 at 1:52 PM, confirmed all 4 side rails were raised, and there were no fall mats in place. CNA #3 stated, She doesn't use any fall mats; not that I know of. CNA #3 stated the bed was always supposed to be in the lowest position; however, it had to be raised for meals to get the over-bed table in place. When told of the observation on 9/18/17 at 8:08 AM, she stated staff, may have forgotten to lower the bed after the resident's meal was finished. During the interview on 9/18/17 at 1:52 PM, CNA #3 stated she always used all 4 side rails for the resident when she was in bed. She stated the resident had a leg amputation earlier this year, and After she came back from the hospital, we was (were) told to use all 4 side rails with her because she's a fall risk. Further interview with CNA #3 revealed the resident doesn't try to climb over - she goes out the end (of the bed) instead. CNA #3 stated she was the staff who witnessed Fall #5 on 9/11/17, saying, Just last week, I found her sliding out the end of the bed when she could not exit the bed in a normal fashion because all 4 side rails were raised. Further interview with CNA #3 revealed each resident had a Care Plan posted in their closet and this information was used to know what type of assistance and devices were needed. She went to Resident #4's closet and showed there was a Care Plan posted on the left door of the resident's closet. Review of the documents which CNA #3 referred to revealed the Safety care plan included only one intervention - Mattress stops in place to prevent mattress from sliding down. CNA #3 reviewed the Safety Care Plan and confirmed it did not show the need for fall mats, low bed, and only 1 side rail to the lower left side of the bed. Interview with the DON about Resident #4 on 9/18/17 at 2:10 PM, the DON stated, She's fallen more times than you can count. When informed the Safety Care Plan provided by CNA #3 did not include multiple interventions which had been identified to prevent falls, the DON provided another document titled Safety Careplan and stated this was also posted in the resident's closet (on the right door of the closet.) Review of this Safety Careplan revealed the resident was supposed to have: Bed in lowest position at all times. Fall mats. Remind her to use call light. Raise Lower Bedrail on bed to help with safe sleep. Further interview with the DON at this same time revealed she was unaware staff were not consistently using a low bed and were not using fall mats when the resident was in bed. The DON stated historically the facility did not assess for the use of side rails. She stated, although the facility was in the process of adding side rail assessments to the admission packet, Resident #4 did not have a side rail assessment completed. The DON stated she had no evidence the facility had conducted a thorough assessment of the safety of this equipment relative to the resident's condition. Continued interview with the DON revealed after the fall in (MONTH) (YEAR), the fall team decided the resident should only have 1 side rail (lower left) raised when she was in bed. She stated she was unaware staff were using all 4 side rails when the resident was in bed. The DON added she was unaware all 4 side rails were in use at the time of the 9/11/17 fall, and confirmed the investigation should have addressed this as a possible root cause and determined if the fall from the end of the bed occurred because all 4 side rails were raised and Resident #4 could not get out of bed in a routine manner. The DON was interviewed about other interventions listed on the investigations and care plans to prevent further accidents. She stated the repeated addition of the call light was not appropriate, based on the resident's cognition, which she stated had declined since admission. Interview with the Care Plan Coordinator on 9/19/17 at 9:50 AM revealed if the call light was already listed on the Care Plan, the Care Plan should have been revised with a different intervention - Not one that was already on there. Further interview with the Care Plan Coordinator on 9/19/17 at 4:35 PM revealed Anyone can update the Care Plan when the falls team meets. He could provide no explanation as to why Care Plan approaches were not updated per the Event Report documentation, and stated, It should have been done. Medical record review revealed Resident #7's with [DIAGNOSES REDACTED]. Review of the resident's most recent assessment, a Quarterly MDS dated [DATE], revealed the resident was moderately cognitively impaired, was totally dependent on staff for transfer, and required extensive assistance with bed mobility. The resident did not walk and required either supervision or limited assistance from staff with locomotion in her wheelchair. Medical record review revealed Resident #7 had a history of [REDACTED]. -11/10/16 skin tear to left lower extremity during transfer to wheelchair by staff -1/3/17 skin tear to back of right calf during transfer by staff -2/18/17 skin tear to right thigh -3/23/17 skin tear to left forearm -4/30/17 skin tear to right hand -6/22/17 skin tear to left upper extremity (x2) -7/19/17 skin tear to left lower extremity -7/19/17 skin tear to right lower extremity -8/6/17 skin tear to left wrist -8/21/17 skin tear to second knuckle of right hand Review of Resident #7's Comprehensive Care Plan, dated 9/7/17, revealed that since 11/30/15, the resident has impaired/potential for impaired skin integrity r/t impaired mobility, incontinence of bowel and bladder, age related skin changes, ASA (aspirin) in use. Venous insufficiency, chronic edema. Approaches to help the resident meet the goal of avoidable skin breakdown included 8/21/16 - Geri-sleeves to be in place. Review of the Safety Care Plan used by direct care staff and posted in the resident's closet also revealed the instructions: Geri-sleeves to be in place at all times d/t (due to) frequent STs (skin tears) - 8/21/16. Observation of Resident #7 on 9/18/17 at 8:48 AM, 3:00 PM, 5:06 PM, and 9/19/17 at 8:10 AM, 8:26 AM, and 3:15 PM revealed the resident was not wearing geri-sleeves. Bruising was noted on the resident's right hand, which extended from the index finger to the thumb, across the back of the hand. Interview on 9/19/17 at 8:26 AM with CNA #1 confirmed the resident was not wearing geri-sleeves at that time, and her arms were bare from below her elbow. CNA #1 stated, No, she doesn't use them. Interview with CNA #1 revealed she was unaware that the resident's Care Plan called for the use of geri-sleeves at all times. Interviews on 9/19/17 at 3:15 PM with LPN #1 and on 9/19/17 at 3:22 PM with UM #1 both confirmed that the facility had geri-sleeves available for use. Each confirmed that this assistance device to prevent injuries should have been used per Resident #7's care plan. Review of Resident #8's most recent Comprehensive Assessment (admission MDS of 11/17/16) revealed the resident was cognitively intact, as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. The resident was bedfast and totally dependent on staff for all ADLs, including bed mobility and turning/repositioning. Review of a readmission History and Physical, dated 5/17/17 revealed the resident had a tracheostomy, and was ventilator and dialysis dependent. Demographic information revealed the resident also had [DIAGNOSES REDACTED]. Review of the most recent Fall Risk assessment form, completed 8/31/17, revealed the resident was at risk for falls based on intermittent confusion/poor recall/judgement/safety awareness, decreased muscular coordinator, incontinence, medication use, and neuromuscular//functional status. Resident #8's Comprehensive Care Plan, initiated 11/10/16, was reviewed on 9/18/17. The Care Plan stated the resident is at risk for falls r/t dependent on staff for ADLs, limited mobility, antihypertensive and psychotropic medications in use. To meet the goal of no avoidable falls, interventions since 12/20/16 included Floor mats at bedside. Observation on 9/18/17 at 5:34 PM revealed Resident #7 was in his bed, which was in a high position. A fall mat was observed on the left side of the bed. However, no fall mat was present on the right side of the bed. A fall mat was noted on the floor in the bathroom, underneath a reclining chair in storage. Additional observations on 9/19/17 at 8:30 AM and 10:04 AM also revealed, while the resident was in bed, there was no fall mat on the right side of the bed, which was in a high position. Interview on 9/19/17 at 10:04 AM with CNA #2 confirmed there was no fall mat on the right side of the resident's bed. She stated, I think it's family preference that there was no mat on one side of the bed. She stated if a Care Plan intervention was not being used, it should be reported to the nurse; however, she had not done so. CNA #2 was also asked about the height of Resident #7's bed, which increased the potential for injury, should a fall occur. She stated, Oh, he wants it that way. You can ask him. When interviewed at this time, Resident #7 responded No, he did not want his bed to be in a high position. When asked if he wanted his bed lower, he replied, Yes. CNA #2 then stated, Oh, well and did not lower the resident's bed before she left the room. Further review of Resident #8's Care Plan on 9/19/17 revealed the intervention of fall mats, which had been in effect since (YEAR), was no longer on the Care Plan. Review of the Care Plan History revealed the intervention of fall mats was deleted on 9/18/17 after surveyor intervention. The reason for the discontinuation of the mats on the Care Plan was listed as prior admit. Interview with the Care Plan Coordinator on 9/19/17 at 4:45 PM revealed he had deleted the intervention of fall mats after the survey team left the faciity on [DATE] because, I was just trying to make the Care Plans right and the fall mats had been in place on the Care Plan since the resident's last admission. He confirmed that each of the other interventions listed on the Care Plan were also in place since the last admission, and could provide no explanation as to why he had discontinued the one intervention on the Care Plan which the survey team identified was not being implemented by staff. Interview with a corporate representative who was present during this interview revealed the Care Plan approach of fall mats should not have been removed without an assessment of the resident's current needs and ongoing fall risk. Review of Resident #9's Admission Notes dated 8/7/17 revealed the resident was admitted to the facility with [DIAGNOSES REDACTED]. The admission note documented the resident's right side was flaccid, but he could move his left arm within the functional limitation. Demographic information revealed additional [DIAGNOSES REDACTED]. An Admission Fall Risk assessment completed 8/7/17 revealed the resident was at risk for falls, based on his incontinence, use of multiple medications, neuromuscular/functional status, and length of stay in the facility. Resident #9's admission MDS, dated [DATE] revealed the resident was moderately cognitively impaired, was bedfast, and was totally dependent on staff for all care, including transfers and bed mobility. Review of Resident #9's Comprehensive Care Plan revealed it was initiated on 8/23/17. The Care Plan noted the resident was at risk for falls r/t weakness S/P CVA (cerebrovascular accident - stroke). In response, 4 standard nursing interventions were listed as interventions - administer medications per orders, anticipate needs proactively, get assistance with ADLS to ensure safety as needed and observe for unsafe actions - intervene immediately. Review of Resident #9's Progress Notes revealed on 9/2/17, Nursing staff have had to assist resident back into proper position multiple times this shift. Resident has been found with legs out of bed. Progress Notes on both 9/8/17 and 9/9/17 documented the resident was in a low bed with call light in reach. Progress Notes on 9/15/17 documented the resident was noted with more activity, movement in legs, reaching, turning self from side to side .Bed currently in low position for patient safety. However, review of the Care Plan revealed it was not revised to reflect the fall risk related to the resident being found with portions of his body out of bed, his increased mobility and movement in legs, or the need for a low bed and call light that was identified by staff. Review of an Event Report revealed on 9/17/17 at 2:20 AM, a staff was walking hallway, noted resident OOB (out of bed) and yelled for assistance. Upon entering room, resident noted on R (right) side on floor between A and B bed. The report noted injuries from the fall, as the resident was decannulated (tracheostomy tube came out), complained of pain after the fall and had to have a .new trach placed . Per the Event Report, the facility was unable to determine the root cause of the fall, noting the resident was non-verbal/clean and dry. In response to this fall, the Care Plan was updated for a .Low bed when unattended . Observation on 9/18/17 at 5:24 PM revealed the resident was asleep in bed, with his tracheostomy in place, and nutrition infusing via gastrostomy tube. No staff were present in the room. The resident's bed was not in a low position. Interview on 9/18/17 at 5:29 PM with LPN #3 revealed, although he was aware Resident #9 had fallen from bed the previous day, he did not know the resident had been injured or required trach placement in response to the fall. He stated, He's been trying to get out of bed again today, especially this morning. LPN #3 stated, although the resident was totally dependent on staff for turning and repositioning, the resident had limited use of one arm and one foot, which he was using to wriggle himself across the bed. LPN #3 stated We put some pillows in to help keep the resident's position in the center of the bed to prevent further falls. Further observations of Resident #9 in bed on 9/18/17 at 5:33 PM, and on 9/19/17 at 8:33 AM and 2:03 PM revealed there were no pillows being used to",2020-09-01
958,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2019-12-11,600,D,1,1,JMLT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility documentation review and interview the facility failed to ensure 3 (#3, #18, #56) of #35 residents reviewed was free from abuse. The findings include: Facility policy review Abuse, Neglect, Misappropriation of Funds, revised 9/28/19 revealed, .to establish a policy and procedure designed to prohibit abuse, neglect, exploitation, involuntary seclusion of residents and/or misappropriation of resident property .the facility has a zero tolerance policy for abuse, involuntary seclusion, neglect, exploitation and misappropriation of resident property .any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator or Director of Nursing .allegation of Abuse and/or Serious Bodily Injury-2 Hour Limit: if the events that cause the reasonable suspicion of abuse immediately, but not later than 2 hours after forming the suspicion . Review of the facility investigation dated 11/4/19 revealed a witnessed altercation between Resident #3 and Resident #56. Continued review revealed Resident #56 slapped Resident #3 on 11/3/19. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Dementia without Behavioral Disturbance, Anxiety Disorder and Major [MEDICAL CONDITION]. Medical record review of Resident #3's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. Medical record review revealed Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #56's Quarterly MDS dated [DATE] revealed the resident had a BIMS score of 99 indicating the resident was unable to complete the interview. Continued review revealed the resident exhibited verbal behaviors. Interview with Certified Nursing Technician (CNT) #3 on 12/11/19 at 12:50 PM in the Atrium Dining room revealed Residents #3 and #56 had a physical altercation. Continued interview revealed Resident #56 smacked Resident #3. Interview with the Director Of Nursing (DON) on 12/11/19 at 3:18 PM in her office revealed she was informed on 11/3/19 of a verbal atercation between Resident #3 and #56. Continued interview revealed she was notified the next day 11/4/19 the altercation between Resident #3 and Resident #56 became physical. Continued interview when asked to look at the incident date and the reporting date confirmed It was turned in late because I wasn't aware of the possible hitting until the next day after the incident. Review of facility investigation initiated on 11/2/19 revealed an unwitnessed altercation occurred between Resident #29 and Resident #56. Medical record review revealed Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #29's Quarterly MDS dated [DATE] revealed the resident had a BIMS score of 13 indicating the resident had no cognitive impairment. Continued review revealed the resident exhibited no behaviors. Interview with CNT #1 on 12/9/19 at 2:28 PM in the 3rd floor nurse station revealed Resident #56 was in Resident #29's room; Resident #29 was telling Resident #56 she needed to leave because that wasn't her room. Continued interview she stated I didn't see anything but Resident #29 told me Resident #56 hurt her finger and smacked her arm; I removed Resident #56 and notified the nurse. Interview with Resident #29 on 12/09/19 at 11:34 AM in her room when asked concerning an altercation with her and Resident #56 she stated, I was in my room watching T.V. (television) when the lady came into my room; I asked her to leave the room and she kept coming, she tried going around the corner of my bed so I tried to put my table in front of her to keep her from coming into my room. I kept pushing the table in front of her and she kept kicking my table then she hit me on my right arm. Interview with the DON on 12/11/19 at 3:17 PM in her office revealed she was notified that Resident #56 hit Resident #29 on the arm. Continued interview confirmed Resident #56 hit Resident #29. Review of the facility's investigation dated 11/27/19 revealed an unwitnessed physical altercation between Resident #18 and Resident #26. Further review revealed Resident #26 told the Director of Nursing that she became frustrated because she was trying to watch television when Resident #18 and Resident #3 were arguing; she (named Resident #26) asked them (Resident #3 and #18) to be quiet and they wouldn't be quiet so she slapped Resident #18 on the face. Medical record review revealed Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #26's Quarterly MDS dated [DATE] revealed the resident had a BIMS score of 14, indicating the resident had no cognitive impairment. Interview with Resident #26 on 12/9/19 at 3:02 PM in the third floor dining room when asked about the incident between her and Resident #18 she stated, We were kind of fussing last Thursday in the dining room; she didn't want me to sit where I was sitting and cussed me so I slapped her (named resident #18) across the face. Interview with the DON on 12/10/19 at 6:40 PM in her office revealed a physical altercation between Resident #18 and Resident #26 was reported to her on 11/27/19. Continued interview revealed Resident #26 slapped Resident #18 across the face. Review of the facility investigation dated 12/3/19 revealed a physical altercation between Resident #65 and Resident #18 occurred in the dining room witnessed by Resident #58. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #18's Quarterly MDS dated [DATE] revealed the resident had a BIMS score of 4, indicating the resident had severe cognitive impairment. Medical record review revealed Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #58's MDS dated [DATE] revealed the resident had a BIMS score of 15, indicating the resident had no cognitive impairment. Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #65's Quarterly MDS dated [DATE] revealed the resident had a BIMS score of 15, indicating the resident had no cognitive impairment. Interview with the Resident #65 on 12/9/19 at 2:53 PM in the third floor dining room when asked about an incident between her and Resident #18, she stated (named Resident #18) has a tendency to cuss me and I got mad and just went off and hit her. Interview with CNT #2 on 12/10/19 at 3:35 PM in the third floor nurses station when asked about the altercation between Resident #18 and #65 she stated, I heard (named Resident #18) screaming and I went in the dining room and she was sitting at the table with a cup of coffee and (named Resident #65) had a hold of (named Resident #18) arm. Continued interview revealed she removed Resident #18 and notified her supervisor. Interview with Resident #58 on 12/10/19 at 4:02 PM in the resident's room when asked if she witnessed an altercation between two residents she stated (named Resident #65) can't get along with (named Resident #18); They started arguing and (named Resident #65) went to (named Resident #18) table and started fighting with her (named Resident #18), hitting her. Interview with the DON on 12/10/19 at 6:52 PM in her office revealed the nursing supervisor notified her of a physical altercation between Resident #18 and Resident #65. Continued interview confirmed Resident #65 grabbed Resident #18's arm and Resident #18 hit Resident #65.",2020-09-01
959,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2019-12-11,609,D,1,1,JMLT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review and interview the facility failed to report an allegation of abuse timely for Resident #3. The findings include: Facility policy review Abuse, Neglect, Misappropriation of Funds, revised 9/28/19 revealed, .to establish a policy and procedure designed to prohibit abuse, neglect, exploitation, involuntary seclusion of residents and/or misappropriation of resident property .the facility has a zero tolerance policy for abuse, involuntary seclusion, neglect, exploitation and misappropriation of resident property .any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator or Director of Nursing .allegation of Abuse and/or Serious Bodily Injury-2 Hour Limit: if the events that cause the reasonable suspicion of abuse immediately, but not later than 2 hours after forming the suspicion . Review of the facility investigation dated 11/4/19 revealed a witnessed altercation between Resident #3 and Resident #56. Continued review revealed on 11/3/19 Resident #56 slapped Resident #3. Further review revealed the Director of Nursing (DON) was notified of the incident on 11/4/19. Continued review revealed the DON reported the incident to the state agency on 11/4/19. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #3's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. Medical record review revealed Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #56's MDS dated [DATE] revealed the resident had a BIMS score of 99, indicating the resident was unable to complete the interview. Continued review revealed the resident exhibited verbal behaviors. Interview with Licensed Practical Nurse (LPN) #2 on 12/11/19 at 10:40 AM on the third floor hallway revealed he didn't witness the altercation between Resident #3 and #56. Continued interview revealed he was unaware of the incident until he was going to clock out and an unnamed tech informed him of a physical altercation between Resident #3 and Resident #56. Continued interview revealed he reported the incident to his supervisor. Interview with Certified Nursing Technician (CNT) #3 on 12/11/19 at 12:50 PM in the Atrium Dining room revealed Resident #3 and Resident #56 had a physical altercation. Further interview revealed Resident #56 smacked Resident #3. Continued interview revealed CNT #3 reported the incident to her supervisor. Interview with the Director Of Nursing on 12/11/19 at 3:18 PM in her office revealed the staff informed her on 11/4/19 of an altercation between Resident #3 and Resident #56 that occurred on 11/3/19. Continued interview when asked to look at the incident date and the reporting date confirmed It was turned in late because I wasn't aware of the possible hitting until the next day after the incident.",2020-09-01
960,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2019-12-11,657,D,0,1,JMLT11,"**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 revise a care plan for 1 (#20) of 35 residents reviewed for care plans. The findings include: Review of the facility policy, Care Plans, Comprehensive Person-Centered, revised (MONTH) (YEAR), revealed .Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change .At least quarterly, in conjunction with the required quarterly Minimum Data Set (MDS) . Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #20's Physician Orders dated 9/29/19 revealed Isolation: Patient on contact and droplet for Extended Spectrum Beta-Lactamases (ESBL)-Escherichia Coli (E-Coli) in urine and Pseudomonas in Sputum. Medical record review of Resident #20's comprehensive care plan dated 9/10/19 revealed Resident #20 required isolation related to DX (diagnosis) ESBL in her urine. Continued review revealed no care plan for Isolation related to Pseudomonas in Sputum. Interview with the MDS Coordinator on 12/11/19 at 8:30 PM in the conference room confirmed physician orders were reviewed with MDS updates and care plans were updated according to the orders. Further interview confirmed Resident #20's care plan was not updated for respiratory precautions. She stated I missed it.",2020-09-01
961,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2019-12-11,658,D,0,1,JMLT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview the facility failed to follow physician's orders for 2 (#'s 4, #82) residents of 35 residents reviewed for physician orders being followed. The findings include: Facility policy review, Physician Orders, revised (MONTH) 2004, revealed .Physician orders must be given and managed in accordance with applicable laws and regulations .all staff providing care to residents must follow the physician orders . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #4's Physician Order Report dated 7/8/19 revealed .HgbA1C (glycated hemoglobin, a blood test to determine blood sugar levels over a 3 month period) every 3 months . Medical record review of Resident #4's laboratory results revealed there was no HgbA1C obtained for the month of (MONTH) 2019. Interview with the Assistant Director of Nursing on 12/11/19 at 2:50 PM in the conference room confirmed Resident #4 did not have a HgbA1C obtained in (MONTH) 2019. She stated the nurse who put the order in the computer placed the order in the general orders instead of the lab order; so it didn't get done. Interview with the Director of Nursing (DON) on 12/11/19 at 3:18 PM in her office confirmed the HgbA1C was not obtained in (MONTH) 2019 for Resident #4. Medial record review revealed Resident #82 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #82's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #82 has a Brief Interview for Mental Status score of 3, indicating severe cognitive impairment, Continued review revealed limb restraint used daily. Medical record review of Resident #82's Physician's Orders dated 6/9/19 revealed .Quarterly Restraint Reduction Assessment once a day every 90 days . Medical record review revealed Resident #82 had no quarterly restraint reduction assessments. Interview with the Director of Nursing (DON) on 12/11/19 at 2:20 PM in her office confirmed no quarterly restraint reduction assessments for Resident #82 had been completed.",2020-09-01
962,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2019-12-11,695,D,0,1,JMLT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility procedure review, medical record review, observation and interview, the facility failed to properly store suction tubing prevent the spread of infection for 1 resident (#41) of 48 residents who received respiratory services. The findings include: Facility procedure review, [MEDICAL CONDITION] Suction, undated, and Inline [MEDICAL CONDITION] Suction, undated, revealed .Attach connective tubing to closing cap on lid of canister . Medical record review revealed Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #41's Physician order [REDACTED].Tracheal Suction . Observation on 12/9/19 at 12:43 PM in Resident #41's room revealed suction tubing laying on bedside table, not connected to machine and exposed Interview with Respiratory Therapist #2 on 12/9/19 at 12:43 PM in Resident #41's room confirmed suction tubing was left exposed and not connected to the suction canister. Interview with the Respiratory Director on 12/11/19 at 8:52 AM in the conference room confirmed if there is an open tube it should be covered while not in use and if found uncovered the tubing would be changed.",2020-09-01
963,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2019-12-11,758,D,0,1,JMLT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview the facility failed to write a stop date for an as needed [MEDICAL CONDITION] medication for 2 (#33, #56) of 14 residents reviewed for [MEDICAL CONDITION] medications. The findings include: Facility policy review, Antipsychotic Medication Use, dated 3/15/18 revealed .The need to continue PRN (as needed) orders for [MEDICAL CONDITION] medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order . Medical record review revealed Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #33's Physician order [REDACTED].[MEDICATION NAME] (an antianxiety medication) tablet 0.25 mg(milligram)1 tab (tablet) gastric tube Three Times A Day - PRN . Medical record review of Resident #33's Pharmacy Communication/Recommendations dated 11/27/19 revealed .[MEDICATION NAME] 0.25mg .PRN [MEDICAL CONDITION] medications are limited to 14 days, unless a prescriber documents in the medical record rationale, including duration, for extended therapy . Interview with the Director of Nursing (DON) on 12/11/19 at 6:55 PM in her office revealed when asked to review Resident #33's Physician order [REDACTED]. Medical record review revealed Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #56's Physician order [REDACTED].[MEDICATION NAME] (lorazapam) (medication used to treat anxiety) Schedule IV tablet; 0.5 mg; oral Special Instructions: anxiety and tremors every 3 hours-PRN . Medical record review of Resident #56's Pharmacy Communication/Recommendations dated 11/25/19 revealed .[MEDICATION NAME] 0.5 mg .PRN [MEDICAL CONDITION] medications are limited to 14 days, unless a prescriber documents in the medical record rationale, including duration, for extended therapy . Medical record review of Resident #56's Medication Administration Record [REDACTED]. Interview with the Director of Nursing on 12/11/19 at 8:55 AM in her office confirmed there was no stop date for Resident #56's PRN [MEDICATION NAME]. Interview with Resident #33 and #56's Physician on 12/11/19 at 6:45 PM at the second floor nurse station he stated generally don't write stop dates and the resident needs these medications.",2020-09-01
964,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2019-12-11,880,D,0,1,JMLT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record review, observation and interview, the facility failed to post correct signage for droplet isolation precautions for 1 resident (#20) and failed to wear proper personal protective equipment (PPE) before entering the room for 1 (#38) of 14 residents reviewed for transmission based precautions. The findings include: Facility policy review, Isolation, dated (MONTH) 1, 2008 and revised (MONTH) (YEAR) revealed .Signs-Use color coded signs and/or other measures to alert staff of the implementation of Isolation or Droplet Precautions .Transmission-Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent or control the spread of infection .In addition to Standard Precautions, Implement Droplet Precautions for an individual documented or suspected to be infected with microorganisms transmitted by droplets . Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #20's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required suctioning and [MEDICAL CONDITION] care. Medical record review of Resident #20's Physician order [REDACTED].Isolation: Patient on contact and droplet for Extended Spectrum Beta-Lactamases (ESBL)-Escherichia Coli (E-Coli) in urine Pseudomonas in Sputum . Observation on 12/9/19 at 11:20 AM outside of Resident #20's room revealed signage on the door was for contact isolation and no signage for respiratory isolation. Observation on 12/10/19 at 9:49 AM outside of Resident #20's room revealed Respiratory Signage speak with nurse before entering room .wash hands, mask and gloves . Interview with the Registered Respiratory Therapist (RRT) on 12/09/19 at 11:25 AM revealed resident #20 was in contact and droplet isolation. Further interview confirmed the Droplet Precautions were not posted. Interview with the ADON on 12/11/19 at 4:13 PM in her office confirmed she expected to find the correct isolation signage and PPE's on respective doors per facility policy. Medical record review revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #38's Admission MDS dated [DATE] revealed the resident received suctioning and [MEDICAL CONDITION] care. Medical record review of Resident #38's Physician order [REDACTED].Isolation: Patient on droplet isolation for Pseudomonas Sputum . Observation on 12/11/19 at 8:15 AM outside of Resident #38's room revealed Registered Nurse (RN) #1 entered the resident's room without applying proper PPE. Interview with RN #1 confirmed she did not apply the proper PPE before entering resident #38's room. Interview with the Director of Nursing (DON) on 12/11/19 at 8:15 AM in her office confirmed nursing must apply proper PPE prior to entering isolation rooms at all times.",2020-09-01
965,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2019-01-16,577,C,0,1,HIXZ11,"Based on observation and interview, the facility failed to provide the most recent survey results for resident and public review in the facility's survey notebook. The findings include: Observation on 1/14/19 at 11:45 AM, at the facility entrance, revealed a survey notebook on a table. Continued obsevation revealed the contents of the notebook did not contain the survey results from the last recertification survey from 2/6/18. Interview with the Administrator on 1/14/19 at 2:30 PM, in the Administrator's office confirmed the survey results from 2/6/18 had not been placed in the notebook.",2020-09-01
966,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2019-01-16,584,E,0,1,HIXZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain a safe, clean, homelike environment on 3 of 5 resident hallways (wings) and in 2 of 3 shower rooms observed for physical and homelike environment. The findings include: Observations on the East Wing on 1/14/19 revealed the following: room [ROOM NUMBER]B had a significant amount of dirt and debris on the floor behind the headboard and underneath the bed. The wall at the headboard had pieces of sheet rock and wallpaper missing, and the floor tile in the room was heavily scuffed with black marks, was visibly dirty, and dull in appearance. The floor tile in rooms 201, 215, 216, 228, 229, and 234, were heavily scuffed with black marks and were visibly dirty and dull. The wall coverings in the hallway near rooms [ROOM NUMBERS] were visibly stained and dirty. The threshold of room [ROOM NUMBER] was noted to be covered with black duct tape which was torn and raggedy. Observations around the East Wing Nurse's station revealed: Carpet at the Nurse's station was loose, worn, and ripped in multiple areas with a significant amount of debris and loose particles on the carpet. The wall covering near the pantry had stuck on brown/crusty debris and stained with a brown substance. An electrical outlet across from the Nurse's station revealed a thick, white colored, debris covering the outlet. Brown and white crusty debris was noted on the outside wall of the Nurse's station near the shower room. Observation of the East Wing shower room revealed several tiles missing on the divider wall and a black substance on wall tiles. Observations of the West Wing revealed the following: The threshold to room [ROOM NUMBER] was missing and broken floor tile was observed next to the bed nearest the window. Observation inside the West Wing Nurse's station revealed loose, worn, ripped carpet with a significant amount of loose particles and debris. Observation on the handrail nearest the Nurse's station and fire door revealed white dusty debris. Observation of the fire doors revealed loose particles, and white dusty debris behind the door. Observation of the West Wing shower room, revealed a raised toilet seat with rust under the seat and legs of the devices. 2 bedside toilets stored in the shower room also had rusted legs. Interview with the Administrator on 1/15/19 at 2:45 PM, in room [ROOM NUMBER], revealed the facility staff focused on deep cleaning the resident rooms identified in the recent complaint survey. Further interview revealed deep cleaning the floors along with having to clean the newly renovated rooms, the facility staff had not deep cleaned other areas of the facility. Interview with the Housekeeping Supervisor on 1/15/19 at 2:53 PM, in room [ROOM NUMBER], revealed the facility had been short staffed in the housekeeping department. Interview with the Administrator on 1/16/19 at 8:40 AM, in his office, confirmed the facility had some areas that needed to be deep cleaned. Interview with the Housekeeping Supervisor on 1/16/19 at 2:00 PM, in the conference room, confirmed the facility failed to maintain a clean, home like environment in the facility.",2020-09-01
967,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2019-01-16,585,D,0,1,HIXZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, review of the facility's Grievance Log, and interview, the facility failed to investigate reported grievances for 2 residents (#40,#57) of 28 sampled residents. The findings include: Review of the facility policy, Filing Grievances/Complaints revised 11/2010 revealed .Any resident .may file a grievance or complaint concerning .behavior of another resident . Review of the facility policy, Investigating Grievances/Complaints revised 11/2010 revealed .Grievances and/or complaints may be submitted orally . Review of facility policy, Grievance/Complaints - Staff Responsibility revised 11/2010, revealed .Should a staff member .be the recipient of a complaint voiced by a resident .concerning .the behavior of another resident .the staff member is encouraged to guide the resident .as to how to file a written complaint with the facility . Review of the facility policy, Grievance/Complaint Log revised 11/2010, revealed .The disposition of all .complaints must be recorded on the Resident Grievance/Complaint Log .The following information, as a minimum, must be recorded: a. The date the .complaint was received .b. The name and room number of the resident filing the .complaint .d. The date the alleged incident took place; e. the name of the person(s) investigating the incident; f. The date the resident .was informed of the findings; and g. The disposition of the grievance (i.e., resolved, dispute, etc.) . Medical record review revealed Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #40's annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #40 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Interview with Resident #40 on 1/14/19 at 11:11 AM, in the resident's room, confirmed she had mentioned an incident at the facility involving another resident to several staff, including the Activities Assistant. Interview with the Activities Director on 1/16/19 at 8:07 AM, in the activities room, confirmed she was aware of the alleged incident of another resident yelling at Resident #40. Further interview confirmed We don't have any documentation for that (the investigation) . Medical record review revealed Resident #57 was admitted on the facility on 8/6/18 with [DIAGNOSES REDACTED]. Medical record review of Resident #57's annual MDS dated [DATE] revealed Resident #57 had a BIMS of 15, indicating the resident was cognitively intact. Interview with Resident #57 on 1/15/19 at 1:30 PM, in the activities room revealed a large bottle of body spray had gone missing from her personal belongings in her room. Continued interview revealed Resident #57 had reported the missing item to the Social Services Director. Review of the facility monthly Grievance Log dated 1/2018 through 12/2018, revealed the facility failed to document Resident #57's missing body spray. Further review revealed the facility failed to document the alleged incident of another resident yelling at Resident #40. Interview with the Social Services Director (SSD) and the Director of Nursing (DON) on 1/15/19 at 2:24 PM, in the social services office, confirmed the missing body spray was verbally brought to the attention of the SSD during the summer and the missing item had not been recorded on the Grievance Log. Further interview confirmed no investigation was conducted and the steps of the grievance policies were not followed. Interview with the DON on 1/16/19 at 9:27 AM, in the Admission's office, confirmed Resident #40 was not encouraged to file a written complaint with the facility and the incident was not recorded on the Grievance Log. Further interview confirmed .We do not have documentation or (an) investigation into this incident. I did not feel we needed to investigate into this incident . Continued interview confirmed the facility failed to follow their policies.",2020-09-01
968,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2019-01-16,679,D,0,1,HIXZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to revise an ongoing activity program and provide activities for 1 resident (#37) of 3 residents reviewed for activities of 28 sampled residents. The findings include: Medical record review revealed Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Activities Evaluation dated 3/29/16 revealed the resident's preferences included animals/pets, movies, music, radio, reading, religious services, religious studies, and television. Medical record review of Resident #37's Record of One to One Activities dated 5/3/18 to 8/31/18 revealed the resident .prefers not to participate in group activities .frequency of one to one activity .2 times a week . Further review revealed the staff watched television with the resident and read stories to her. Continued review revealed the time spent with the resident on the one to one activities was between 5 to 10 minutes. Further review revealed one to one activity had been documented for Resident #37 after 8/31/18. Medical record review of the Care Plan Conference Summary dated 9/6/18 revealed .Activities 1 on 1 in room . Further review revealed the resident's Power of Attorney (POA) agreed with the plan of care established. Medical record review of the Interdisciplinary Progress Notes dated 9/6/18 revealed .Quarterly Act (activity) Rec (recreational): Pt (patient) continues to receive 1:1 services. Pt. enjoys having a book read to her. Pt. continues to be confused. Will continue to encourage leisure participation and provide recreational opportunities . Medical record review of the Therapeutic Recreation Care Plan implemented on 9/9/18 revealed the Resident #37 was independent for activities, cognitive stimulation and social interaction. Continued review revealed the resident had physical limitations and cognitive deficits. Further review revealed the interventions were as follows: celebrations/parties, 1:1 visits, and small group activities. Medical record review of the Interdisciplinary Progress Notes dated 12/3/18 revealed .Annual Act/Rec: Pt. continues to receive 1:1 services 2 x (times) per week. Staff completed assessment. Pt. enjoys listening to music and listening to a book read to her. Pt. continues to be confused. Will continue to encourage leisure participation and provide recreational opportunities . Observation of the resident on multiple occasions from 1/14/19 at 10:30 AM until 1/16/19 at 11:00 AM during hours of survey revealed the resident lying in the bed, with no activity except the television set turned on being provided. Interview with the Activity Director on 1/15/19 at 2:00 PM, in the conference room, revealed the 1:1 in room activities were stopped in (MONTH) due to they felt the resident .did not benefit from 1:1 in room activities . She stated, a service animal did come to the facility every 2 weeks and the resident acknowledged the animal, however documentation of this activity was not completed. Telephone interview with the resident's POA on 1/15/19 at 2:10 PM revealed he thought they were reading to her and providing 1:1 in room activities. Further interview revealed the resident liked romance novels, blue grass music and animals. Continued interview revealed he would like anything that they could do for her that would occupy her time. Further interview revealed reading to her helps to occupy her mind and he was not informed the 1:1 activities had been discontinued. Interview with the Activity Director on 1/15/19 at 4:15 PM, in the activities room, confirmed the resident's Activity Program had not been revised to include current interests and available activities, and the resident had not received in room activities since (MONTH) (YEAR).",2020-09-01
969,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2019-01-16,757,D,0,1,HIXZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to ensure each resident was free of unnecessary drugs by failing to adequately monitor residents receiving psychoactive medications for 6 residents (#33, #36, #37, #39, #41, and #56) of 28 sampled residents. The findings include: Medical record review revealed Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #33's quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score 15, indicating the resident was cognitively intact. Continued review revealed no mood/behavior in the 7 day look back period. Further review revealed Resident #33 received anti-psychotics, anti-anxiety, and anti-depressant medications during the 7 day look back period. Medical record review of Resident #33's care plan dated 8/28/18 revealed the use of psychoactive medications with interventions including monitoring for behavior symptoms and side effects. Medical record review revealed Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #36's quarterly MDS dated [DATE] revealed a BIMS score of 15, indicating the resident was cognitively intact. Continued review revealed the resident experienced delusions and no mood/behavior in the 7 day look back period. Further review revealed Resident #36 received anti-anxiety and anti-depressant medications during the 7 day look back period. Medical record review of Resident #36's care plan dated 9/6/18 revealed the use of psychoactive medications with interventions including monitoring for behavior symptoms and side effects. Medical record review revealed Resident #37 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #37's quarterly MDS dated [DATE] revealed a BIMS score of 0 indicating severe cognitive impairment. Continued review revealed Resident #37 experienced delusions and had no mood/behavior during the 7 day look back period. Further review revealed the resident received anti-anxiety and anti-depressant medications during the 7 day look back period. Medical record review of Resident #37's care plan implemented 12/3/18 revealed the use of psychoactive with interventions including monitoring for behavior symptoms and side effects. Medical record review revealed Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #39's quarterly MDS dated [DATE] revealed a BIMS score of 0, indicating severe cognitive impairment. Continued review revealed no mood/behavior during the 7 day look back period. Further review revealed Resident #39 received anti-psychotic and anti-depressant medications during the 7 day look back period. Medical record review of Resident #39's care plan dated 6/27/18 revealed the use of psychoactive medications with interventions including monitoring for behavior symptoms and side effects. Medical record review revealed Resident #41 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #41's quarterly MDS dated [DATE] revealed a BIMS score of 11, indicating moderate cognitive impairment. Continued review revealed no mood/behavior in the 7 day look back period. Further review revealed Resident #41 received anti-depressant medications during the 7 day look back period. Medical record review of Resident #41's care plan dated 9/19/18 revealed the use of psychoactive medications with interventions including monitoring for behavior symptoms and side effects. Medical record review revealed Resident #56 was admitted to facility on 7/31/18 with [DIAGNOSES REDACTED]. Medical record review of Resident #56's admission MDS dated [DATE] revealed the resident's BIMS was 5, indicating severe cognitive impairment. Continued review revealed no mood/behavior in the 7 day look back period. Further review revealed Resident #56 received anti-depressant medications during the 7 day look back period. Medical record review of Resident #56's care plan dated 4/23/18 revealed the use of psychoactive medications with interventions including monitoring for behavior symptoms and side effects. Review of the Behavior/Intervention Monthly Flow Records for 11/1/18 through 1/16/19 revealed incomplete documentation for Residents #33, #36, #37, #39, #41, and #56. Interview with the Director of Nursing on 1/16/18 at 2:45 PM, in the Admission Office, confirmed behavior monitoring had not been done consistently from 11/1/18 - 1/16/19 for Residents #33, #36, #37, #39, #41, and #56.",2020-09-01
970,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2019-01-16,867,E,0,1,HIXZ11,"Based on facility policy review, review of the most recent Plan of Correction (P[NAME]) from a complaint survey, current survey findings, and interview, the facility failed to maintain sustained compliance with prior plans of correction related to the physical environment by not maintaining a safe, clean, and homelike environment for the residents. The findings include: Review of the Quality Assurance Performance Improvement (QAPI) undated revealed .Provide the highest standards of care focusing on all residents' .quality of life .Identify opportunities for improvement .Develop and implement an improvement or corrective plan .monitor effectiveness of interventions .We will use QAPI .to identify areas of improvement .The QAPI team will review .patterns .in our systems of care that could result in quality problems .to make improvements. Areas of review will include .State survey results and deficiencies . Review of the most recent complaint survey and the P[NAME] with a completion date of 11/02/19, revealed the facility was cited for failure to provide a safe, clean, comfortable, homelike environment. Review of the P[NAME] revealed .The Administrator and Maintenance Director will make routine rounds of the facility (no less than monthly) to identify all maintenance/environmental repairs to maintain a homelike environment .a plan will be developed to address each area in need of improvement .The Maintenance Director will report to the QAPI Committee monthly on the findings of the environmental rounds made with the Administrator and detail all maintenance/environmental repairs that need made and the progress with the corrective action needed . During the recertification survey, conducted from 1/14/19 - 1/16/19, observations revealed the facility failed to maintain a safe, clean, and homelike environment for the residents. Interview with the Administrator on 1/16/19 at 4:05 PM, in the Administrator Office, confirmed the facility made maintenance rounds but not housekeeping rounds. Continued interview confirmed the facility had no documentation to indicate rounds had been completed. Further interview confirmed the facility had been mainly focused on life safety and carpet issues. Continued interview confirmed the staff had been redirected to focus on the new renovation process in the facility.",2020-09-01
971,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2019-01-16,880,D,0,1,HIXZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation, and interview the facility failed to maintain acceptable infection control practices during the ice/water pass on 1 of 2 hallways observed of 5 hallways total; during food tray delivery on 1 of 5 hallways observed of 5 hallways total; and during medication administration of 1 of 2 medication carts observed of 3 medication carts total. The findings include: Review of the facility policy, Serving Drinking Water, revised 10/ 2010, revealed .take the water pitcher to the ice cart outside the room. Fill the pitcher with ice .return the water pitcher to the resident's bedside stand .Wash your hands . Review of the facility policy, Handwashing/Hand Hygiene, revised 8/2015 revealed .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections .Use an alcohol-based hand rub .or .soap (antimicrobial or non-antimicrobial) and water for the following .After contact with objects .before handling food . Observation on 1/14/19 at 11:07 AM, on the unit 2 hallway, revealed Certified Nursing Assistant (CNA) #1 passing ice. Further observation revealed CNA #1 entered a resident room, retrieved a water pitcher, came out into the hallway, and filled the water pitcher with ice. Continued observation revealed CNA #1 re-entered the room, placed the water pitcher on the bedside table, and exited the room without sanitizing the hands. Further observation revealed CNA #1 entered a different resident room, retrieved a water pitcher, came out into the hallway, and filled the water pitcher with ice. Continued observation revealed CNA #1 re-entered the room, placed the water pitcher on the bedside table, and exited the room without sanitizing the hands. Interview with CNA #1 on 1/14/19 at 11:12 AM, on the unit 2 hallway, confirmed she had failed to sanitize her hands before exiting the resident's room after filling up the water pitcher and placing it on the bedside table. Further interview confirmed she entered another resident room, filled up the water pitcher, placed it on the bedside table, and exited the room without sanitizing the hands. Observation on 1/14/19 at 12:26 PM, on the H hall, revealed CNA #2 entered room [ROOM NUMBER] with a meal tray, and set the tray down. Continued observation revealed CNA #2 touched the resident's wheelchair (w/c) handles, touched the light switch, and touched the tray table. Further observation revealed CNA #2 then set up the resident's tray without washing her hands. Interview with CNA #2 on 1/14/19 at 12:29 PM, on the H hall, confirmed CNA #2 had entered room [ROOM NUMBER] with a meal tray and set the tray down. Continued interview confirmed CNA #2 touched the resident's w/c handles, the light switch, the tray table, and exited the resident's room without washing her hands. Interview with the Director of Nursing (DON) on 1/15/19 at 8:53 AM, in her office, revealed CNA #1 had failed to follow the facility's infection control policy for passing ice. Interview with the DON on 1/15/19 at 3:27 PM, in the conference room, confirmed the facility failed to follow the Handwashing/Hand Hygiene policy. Observation on 1/15/19 at 8:10 AM, at the East Wing cart 1 medication cart, revealed Licensed Practical Nurse (LPN) #1 was preparing medication for Resident #44. Further observation revealed LPN #1 dropped 2 pills on top of the medication cart, picked the pills up with her bare hands, and placed the medication in a small plastic cup. Continued observation revealed LPN #1 entered Resident #44's room and administered the medications. Interview with LPN #1 on 1/15/19 at 8:30 AM, in the East Wing hallway, at #1 medication cart, confirmed she had failed to follow infection control practices during medication administration by touching the medication with her bare hands. Interview with the DON on 1/15/19 at 8:53 AM, in her office, confirmed LPN #1 failed to follow the infection control policy during medication administration.",2020-09-01
972,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2018-02-06,550,D,0,1,4NS111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure clothing promoted dignity for one resident (#29) and failed to achieve a dignified appearance for one resident (#17) of 20 residents reviewed. The findings included: Medical record review revealed Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) annual assessment dated [DATE], revealed Resident #29 had a Brief Interview of Mental Status (BIMS) score of 2, indicating the resident was severely cognitively impaired. Medical record review of a care plan dated 9/11/17 revealed .unable to dress .the resident will receive appropriate staff support with .dressing . Observation of Resident #29 on 2/4/18 at 11:58 AM, on the 200 hall outside of the resident's room, revealed Resident #29 sitting in a wheel chair wearing a shirt that was stretched out around the neck and pulled down in the front exposing her chest. Observation of Resident #29 on 2/5/18 at 3:37 PM, on the 200 hall outside of the resident's room, revealed the resident was sitting in a wheel chair wearing the same shirt she had on the day before, and it was pulled down in the front exposing her chest area. Interview with Certified Nurse Assistant (CNA) #2 on 2/05/18 at 4:05 PM, at the 200 hall nurse's station, confirmed .no it's not okay for her to have on a shirt that is exposing her chest area .I did see her in that shirt yesterday also . Interview with the Director of Nursing (DON) on 02/05/18 at 4:16 PM, confirmed Resident #29 was not wearing clothing to promote dignity. Medical record review revealed Resident #17 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE], revealed the resident was totally dependent for bed mobility, transfers, dressing, toilet use, and personal hygiene. Observations on 2/4/18 at 11:25 AM, 2/5/18 at 2:40 PM, and 2/5/18 at 2:50 PM, revealed Resident #17 had a large amount of facial hair on her chin. Interview during observation on 2/5/18 at 2:40 PM, revealed she did not like the facial hair on her chin. Continued interview with the resident revealed the facility had not removed it since she had been admitted and she would like the hair removed. Interview with the Social Services Director on 2/5/18 at 2:50 PM, in the resident's room, confirmed the resident had facial hair on her chin. Continued interview confirmed the resident should be able to have the facial hair removed if desired.",2020-09-01
973,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2018-02-06,689,D,0,1,4NS111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to implement interventions to prevent falls for 1 resident (#5) of 4 residents reviewed for falls. The findings included: Medical record review revealed Resident #5 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 maximum assistance of 2 staff for transfers, was able to propel self in her wheel chair with supervision, and was non-ambulatory. Medical record review of an Incident/Accident Report dated 1/28/18 revealed Resident #5 was seated in her wheel chair with staff pushing the chair, and the resident .tumbled forward onto knees and then scraped forehead on floor. Causing abrasion/carpet burn to forehead . Medical record review of the Incident/Accident Report dated 1/29/18 revealed Resident #5 was seated in her wheel chair in her room and .Attempted to get out of chair and slid out of chair onto floor, hitting outer left eye on floor causing a purple knot .Steps taken to prevent recurrence .(non-skid surface) to w/c . Medical record review of Resident #5's care plan revised on 1/29/18 revealed non-skid surface to w/c . Observation on 2/5/18 at 7:30 AM, 9:30 AM, 1:15 PM, 2:30 PM, 3:00 PM, 3:30 PM, in various places, revealed Resident #5 sitting in her wheelchair without the non-skid surface in the seat to prevent sliding out of the wheel chair. Continued observation revealed the resident's face was brown/blue/purple around the forehead and eyes. Observation and interview with the Director of Nursing (DON) and Certified Nurse Assistant (CNA) #3 on 2/5/18, at 3:50 PM in the main hallway near the kitchen, revealed CNA #3 and the DON assisted Resident #5 to stand from the wheel chair. Continued observation revealed the non-skid surface was not present in the seat to prevent Resident #5 from sliding out of the wheel chair. Interview with the DON confirmed the intervention to prevent further falls was to have non-skid surface in the resident's wheel chair and the non-skid surface was not present.",2020-09-01
974,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2018-02-06,761,D,0,1,4NS111,"Based on review of facility policy, observation, and interview, the facility failed to assure medications were secure and inaccessible for one resident (#68) of 82 residents observed. The findings included: Review of the facility's policy, Storage of Medications revised (MONTH) 2007, revealed The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Observation on 2/4/18 at 11:30 AM, in Resident #68's room, revealed a bottle of antacid on the resident's bedside table. Interview with Licensed Practical Nurse #5 on 2/4/18 at 11:35 AM, at the unit 2 nurse's desk, confirmed medications were not to be at the bedside. Interview with the Director of Nursing on 2/5/18 at 9:30 AM, in the hallway near the activity room, confirmed medications were not to be at the bedside.",2020-09-01
975,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2018-02-06,880,D,0,1,4NS111,"Based on facility policy, observation, and interview, the facility failed to follow the facility's policy for hand hygiene during medication administration for one resident (#62) of 8 residents observed; and failed to follow infection control practices during a wound dressing change for one resident (#52), of two residents reviewed for infection control, of 20 sampled residents. The findings included: Review of the facility's policy Instillation of eye drops revised (MONTH) 2014, revealed . 2. Wash and dry your hands thoroughly. 3. Put on gloves . Review of the facility's policy, Wound Care, revised date (MONTH) 2010, revealed .Steps in the Procedure. 1. Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly. 3. Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. 4. Put on exam gloves Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly .21. Wipe reusable supplies with alcohol as indicated (i.e. outside of containers that were touched by unclean hands, scissor blades, etc.) Return reusable supplies to resident's drawer in treatment cart. 22. Take only the disposable supplies that are necessary for the treatment into the room. Disposable supplies cannot be returned to the cart. 23. Wash and dry your hands thoroughly . Observation of Registered Nurse (RN) #1 during medication administration on 2/5/18 at 8:14 AM in Resident #62's room, revealed RN #1 failed to wash his hands and apply gloves prior to administering eye drops. Interview with RN #1 on 2/5/18 at 8:18 AM, in the unit two hallway, confirmed hands were to be washed and gloves applied prior to administering eye drops. Interview with the Director of Nursing (DON) on 2/5/18 at 9:30 AM, in the hallway near the activity room, confirmed it was the facility's policy to wash hands and put on gloves prior to administering eye drops. Observation of a dressing change for Resident #52 on 2/4/18, at 10:25 AM, in the resident's room, revealed Licensed Practical Nurse (LPN) #3 was preparing to perform a dressing change on 3 wounds on the resident's right foot. Continued observation revealed the following: 1. Gathered supplies in a large see-through plastic bag. The large plastic bag was placed on the bedside table with no barrier. 2. Donned gloves, removed old dressing. 3. Retrieved clean supplies from the large plastic bag with the same gloves. 4. Opened the supplies, laid the supplies and scissors on the resident's bed. (No barrier). 5. Cleaned wound, with the same gloves, and retrieved additional supplies from the plastic bag. (The LPN had a scarf around her neck, observation revealed each time she bent to do anything to the resident's wounds, the scarf was touching bed, and resident's linen.) 6. Applied an ointment on the wound with applicator using the same gloves. 7. Picked up supplies and scissors from the resident's bed and placed them on the bedside table. 8. Removed the gloves, washed hands, exited the room, returned with additional supplies and placed supplies on bedside table. 9. Donned gloves, opened gauze packages, placed gauze on the resident's wounds, wrapped gauze around the entire foot, taped and dated dressing. 10. Removed the gloves, gathered the unused supplies and scissors, placed them in the plastic bag, disposed of garbage. Exited the resident's room, without disinfecting hands, took the plastic bag of supplies to the supply room, and disinfected hands after entering the room. Interview with the Infection Control Nurse on 2/6/18 at 8:00 AM, in the dining area, confirmed the facility had failed to follow infection control practices during the dressing change. Continued interview confirmed the gloves were to be changed after removing the old dressing, barriers were to be placed, scissors were to be disinfected after use, and only the supplies needed for the resident were to be taken in the room. The Infection Control Nurse confirmed the LPN #3 was not to wear a scarf during the dressing change due to possible cross-contamination. Interview with the DON on 2/6/18 at 8:20 AM, in the dining area, confirmed the facility had failed to follow infection control practices during the dressing change and failed to follow policy.",2020-09-01
976,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2020-02-26,557,E,0,1,HJSI11,"Based on observation and interview, the facility failed to promote dignity during meal service for 12 of 14 residents observed for dining. The findings include: During observation on [DATE] at 12:35 PM, the lunch meal was being served to 12 residents in the dining room. The dome lid covers used to keep the food warm during service were removed from the plates and left setting on the dining table for 8 of 12 residents during the meal service. Six residents were served juice or milk, and the beverages were served in the cartons instead of being poured into a glass. When the meals were served, all 12 residents had plates, utensils and beverages left on the service trays, rather than being placed on the dining table. During an interview on [DATE] at 4:30 PM, the Registered Dietitian (RD) stated the facility previously had fine dining .before the construction.maybe got away from it. The RD stated it was her expectation the meals not be left on the service trays and beverages in cartons be poured into a glass, unless requested by the resident.",2020-09-01
977,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2020-02-26,558,D,0,1,HJSI11,"**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 provide water and ice at the bedside for 1 resident (Resident #6) of 14 residents reviewed. The findings include: Review of the facility policy titled, Safe Distribution of Water and Ice, undated, showed .Pass fresh ice water to residents three times daily, approximately every eight hours and prn (as needed). Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] showed Resident #6 was cognitively intact. During observation and interview on [DATE] at 11:35 AM, in the resident's room, Resident #6 stated the facility did not regularly fill up the water pitchers. The resident had 2 water pitchers in the room and both pitchers were empty. Observation on [DATE] at 9:07 AM, in the resident's room, showed 2 water pitchers in the room and both pitchers were empty. During an interview on [DATE] at 3:09 PM, Registered Nurse (RN) #1 confirmed Resident #6 preferred to have 2 water pitchers. The resident preferred one water pitcher to have ice in it to pour soda over and the other water pitcher to have ice and water. During interview and observation on [DATE] at 3:34 PM, Resident #6 confirmed she wanted water and ice in one water pitcher, and only ice in the other pitcher, so she could pour soda in it. One water pitcher had ice with a small amount of water and the other water pitcher was empty. During an interview on [DATE] at 5:26 PM, the Director of Nursing confirmed it was her expectation for ice and water to be passed every shift to the residents.",2020-09-01
978,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2020-02-26,569,D,0,1,HJSI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility's Trust Statement Report, and interview, the facility failed to refund personal funds within 30 days of discharge for 1 resident (Resident #247) of 28 residents reviewed. The findings include: Resident #247 was admitted to the facility on [DATE] and discharged home on[DATE]. Review of the facility's Trust Statement dated 12/31/2019 showed Resident #247 had $2,478.00 remaining in the trust fund. During an interview conducted on 2/25/2020 at 9:40 AM, the Administrator and Social Service Director confirmed the facility failed to refund personal funds within 30 days from discharge for Resident #247. During an interview conducted on 2/25/2020 at 9:50 AM, the Business Office Manager confirmed Resident #247 was discharged on [DATE] with a remaining balance of $2,478.00 in his trust fund.",2020-09-01
979,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2020-02-26,580,D,0,1,HJSI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to notify the physician an orthopedic consult was not obtained as ordered for 1 resident (Resident #10) of 28 residents reviewed. The findings include: Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] showed Resident #10 was cognitively intact, able to walk independently without assistive devices, and had not had any falls. Review of a Situation Background Assessment and Recommendation (SBAR) Communication Form and progress note dated 10/21/2019, for Resident #10 showed .slip/fall to knees .resident was walking down the hall when she slipped and landed on her knees. mainly on her right knee. denies pain at this time . Medical record review of nurse's notes and x-ray results revealed Resident #10 began to experience swelling and pain on 10/30/2019 and the facility obtained an x-ray on 10/30/2019 that showed the resident had a right knee fracture. Review of a nurse's note dated 10/30/2019 at 3:55 PM showed .Residents' radiology report back .Acute right knee fracture .(Nurse Practitioner #1) .instructed staff to instruct resident to stay off knee, Therapy needs to get resident something to immobilize her knee .get resident an appointment with a orthopedic as soon as possible . Review of a nurse's note dated 10/31/2019 showed .Unit manager received a order for resident (#10) to go to emergency room for eval (evaluation) of fracture to her right patella .returned to facility at 1:10 PM. She is wearing a full brace to RLL (right lower leg) .Already has order for consult with ortho (orthopedic) . Review of the emergency room visit summary dated 10/31/2019, showed Resident #10 was to follow up with the orthopedic clinic in 2 days related to a closed [MEDICAL CONDITION] patella. Review of nurse's notes dated 11/1/2019 - 11/15/2019 showed Resident #10 was ambulating without the right knee brace. Review of a nurse's note dated 11/10/2019 showed .Resident (#10) ambulatory .(orthopedic clinic) contacted re (regarding) Consult r/t (related to) fracture; stated she can come into Walk in Clinic. Will Schedule transportation . Review of the medical record and nurse's notes showed no documentation Resident #10 was seen at the orthopedic clinic for consult of the right patellar fracture 2 days after the emergency room visit, as ordered, or after the call to the orthopedic clinic on 11/10/2019. The medical record showed no documentation the physician was notified of the missed orthopedic consult appointment. Observation on 2/23/2019 at 11:05 AM and 12:33 PM, showed Resident #10 ambulating in her room and in the hall without a right knee brace. During an interview on 2/24/2020 at 7:45 AM, Licensed Practical Nurse (LPN) #1 stated she was aware Resident #10 had a physician's orders [REDACTED]. LPN #1 stated she was not aware if the resident went to the consultation appointment and was not able to find documentation the resident had the consultation. LPN #1 confirmed she had not notified the Nurse Practitioner (NP) or the Physician of the missed orthopedic appointment for Resident #10. Telephone interview with Resident #10's orthopedic clinic on 2/26/2020 at 8:55 AM, confirmed the resident had not been seen by the clinic for consultation of the right knee fracture. During telephone interview on 2/26/2020 at 9:35 AM, the facility Nurse Practitioner (NP #1) was not aware the resident had not been seen by the orthopedic clinic and had not been notified of the missed appointment.",2020-09-01
980,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2020-02-26,584,D,0,1,HJSI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, medical record review, observation, and interview, the facility failed to maintain resident wheelchairs in good repair for 2 residents (Residents #17 and #27) of 28 sampled residents. The findings include: Review of the facility policy titled, Maintenance Service, revised December 2009, showed .The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] showed Resident #17 had severe cognitive impairment and used a wheelchair for mobility. During observation and interview on [DATE] at 12:36 PM, LPN #3 stated the wheelchair Resident #17 was seated in belonged to the facility and confirmed the back rest of the wheelchair was torn approximately 1 inch on each side beside the handles. Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation in Resident #27's room on [DATE] at 11:00 AM showed a wheelchair cushion in the resident's reclining wheelchair had cracks in the cover of the cushion and cracks on the right side of the headrest cover. During an interview on [DATE] at 11:40 AM, the Director of Nursing (DON) confirmed the right headrest and cushion to Resident #27's wheelchair was cracked. During an interview on [DATE] at 12:44 PM, the Director of Rehab stated the staff should report any tears to the wheelchairs to him so the chair could be replaced. During an interview on [DATE] at 4:10 PM, the Director of Rehab confirmed the cushion to Resident #27's wheelchair was cracked and should be replaced. During an interview on 2/26/2020 at 7:42 AM, the Director of Nursing (DON) confirmed it was her expectation that wheelchairs with tears would be reported so the items could be repaired or replaced.",2020-09-01
981,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2020-02-26,684,D,0,1,HJSI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to obtain a physician's order for hospice services for 1 resident (Resident #34) of 5 residents reviewed for hospice. The findings include: Resident #34 was admitted from an acute care hospital to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Hospice Coordinated Plan of Care showed the first visit and the plan of care was initiated at the facility on 10/23/2019. Review of the admission Minimum Data Set ((MDS) dated [DATE], showed Resident #34 received hospice services. Review of the care plan revised 1/23/2020, showed Resident #34 had a terminal prognosis related to [MEDICAL CONDITION] with the interventions of working cooperatively with the hospice team to provide for the resident's spiritual, emotional, physical and social needs. Review of the medical record showed no documentation of a physician's order to admit to or to continue hospice services for Resident #34. Review of the current Physician's orders dated 2/4/2020 showed no order for hospice services. During an interview on 2/26/2020 at 1:00 PM, the Director of Nursing (DON) stated Resident #34 received hospice services at home prior to admittance to the facility. The DON stated the Medical Director for the hospice service and the facility's Medical Director were the same physician and did not feel a new order was necessary. The DON confirmed the facility did not obtain a new order to admit to hospice services or to continue hospice services upon Resident #34's admission to the facility.",2020-09-01
982,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2020-02-26,686,G,0,1,HJSI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to complete weekly monitoring and documentation of pressure ulcers and failed to provide physician ordered wound treatment for 1 resident (Resident #6) of 3 residents reviewed for pressure ulcers. The facility's failure to monitor and provide treatment resulted in worsening of a pressure ulcer and Harm for Resident #6. The findings include: Review of the facility policy titled, Pressure Ulcers/Skin Breakdown- Clinical Protocol, revised 4/2018, showed .the nurses shall describe and document/report the following .Full assessment of pressure sore (pressure ulcer, an injury to the skin resulting from prolonged pressure) including location, stage (severity of the pressure ulcer), length, width and depth, presence of exudates (fluid drainage) or necrotic tissue (dead tissue) .The physician will order pertinent wound treatments, including .dressings .and application of topical agents (medications applied to the skin) . Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Order Summary Report revealed Resident #6 had wound care orders dated 11/29/2019 for Dakins Solution 0.25% (a wound care medication to prevent infection) to be applied to the wounds on the resident's legs topically every 24 hours as needed for wound care. There was no documentation of any other wound treatment orders. Medical record review revealed Resident #6 was treated for [REDACTED]. Review of the medical record showed the facility had not maintained copies of the wound care clinic notes or wound care clinic orders in Resident #6's medical record. The wound care clinic notes were obtained from the clinic at the request of the surveyor. Review of the admission Minimum Data Set ((MDS) dated [DATE] showed Resident #6 was cognitively intact, required extensive assistance of 2 staff members with bed mobility, had impaired range of motion to both legs, and had pressure ulcers present on admission to the facility. Review of Resident #6's wound care clinic progress note dated 12/9/2019, showed the resident had pressure ulcers to the right calf, left calf, left heel, and sacrum. Wound descriptions were as follows: right calf 13.5 centimeters (cm) (length) by (x) 3.5 cm (width); left calf 10.5 cm x 2.0 cm; left heel 2.5 cm x 3.0 cm; and sacrum 1.5 cm x 1.0 cm x 2.0 cm (depth of wound). The treatment completed by the wound care clinic was .Sorbact (type of wound dressing used to remove bacteria) to wound beds, covered with [MEDICATION NAME] (foam wound dressing), secured with Kerlix (type of gauze dressing) . Medical record review of Resident #6's Treatment Administration Record (TAR) revealed a treatment with a start date of 12/11/2019 for Sorbact to wound beds, cover with [MEDICATION NAME], and change daily. Review of the medical record showed the last date the facility nurses completed any weekly monitoring, measurements, or description of Resident #6's pressure ulcers was on 12/13/2019. Review of the care plan dated 12/14/2019 showed Resident #6 had pressure ulcers to the sacrum, buttock, and both calves. Interventions included: administer medications as ordered, assess/record wound healing weekly, and weekly treatment documentation to include the measurements and tissue type of the wound. Review of the wound care clinic note dated 12/19/2019 showed the following pressure ulcer descriptions: right calf 19.6 cm x 2.6 cm x 1.9 cm; left calf 16.2 cm x 5.6 cm x 2.1 cm; left heel 7.0 cm x 6.5 cm x 0.6 cm with undermining (wound tunneling); sacrum 2.1 cm diameter and 1.6 cm depth. All of the wounds had copious amount of purulent drainage and a strong foul odor. Resident #6 was ordered antibiotics and the wound care clinic treatment was [MEDICATION NAME] (antimicrobial silver dressing) applied to all wound beds. Resident #6 was to return to the wound clinic in 3 - 5 days. Review of Resident #6's wound care clinic progress note dated 12/23/2019 showed the following pressure ulcer descriptions: right calf 35 cm x 2.1 cm x 1 cm, and a strong foul odor; left calf 4 cm x 2 cm; left heel 3 cm x 2.4 cm; and sacrum 2.4 cm diameter and 1 millimeter (mm) depth, moderate thick yellow drainage with a foul odor. The progress noted stated .Very concerned about the right calf. Is extremely wet and the wound personnel (nursing staff in the nursing home) has been putting wet silver over it, which is causing it to become macerated (overly wet for prolonged period of time). Changing plan of care to do daily Dakin's full-strength wet-to-dry dressing changes in an effort to kill the bacterial load as well as dry these areas up .orders were .faxed to the nursing home. They are to call the office if she has worsening signs and symptoms of infection, otherwise follow-up with me in 1 week . Review of the Physician Orders from the wound care clinic dated 12/23/2019 revealed the facility was to wash the lower leg wounds with [MEDICATION NAME] (antimicrobial skin cleanser) or a like product; Dakins full strength wet to dry dressing daily to the lower leg wounds, secured with Kerlix from the base of the toes to the bend of the knee; and the wound to the sacrum was to be packed daily with Sorbact, with no substitutions for the Sorbact, and cover with [MEDICATION NAME]. Review of the Treatment Administration Record (TAR) dated 12/1/2019-12/31/2019 showed the following: 1. Order start date 11/29/2019 - Dakins solution 0.25% apply to legs every 24 hours as needed for wound care. There was no documentation the treatment was completed on any day in December. 2. Order start date 11/30/2019 - Cleanse with [MEDICATION NAME], cover with [MEDICATION NAME], and [MEDICATION NAME], cover the entire leg with Kerlix every day. The TAR documentation showed the treatment was not completed on 12/1, 12/4 - 12/8, 12/10, 12/13 - 12/15, 12/17 - 12/19, 12/21, 12/23, 12/24, 12/28, and 12/29. 3. Order start date 12/11/2019 - [MEDICATION NAME] wash (or like product) to all wounds. Both lower leg wounds and the left heel were to have Sorbact to wound beds, cover with [MEDICATION NAME] (or like product), and change daily. The TAR documentation showed the treatment was not completed on 12/13 - 12/15, 12/17 - 12/19, 12/21, 12/23, 12/28, and 12/29. Review of the TAR and the Order Summary Report revealed the wound clinic physician orders dated 12/23/2019 were not on the TAR or the summary report. Review of a Physician's order from the wound care clinic dated 12/31/2019, showed the facility was to wash the bilateral lower legs and sacral wounds with [MEDICATION NAME], use a Dakins compress for 15 minutes to the right lower leg wound, and pack all 3 wounds with Sorbact and cover with [MEDICATION NAME]. The lower leg wounds were to be wraped with Kerlix. Review of the TAR and the Order Summary Report revealed the wound clinic physician orders dated 12/31/2019 were not on the TAR or the summary report. Review of Resident #6's wound care clinic progress note dated 1/6/2020, showed .She and her mom state the nursing home has told her that they (nursing home staff) have ordered the Sorbact multiple times, however it has not been delivered yet. They (nursing home staff) have been applying 'some silver gel' . The pressure ulcer descriptions were as follows: right calf 17.0 cm x 4.2 cm x 0.6 cm; left calf 4 mm; left heel 4.0 cm x 3.2 cm; sacrum was stable with no change in size; and there was a new stage 1 pressure ulcer to the entire left buttock with a new stage 2 pressure ulcer to the center of the left buttock. The wound care clinic treatment was [MEDICATION NAME] to the left buttock and both legs. The progress note stated .Very concerned about the right lateral calf .Since the nursing home has been unable to obtain the Sorbact, change her back to [MEDICATION NAME]. They (nursing home staff) are to leave the leg dressings on this week without changing them until such time they can get the [MEDICATION NAME] .follow-up with me in 1 week . Review of a Physician's order from the wound care clinic dated 1/6/2020, showed the facility was to leave to leg dressings on until the next wound care clinic visit. Review of Resident #6's wound care clinic progress note dated 1/13/2020 showed the following pressure ulcer descriptions: right calf 13.0 cm x 3.8 cm x 0.7 cm; left calf almost closed; left heel pressure ulcer 2.5 cm x 2.0 cm; and the sacrum remained the same. [MEDICATION NAME] was applied to all wounds. Review of a Physician's order from the wound care clinic dated 1/13/2020, showed the facility was to change the dressings to the sacrum daily and as needed, but to leave the lower leg dressings on until the next wound clinic visit. Review of Resident #6's Order Summary revealed a physician's order dated 1/15/2020, to ensure the dressings placed by the wound care clinic to lower leg pressure ulcers remained in place and dry. Review of the TAR dated 1/1/2020-1/31/2020 showed the following: 1. Order start date 11/29/2019 - Dakins solution 0.25% apply to legs every 24 hours as needed for wound care. There was no documentation the treatment was completed on any day in January. 2. Order start date 11/30/2019 and stop dated of 1/7/2020 - Cleanse with [MEDICATION NAME], cover with [MEDICATION NAME], and [MEDICATION NAME], cover the entire leg with Kerlix every day. The TAR documentation showed the treatment was completed as ordered. 3. Order start date 12/11/2019 and a stop date of 1/15/2020 - [MEDICATION NAME] wash (or like product) to all wounds. Both lower leg wounds and the left heel were to have Sorbact to wound beds, cover with [MEDICATION NAME] (or like product), and change daily. The TAR documentation showed the treatment was not completed on 1/7 - 1/9, 1/11, and 1/14. 4. Start date 1/15/2020 - [MEDICATION NAME] wash (or like product) to sacral wounds, Sorbact to wound beds, cover with [MEDICATION NAME] (or like product), change daily and as needed. The TAR documentation showed the treatment was not completed on 1/15, 1/16, 1/19 - 1/23, 1/25 - 1/28, and 1/30. 5. Start date 1/15/2020 - ensure dressings applied to both lower leg wounds remained in place and dry. The dressings were to be checked every shift. The TAR documentation showed the dressings were not checked for 32 of 48 shifts, with no documentation the dressings were checked for the entire day on 1/16, 1/19, 1/21 - 1/23, 1/27, and 1/28. During an interview on 2/23/2020 at 11:39 AM, Resident #6 stated she had wounds to both of her legs and on her sacrum that had developed at another facility. She stated she went to the wound care clinic once per week. The wound clinic staff had been providing the dressing changes to her legs because the facility had been unable to get the dressing the wound clinic had ordered to be used. During an interview on 2/25/2020 at 8:21 AM, Licensed Practical Nurse (LPN) #3 stated she was unsure why the TAR documentation was incomplete. The wound care nurse had been sick and had frequent absences from work and was unavailable at the time of the survey. The floor nurses were to provide wound care to the residents when the wound care nurse was absent. During a phone interview with the wound care clinic Nurse Practitioner (NP #2) on 2/25/2020 at 1:43 PM, NP #2 stated the resident had been seen in the clinic on 2/24/2020 with the wound on the right calf measuring 18.5 cm by 4.7 cm by 0.6 cm. NP #2 also stated on 12/31/2019, the clinic changed the dressing to the resident's right calf and the nursing home staff was not to change the dressing until the resident was seen again at the clinic on 1/6/2020. After the nursing home had been unable to provide the Sorbact for 2 weeks, the clinic took over the dressing changes on 1/6/2020. The wound on the right calf had worsened due to the .burden of infection . in the wound. NP #2 stated the treatment needed to be provided 3 times weekly and the clinic was unable to see the resident 3 times per week. The facility's inability to provide the ordered wound care dressing and change it 3 times weekly had contributed to the continuing infection and worsening of the wound. During an interview on 2/25/2020 at 2:43 PM, Licensed Practical Nurse (LPN) #1 stated the wound care clinic had ordered Sorbact to be used for Resident #6's wound to the right calf. The facility had been unable to obtain the dressing from their supplier or their pharmacy. The LPN had not contacted the wound care clinic regarding the facility's inability to obtain the dressing and the LPN was unsure what discussions the wound care nurse (who was unavailable during the time of the survey) had with the wound care clinic in regards to the facility's inability to obtain the dressing. During a phone interview on 2/26/2020 at 9:44 AM, the facility's NP (NP #1) stated she was not aware of the facility's inability to obtain an ordered wound care dressing for Resident #6, requiring the wound care clinic to provide the dressing changes. During an interview on 2/26/2020 at 3:05 PM, the Director of Nursing confirmed the facility's nursing staff did not complete weekly monitoring, measuring, and documentation for Resident #6's wounds.",2020-09-01
983,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2020-02-26,689,E,0,1,HJSI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to complete a fall investigation for 1 resident (Resident #10); failed to complete fall risk assessments for 2 residents (Residents #10 and #29) of 4 residents reviewed for falls; and failed to ensure assistive devices were correctly applied for 3 residents (Residents #5, #41, and #43) of 23 residents sampled. The findings include: Review of the facility policy titled, Maintenance Service, revised (MONTH) 2009, showed .The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . Review of the manufacturer's guidelines titled, Safety & Handing of Wheelchairs, revised 12/16/2014, showed .the use of anti-tippers (device used to prevent wheel chairs from tipping over) is required for .Recliner models .Anti-tippers must be fully engaged. Ensure both anti-tippers are adjusted to the same height . Review of the facility policy titled, Assessing Falls and Their Causes revised 3/2018, showed .The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall .Residents must be assessed upon admission and regularly afterward for potential risk of falls .Observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall, and will document findings in the medical record .Complete an incident report for resident falls no later than 24 hours after the fall occurs .Within 24 hours of a fall, begin to try to identify possible or likely causes of the incident .Evaluate chains of events or circumstances preceding a recent fall .Continued to collect and evaluate information until the cause of falling is identified or it is determined that the cause cannot be found .If the cause is unknown but no additional evaluation is done, the physician or nursing staff should note why .When a resident falls, the following information should be recorded in the resident's medical record .Completion of a falls risk assessment . Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE], showed Resident #10 was cognitively intact, able to walk independently without assistive devices, and had not had any falls. Review of the Fall Prevention Care Plan updated 10/21/2019 showed a fall risk assessment was to be completed upon admission and quarterly. Review of a Situation Background Assessment and Recommendation (SBAR) Communication and progress note Form dated 10/21/2019, showed .slip/fall to knees .resident (#10) was walking down the hall when she slipped and landed on her knees. mainly on her right knee. denies pain at this time . Review of the medical record showed no documentation a fall investigation or fall assessment was completed for Resident #10 after the fall on 10/21/2019. Medical record review of nurse's notes and x-ray results revealed Resident #10 began to experience swelling and pain on 10/30/2019 and the facility obtained an x-ray that showed the resident had a right knee fracture. Review of a nurse's note dated 10/31/2019 showed .Unit manager received a order for resident (#10) to go to emergency room for eval (evaluation) of fracture to her right patella .returned to facility at 1:10 PM. She is wearing a full brace to RLL (right lower leg) .Already has order for consult with ortho (orthopedic) . Review of nurse's notes dated 11/1/2019 - 11/15/2019 showed Resident #10 continued to ambulate independently with difficulty and without the right knee brace. Review of the quarterly MDS dated [DATE], showed Resident #10 was cognitively intact, able to walk independently without assistive devices, and resident had 1 fall since the last assessment. Review of the care plan revised 12/19/2019, showed Resident #10 was at risk for falls with interventions of .Review information on past falls and attempt to determine cause of falls .Record possible root causes . During observations on 2/23/2019 at 11:05 AM and 12:33 PM, 2/24/2020 at 8:30 AM, and 2/25/2020 at 7:30 AM, Resident #10 was ambulating independently. During interview on 2/23/2020 at 3:50 PM, Resident #10 stated she no longer wore the knee brace. During an interview on 2/25/2020 at 4:10 PM, the MDS Coordinator stated Resident #10 fell on [DATE] and an SBAR was completed. The MDS Coordinator stated she did not know if a fall investigation or fall risk assessment had been completed. During an interview on 2/25/2020 at 4:50 PM, the Director of Nursing (DON) confirmed the facility had not completed a fall investigation and had not completed the fall risk assessment after the fall for Resident #10. Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a fall investigation dated 1/6/2020 showed Resident #29's roommate used the call light to inform staff Resident #29 had fallen in the bathroom. Resident #29's walker was at her bedside. The resident did not sustain any injuries. Review of an admission MDS dated [DATE] showed Resident #29 had moderate cognitive impairment, required limited assistance with 1 person physical assist for transfers and ambulation, and utilized a walker and a wheelchair for mobility. Review of a fall investigation dated 2/17/2020 showed Resident #29 was found in the floor lying beside her bed with her feet wrapped in bedding. The resident stated she thought she was walking with her husband and she must have been dreaming. The resident did not sustain any injuries. Review of a care plan revised 2/17/2020, showed Resident #29 was at risk for falls with interventions including ensuring the call light was in reach and encouraging the resident to call for assistance, ensuring the resident wore appropriate footwear when ambulating, keeping floors free from clutter, and the bed in low position. During observation and interview on 2/23/2020 at 10:45 AM, in the resident's room, Resident #29 was observed with bruising to her left eye. She stated she was dreaming while sleeping, and rolled out of her bed onto the floor. Resident #29 stated the staff lowered her bed after the fall. Observation showed the resident was in a low bed. Medical record review showed no documentation fall risk assessments had been completed on admission or after the falls on 1/6/2020 and 2/17/2020. During an interview on 2/26/2020 at 1:20 PM, the Director of Nursing confirmed fall risk assessments were not completed on admission or after the falls for Resident #29. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] showed the resident was cognitively intact, used a wheelchair for mobility, and had not experienced any falls. During observation on 2/23/2020 at 11:06 AM, Resident #5 was seated in the day room watching television. The resident was seated in a reclining wheelchair with a rear anti-tipper (equipment on the back rear of the chair to prevent it from tilting) on the right side of the chair, and no rear anti-tipper for the left side of the wheelchair. During an interview on 2/23/2020 at 12:30 PM, Licensed Practical Nurse (LPN) #3 confirmed Resident #5 had only 1 rear anti-tipper on the right side of the wheelchair. During an interview on 2/23/2020 at 12:44 PM, the Director of Rehab confirmed Resident #5 should have 2 rear anti-tippers on the wheelchair. Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS revealed Resident #41 was severely cognitively impaired, required extensive assistance of 1 person for locomotion, utilized a wheelchair for mobility, and had 2 falls with no injuries since the previous assessment. During observation on 2/23/2020 at 10:55 AM, Resident #41 was self-propelling in a wheelchair in the hallway. The left side rear anti-tipper was tilted inwards and was improperly positioned (should be positioned straight and down). Medical record review revealed Resident #43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment revealed Resident #43 had moderately impaired cognition, required extensive assistance of 1 person for locomotion, and had 1 fall with no injuries since the previous assessment. Observation of Resident #43 on 2/23/2020 at 10:57 AM, in the wheelchair in the hallway, revealed the right side rear anti-tipper was tilted inward and was improperly positioned. During an interview on 2/23/2020 at 11:40 AM, the DON confirmed the rear anti-tippers to Resident #41 and Resident #43's wheelchairs were improperly positioned. During an interview on 2/26/2020 at 7:42 AM, the Director of Nursing (DON) confirmed it was her expectation for missing anti-tippers to be reported so the items could be repaired or replaced.",2020-09-01
984,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2020-02-26,692,D,0,1,HJSI11,"**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 document the amount of a nutritional supplement consumed and failed to discuss artificial nutrition (feeding tube in the stomach to infuse liquid nutrition) after an unavoidable weight loss for 1 resident (Resident #19); and failed to implement dietitian recommendations to increase the rate of enteral nutrition (tube feeding) for 1 resident who had a significant weight loss (Resident #44) of 5 residents reviewed for nutrition. The findings include: Review of the facility policy titled, Weight Assessment and Intervention, Revised 9/2018, showed .Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding the .Resident's target weight range .The relationship between current medical condition or clinical situation and recent fluctuations in weight .Whether and to what extent weight stabilization or improvement can be anticipated .Interventions for undesirable weight loss shall be based on careful consideration of the following .Resident choice and preferences .The use of supplementation and/or feeding tubes .End of life decisions and advance directives . Review of the facility policy titled, Diet Orders and RDN (Registered Dietitian Nutritionist) Order Writing, dated (YEAR) showed .Diet orders will be written by the physician or .a qualified dietician .The physician will delegate order-writing to a qualified dietician or other clinically qualified nutrition care professional who is acting within the scope of practice as defined by state law . Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician's Order for Scope of Treatment (POST) form dated 2/15/2018 showed Resident #19's wished included artificial nutrition to be administered for long term. Review of Resident #19's weight record showed the resident weighed 115 pounds on 9/11/2019. The resident refused to be weighed in October. Review of a Speech Therapy Plan of Care dated 11/19/2019, showed .Staff reports resident with poor PO (by mouth) intake resulting in steady weight loss. Pt. (patient) is unable to maintain adequate hydration and nutrition .IMPRESSIONS .Patient presents with mild oral phase dysphagia (difficulty swallowing) d/t (due to) poor dentition impacting ability to bite and masticate certain textures/food items .Cognitive impairments may contribute to pre-oral phase deficits impacting patient's reasoning & (and) judgement ability and acceptance of PO intake in order to maintain adequate hydration and nutrition . Review of a Diet Order Communication dated 11/22/2019 revealed the resident was on a regular diet with whole milk for breakfast; Mighty Shake (nutritional supplement) for breakfast, lunch and dinner; and Magic Cup (nutritional supplement) for lunch and dinner. Review of Resident #19's weight record showed the resident weighed 97 pounds on 11/30/2019. Review of a Diet Order Communication form by the Speech Language Pathologist (SLP) dated 12/2/2019 showed Resident #19 had chewing and swallowing problems and the diet was changed to pureed with soup added for lunch and supper. Review of the Physician's Order Summary Report showed an order with a start date of 12/11/2019 for the addition of a nutritional supplement, MedPass 120 milliliters (ml) 4 times a day, and to record the amount consumed. Review of the annual Minimum Data Set ((MDS) dated [DATE] showed Resident #19 had severe cognitive impairment. The resident required extensive assistance of 1 person for eating. The resident weighed 97 pounds and had non-prescribed weight loss. Review of Resident #19's weight record showed the resident weighed 97 pounds on 12/30/2019. Review of a Registered Dietitian note dated 12/30/2019 showed Resident #19 had a 10% weight loss in 90 days, but had a stable weight for 30 days. The resident was to continue receiving MedPass 120 ml 4 times daily, Magic Cup twice daily, and Fortified Foods. Review of the Medication Administration Record (MAR) for (MONTH) 2019 revealed the MedPass was administered to the resident, but no documentation of the amount consumed. Review of the care plan revised 1/1/2020, showed Resident #19 had Activities of Daily Living (ADL) self-care performance deficit with interventions including assistance of 1 staff for eating and had an .unplanned/unexpected weight loss r/t (related to) Poor food intake and cognitive deficits impacting pre-oral phase of swallowing .Dysphagia .Monitor and record food intake . The resident had an Advance Directives POST and .Advance Directive will be followed as needed . Review of Resident #19's weight record showed the resident weighed 98.6 pounds on 1/28/2020. Review of the MAR for 1/2020 showed an order for [REDACTED]. The MedPass was documented as given 4 times a day, but there was no documentation of the amount consumed. Review of the Nutrition Report showed the resident had an average meal intake of 41% for the week of 1/31/2020, 43% for the week of 2/7/2020, 46% for the week of 2/14/2020, and 50% for the week of 2/21/2020. Review of the MAR for 2/2020 showed an order for [REDACTED]. The MedPass was documented as given 4 times a day, but there was no documentation of the amount consumed. Review of Resident #19's weight record showed the resident weighed 93.6 pounds on 2/12/2020. Review of a dietary note dated 2/13/2020 showed .Weight Variance with appropriate diet order and nutritional interventions in place, increased MedPass 240 ml TID (three times daily) . Review of a Verbal Physician's Order dated 2/14/2020 showed MedPass 120 ml 4 times per day was discontinued and the MedPass was increased to 240 ml 3 times daily, with instructions to document the amount consumed. Review of the MAR for 2/2020 showed an order for [REDACTED]. The MedPass was documented as given 3 times a day, but there was no documentation of the amount consumed. Review of a Nurse Practitioner Progress Note dated 2/20/2020 showed .ACTIVE PROBLEMS .Weight Loss .social worker is asking if patient is hospice appropriate .her weight has gone down. she is at 93.6 (pounds) .Systemic symptoms weight loss . Appetite poor .Not well nourished .would recommend hospice care, related to advanced dementia, progression of disease, and weight loss .social services will talk to family about conditions and hospice recommendations . Observation on 2/24/2020 at 8:15 AM showed Resident #19 consumed 25% of breakfast and drank 100% of a Mighty Shake. During an interview on 2/24/2020 at 3:45 PM, the Registered Dietitian stated Resident #19's weight had remained stable and then the resident's weight decreased to 93.6 pounds on 2/12/2020. The MedPass was then increased to 240 ml 3 times a day. The RD confirmed she had not seen documentation of the specific amount of MedPass consumed and did not know how much of the MedPass the resident consumed at each administration. The RD reviewed the resident's record and stated she did not know when the Mighty Shake and Magic Cup were ordered and she did not see documentation of when they were ordered. During an interview on 2/24/2020 at 4:50 PM, Licensed Practical Nurse (LPN) #5 stated the resident only consumed 2 ounces (60 ml) of the MedPass at each administration and the resident did not like the taste of the MedPass. LPN #5 stated she did not document the amount of MedPass that was consumed on the MAR because there was not a place to document it on the facility's MAR. Observation on 2/25/2020 at 8:30 AM showed Resident #19 consumed 75% of breakfast, and 100% of a Mighty Shake. During interview on 2/25/2020 at 8:35 AM, Certified Nursing Assistant (CNA) #1 stated the MedPass amounts were documented in the computer. I think you can put a percentage or amount in there. CNA #1 was unable to provide the documentation on the amount of the MedPass consumed by Resident #19. During an interview on 2/25/2020 at 10:30 AM, the RD stated she was not aware of Resident #19's wishes on the POST form for a feeding tube. The RD stated she was not aware of the amount of MedPass consumed by Resident #10. The RD was not aware the amount of MedPass had not been documented on the MAR. The RD was not aware Resident #19 preferred the mighty shake over the MedPass. The RD stated the facility staff had not advised her Resident #10 had not consumed the ordered amount of the MedPass. During telephone interview on 2/25/2020 at 11:00 AM, Resident #19's family member stated he was aware the resident had declined and had weight loss. The family member reported the facility had not discussed the option of a feeding tube with him but he did want to discuss the pros and cons with the facility staff. During an interview on 2/25/2020 at 1:32 PM, the Director of Nursing (DON) confirmed the percentage of MedPass had not been documented on the 1/2020 and 2/2020 MARs. During observation on 2/26/2020 at 7:40 AM, Resident #19 consumed 50% of breakfast and drank 100% of the Mighty Shake. During telephone interview on 2/26/2020 at 9:33 AM, the Nurse Practitioner (NP #1) stated she was aware of the resident's weight loss and had recently recommended hospice services. NP #1 was not aware the resident's POST form indicated a desire for artificial nutrition. NP #1 stated when the facility recognized the significant weight loss, the facility staff should have communicated with the family and discussed the resident's wishes. NP #1 stated she had not spoken with the family regarding a feeding tube. Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a care plan dated 11/24/2019 showed Resident #44 required a feeding tube with interventions including .RD to evaluate quarterly and PRN (as needed) .Make recommendations for changes to tube feeding as needed . Review of the quarterly MDS dated [DATE] showed Resident #44 had severe cognitive impairment, had a feeding tube, and had a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months (significant weight loss). Review of a dietary progress note dated 2/14/2020 showed .spoke with nursing and resident tolerating rate and formula .increasing rate to 65 ml (milliliter)/24 hour . Observation on 2/23/2020 at 10:55 AM, in Resident #44's room, showed a feeding pump infusing tube feeding formula at 55 ml/hour. During an interview on 2/24/2020 at 1:20 PM, LPN #3 stated there was a physician's order for Resident #44's tube feeding to infuse at 55 ml/hour. During observation and interview on 2/24/2020 at 2:55 PM, the RD confirmed the tube feeding was infusing at 55 ml/hour. The RD stated on 2/14/2020 she discussed the recommendation of increasing the enteral feeding from 55 ml/hour to 65 ml/hour with LPN #4 and was told LPN #4 .would take care of it . Review of a Medication Administration Record dated 2/1/2020-2/29/2020 and the Order Summary Report showed the tube feeding was increased to 65 ml/hr on 2/24/2020.",2020-09-01
985,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2020-02-26,695,D,0,1,HJSI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to properly store a nebulizer mask and tubing in a sanitary manner for 1 resident (Resident #38) of 6 residents reviewed receiving respiratory care. The findings include: Review of the facility policy titled, Department (Oxygen Respiratory Therapy) - Prevention of Infection, dated 10/1/2018, showed .To provide a guide to prevention of infection associated with oxygen respiratory therapy tasks and equipment .Keep the oxygen cannula .in a plastic bag when not in use . Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] showed Resident #38 received oxygen therapy. Review of the care plan revised 2/21/2020 showed Resident #38 had a respiratory infection with an intervention of [MEDICATION NAME][MEDICATION NAME] (medication to open airways) via nebulizer (aerosol treatment machine) as ordered by the physician. Review of the Physician's order dated 2/21/2020, showed .[MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME]) Solution .inhale orally four times a day for dyspnea (difficulty breathing/shortness of breath) . Observation on 2/23/2020 at 11:13 AM, showed Resident #38 had a nebulizer treatment machine with the treatment tubing and mask lying in the chair beside the resident's bed, uncovered, and not stored in a bag. During an interview conducted on 2/23/2020 at 11:20 AM, in Resident #38's room, Licensed Practical Nurse #2 confirmed the nebulizer mask was not stored in a plastic bag. During an interview with the Director of Nursing (DON) on 2/23/2020 at 3:31 PM, the DON confirmed it was her expectation for nebulizer tubing and masks to be stored in a plastic bag when not in use.",2020-09-01
986,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2020-02-26,757,E,0,1,HJSI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to maintain complete and accurate documentation of behavior monitoring for 5 residents (Residents #26, #29, #32, #38, and #41) of 5 residents reviewed for unnecessary medications. The findings include: Review of the facility's Behavior/Intervention Monthly Flow Record revealed, Directions: Enter target behavior in one of the Behavior Sections. Record the number of episodes by shift with initials. Enter the Intervention Code, Outcome Code and Side Effects Codes with initials for each shift .This monitoring form is to be used for the following drug classes when appropriate .Antianxiety Agent, Antidepressant, Antipsychotic, Sedative/Hypnotic . Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] showed Resident #26 had moderate cognitive impairment. The resident had delusional behaviors and had received antipsychotic and antidepressant medications. Record review revealed no documentation a Behavior/Intervention Monthly Flow Record had been completed for Resident #26 for the months of 12/2019 or 1/2020. Review of the Behavior/Intervention Monthly Flow Record dated 2/2020 showed it was not completed 2/1/2020, 2/2/2020, 2/4/2020-2/8/2020, and for 6 of 51 shifts between 2/9/2020-2/25/2020. Resident #29 was admitted to facility on 12/31/19 with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] showed Resident #29 had moderate cognitive impairment and received antianxiety and antidepressant medications. Record review revealed there was no documentation a Behavior/Intervention Monthly Flow Record had been completed for Resident #29 for the month of 1/2020. The Flow Record was not completed for the dates of 2/1/2020, 2/2/2020, 2/4/2020-2/8/2020, and for 7 of 51 shifts between 2/9/2020-2/25/2020. Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #32's quarterly MDS dated [DATE] showed the resident was cognitively intact. The resident had received antipsychotic, antidepressant, and antianxiety medications daily. Review of the Behavior/Intervention Monthly Flow Record dated 9/2019 showed it had not been completed for 19 of 90 shifts. Review of the Behavior/Intervention Monthly Flow Record dated 10/2019 showed it had not been completed for 45 of 93 shifts. Review of the medical record showed there was no documentation a Behavior/Intervention Monthly Flow Record had been completed for Resident #32 for the months of 11/2019, 12/2019, or 1/2020. Review of the Behavior/Intervention Monthly Flow Record dated 2/2020 showed it was not completed for the dates of 2/1/2020-2/2/2020, 2/4/2020-2/8/2020, and for 8 of 51 shifts between 2/9/2020-2/25/2020. Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] showed Resident #38 had severe cognitive impairment and received antianxiety medication 2 days and antidepressant medication 7 days of the past 7 days. Review of the Behavior/Intervention Monthly Flow Record dated 9/2019 showed it had not been completed for 17 of 90 shifts. Review of the Behavior/Intervention Monthly Flow Record dated 10/2019 showed it had not been completed for 43 of 93 shifts. Review of the medical record showed there was no documentation a Behavior/Intervention Monthly Flow Record had been completed for Resident #38 for the months of 11/2019, 12/2019, 1/2020, or 2/2020. Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] showed Resident #41 had severe cognitive impairment and had received antidepressant medications. Review of the Behavior/Intervention Monthly Flow Record dated 9/2019 showed it had not been completed for 19 of 90 shifts. Review of the Behavior/Intervention Monthly Flow Record dated 10/2019 showed it had not been completed for 45 of 93 shifts. Review of the medical record showed there was no documentation a Behavior/Intervention Monthly Flow Record had been completed for Resident #41 for the months of 11/2019, 12/2019, or 1/2020. Review of the Behavior/Intervention Monthly Flow Record dated 2/2020 showed it had not been completed for the dates of 2/1/2020-2/2/2020, 2/4/2020-2/8/2020, and for 31 of 51 shifts between 2/9/2020-2/25/2020. During an interview on 2/26/2020 at 2:55 PM, the Director of Nursing (DON) confirmed the medical records were incomplete for Residents #6, #26, #29, #32, #38, and #41.",2020-09-01
987,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2020-02-26,758,D,0,1,HJSI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure a PRN (as needed) anti-anxiety medication was not used beyond 14 days without a rationale and without documentation of duration for 2 Residents (Residents #26 and #29) of 5 residents reviewed for unnecessary medications. The findings include: Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] showed Resident #26 had moderate cognitive impairment, delusional behaviors, and received antipsychotic and antidepressant medications for 7 days of the past 7 days. Review of a physician's orders [REDACTED]. Review of a Consultant Pharmacist Communication to the Physician dated 2/14/2020 (almost 1 month after the last [MEDICATION NAME] order) showed a recommendation .[MEDICATION NAME] 0.5 mg q (every) 12 hours prn anxiety .All PRN [MEDICAL CONDITION] orders to be complete should include drug, dose, schedule and PRN Reason to give and only 14 day duration. Please d/c (discontinue), add 14 day stop date, or document with a detailed progress note explaining continual need past 14 days to make the order complete . The physician replied .Continue PRN dt (due to) SOB (shortness of breath), Anxiety. PRN dose necessary for comfort . Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #29's Order Summary Report showed orders written 12/31/2019 for [MEDICATION NAME] ([MEDICATION NAME]) 0.5 mg every 4 hours as needed for anxiety, and [MEDICATION NAME] 0.5 mg 2 tablets every 4 as needed for anxiety and air hunger, with no documentation of when the [MEDICATION NAME] was to be discontinued. Review of the admission MDS dated [DATE] showed Resident #29 had moderate cognitive impairment, received antianxiety and antidepressant medications, and received hospice services. Review of a Consultant Pharmacist Communication dated (MONTH) 2020 for the [MEDICATION NAME] 1 mg every 4 hours prn showed, .Please d/c, add 14 day stop date, or document with a detailed progress note explaining continual need past 14 days to make the order complete . The physician's response dated 2/6/2020 (over 1 month after the order was written) stated .(Resident #29) Has periodic anxiety in which a longer dose is necessary. Under Hospice care. Necessary for patient's comfort . Review of a Consultant Pharmacist Communication dated (MONTH) 2020 for the [MEDICATION NAME] 0.5 mg every 4 hours prn showed, .Please d/c, add 14 day stop date, or document with a detailed progress note explaining continual need past 14 days to make the order complete . The physician's response dated 2/6/2020 (over 1 month after the [MEDICATION NAME] order was written) stated .Hospice Care. Has periodic episodes of Anxiety in which [MEDICATION NAME] is necessary. Necessary for patient's comfort . Interview with the Director of Nursing (DON) on 2/26/2020 at 2:58 PM, confirmed Resident #26 and Resident #29 had PRN antianxiety MEDICATION ORDERS FOR [REDACTED].",2020-09-01
988,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2020-02-26,807,D,0,1,HJSI11,"**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 provide water and ice at the bedside for 1 resident (Resident #6) of 14 residents reviewed. The findings include: Review of the facility policy titled, Safe Distribution of Water and Ice, undated, showed .Pass fresh ice water to residents three times daily, approximately every eight hours and prn (as needed) . Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] showed Resident #6 was cognitively intact. During observation and interview on 2/23/2020 at 11:35 AM, in the resident's room, Resident #6 stated the facility did not regularly fill up the water pitchers. The resident had 2 water pitchers in the room and both pitchers were empty. Observation on 2/24/2020 at 9:07 AM, in the resident's room, showed 2 water pitchers in the room and both pitchers were empty. During an interview on 2/24/2020 at 3:09 PM, Registered Nurse (RN) #1 confirmed Resident #6 preferred to have 2 water pitchers. The resident preferred one water pitcher to have ice in it to pour soda over and the other water pitcher to have ice and water. During interview and observation on 2/24/2020 at 3:34 PM, Resident #6 confirmed she wanted water and ice in one water pitcher, and only ice in the other pitcher, so she could pour soda in it. One water pitcher had ice with a small amount of water and the other water pitcher was empty. During an interview on 2/24/2020 at 5:26 PM, the Director of Nursing confirmed it was her expectation for ice and water to be passed every shift to the residents.",2020-09-01
989,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2020-02-26,812,F,0,1,HJSI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, and interview, the facility failed to maintain dome covers and dietary equipment in clean working condition, failed to ensure food was covered and dated, and failed to discard expired items in the dietary department which had the potential to affect 44 of 46 residents residing in the facility. The findings include: Review of the facility policy titled, Food Safety and Sanitation, dated (YEAR), showed .Food Storage .When a food package is opened, the food item should be marked to indicate the open date. This date is used to determine when to discard the food .Leftovers are used within 72 hours (or discarded) .Perishable food with expiration dates is used prior to the use by date on the package . Review of the facility policy titled, Food Storage, dated (YEAR), showed .Food will be stored, at appropriate temperatures and by methods designed to prevent contamination or cross contamination .Date marking to indicate the date or day by which a ready-to-eat, time/temperature control for safety food should be consumed, sold, or discarded will be visible on all high-risk food .Foods will be stored and handled to maintain the integrity of the packaging until ready for use . Review of the facility policy titled, Dry Storage Areas, dated (YEAR), showed .Refrigerated and frozen foods will be dated upon delivery. Foods with expiration dates are used prior to the date on the package . Observation and tour of the kitchen on [DATE] at 10:12 AM, with the Dietary Aide showed the following: * 29 of 88 plastic dome cover lids for plate service had flaking and peeling plastic under the lid * 33 slices of chocolate pie on a rack in the walk in cooler were uncovered and undated * 8 Pieces of salami in a plastic bag in the walk in cooler was open to air and undated * 3 pieces of sliced ham with an expiration date of [DATE] in the walk in cooler * 10 pound box sausage patties, less than ,[DATE] used, open to air in the freezer with no open date * 7 loaves of white sandwich bread with a best by date of [DATE] * 12 packs of hamburger buns with a best by date of [DATE] * Dried food debris on the can opener, oven, and microwave. During an interview on [DATE] at 10:20 AM, the Dietary Aide confirmed the plastic dome cover lids were in poor and unsanitary condition, with peeling and flaking plastic inside the lid. The Dietary Aide confirmed the chocolate pies were uncovered and undated; the 8 pieces of salami in the cooler was open to air and undated; and the 3 slices of ham in the walk in cooler, the sandwich bread, and hamburger buns had expired and all were available for resident use. The Dietary Aide confirmed there was dried debris and food on the can opener and inside the microwave, and the oven and was not in a clean and sanitary condition. During an interview on [DATE] at 12:35 PM, the Certified Dietary Manager confirmed expired foods were to be discarded, opened foods were to be properly stored and dated, the dome lids for food service were peeling and flaking plastic material and were not in a safe and sanitary condition. During an interview on [DATE] at 4:30 PM, the Registered Dietitian confirmed the ham, salami, and sausage patties were to be discarded when left open to air or expired, and the chocolate pies were to be covered to prevent cross contamination.",2020-09-01
990,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2020-02-26,842,E,0,1,HJSI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to maintain complete and accurate documentation of behavior monitoring in the medical record for 5 residents (Residents #26, #29, #32, #38, and #41) of 5 residents reviewed for unnecessary medications. The findings include: Review of the facility's Behavior/Intervention Monthly Flow Record revealed, Directions: Enter target behavior in one of the Behavior Sections. Record the number of episodes by shift with initials. Enter the Intervention Code, Outcome Code and Side Effects Codes with initials for each shift.This monitoring form is to be used for the following drug classes when appropriate.Antianxiety Agent, Antidepressant, Antipsychotic, Sedative/Hypnotic. Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] showed Resident #26 had moderate cognitive impairment. The resident had delusional behaviors and had received antipsychotic and antidepressant medications. Record review revealed no documentation a Behavior/Intervention Monthly Flow Record had been completed for Resident #26 for the months of 12/2019 or 1/2020. Review of the Behavior/Intervention Monthly Flow Record dated 2/2020 showed it was not completed 2/1/2020, 2/2/2020, 2/4/2020-2/8/2020, and for 6 of 51 shifts between 2/9/2020-2/25/2020. Resident #29 was admitted to facility on 12/31/19 with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] showed Resident #29 had moderate cognitive impairment and received antianxiety and antidepressant medications. Record review revealed there was no documentation a Behavior/Intervention Monthly Flow Record had been completed for Resident #29 for the month of 1/2020. The Flow Record was not completed for the dates of 2/1/2020, 2/2/2020, 2/4/2020-2/8/2020, and for 7 of 51 shifts between 2/9/2020-2/25/2020. Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #32's quarterly MDS dated [DATE] showed the resident was cognitively intact. The resident had received antipsychotic, antidepressant, and antianxiety medications daily. Review of the Behavior/Intervention Monthly Flow Record dated 9/2019 showed it had not been completed for 19 of 90 shifts. Review of the Behavior/Intervention Monthly Flow Record dated 10/2019 showed it had not been completed for 45 of [AGE] shifts. Review of the medical record showed there was no documentation a Behavior/Intervention Monthly Flow Record had been completed for Resident #32 for the months of 11/2019, 12/2019, or 1/2020. Review of the Behavior/Intervention Monthly Flow Record dated 2/2020 showed it was not completed for the dates of 2/1/2020-2/2/2020, 2/4/2020-2/8/2020, and for 8 of 51 shifts between 2/9/2020-2/25/2020. Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] showed Resident #38 had severe cognitive impairment and received antianxiety medication 2 days and antidepressant medication 7 days of the past 7 days. Review of the Behavior/Intervention Monthly Flow Record dated 9/2019 showed it had not been completed for 17 of 90 shifts. Review of the Behavior/Intervention Monthly Flow Record dated 10/2019 showed it had not been completed for 43 of [AGE] shifts. Review of the medical record showed there was no documentation a Behavior/Intervention Monthly Flow Record had been completed for Resident #38 for the months of 11/2019, 12/2019, 1/2020, or 2/2020. Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] showed Resident #41 had severe cognitive impairment and had received antidepressant medications. Review of the Behavior/Intervention Monthly Flow Record dated 9/2019 showed it had not been completed for 19 of 90 shifts. Review of the Behavior/Intervention Monthly Flow Record dated 10/2019 showed it had not been completed for 45 of [AGE] shifts. Review of the medical record showed there was no documentation a Behavior/Intervention Monthly Flow Record had been completed for Resident #41 for the months of 11/2019, 12/2019, or 1/2020. Review of the Behavior/Intervention Monthly Flow Record dated 2/2020 showed it had not been completed for the dates of 2/1/2020-2/2/2020, 2/4/2020-2/8/2020, and for 31 of 51 shifts between 2/9/2020-2/25/2020. During an interview on 2/26/2020 at 2:55 PM, the Director of Nursing (DON) confirmed the medical records were incomplete for Residents #6, #26, #29, #32, #38, and #41.",2020-09-01
991,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2020-02-26,865,F,0,1,HJSI12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, review of the Plan of Correction (POC) and interview, the facility's Quality Assurance Performance Improvement (QAPI) Committee failed to implement the facility's POC for resident trust funds. The findings include: Review of the policy titled, Quality Assurance and Performance Improvement (QAPI) Program, dated 2/2020, showed .provides a means to measure .outcomes of care and quality of life .process for identifying and correcting quality deficiencies .tracking and measuring .developing and implementing corrective action . Review of the facility's POC with a compliance date of 4/14/2020 revealed, .The Facility Administrator and Business Office Manager (BOM) will review all discharges for the month for three months to ascertain that any funds remaining in resident trust were conveyed within thirty days of discharge. The findings of these reviews will be reported to the Quality Assurance Performance Improvement Committee x (times) months for review and further recommendations . During an interview with the Administrator, on 8/4/2020 at 11:15 AM, in the Administrator's office, the Administrator stated he looked at the resident trust refund balance daily, and was aware discharged residents funds had not been returned within 30 days. During an interview with the Administrator on 8/5/2020 at 10:20 AM, the Administrator confirmed the QAPI committee met monthly. During the interview, the Administrator confirmed his role was .[MEDICATION NAME], timekeeper, and facilitator . of the committee. He confirmed he reviewed and reported discharged residents trust fund balances .there was an awareness of an issue there .my corrective action was to get them (corporate billing) to do research and be paid in a timely manner . He stated the committee looked at it .periodically .we didn't do it formally . The Administrator confirmed the QAPI Committee failed to monitor and evaluate corrective actions for the return of discharged resident's funds within 30 days. In summary, the QAPI Committee failed to maintain compliance with the POC for Notice and Conveyance of Personal Funds. Upon review of the POC, the QAPI Committee, after identifying the issue of nonpayment of resident funds within 30 days, failed to develop, implement, and refund 4 discharged resident funds.",2020-09-01
992,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2020-02-26,880,D,0,1,HJSI11,"**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 follow infection control practices for 1 resident (Resident #6) of 14 sampled residents. The findings include: Review of the facility policy titled, Isolation- Categories of Transmission-Based Precautions, revised 1/2012, showed .Transmission-Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent or control the spread of infection .Contact Precautions .implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment .wear gloves .when entering the room .remove gloves before leaving the room and perform hand hygiene .wear a disposable gown upon entering the Contact Precautions room . Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Physician's order dated 2/24/2020 showed the resident required isolation with Contact Precautions due to an infection in a wound. Observation of Resident #6's room on 2/25/2020 at 7:30 AM, showed a Contact Isolation sign was on the resident's door. The Social Service Director (SSD) was observed in the resident's room with no gloves or gown on. The SSD exited the room carrying juice in her hand, without performing any type of hand hygiene. Interview with the SSD confirmed there was a Contact Isolation sign on the door. The SSD confirmed she had not donned gloves or gown prior to entering the room, and had not performed any type of hand hygiene prior to exiting the room. During observation of wound care for Resident #6 on 2/25/2020 at 3:02 PM, 2 Licensed Practical Nurses (LPN) donned gloves and gowns prior to entering the resident's room. LPN #3 exited the room at 3:07 PM still wearing the gown and gloves. She re-entered the room at 3:08 PM with the same gown and gloves on, and carrying a package of incontinence wipes to provide incontinence care to the resident. LPN #3 then removed the dirty gloves she had on and put clean gloves on, without performing hand hygiene. LPN #3 exited the room again at 3:14 PM to obtain gauze to clean a wound. She removed her gloves, but did not remove the gown prior to exiting the room, and did not perform any type of hand hygiene. LPN #3 exited the room again at 3:21 PM to obtain a measuring device to measure a wound. She removed her gloves prior to leaving the room, but did not remove her gown. LPN #3 exited the room again at 3:25 PM to obtain a dressing for one of the resident's wounds. She removed the gloves, but did not remove the gown. LPN #3 returned to the room at 3:26 PM and donned clean gloves, without performing any type of hand hygiene. During an interview on 2/25/2020 at 3:32 PM, LPN #3 confirmed she had exited the room [ROOM NUMBER] times during wound care to obtain supplies, without removing her gown, and did not always perform hand hygiene prior to exiting the room or with glove changes. During an interview on 2/25/2020 at 4:43 PM, the Director of Nursing confirmed it was her expectation for staff to remove the gown and gloves and to wash the hands prior to exiting an isolation room.",2020-09-01
993,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2017-05-02,371,F,1,0,5GRM11,"> Based on review of facility policy, observation, and interview, the facility failed to maintain sanitary conditions in the dietary department and failed to maintain proper food temperatures in 1 of 1 observations made. The findings included: Review of facility policy Food Preparation and Service, last revised 2014, revealed .maintain clean food storage areas at all times .mechanically altered hot foods .must stay above 135 degrees .during preparation . Observation and interview with the Dietary Manager on 5/2/17 from 10:59 AM to 11:05 AM, during tour of the dietary department, revealed debris including paper clutter, a tray top, and a coffee cup on the floor behind and beneath the clean dish rack. Continued observations of the dry storage area revealed a 6 pound 9 ounce can of tomato sauce, two 111 ounce cans of northern beans, and a 6 pound can of mandarin oranges stored dented and ready for use. Further observations of the walk in refrigerator revealed five 2 pound bags of shredded coconut with an expiration date of 8/15/2015 and 67 pints of milk with an expiration date of 4/30/17. Continued observation of food temperatures during tray line preparation revealed the pureed spaghetti sauce was 116.2 degrees Fahrenheit (low) and the pureed carrots were 79 degrees Fahrenheit (low). Interview with the Dietary Manager confirmed the facility failed to maintain sanitary conditions in the kitchen, failed to ensure expired foods and dented cans of food were not available for resident use, and failed to ensure prepared foods were served at the appropriate temperature.",2020-09-01
994,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2017-05-02,465,F,1,0,5GRM11,"> Based on observation and interview, the facility failed to maintain the function and the sanitary conditions in 2 shower rooms (east wing and west wing) of 3 shower rooms observed. The findings included: Observation during initial tour of the east wing shower room toilet facilities on 5/1/17 at 12:12 PM revealed the following: 1. 2 candy wrappers, 3 previously used vinyl gloves, 2 candy sucker sticks, previously used alcohol prep pads, and plastic wrappers lying on the floor; 2. 1 overfilled 50 gallon trash can with numerous soiled adult briefs and pads, within it; 3. Brown colored debris on the floor near the shower drain; 4. Brown colored debris on the flooring in front of and near the toilet; 5. Yellow colored stains in front the toilet; 6. The commode was clogged with dark black and brown debris and was unable to be flushed; 7. Brown colored debris on the toilet bowl and a bariatric chair situated above the commode; 8. The shower had an overwhelming odor of urine and feces; 9. 1 pair of soiled adult briefs atop the faucet handles of the handwashing sink; 10. Clean adult briefs stored next to the center of the shower room floor, between the trash cans and the shower stalls. 11. Shower chairs located in two of the shower stalls were stored wet and had brown stains on the seats; 12. The hand held shower heads were stained and were dripping water. Observation of the west wing shower room on 5/1/17 at 1:40 PM, revealed the following: 1. The commode was clogged with a large amount of dark black and brown debris and was unable to be flushed; 2. Dark brown and black debris was smeared on the inner commode rim; 3. The floor in front of the toilet was soiled with dark brown and yellow colored debris; 4. A small trash can was overfilled with soiled adult briefs and other assorted trash; 5. The shower room had an overwhelming odor of urine and feces; 6. The shower heads were stained. Continued observation revealed 3 staff members entered the west wing shower room, removed the trash can filled with soiled briefs, replaced the barrel with an empty receptacle, and exited the shower room without any further cleanup of the shower room. Interview with the Director of Nursing (DON) on 5/1/17 at 2:30 PM, in the DON's office, confirmed the facility failed to maintain sanitary conditions in the shower rooms and failed to ensure the commodes functioned and were available for resident use.",2020-09-01
995,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2018-09-20,584,E,1,0,4QHC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and review of facility maintenance records, the facility failed to maintain clean, comfortable and home like conditions on 3 of 4 resident units observed for physical environment. The findings include: Observations of facility dining area and front lobby during initial tour revealed it was closed due to renovations in progress. Observations during the initial tour revealed the front lobby, front hallway, dining area and common seating areas adjacent to the lobby were cordoned off by a black, vinyl curtain with a zipper and sign that informed viewers that section of the facility was closed due to renovation. Continued observation revealed the dining room appeared to be renovated with new flooring, wall coverings and carpet. Rolls of new flooring materials were in the floor near the wall adjacent to the kitchen door of the dining room and the dining room appeared to have been unused for a substantial period of time as evidenced by dust on a few of the tables near the rear of the dining room adjacent to the kitchen. Staff offices in the construction area were in use, including the medical records department, admissions office, conference room and Administrator's Office. Interview with the Director of Nursing (DON) and construction foreman during the initial tour revealed the dining area and a major portion of the West Wing had been under renovation since (MONTH) (YEAR), and residents had been required to dine in their rooms or on the unit hallways since then. Observations of the East Wing, H Wing Hallway and portions of the West Wing still in use, with the DON, on 9/18/18, from 2:39 PM to 3:30 PM revealed the following: East Wing 1. A pervasive odor of urine was present in the hallway, attributed to the carpet, between rooms 205-212. room [ROOM NUMBER] was closed for renovations and was reported to have a pervasive odor prior to renovation due to odors absorbed by the wall coverings. 2. Crusty matter which appeared to be dried food particles were present ground into the carpet in front of the East Wing Nursing Station between rooms [ROOM NUMBERS]. 3. There was a pervasive odor of urine at the distal end of the East Wing again attributed to carpeting in the hallway in the vicinity of room [ROOM NUMBER], which extended to the exit door at the end of the unit. 4. Observations of the carpeting revealed the carpet was worn with multiple bare spots near the carpet edges, and heavy black staining throughout the East Unit. 5. The tile floors of rooms, 203-209, 223, 226, 230 and 231, were heavily scuffed with black marks, and appeared heavily worn, dirty and dull. 6. The wall covering near the door in room [ROOM NUMBER] was visibly stained and dirty. The wall covering around the air condition unit in room [ROOM NUMBER] was in a state disrepair, scuffed and dirty. 7. Observations of the East Wing Shower room revealed the metal box which contained the thermostat was hanging open. A single used vinyl glove was inside the lid of the box which hung by the hinges below the box. The plastic thermostat cover was lying in the hanging portion of the box. The thermostat mechanism itself with single red and white wires visible, was exposed to open air. A paper clip was noted to be present protruding from the lock mechanism on the upper front portion of the box which was inoperable. The box could not be closed by the DON who attempted secure it and it would fall open when attempts to close it were made. Continued observations of the H Hallway (between the East and West Units) revealed the following: 1. The H Hallway carpet was heavily worn and stained with a black stain that appeared water like in pattern, throughout the entire length of the hallway. A pervasive, musty odor was present the length of the hallway between the East and West units. There was dirt and debris ground into the carpet near the nursing stations at either end of the hallway. 2. Observations of the flooring in the H Hallway shower room revealed it to be in a state of disrepair. Sections of the flooring were loose and appeared to have become detached from the sub flooring beneath. The DON reported the shower had been out of use for several months due to the flooring issues and the owners of the facility had ordered it closed in lieu of repair, due to planned renovation. The DON reported at the time, the facility used the 2 remaining shower rooms (East wing shower at the other end of the H Hallway, and another shower room on the main hall entrance to the East Wing) for all 65 residents who remained in the facility. Observations of the West Wing revealed the following: 1. The carpet on the unit from the nursing station to the end of the unit was heavily worn and soiled with black stains similar to those noted on both the East and H Hallways. 2. A pervasive musty odor was present at the far end of the West Hallway. 3. The tile floors in the resident rooms were noted to be heavily scuffed, dirty and worn in rooms 122, 123, 125 and 131. The threshold of room [ROOM NUMBER] was noted to be covered with gray duct tape, which was torn at the edge adjacent to the door frame, wood fragments were noted to be in the floor atop the duct tape, which appeared to have flaked off the finish of the room door. Interview with the interim Housekeeping Supervisor (HS) revealed she had been in the position for 2 weeks. The HS reported the facility did not own a floor cleaner or tile buffer and the tile floors had not been cleaned other than routine mopping. The HS reported the facility did not own a carpet cleaner as well and staff attempted to keep the carpets clean via sweeping it or vacuuming it after meals. The HS confirmed for several months residents had taken meals in the hallways or their rooms as the dining hall had been closed due to renovations. The HS reported her predecessor had advised her and other members of the housekeeping staff, the facility owners did not wish to spend money on carpet or floor cleaning equipment or commercial carpeting cleaning services, due to the costs of ongoing renovations and plans to change the flooring. The HS reported the facility carpets had not been deep cleaned since before the last annual survey sometime in (YEAR). Review of the facility carpet cleaning receipts revealed the facility had not contracted for carpet cleaning since (MONTH) of (YEAR). There were no receipts for tile floor cleaning. Interview with the DON on 9/18/18 at 5:00 PM, in the conference room confirmed the facility did not own a tile floor buffer or carpet cleaner other than a standard vacuum cleaner, and confirmed the facility had not contracted for cleaning services for the floors since (MONTH) (YEAR) per the receipts. The DON confirmed the facility dining hall had been closed for 10 consecutive months due to renovations and confirmed the facility failed to maintain a clean, comfortable and homelike environment on the East Wing, H Hallway and West Wings as identified during observations.",2020-09-01
996,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2019-09-25,600,D,1,0,ZR0911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of a facility investigation, medical record review, observation, and interview, the facility failed to prevent abuse for 1 resident (#2) of 7 residents reviewed for abuse. The findings included: Review of facility policy Abuse Neglect, Mistreatment and Misappropriation of Resident Property, last revised 10/2017, revealed .it is the policy of this facility to prevent abuse .Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pair or mental anguish .Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Review of a facility investigation dated 7/27/19 revealed on 7/27/19 at approximately 11:00 AM Resident #6 entered Resident #2's room. Further review a nurse entered Resident #2's room after hearing the residents cursing loudly. Continued review revealed as the nurse was removing Resident #6 from Resident #2's room; Resident #6 reached over and hit Resident #2 on the foot. Further review revealed the nurse grabbed Resident #6's arm and placed it close to his body, but Resident #6 quickly reached back and hit Resident #2's foot again. Medical record review revealed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE], with the [DIAGNOSES REDACTED]. Review of Resident #2's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was not completed due to .resident is rarely/never understood . Review of a Staff Assessment for mental status revealed the resident's short and long memory was good. Medical record review revealed Resident #6 was admitted to the facility on [DATE] and discharged [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #6's Annual MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 4, indicating the resident had severe cognitive impairment. Observation and interview with Resident #2 and Licensed Practical Nurse (LPN) #1 on 9/23/19 at 10:20 AM, in the hallway outside the resident's room, revealed the resident was seated in a wheelchair, was well groomed, and had no anxious or fearful behaviors. Interview with Resident #2 revealed .(Resident #6) hit my foot (translated by LPN #1) . Telephone interview with LPN #2 on 9/23/19 at 1:40 PM revealed .He (Resident #6) was in (Resident #2's) room visiting her roommate .(Resident #2) was yelling so I went in the room and was rolling him (Resident #6) out. When we passed the foot of her (Resident #2's) bed he (Resident #6) reached out .hit her (Resident #2's) foot .before I could get (Resident #6's) arms he hit (Resident #2's) foot again .he meant to hit her . Interview with the Director of Nursing on 9/25/19 at 11:18 AM, in the conference room, confirmed Resident #6 deliberately hit Resident #2 on her foot twice. In summary, the facility failed to prevent abuse to Resident #2.",2020-09-01
997,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2017-10-18,465,F,1,0,RWX011,"> Based on observation and interview, the facility failed to maintain a clean, comfortable, and homelike environment on 2 of 2 units observed. The findings included: Observations on 10/18/17 from 10:30 AM to 10:55 AM revealed the carpet on the East and West Wing hallways had large dark brown to black stains. Continued observation on the West Wing hallway revealed the carpeting at the nursing station was loose from the floor and an elevated ridge had formed. Further observation revealed the West Wing nursing station dry wall was unfinished and unpainted. Continued observation revealed the West Wing fire doors located between the entrance to the unit and the central hallway had rough and small irregular chunks missing from the door edges and the wood beneath the finish was exposed. Further observation revealed the threshold in room 214 was cracked and there were 2 large fist sized holes located above bed B. Continued observation revealed the paint was chipped from the wall around the sink and soap dispenser located in room 214. Interview with the Administrator on 10/18/17 at 11:00 AM, in the conference room, confirmed the facility failed to maintain a clean, comfortable, and homelike environment on both the East and West Wings.",2020-09-01
998,"WEXFORD HOUSE, THE",445207,2421 JOHN B DENNIS HIGHWAY,KINGSPORT,TN,37660,2018-01-18,657,D,0,1,8C9J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility fall investigation, observation and interview the facility failed to revise a care plan for 1 resident (#64) of 32 residents reviewed. The findings included: Medical record review revealed Resident #64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physicians Order dated 8/4/12 revealed .up high Back w/c (wheelchair) with Front Back Tip guards with (decreased) safety awareness . Medical record review of the residents care plan dated 8/4/12 revealed .Up in high back w/c with front/back tip guards . Medical record review of the residents care plan last revised 1/10/18 revealed the care plan was not updated to reflect high back wheelchair (w/c) with front and back tip guards. Interview with Licensed Practical Nurse (LPN) #2 on 1/18/18 at 3:00 PM, in the conference room, confirmed the current care plan was not updated to reflect the resident was to use a high back w/c with front and back tip guards.",2020-09-01
999,"WEXFORD HOUSE, THE",445207,2421 JOHN B DENNIS HIGHWAY,KINGSPORT,TN,37660,2018-01-18,689,D,0,1,8C9J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility fall investigation, observation, and interview the facility failed to ensure 1 resident (#64) was free from accidents of 6 residents reviewed for falls. The findings included: Medical record review revealed Resident #64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a care plan dated 8/4/12 revealed .Up in high back w/c (wheelchair) with front/back tip guards . Medical record review of a Physicians Order dated 8/4/12 revealed .up high Back w/c with Front Back Tip guards with soft belt . Medical record review of a Physicians Order dated 1/10/18 revealed .send to ER (emergency room ) for eval (evaluation) s/p (status [REDACTED]. Medical record review of a Nurse Practitioner's note dated 1/10/18 revealed .Pt (Patient) is seen today for fall, was in standard wheelchair when she tipped over .Abrasion + (plus) subcutaneous (below the skin) swelling to scalp . Medical record review of a Nurse's note dated 1/10/18 revealed .observed resident up in w/c with w/c lying on it's left side on the floor .raised area to left upper forehead and abrasion noted with active bleeding. Appears that resident struck her head on the bottom of the dresser. Resident was in a standard w/c . Medical record review of the facility investigation dated 1/10/18 revealed .observed resident up in w/c lying on to its left side against the floor .abrasion and raised area noted to left side of upper forehead approx. (approximate) size of quarter .education with staff .19. Was the care plan followed .No .not in high back w/c . Medical record review of an emergency room report dated 1/10/18 revealed XXX[AGE] year old female who presents .after falling out of a wheelchair. Patient sustained an injury to the front of her head .CT scan (Cat scan-test that uses x-ray to provide detailed picture) of her head neck today are unremarkable .She will be treated with a dressing and wound care . Medical record review of the CT report dated 1/10/18 revealed .small left frontal scalp hematoma (collection of blood outside the blood vessell) with no acute intracranial (within the skull) abnormality . Observation of Resident #64 on 1/16/18-1/18/18 revealed the resident was sitting in a high back w/c with anti-tip guards. Continued observation revealed the resident had old bruising to left side of the face. Interview with Licensed Practical Nurse (LPN) #1 on 1/18/18 at 1:00 PM, at the nurse's station, confirmed on 1/10/18 Resident #64 was in a standard 18 inch wheelchair while staff cleaned her high back wheelchair. Continued interview confirmed the resident tipped the w/c over, struck her head, had bruising to her face and an abrasion to her forehead. Further interview confirmed the resident was sent to the hospital for evaluation and confirmed the resident was put in the wrong wheelchair. Interview with Quality Assurance LPN on 1/18/18 at 1:20 PM, in the conference room, confirmed Resident #64 was to be in a high back wheelchair with anti-tip guards. Further interview confirmed on 1/10/18 the resident was put in the wrong wheelchair and tipped it over, causing the resident to hit her head. Continued interview confirmed Resident #64 had an abrasion and bruising to her head, was sent to the hospital for evaluation and returned to the facility.",2020-09-01
1000,"WEXFORD HOUSE, THE",445207,2421 JOHN B DENNIS HIGHWAY,KINGSPORT,TN,37660,2018-01-18,761,D,0,1,8C9J11,"Based on review of facility policy, observation, and interview the facility failed to ensure medication was disposed of in an appropriate manner. The findings included: Review of the facility policy, Sharps Containers revealed .Disposal of all sharps and medication vial shall be disposed in the sharps container . Observation of the dumpster on 1/16/18 at 11:20 AM, with the Dietary Manager revealed an insulin vial on the ground outside of the dumpster. Continued observation revealed the insulin vial was 1/4 full of clear liquid remaining in the vial. Interview with the Director of Nursing (DON) on 1/17/18 at 11:55 AM, in the conference room confirmed insulin vials are to be disposed of in the sharps containers, and the facility failed to follow their policy.",2020-09-01