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
4900,"NHC HEALTHCARE, OAKWOOD",445002,244 OAKWOOD DR,LEWISBURG,TN,37091,2016-05-25,278,D,0,1,4W6411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to accurately assess resident behaviors for 1 of 11 (Resident #4) sampled residents of the 23 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference date of 3/25/16 revealed Resident #4 was severely cognitively impaired and exhibited no behaviors during the 7 day review period. Review of the Task Administration Record Report for the month of (MONTH) (YEAR) revealed Resident #4 exhibited severe verbal and physical aggression on 3/23/16. This behavior was not reflected on the quarterly MDS 3/25/16. Interview with the MDS Coordinator on 5/25/16 at 11:10 AM, in her office, the MDS Coordinator was asked if the behaviors exhibited on 3/23/16 should have been reflected on the quarterly MDS dated [DATE]. The MDS Coordinator stated, Yes, it probably should have .",2019-06-01
4901,"NHC HEALTHCARE, OAKWOOD",445002,244 OAKWOOD DR,LEWISBURG,TN,37091,2016-05-25,371,E,0,1,4W6411,"Based on policy review, observation and interview, the facility failed to ensure food was prepared and served under sanitary conditions as evidenced by a dirty ice machine, a mixer with dried substance on the base of the mixer, a dirty deep fat fryer, and the double ovens were dirty with dried food particle buildup. The facility had a census of 53 with 51 of those residents receiving a meal tray from the kitchen. The findings included: 1. The facility's Safety & Sanitation Best Practice Guidelines .CLEANING PR[NAME]EDURES .MIXER policy documented, .Frequency .cleaning instructions .After each use . 2. The facility's Safety & Sanitation Best Practice Guidelines .CLEANING PR[NAME]EDURES .DEEP FRYER policy documented, .cleaning instructions. After each use . 3. The facility's Safety & Sanitation Best Practice Guidelines .CLEANING PR[NAME]EDURES .OVENS policy documented, .Frequency: Daily, weekly, or as needed . 1. Wipe up spills as they occur .Scrape burned-on particles from hearth . 4. Observations in the kitchen on 5/24/16 at 10:12 AM, 11:20 AM, and on 5/25/16 at 8:55 AM, revealed the following: a. A small hole in the ice machine draining brown liquid. b. Brown dried substance on the mixer base. c. Black buildup on the metal part inside of the deep fat fryer. d. Black build up and dried food particles on the bottoms of the double ovens. Interview with the Dietary Manager (DM) on 5/24/16 at 10:14 AM, in the kitchen, the DM was shown the brown water that was coming out of the small hole in the ice machine and was asked should there be brown water dripping in the ice machine. The DM stated, No, it shouldn't . The DM was shown the hand held mixer and was asked should the mixer have a brown dried substance on it. The DM stated, .looks like someone didn't clean it well . The DM was then shown the deep fat fryer and was asked what was the black substance on the metal inside of the deep fryer. The DM stated, .it's build up .needs to be cleaned .",2019-06-01
5950,"NHC HEALTHCARE, OAKWOOD",445002,244 OAKWOOD DR,LEWISBURG,TN,37091,2015-10-07,157,D,1,0,SQJ611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # TN 985 Based on policy review, medical record review and interview, the facility failed to notify the physician and responsible party of a change in condition of 1 of 3 (Resident #1) sampled residents. The findings included: Review of the facility's policy and procedure regarding change in patient status 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 . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was do not resuscitate status and provide comfort measures. A nurse's note dated 3/18/15 documented, .11:00 AM . Pt (patient) having 35- (to) 60 secs (seconds) apnea. Pulse Ox (oximetry) 86% (percent) RA (room air). O2 (oxygen) applied at 2.5 L (liters) / NC (nasal cannula) per concentrator . B/P (Blood Pressure) 60/42, P (pulse) 85 . The facility was unable to provide documentation that the resident's responsible party or the attending physician had been notified of a change in the resident's condition. Telephone interview with the resident's responsible party (RP) (wife) on 10/7/15 at 11:30 AM, in the conference room, the resident's RP was asked if she was notified of the change in the resident's. The resident's RP stated, I called that morning before 7 o'clock and was told he had been restless the night before. I called again at 2 PM and was told he was on oxygen and his B/P was 84/52. They never called and notified me of the change in his condition. When I got here shortly after 3 o'clock I said to the nurse he's dying isn't he. The nurse said Yes, I wish they had called me so that me and my daughter could have been with him all day. His sister would have wanted to be here with him as well. Interview with the Director of Nursing (DON) on 10/7/15 at 11:56 AM, in the conference room, the DON was asked when is the physician made aware of a change in a resident's condition. The DON stated, When there's a change in the resident's condition the nurse assess the resident, if there's a huge change from baseline the physician will be notified and the family will be notified. The DON verified there was no documentation of the resident's responsible party or the attending physician being being made aware of a change in the resident's condition.",2018-10-01
5951,"NHC HEALTHCARE, OAKWOOD",445002,244 OAKWOOD DR,LEWISBURG,TN,37091,2015-10-07,309,D,1,0,SQJ611,"Based on policy review, medical record review and interview, the facility failed to monitor and document vital signs (V/S) every shift for 72 hours for 1 of 3 (Resident #1) sampled residents. The findings included: The facility's documentation guidelines policy documented, .Alert Charting: The process of every shift monitoring and documentation following an initial event, a change in condition, or institution of a new treatment or medication . Events/conditions for which Alert Charting should be initiated include, but are not limited to . Admissions, readmissions . Review of the vital signs records revealed the following: a. 3/16/15 - V/S were checked on admission at 8:20 PM and 8:40 PM. b. 3/17/15 - V/S were checked on the 2 PM to (-) 10 PM shift and on the 10 PM - 6 AM shift. There was no documentation of the resident's V/S being checked on the 6 AM -2 PM shift. The facility failed to monitor the resident's V/S on every shift as per policy. Nurses' notes documented the the following: a. 3/16/15 - an admission note was documented at 8:20 PM (2 PM - 10 PM shift) and on the 10 PM 6 AM shift. b. 3/17/15 - there was no documentation of a nurse's note on the 6 AM - 2 PM shift or on the 2 PM - 10 PM shift. The facility failed document on the resident every shift as per policy. Interview with the Director of Nursing (DON) on 10/7/15 at 11:56 AM, in the conference room, the DON was asked how often are newly admitted residents charted on and how often are vital signs checked on new admissions. The DON stated, On new admissions alert charting is done for 3 days on each shift as well as the vital signs are checked on every shift. If there are any problems past 3 days then they are kept on alert charting.",2018-10-01
6152,"NHC HEALTHCARE, OAKWOOD",445002,244 OAKWOOD DR,LEWISBURG,TN,37091,2015-04-28,247,D,0,1,VDPT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, the facility failed to give advance notification of a new roommate for 1 of 27 (Resident #7) who were interviewed about a room or roommate change. The findings included: The facility's residents' rights policy documented, .ROOM ASSIGNMENT . At all times you will be notified of a change in your room or in your roommate . Medical record review revealed Resident #54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 14 day Minimum Data Set (MDS) assessment dated of 2/17/15 documented, no cognitive impairment. The facility was unable to provide documentation that Resident #54 had been informed of any new roommates. Interview with Resident #54 on 4/26/15 at 2:17 PM, in Resident #54's room, Resident #54 was asked, if she had been moved to a different room or had a roommate change in the last nine months. Resident #54 stated, Yes, have had several since (MONTH) (2015). Resident #54 was asked, were you given notice before room or roommate changes. Resident #54 stated, No, they (staff) didn't tell me until they brought them in here and introduced me to them. Didn't tell me until they (new roommates) were here. Resident #54 was asked, How many is several. Resident #54 stated, Four since (MONTH) (2015). Interview with the Social Worker (SW) on 4/27/15 at 1:15 PM, in the Social Services office, the SW was asked, when are the residents notified that they are changing rooms or getting a new roommate. The SW stated, As soon as we know it. The SW was asked, where is it documented that the resident has been informed that the resident will be getting a new roommate. The SW looking at the chart and stated, There is no documentation of notifying her(Resident #54) here in my notes. I am the one that normally does that, but on weekends it could have been the nurse. Interview with the Director of Nursing (DON) on 4/27/15 at 1:50 PM, at the nurses station, the DON was asked, when do the staff tell a resident that they are getting a new roommate. The DON stated, We (the staff) tell them as soon as we get a confirmation that a resident is coming and the SW normally documents it. The DON confirmed that the SW notes did not document that Resident #54 was notified of getting a new roommate on 3/30/15.",2018-09-01
6153,"NHC HEALTHCARE, OAKWOOD",445002,244 OAKWOOD DR,LEWISBURG,TN,37091,2015-04-28,253,D,0,1,VDPT11,"Based on observation and interview, the facility failed to maintain a sanitary and comfortable environment that was free from lingering pervasive odors on 1 of 2 (West hall) halls. The findings included: Observations on the west hall on 4/26/15 at 10:48 AM, revealed a strong pervasive odor between rooms 25, 26, 27 and 28. Observations on the west hall 4/26/15 at 10:51 AM, revealed a strong pervasive odor in the bathroom of room 34, and a yellow liquid on the floor between the sink and the commode. Observations on the west wing on 4/26/15 at 11:22 AM, revealed a strong pervasive odor in room 27. Interview with housekeeping staff member (HSM) #1 on 4/28/15 at 1:30 PM, on the west hall beside room 27, HSM #1 was asked what was done in the facility to control odors. HSM #1 stated, The area is cleaned with bleach or peroxide repeatedly until odors are eliminated. HSM #1 was asked if it was acceptable for the facility to have odors. HSM #1 stated, No, it is not.",2018-09-01
6154,"NHC HEALTHCARE, OAKWOOD",445002,244 OAKWOOD DR,LEWISBURG,TN,37091,2015-04-28,309,D,0,1,VDPT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the contract review, policy review, medical record review, observation and interview, the facility failed to follow the [MEDICAL TREATMENT] contract, failed to maintain intake and output (I&O) measurements and failed to follow the physician's orders [REDACTED].#5) sampled resident receiving [MEDICAL TREATMENT] included in the stage 2 review. The findings included: The facility's SNF (skilled nursing facility) OUTPATIENT [MEDICAL TREATMENT] SERVICES AGREEMENT contract documented, .Obligations of Nursing Facility and/or Owner . [MEDICAL CONDITION] (end stage [MEDICAL CONDITION]) Residents Information. The Nursing Facility shall ensure that all appropriate medical and administrative information accompanies all [MEDICAL CONDITION] Residents at the time of referral to the [MEDICAL CONDITION] [MEDICAL TREATMENT] Unit . Mutual Obligations . 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 . The facility failed to follow the outlined contract. The facility's D[NAME]UMENTATION GUIDELINES policy documented, .Intake and Output Records are used when requested by a physician or at the discretion of the charge nurse . Intake/Output records include . Total fluid intake in ml's (milliliters) . Total fluid output in ml's or number of times voided, as appropriate . Date . and shift . Initials of person recording . Correct addition of total fluids for 24 hours . Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented that Resident #5 had some cognitive difficulty in new situations only, required extensive staff assistance with activities of daily living, was non-ambulatory, and was receiving [MEDICAL TREATMENT] services. The care plan for Resident #5 dated 2/18/15 documented, .[MEDICAL TREATMENT] .1000ml fluid restriction. 640ml from ngs (nursing staff), 360ml from dty (dietary) . The physician orders [REDACTED].FLUID RESTRICTION . 1000ML FLUID RESTRICTION . RENAL . [MEDICAL TREATMENT] EVERY MONDAY, WEDNESDAY AND FRIDAY . The dietary progress notes documented .2/10/15 . 1000 ml fluid restriction . 3/24/15 . fluid gains . not following restrictions . 4/21/15 . Observations in Resident #5's room on 4/27/15 at 2:35 PM and 5:00 PM, revealed Resident #5 had a large drinking cup containing liquid on the bedside table. The facility failed to maintain I&O measurements and failed to follow the physician's orders [REDACTED]. Interview with the Director of Nursing (DON), on 4/27/15 at 2:38 PM, in the conference room, the DON was asked how the facility communicates with the [MEDICAL TREATMENT] clinic. The DON stated, If they are concerned or have any changes, they will call us. Won't get any written documentation. The DON was asked if the facility sends any written documentation regarding Resident #5's weights and vital signs. The DON stated, She goes by ambulance, give report to them. They give report to [MEDICAL TREATMENT]. When they bring her back, they (ambulance attendant) give report to us. Interview with Registered Nurse (RN) #1, on 4/27/15 at 3:04 PM. in the conference room, RN #1 was asked how the facility communicated with the [MEDICAL TREATMENT] clinic. RN #1 stated, They will call us or the ambulance people tell us. Very seldom do we get anything from [MEDICAL TREATMENT] or send anything. RN #1 was asked if Resident #5 was on fluid restrictions. RN #1 stated, Let me get the book. RN #1 was asked who performed labs on Resident #5. RN #1 stated, I think they ([MEDICAL TREATMENT] clinic) may. RN #1 was asked if the [MEDICAL TREATMENT] clinic shared the lab results with the facility. RN #1 stated, Sometimes. Interview with the Registered Dietician (RD), on 4/27/15 at 3:20 PM, in the conference room, the RD was asked to explain Resident #5's fluid restrictions. The RD stated, The RD from [MEDICAL TREATMENT] called and said fluid gains were high. She ([MEDICAL TREATMENT] RD) calls me every month. The month of (MONTH) (Resident #5) gained 8 to 9 pounds. This isn't abnormal for her. The RD was asked how much fluid dietary sends with Resident #5's meal trays. The RD stated, Only 4 ounces, on strict restrictions. The RD was asked should Resident #5 have fluids left at the bedside. The RD confirmed no fluids should be left at Resident #5's bedside. Interview with Certified Nursing Assistant (CNA) #1 on 4/27/15 at 3:44 PM, in the break room, CNA #1 was asked if she provided care for Resident #5. CNA #1 stated, Yes. CNA #1 was asked whether Resident #5 could walk. CNA #1 stated, No. CNA #1 was asked how much fluid Resident #5 was allowed to have. CNA #1 stated, They didn't really tell us how much intake, not really for sure. Interview with Resident #5, on 4/27/15 at 5:00 PM, in Resident #5's room, Resident #5 was asked if the staff always keeps ice in the large cup on her bedside table. Resident #5 stated Yes.",2018-09-01
6155,"NHC HEALTHCARE, OAKWOOD",445002,244 OAKWOOD DR,LEWISBURG,TN,37091,2015-04-28,323,D,0,1,VDPT11,"Based on observation and interview, the facility failed to ensure the laundry area was free of accident hazards as evidenced by unsecured chemicals in 1 of 1 laundry room. The findings included: Observations in the laundry room on 4/26/15 at 11:29 AM and 4/26/15 at 5:47 PM, revealed the door was unlocked, and the following chemicals were unattended and accessible to residents: a. 2 buckets of 5 gallon-sized Supreme Lemon scented laundry detergent. b. 1 bottle of 22 fluid (fl) ounces (oz) resolve pre-treat spray. c. 3 spray bottles of 32 oz liquid furniture polish d. 1 gallon of supreme super foam extraction cleaner. e. 1 bottle of 6.5 oz fresh scent metered air fresher. f. 1 gallon of grout renew. g. 1 gallon of Bleach, 2 bottles of glass cleaner. h. 6 pound container of bleach wipes. Interview with the Director of Environmental Services (DES) on 4/27/15 at 8:06 AM, by the laundry door, the DES was asked if the door should be unlocked when the room was unattended. The DES stated, (The laundry room door) should always be locked if there is no one in here.",2018-09-01
6156,"NHC HEALTHCARE, OAKWOOD",445002,244 OAKWOOD DR,LEWISBURG,TN,37091,2015-04-28,333,D,0,1,VDPT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of an incident report and interview, the facility failed to obtain a physician's clarification order for psychoactive medications for 1 of 5 (Residents #37) sampled residents of the 27 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #37 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] documented Resident #37 was severely cognitive impairment, feelings of depression or hopelessness, and the use of antipsychotic, antianxiety and antidepressant medications. The physician's orders [REDACTED].[MEDICATION NAME] 2mg (milligrams) TABLET (1/2) HALF (1/2) TAB (tablet) DAILY BY MOUTH . The psychiatric progress notes dated 2/27/15 documented, .1. [MEDICATION NAME] 2mg - 1/2 tab (1 mg) po (by mouth) q (every) daily 2. Add [MEDICATION NAME] 2mg po q daily . The medication and treatment administration record report for (MONTH) 1, (YEAR) through (MONTH) 21, (YEAR), revealed Resident #37 continued to receive [MEDICATION NAME] 2mg TABLET (1/2) daily. The incident report dated 4/27/15 documented, .Description of what happened: recommendation to increase [MEDICATION NAME] to 2 mg daily 2/27/15 and md (medical doctor) agreed. Order not processed and filed in chart. Found 4/28/15 and processed. Witness 1 comments: med (medication) order corrected and correct dose given this am . Interview with Licensed Practical Nurse (LPN) #1 on 4/28/15 at 9:39 AM, in the west hall, LPN #1 was asked what dose of [MEDICATION NAME] Resident #37 received. LPN #1 stated, 1 mg at 10 AM. LPN #1 was asked how are the psychiatric orders written. LPN #1 stated, I'm not sure. Our unit manager talks to psych (psychiatric providers). Interview with Unit Manager #1 on 4/28/15 at 9:45 AM, in the west hall, Unit Manager #1 was asked how are the psychiatric orders written. Unit Manager #1 stated, Fax doctor the recommendation, he (physician) signs off and faxes them back or calls. I note them on the bottom, unless someone accidentally files them and I don't see them (orders). Shouldn't have been filed (psychiatric progress note). Unit Manager #1 was asked how this would be corrected. Unit Manager #1 confirmed that this was a medication error. Interview with the Director of Nursing (DON) on 4/28/15 at 12:15 PM, in the conference room, the DON was asked if the failure to increase the dosage of [MEDICATION NAME] was a medication error. The DON stated, It ([MEDICATION NAME]) should have been increased to 2mg. The failure to increase the [MEDICATION NAME] dosage from 1 mg to 2mg as ordered by the physician for Resident #37 resulted in significant medication errors.",2018-09-01
6157,"NHC HEALTHCARE, OAKWOOD",445002,244 OAKWOOD DR,LEWISBURG,TN,37091,2015-04-28,514,D,0,1,VDPT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure a medical record had accurate documentation of weight for 1 of 27 (Resident #7) sampled resident of the 27 included in the stage 2 review. The findings included: Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nutritional assessment for Resident #7 dated 12/19/14 documented a weight of .127.0 however admission weight was 113.0 Hospital wt (weight) of 118.0. UBW (usual body weight) 120 per pt. BMI (body mass index) 20.5 using wt of 127 . The admission Minimum Data Set (MDS) for Resident #7 with an Assessment Reference Date (ARD) of 12/20/14 documented weight of 127. Resident #7's weight records documented the following weights; 12/14/14 - 113.0 standing, 12/17/14 - 127.0 wheelchair, 12/31/14 - 119.0 standing, 1/2/15 - 120.8 standing, 1/22/15 - 117.0 wheelchair, 1/27/15 - 119.0 wheelchair and 2/5/15 - 118.2 standing. Interview with the Registered Dietician (RD) on 4/27/15 at 3:09 PM, in the dining room, the RD was asked about Resident #7's weight loss. The RD stated, I don't think that weight is correct (referring to the 12/27/14 weight). Interview with the Assistant Director of Nursing (ADON) on 4/27/15 at 5:26 PM, the ADON was asked if the weight of 127 on 12/19/15 was correct since the admission weight was 113 and the hospital discharge weight was 118. The ADON stated, No, I doubt she gained 15 or so pounds in 3 days and then lost down that quick. If she did I need on that diet.",2018-09-01
7880,"NHC HEALTHCARE, OAKWOOD",445002,244 OAKWOOD DR,LEWISBURG,TN,37091,2013-10-01,246,D,0,1,5LIL11,"Based on observation and interview, it was determined the facility failed to accommodate the needs and choices of 2 of 13 (Residents #93 and 96) sampled residents of the 28 residents included in the stage 2 review. The findings included: 1. Observations in Residents #93's room on 10/1/13 at 8:03 AM, revealed Resident #93's door was open. During an interview in Resident #93's room on 10/1/13 at 8:03 AM, Resident #93 stated, They (staff) leave the door open and it lets cold in from the hall. They just forget (to close the door). 2. Observations in Residents #96's room on 10/1/13 at 8:03 AM, revealed Resident #96's door was open. During an interview in Resident #96's room on 10/1/13, Resident #96 stated, I ask them (staff) every time they come in to shut the door and leave it cracked so it doesn't get stuffy. We can tell them 500 times and they still forget to close it (the door). 3. During an interview at the nurses station on 10/1/13 at 8:50 AM, the Director of Nursing (DON) was asked what she expected the nurses to do when a resident asked that their door be kept closed. The DON stated, .Communicate to all the staff . Keep the door closed .",2017-09-01
7881,"NHC HEALTHCARE, OAKWOOD",445002,244 OAKWOOD DR,LEWISBURG,TN,37091,2013-10-01,253,D,0,1,5LIL11,"Based on observation and interview, it was determined the facility failed to keep the facility free from odors on 1 of 2 (west hall) halls. The findings included: Observations on the west hall on 9/29/13 at 8:10 AM and 10:38 AM, on 9/30/13 at 4:25 PM and 4:50 PM and on 10/1/13 at 7:15 AM and 7:34 AM, revealed the presence of a urine odor in the hallway. During an interview in the west hall on 10/1/13 at 9:20 AM, the Administrator was asked about the odor in the west hall. The Administrator stated, .do know it is a smell .There is a scent .",2017-09-01
7882,"NHC HEALTHCARE, OAKWOOD",445002,244 OAKWOOD DR,LEWISBURG,TN,37091,2013-10-01,280,D,0,1,5LIL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, it was determined the facility failed to revise the care plan to reflect the current status of residents related to dental and a nutritional supplement for 2 of 13 (Residents #54 and 56) sampled residents of the 28 residents included in the stage 2 review. The findings included: 1. Medical record review for Resident #54 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented it requires one person physical assistance to brush the resident's teeth to maintain oral care. Review of the care plan dated 9/13/13 documented, .Oral care daily and as needed . has his own teeth . During an interview at the nurses station on 10/1/13 at 8:50 AM, the Certified Nursing Assistant (CNA) #1 was asked about oral care to brush the resident's teeth. CNA #1 stated, There are two ways to brush his teeth . if he pats his cheeks means that his teeth are hurting . use a toothett with mouth wash . if the resident smiles . use the toothbrush with toothpaste . The care plan did not include the interventions as noted above for oral care for Resident #54. 2. Medical record review for Resident #56 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the dietary progress notes documented, .5/16/13 . 2 oz (ounces) Medpass TID (three times a day) added for additional nutrition option . 6/4/13 . 2 oz Medpass TID discontinued at this time . Review of the care plan dated 8/22/13 documented, .PROBLEM . PATIENT AT NUTRITIONAL RISK . APPROACHES . 2 OZ MEDPASS TID FOR ADDITIONAL NUTRITION . During an interview in the conference room on 10/1/13 at 9:15 AM, the Registered Dietician (RD) was asked about weight loss for this resident. The RD stated this resident was started on Medpass, but she did not like the Medpass so it was discontinued. The RD was asked about the intervention of Medpass on the care plan. The RD stated, .must have been a mistake on the care plan since it (Medpass) was discontinued .",2017-09-01
7883,"NHC HEALTHCARE, OAKWOOD",445002,244 OAKWOOD DR,LEWISBURG,TN,37091,2013-10-01,333,D,0,1,5LIL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the MED-PASS COMMON INSULINS provided by the American Consultant Pharmacists, policy review, medical record review, observation and interview, it was determined the facility failed to ensure 1 of 2 (Nurse #1) nurses administered medications free of a significant medication error. Nurse #1 failed to administer insulin within the proper time frame related to food intake for Resident #1. The findings included: Review of the facility's Insulin Administration policy documented, .PURPOSE: To ensure that designated partners administer insulin using proper technique into the subcutaneous tissue . OBJECTIVE: To administer insulin to patient and assure appropriate monitoring of diabetic patients . Procedure . [MEDICATION NAME] or Humalog . will be given within a time range of no greater than 15 minutes before a meal thru no later than 30 minutes post consumption of the meal . Review of the MED-PASS COMMON INSULINS: Pharmocokinetics, Compatibility, and Properties provided by the American Society of Consultant Pharmacists for typical dosing administration related to meals documented, .[MEDICATION NAME] . ONSET (In Hours, Unless Noted) .15 min . TYPICAL ADMINISTRATION / COMMENTS . 5- (to) 10 minutes before meals . Medical record review for Resident #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].[MEDICATION NAME] 100 UNIT / ML (milliliters) VIAL . SEVEN UNITS SUBQ (subcutaneously) IF FINGERSTICK GREATER THAN 150 . Observations in Resident #1's room on 9/30/13 at 4:05 PM, Nurse #1 administered 7 units of [MEDICATION NAME]to Resident #1. Resident #1 was not given a snack. Resident #1 did not receive her meal tray until 4:50 PM, 45 minutes after the insulin had been administered. The administration of the insulin more than 15 minutes before Resident #1 received her meal tray, resulted in a significant medication error. During an interview in the Director of Nursing's (DON) office on 10/1/13 at 1:40 PM, the DON was asked what is the expectation when giving a fast-acting insulin, such as [MEDICATION NAME] in relation to eating. The DON stated, .should eat a meal or snack within 15 to 30 minutes .",2017-09-01
7884,"NHC HEALTHCARE, OAKWOOD",445002,244 OAKWOOD DR,LEWISBURG,TN,37091,2013-10-01,441,D,0,1,5LIL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation and interview, it was determined 2 of 2 (Nurses #1 and 2) nurses failed to ensure practices to prevent the potential spread of infection were maintained during medication administration. The findings included: 1. Review of the facility's HANDWASHING policy documented, .PROCEDURE . Wash hands before and after contact with each patient, after toileting, smoking or eating, and before and after removal of gloves . 2. Observations in front of room [ROOM NUMBER]A on 9/30/13 at 3:55 PM, Nurse #1 applied gloves, cleansed the accucheck machine and then removed her gloves. Nurse #1 did not perform hand hygiene. Nurse #1 then entered room [ROOM NUMBER]A, applied gloves and administered insulin to a resident. Nurse #1 then removed her gloves and washed her hands. 3. Observations in room [ROOM NUMBER]A on 9/30/13 at 8:10 AM, Nurse #2 applied gloves, cleansed the bedside table and applied barriers on the table. Nurse #2 returned to the medication cart, opened the cart and obtained a bin from the cart and cleansed with a sanicloth. Nurse #2 removed gloves and continued to prepare medications at the cart, without performing hand hygiene. Nurse #2 entered room [ROOM NUMBER]A, applied gloves and prepared water in cups and removed his gloves. Nurse #2 applied new gloves, without performing hand hygiene and administered medications through a percutaneous gastrostomy tube to a resident. Nurse #2 then removed his gloves and washed his hands. Observations in front of room [ROOM NUMBER]A on 10/1/13 at 10:25 AM, Nurse #2 applied gloves, prepared insulin and removed his gloves. Nurse #2 applied new gloves, without performing hand hygiene before preparing the medications. Nurse #2 removed his gloves and applied new gloves, without performing hand hygiene before administering oral medications to a resident. Nurse #2 administered an inhaler to a resident, then wheeled a resident into room [ROOM NUMBER]A, and administered insulin to a resident. Nurse #2 then removed his gloves and washed his hands. 4. During an interview in the Director of Nursing's (DON) office on 10/1/13 at 1:35 PM, the DON was asked what is the expectation when using gloves. The DON stated, Should use gloves between each patient contact, and wash hands between patients. The DON was asked what was the expectation when changing gloves. The DON stated, Should use hand sanitizer or wash hands.",2017-09-01
9886,"NHC HEALTHCARE, OAKWOOD",445002,244 OAKWOOD DR,LEWISBURG,TN,37091,2011-10-21,221,D,0,1,GOV611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, it was determined the facility failed to ensure restraint assessments were completed or a physician's orders [REDACTED].#49) sampled residents reviewed of 7 residents with potential restraint use. The findings included: Review of the facility's Restraints Physical or Chemical policy documented, .They (restraints) may be used only with a physician's orders [REDACTED]. Physical restraints are defined by federal regulations as any manual or physical or mechanical device, material or equipment attached or adjacent to the residents body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body .Included are facility practices that meet the definition of restraints such as bed rails which are used to keep a resident from voluntarily getting out of bed rather than being used for the purpose of enhancing mobility while in bed . Medical record review for Resident #49 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].okay for pt (patient) to ambulation (ambulate) independently c (with) RW (rolling walker) to/from bathroom in room from P.T. (physical therapist) standpoint . Review of the comprehensive care plan dated 8/17/11 documented, .SR (side rail) as needed WIB (when in bed) to enable bed mobility . There was no documentation of a physician's orders [REDACTED]. Observations in Resident #49's room on 10/19/11 at 3:00 PM, revealed Resident #49 seated in a regular chair with a rolling walker in front of her. Observations in Resident #49's room on 10/20/11 at 8:45 AM and 6:05 PM, revealed Resident #49 lying in bed with a 3/4 side rail up on both sides of the bed. During an interview in Resident #49's room on 10/17/11 at 4:40 PM, Resident #49 stated she could sit on the side of the bed and stand if the side rails are not up. During an interview in Resident #49's room on 10/20/11 at 8:47 AM, Certified Nursing Assistant (CNA) #2 was asked how much help Resident #49 needed to get in and out of her bed. CNA #2 stated, Not much, she can sit on the side of the bed and stand with just stand by assist. I don't really help her much at all. During an interview at the nurses' station on 10/20/11 at 9:03 AM, Nurse #3 was asked if Resident #49 could transfer out of bed. Nurse #3 stated, Yes, she can. Nurse #3 was asked if Resident #49 could transfer out of bed when both side rails are up. Nurse #3 stated, She (Resident #49) could slide around the end, but probably thinks she can't. During an interview in the therapy room on 10/20/11 at 9:07 AM, Physical Therapy Assistant (PTA) #1 was asked if Resident #49 can transfer and ambulate independently. PTA #1 stated, Yes, (named Resident #49) was released yesterday to go to the bathroom on her own. The facility was unable to provide documentation of a pre-restraint assessment for use of the side rails.",2016-09-01
9887,"NHC HEALTHCARE, OAKWOOD",445002,244 OAKWOOD DR,LEWISBURG,TN,37091,2011-10-21,272,D,0,1,GOV611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, it was determined the facility failed to ensure that 1 of 19 (Resident #49) sampled residents reviewed of 35 residents included in the Stage 2 review were assessed for the use of a physical restraint. The findings included: Medical record review for Resident #49 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the admission 5 day Minimum Data Set ((MDS) dated [DATE] and the 60 day MDS dated [DATE] documented no use of restraints. There was no documentation of a pre-restraint assessment in the medical record. Observations in Resident #49's room on 10/20/11 at 8:45 AM and 6:05 PM, revealed Resident #49 lying in bed with a 3/4 side rail up on both sides of the bed. During an interview in Resident #49's room on 10/17/11 at 4:40 PM, Resident #49 stated she could sit on the side of the bed and stand if the side rails are not up. During an interview in Resident #49's room on 10/20/11 at 8:47 AM, Certified Nursing Assistant (CNA) #2 was asked how much help Resident #49 needed to get in and out of her bed. CNA #2 stated, Not much, she can sit on the side of the bed and stand with just stand by assist. I don't really help her much at all. During an interview at the nurses' station on 10/20/11 at 9:03 AM, Nurse #3 was asked if Resident #49 could transfer out of bed. Nurse #3 stated, Yes, she can. Nurse #3 was asked if Resident #49 could transfer out of bed when both side rails are up. Nurse #3 stated, She could slide around the end, but probably thinks she can't. During an interview in the therapy room on 10/20/11 at 9:07 AM, Physical Therapy Assistant (PTA) #1 was asked if Resident #49 can transfer and ambulate independently. PTA #1 stated, Yes, (named Resident #49) was released yesterday to go to the bathroom on her own.",2016-09-01
9888,"NHC HEALTHCARE, OAKWOOD",445002,244 OAKWOOD DR,LEWISBURG,TN,37091,2011-10-21,278,D,0,1,GOV611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, it was determined the facility failed to accurately assess residents for incontinence and dressing for 1 of 19 (Resident #76) sampled residents reviewed of 35 residents included in the Stage 2 review. The findings included: Medical record review for Resident #76 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #76 requires limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing-bearing assistance) for Activities of Daily Living (ADL) self-performance, and one person physical assist for ADL support provided. Review of the quarterly MDS assessment dated [DATE] documented Resident #76 requires extensive assist (resident involved in activity; staff provide weight-bearing support) for ADL self-performance, and one person physical assist for ADL support provided. Review of the admission MDS assessment dated [DATE] documented Resident #76 is always continent of urine and bowel. Review of the quarterly MDS assessment dated [DATE] documented Resident #76 is frequently incontinent of urine and bowel. During an interview in the MDS office on 10/20/11 at 12:20 PM, the MDS Coordinator was asked about the decline in ADL status (dressing). The MDS Coordinator stated, This is an error, she (Resident #76) should have been extensive not limited, I will have to do a correction . During an interview in the MDS office on 10/20/11 at 12:25 PM, the MDS Coordinator was asked about the decline in urinary status. The MDS Coordinator stated, I do not see where she has been incontinent, looks like that was an error . I will have to do a correction .",2016-09-01
9889,"NHC HEALTHCARE, OAKWOOD",445002,244 OAKWOOD DR,LEWISBURG,TN,37091,2011-10-21,279,D,0,1,GOV611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, it was determined the facility failed to develop a care plan to reflect the use of a Foley catheter for 1 of 19 (Resident #39) sampled residents of the 35 residents included in the Stage 2 review. The findings included: Medical record review for Resident #39 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/13/11 documented under Section H-A, indicating presence of indwelling catheter. Review of the interim care plan dated 10/17/11 did not address the Foley catheter. Observations in Resident #39's room on 10/17/11 at 10:32 AM, revealed Resident #39 sitting up in bed, alert with ? siderails (SR) elevated times (x) one with a Foley catheter patent to BSB and yellow, cloudy urine. Observations in Resident #39's room on 10/18/11 10:30 AM, revealed Resident #39 sitting up in bed, with 3/4 SR elevated x one and a Foley catheter patent to BSB. Observations in Resident #39's room on 10/19/11 at 2:30 PM, revealed Resident #39 sitting up in bed with a Foley catheter patent to BSB with yellowish, cloudy urine. During an interview in the Director of Nursing's(DON) office on 10/20/11 at 11:30 AM, the DON verified that the care plan did not address the presence of the Foley catheter.",2016-09-01
9890,"NHC HEALTHCARE, OAKWOOD",445002,244 OAKWOOD DR,LEWISBURG,TN,37091,2011-10-21,282,D,0,1,GOV611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, it was determined the facility failed to follow the care plan interventions for an alarm for 1 of 17 (Resident #42) sampled residents reviewed of 35 residents included in the Stage 2 review. The findings included: Medical record review for Resident #42 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] documented the resident had 1 fall with no injury since the prior assessment. Review of the care plan dated 8/24/11 documented, .Risk for falls r/t (related to) .Hx (history) of falls (most recent 9-15-11) . Wandering behavior . pushing w/c's (wheelchairs) . APPROACHES . door alarm on BR (bathroom) door to alert staff pt (patient) is up in bathroom . Review of post falls nursing assessments dated 7/14/11 and 9/15/11 documented Resident #42 had two falls with no apparent injuries. Observations in Resident #42's room on 10/17/11 at 11:05 AM, revealed Resident #42 dressed and lying in bed. Resident #42 did not answer questions. Resident #42 got up from the bed, ambulated to the bathroom and no alarm sounded when the BR door was opened. Observations in Resident 42's room on 10/19/11 at 2:45 PM, revealed an alarm to the bathroom door in the off position. During an interview in Resident #42's room on 10/19/11 at 2:55 PM, Nurse #1 confirmed the alarm to the BR door was off and stated, I don't know why it was off, I guess someone turned it off.",2016-09-01
9891,"NHC HEALTHCARE, OAKWOOD",445002,244 OAKWOOD DR,LEWISBURG,TN,37091,2011-10-21,315,D,0,1,GOV611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of Sorensen and Luckman's Basic Nursing A Psychophysiologic Approach reference book, policy review, medical record review, observation, and interview, it was determined the facility failed to ensure there was a justifiable medical reason for the presence of a Foley catheter and failed to provide appropriate Foley catheter care and treatments for 1 of 3 (Resident #39) sampled residents reviewed of 13 residents with a catheter and 1 of 1 catheter/pericare observed. The findings included: Review of reference book of Sorensen and Luckmann's Basic Nursing A Psychophysiologic Approach, Third Edition page 1187, documented, .the bag (Foley catheter bag) and tubing must never touch the floor . These actions increase the chances for bacteria in the drainage bag to ascend the tubing and possibly to enter the bladder. Bacteria in the drainage bag can lead to UTI (urinary tract infection) and subsequent increased mucus production . Review of the facility's INCONTINENT CARE policy documented, .10. Wash peri-area front to back, pat dry . Medical record review for Resident #39 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Observations in Resident #39's room on 10/19/11 at 2:30 PM, revealed Resident #39 sitting up in bed with a Foley catheter patent to BSB, the urine was cloudy, yellowish in color, and the catheter tubing was touching the floor. Observations in Resident #39 's room on 10/20/11 at 10:35 AM, revealed Certified Nursing Assistant (CNA) #1 gathered supplies, removed her gloves and washed her hands, applied gloves, sprayed a washcloth with soap, washed down the right side of the perineum and then washed down the left side without changing the area of the washcloth,. CNA #1 then cleansed the catheter tubing from the insertion site outward, and then cleansed down the middle using a different area of the washcloth and then patted the area dry. CNA #1 removed her gloves, washed her hands and applied gloves. CNA #1 proceeded to wet a washcloth and sprayed with soap, and then washed from back to front. During an interview in the Director of Nursing's (DON) office on 10/20/11 at 11:30 AM, the DON stated, Catheter was initially for measuring I&O, came from hospital, has now developed excoriation on bottom. We've asked to get it out, has a wound on her stump. No real reason for the catheter, greater chance for infection. During an interview in the DON's office on 10/20/11 at 1:50 PM, the DON was asked about catheter care. The DON stated, They (staff) are always to wash from front to back.",2016-09-01
9892,"NHC HEALTHCARE, OAKWOOD",445002,244 OAKWOOD DR,LEWISBURG,TN,37091,2011-10-21,323,D,0,1,GOV611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, it was determined the facility failed to follow the care plan interventions for an alarm for 1 of 3 (Resident #42) sampled residents reviewed of 4 residents with falls. The findings included: Medical record review for Resident #42 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] documented the resident had 1 fall with no injury since the prior assessment. Review of the care plan dated 8/24/11 documented, .Risk for falls r/t (related to) .Hx (history) of falls (most recent 9-15-11) . Wandering behavior . pushing w/c's (wheelchairs) . APPROACHES . door alarm on BR (bathroom) door to alert staff pt (patient) is up in bathroom . Review of post falls nursing assessments dated 9/15/11 and 7/14/11 documented Resident #42 had two falls with no apparent injuries. Observations in Resident #42's room on 10/17/11 at 11:05 AM, revealed Resident #42 lying in bed and did not answer questions. Resident #42 got up from the bed, ambulated to the bathroom and no alarm sounded when the BR door was opened. Observations in Resident 42's room on 10/19/11 at 2:45 PM, revealed an alarm to the bathroom door in the off position. During an interview in Resident #42's room on 10/19/11 at 2:55 PM, Nurse #1 confirmed the alarm to the BR door was off and stated, I don't know why it was off, I guess someone turned it off.",2016-09-01
9893,"NHC HEALTHCARE, OAKWOOD",445002,244 OAKWOOD DR,LEWISBURG,TN,37091,2011-10-21,329,D,0,1,GOV611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, it was determined the facility failed to ensure 1 of 10 (Resident #65) sampled residents reviewed of 35 residents included in the Stage 2 review were free from unnecessary medication use. The findings included: Review of the facility's CONSULTANT PHARMACIST REPORTS . MEDICATION REGIMEN REVIEW documented, .E .The consultant pharmacist's evaluation includes, but is not limited to reviewing and/or evaluating the following: 1) A written diagnosis, indication, or documented objective findings to support each medication order . Medical record review for Resident #65 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].[MEDICATION NAME] 600 MG (milligram) TABLET ONE (1) PO (by mouth) BID (twice a day) . There was no documented [DIAGNOSES REDACTED]. During an interview in the conference room on 10/20/11 at 10:30 AM, the Director of Nursing (DON) was asked about the [DIAGNOSES REDACTED]. The DON stated .no, I didn't find a diagnosis (for the use of [MEDICATION NAME]) .",2016-09-01
9894,"NHC HEALTHCARE, OAKWOOD",445002,244 OAKWOOD DR,LEWISBURG,TN,37091,2011-10-21,428,D,0,1,GOV611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, it was determined the pharmacist failed to identify and report that 1 of 10 (Resident #65) sampled residents reviewed of 35 residents included in the Stage 2 review had a [DIAGNOSES REDACTED]. The findings included: Review of the facility's CONSULTANT PHARMACIST REPORTS . MEDICATION REGIMEN REVIEW documented, .E .The consultant pharmacist's evaluation includes, but is not limited to reviewing and/or evaluating the following: 1) A written diagnosis, indication, or documented objective findings to support each medication order . Medical record review for Resident #65 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].MUCINEX 600 MG (milligram) TABLET ONE (1) PO (by mouth) BID (twice a day) . There was no documented [DIAGNOSES REDACTED]. During an interview in the conference room on 10/20/11 at 10:30 AM, the Director of Nursing (DON) was asked about the [DIAGNOSES REDACTED]. The DON stated .no, I didn't find a diagnosis (for the use of Mucinex) .",2016-09-01
9895,"NHC HEALTHCARE, OAKWOOD",445002,244 OAKWOOD DR,LEWISBURG,TN,37091,2011-10-21,431,D,0,1,GOV611,"Based on policy review, observation, and interview, it was determined the facility failed to ensure medications were not stored past their expiration date and that internal and externals were not stored together in 2 of 3 (West hall medication cart and North hall medication cart) medication storage areas. The findings included: 1. Review of the facility's Medication Storage policy documented, .9. Drugs shall not be kept on hand after the expiration date . Observations of the West hall medication cart on 10/20/11 at 2:20 PM, revealed Hydrocodone 5/500 milligrams was stored past the expiration date of 05/11. During an interview at the Nurse's station on 10/20/11 at 2:20 PM, Nurse #2 verified the Hydrocodone was stored past the expiration date. 2. Review of the facility's Medication Storage policy documented, .1. Test reagents (Clinitest, Keto-Stix, etc. (etcetera)) germicides, disinfectants and other household substances shall be stored separate from drugs and in a storage area appropriately marked POISON .2. All internal and external medications and preparations intended for human use shall be stored separately. Suppositories, injectables, eye or ear drops and inhalers are considered internals . Observations of the North hall medication cart on 10/20/11 at 2:25 PM, revealed the following medications/chemicals stored together: a. Staphene Disinfectant Spray and Deodorizer. b. Reliv Dietary Supplement. c. Innergizer Sports Drink. d. Chlorhexidine 0.12 percent Rinse. e. Men-Phor Anti-Itch Lotion.",2016-09-01
12738,"NHC HEALTHCARE, OAKWOOD",445002,244 OAKWOOD DR,LEWISBURG,TN,37091,2012-03-20,368,E,1,0,VB9W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Intakes: TN 626 Based on policy review, medical record review, individual interview and staff member interview, it was determined the facility failed to offer bedtime (HS) snacks for 3 of 5 (Residents #2, 3, and 4) sampled residents reviewed. The findings included: 1. Review of the facility's ""HYDRATION / SNACK CART PROGRAM"" policy documented, ""...Each center MUST have a system to ensure that all patients are offered H.S. snacks per federal guidelines..."" 2. Medical record review for Resident #2 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's ""House Med. (medication) Pass, Meal % (percent) BM (bowel movement) Tracking Sheet"" for March 2012 revealed no documentation the resident had been offered an HS snack. 3. Medical record review for Resident #3 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's ""House Med Pass, Meal % BM Tracking Sheet"" for March 2012 revealed no documentation the resident had been offered an HS snack. During an interview in Resident #3's room on 3/19/12 at 4:55 PM, Resident #3 was asked if she was offered a bedtime snack. Resident #3 stated, ""I get a cookie sometimes. The nurse don't always ask if I want a snack..."" 4. Medical record review for Resident #4 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's ""House Med Pass, Meal % BM Tracking Sheet"" for March 2012 revealed no documentation the resident had been offered an HS snack. During an interview in Resident #4's room on 3/19/12 at 4:50 PM, Resident #4 was asked if she was offered a bedtime snack. Resident #4 stated, ""...Sometimes, but they don't always ask me. Depends on who is working."" 5. During an interview at the nurses' station on 3/19/12 at 2:45 PM, Nurse #1 was asked if all residents were offered a bedtime snack. Nurse #1 stated, ""...only the diabetics get an HS snack, unless the physician specifically orders a snack for a resident...""",2015-07-01
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
4610,"NHC HEALTHCARE, DICKSON",445004,812 CHARLOTTE ST,DICKSON,TN,37055,2016-07-07,247,D,0,1,48TR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to inform 1 of 2 (Resident #39) sampled residents of a roommate change of the 19 Residents interviewed in stage 1. The findings included: The facility's PATIENT RIGHTS policy documented, .At all times you will be notified of a change in your room or in your roommate . Medical record review revealed Resident #39 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set ((MDS) dated [DATE] and the quarterly MDS dated [DATE] revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 15 indicated she was cognitively intact. Interview with alert and oriented Resident #39 on 7/5/16 at 5:08 PM, in the resident's room, Resident #39 was asked, have you been moved to a different room or had a roommate change in the last 9 months. Resident #39 stated, Yes. Resident #39 was asked, were you given notice before a room change or a change in roommate. Resident #39 stated, .did not tell me about a roommate change . Interview with alert and oriented Resident #39 on 7/7/16 at 3:31 PM, on the 200 hall, Resident #39 stated, I got a new roommate last night. When asked if she was informed of getting a new roommate, Resident #39 stated, No There was no documentation in the medical record that Resident #39 had been notified of a change of roommate. Interview with the Social Services Director (SSD) on 7/7/16 at 5:24 PM, the SSD confirmed there was no documentation that Resident #39 had been informed of a change in her roommate.",2019-08-01
4611,"NHC HEALTHCARE, DICKSON",445004,812 CHARLOTTE ST,DICKSON,TN,37055,2016-07-07,309,D,0,1,48TR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observations, and interview, the facility failed to monitor behaviors for 1 of 2 (Resident #146) sampled residents of the 2 residents reviewed with behaviors; failed to ensure communication between the facility staff and Hospice for 1 of 1 (Resident #60) sampled residents reviewed for hospice services, and failed to provide treatment to 1 of 1 (Resident #60) sampled residents with skin tears observed during a random observation. The findings included: 1. The facility's Behavior Documentation policy documented, .Behaviors are documented numerically on an every shift basis . Medical record review revealed Resident #146 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] documented Resident #146 had severe cognitive deficits, hallucinates and had delusions, and exhibited physical and verbal behaviors towards others. The physician's orders [REDACTED].[MEDICATION NAME] 125 mg (milligram) .Give two (2) capsules twice daily . The Physician's Progress Note dated 6/7/16 documented, .Patient is on [MEDICATION NAME] for behavior modification . The Medication, Treatment and Task Administration Record Report dated (MONTH) (YEAR) did not document behavior monitoring after (MONTH) 6, (YEAR), 7am-7pm shift. Interview with Registered Nurse (RN) #1 on 7/7/16 at 10:03 AM, at the Unit 1 nursing station, RN #1 was asked why Resident #146 was on [MEDICATION NAME]. RN #1 stated, .in the physician's progress note, it states the [MEDICATION NAME] is prescribed for behavior modification . RN #1 was asked if Resident #146 behaviors should then be monitored every shift. RN #1 stated, I would think so, yes, yes .I can see in the nurses notes they are monitoring behaviors but it is not shift to shift . Observations in Resident #146's room on 7/5/16 at 3:54 PM, revealed Resident #146 in her rock and go wheelchair and attempted multiple times to get out of her chair. Resident #146's sitter was encouraging her to stay seated. Observations at the Unit 1 nursing station on 7/7/16 at 8:27 AM, revealed Resident #146 sitting in her rock and go wheelchair opposite the nursing station. Resident #146 attempted to get out of her chair and disconnected her chair alarm. Resident #146 stated loudly, That stupid thing is going off once again! Interview with the Director of Nursing (DON) on 7/7/16 at 11:45 AM, in the DON's office, the DON was asked if Resident #146's behavior's should have been monitored. The DON stated, .her behavior monitoring every shift should not have been discontinued . 2. The facility's contract with Named Hospice services documented, .Coordination of care .Hospice and Facility shall communicate with one another regularly and as needed for each particular Hospice Patient. Each party is responsible for documenting such communications in its respective clinical records to ensure that the needs of Hospice Patients are met 24 hours per day . Medical record review revealed Resident #60 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Interview with Licensed Practical Nurse (LPN ) #1 on 7/7/16 at 8:00 AM, at the 300 Hall nurses' desk, the LPN was asked where Resident #81's hospice notes were. The LPN stated, .don't have access to the hospice notes . Interview with LPN #2 on 7/7/16 at 8:02 AM, at the 300 Hall nurses' desk, the LPN stated, .they document on their tablet .have a lot of their paperwork in (Team Coordinator) office .Usually here 2-3 times a week . Interview with the 300 Hall Team Coordinator on 7/7/16 at 8:05 AM, the 300 Hall Team Coordinator went to her office and brought to this Surveyor a small stack of Hospice notes. The 300 Hall Team Coordinator was asked how nurses would know what hospice did if they do not have access to the hospice notes. The 300 Hall Team Coordinator stated, I see what you mean. Interview with the 300 Hall Team Coordinator on 7/7/16 at 8:30 AM, in the Team Coordinator's office, the 300 Hall Team Coordinator was asked if the small stack of papers from hospice was all the documentation that they had. The 300 Hall Team Coordinator gave surveyor a large stack of papers from hospice stating, This is what they gave me .my fault. They just come in and hand me a stack . Interview with Hospice RN on 7/7/16 at 10:31 AM, in the education room, the Hospice RN was asked if notes are documented in a tablet, how would the staff nurses get the report. The Hospice RN stated, .I don't know. Interview with the Director of Nursing (DON) on 7/7/16 at 6:15 PM, in the DON office, the DON stated, .there needs to be better communication with hospice . 3. The facility's Accidents and Untoward Occurrences policy documented, .Charting Guidelines .Skin Tears .Description of what happened, if witnessed. If the patient states that a specific object caused the skin tear, document what the patient said .Description of the skin tear .First aid treatment rendered .Notification of physician .Notification of family .Patient's reaction to injury .Initiate Alert Charting . Medical record review revealed no documentation of a skin tear for Resident #60. Observations on 7/5/16 at 12:00 PM and on 7/6/16 at 8:32 AM, revealed 2 dressings on Resident #60's right elbow area dated 6/26 . Interview on 7/7/16 at 8:17 AM, the 300 Hall Team Coordinator confirmed there was no documentation of skin tears to Resident #60's arm. The 300 Hall Team Coordinator was asked if it was acceptable not to provide treatment for [REDACTED]. The 300 Hall Team Coordinator stated, No . Interview with the Director of Nursing (DON) on 7/7/16 at 6:15 PM, in the DON office, the DON stated, .someone should have caught that the dressing had not been changed .",2019-08-01
5952,"NHC HEALTHCARE, DICKSON",445004,812 CHARLOTTE ST,DICKSON,TN,37055,2015-06-25,282,D,0,1,M5UR11,"**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 falls for 1 of 21 (Resident #144) sampled residents reviewed of the 37 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #144 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] documented Resident #144 had a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment, and that Resident #144 required extensive staff assistance for activities of daily living. The MDS documented Resident #144 was not steady and required human assistance to stabilize when moving from a seated to a standing position, and with surface-to-surface transfers. The MDS documented no falls since the prior assessment. The care plan dated 6/5/15 documented, .PROBLEM . Safety risk . at high risk for falls . does not often recognize her limitations . APPROACHES . Keep Wheelchair out of patients (patient's) sight when she is in bed . Observations in Resident #144's room on 6/22/15 at 4:43 PM and 6/23/15 at 7:23 AM and 3:35 PM, revealed Resident #144 lying in the bed with the wheelchair at the bedside within her sight. Interview with Licensed Practical Nurse (LPN) #2 on 6/23/15 at 3:27 PM, at the unit 4 nurses' station, LPN #2 was asked to explain the care plan intervention related to keeping the wheelchair out of Resident #144's sight while she was in bed. LPN #2 stated, That is because when she sees it (wheelchair), she thinks she can get up and go by herself. But, she is not safe to go by herself. Interview with LPN #2 on 6/23/15 at 3:35 PM, in Resident #144's room, LPN #2 was asked if the wheelchair was in the resident's sight at this time while she is in bed. LPN #2 stated, Yes. Right now it is.",2018-10-01
5953,"NHC HEALTHCARE, DICKSON",445004,812 CHARLOTTE ST,DICKSON,TN,37055,2015-06-25,309,D,0,1,M5UR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review and interview, the facility failed to follow physician's orders for the administration of intravenous (IV) antibiotics for 1 of 37 (Resident #329) sampled residents included in the stage 2 review. The findings included: Closed medical record review revealed Resident #329 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented Resident #329 had a cognitive score of 12 indicating the resident was moderately impaired. The Medication Discharge Report documented, 3/26/15 . [MEDICATION NAME] . 2 gm, (gram) Intravenous (IV), Every 24 hours, stop date 4/27 . The Medication, Treatment and Task Administration Record Report for (MONTH) (YEAR) documented the IV antibiotic [MEDICATION NAME] was administered one time on 3/27/15. The facility HISTORY & (and) PHYSICAL documented, DOS (date of services) 3/28/15 . presented (named the hospital) . with fever and chills and back pain. Evaluation accomplished in the hospital revealed that she has a bacterial endocarditis . has been transferred here for continued IV antibiotic therapy, which she will need for a total of six weeks . The Telephone Orders documented, .4/15/15 . pt (patient) went out to Cardiologist apt (appointment) and was admitted to Hospital from that apt . The hospital Discharge Summary documented, .admitted : 4/14/15 . Dischg (discharge) 4/21/15 . History and Physical . recent admission for group B [DIAGNOSES REDACTED] bacteremia was suspected endocarditis, bioprosthetic aortic valve, severe back pain secondary to a [MEDICATION NAME] 12 compression fracture . was recently discharged to (named nursing home facility) after being admitted here . diagnosed with [REDACTED]. was discharged with Peripherally Inserted Central Catheter (PICC) line complete course of [MEDICATION NAME] and [MEDICATION NAME] . was supposed to be on [MEDICATION NAME] for a total of 6 weeks . it appears that her antibiotics were inadvertently discontinued 24 hours after presentation to the skilled nursing facility as we suspect thought that her end date . should have been (MONTH) 27 instead of (MONTH) 27 as we intended . On presentation to the . clinic, it was determined that her antibiotic course was shortened by 1 month and given her symptoms of nausea, vomiting, and worsening back pain . will be admitted to the hospitalist service . and re-initiation of her antibiotics as there is a concern for recurrent bacteremia . Interview with Registered Nurse (RN) #1 on 6/23/15 at 5:46 PM, in the team coordinator's office, Registered Nurse (RN) #1 was asked if she had admitted Resident #329. RN #1 stated, I did not admit her myself . was admitted with endocarditis . had order with IV antibiotics . for recovery of endocarditis . that was her main admitting . RN #1 was asked why Resident #329 had been admitted to the hospital after her doctor's appointment. RN #1 stated, What happen was on the initial orders [MEDICATION NAME] and [MEDICATION NAME] was to run for 10 days . (named the Assistance Director of Nursing (ADON)) put in the order. She hit the zero . was dc'd (discontinue) out the following day had gotten only one day of the [MEDICATION NAME] . until the follow up appt . I was concerned about the mistake . Interview with the Director of Nursing (DON) on 6/24/15 at 6:15 AM, in the care plan office, the DON was asked why Resident #329 was hospitalized on ,[DATE]. The DON stated, Went to doctor's appointment. We sent copy of medication list. Doctor called back . she (Resident #329) was supposed to be on 2 antibiotics for 20 something days . (one medication) was put in on admission wrong. Only got 1 of the antibiotics ([MEDICATION NAME]) for 1 day. The stop date was 4/27 and she (named ADON) put in 3/27. The doctor was concerned because she only got 1 day of 1 of the antibiotics was going to put her in. Interview with Licensed Practical Nurse (LPN) #1 on 6/24/15 at 8:04 AM, in the team coordinator office on unit 1, LPN #1 was asked if she had taken care of Resident #329. LPN #1 stated, One or two times . came in with endocarditis . that was her primary [DIAGNOSES REDACTED]. went to the cardiologist appointment and was straight admitted to the hospital from there. The day I was here the doctor's office called and was looking at medication list. Wanted to know why she wasn't getting the other antibiotic ([MEDICATION NAME]). It was dc'd or something, wasn't given the way it should have been. Interview with the ADON on 6/24/15 at 9:50 AM, in the DON's office, the ADON was asked about Resident #329 antibiotics. The ADON stated, I put her meds in the computer. I don't know how I did it. I put in wrong date (on one medication). The hospital called and said she was being readmitted that they had discovered she wasn't getting her antibiotics as ordered. I talked to the husband and son. Told them both what happened.",2018-10-01
5954,"NHC HEALTHCARE, DICKSON",445004,812 CHARLOTTE ST,DICKSON,TN,37055,2015-06-25,312,D,0,1,M5UR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure a resident, who were unable to carry out activities of daily living (ADLs), received the necessary assistance with dining for 1 of 4 (Resident #252) sampled residents reviewed for ADL care of the 37 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #252 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The significant change Minimum Data Set ((MDS) dated [DATE] documented Resident #252 was severely cognitively impaired, required extensive staff assistance for eating. The care plan dated 4/13/15 documented, .requires max (maximum) assist (assistance) with ADLs . PROBLEM . Altered Food and/or Intake as evidenced by . Hospice services . Encourage greater than 75% intake of diet, supplements, fluid . A hospice case conference summary dated 6/18/15 documented, .Re-Evaluation of patient's overall condition during the past benefit period reveals: FUNCTIONAL DECLINE NOTED IN THAT PT (patient) IS NO LONGER ABLE TO FEED HERSELF AND HAS BECOME A DEPENDENT DINER . TOTAL ASSIST ADL'S . The physician's orders [REDACTED].DIET ORDERS . PUREE . The nurses' note dated 3/24/15 documented Resident #252 was a dependent diner. Nurses' notes dated 4/15/15 and 4/29/15 documented Resident #252 required total staff assistance for ADLs. A nutritional assessment dated [DATE] documented, .Describe the patient's ability to feed themselves: Limited or Extensive Assistance . Deteriorated/Dependent ADL status . Observations on 6/22/15 at 12:35 PM, in the unit 4 dining room revealed Resident #252 sitting at a table alone in a wheelchair. There was a glass of tea with a plastic cover on the table in front of her. Resident #252 was using a spoon to scoop at the cover on the top of the tea glass. Certified Nursing Assistant (CNA) #1 placed a lipped plate containing pureed foods (chicken, potatoes, cabbage) on the table in front of the resident, and placed a straw in the tea glass. CNA #1 left the resident to eat independently. Resident #252 poured the tea out over the pureed food in her plate. CNA #2 observed the Resident pouring the tea over the food and stated, Oh, (named Resident #252). CNA #2 did not get the resident a new plate. At 12:50 PM, CNA #2 gave Resident #252 a bite of potatoes from the same plate, and left the resident to try and finish eating from the same plate independently. At 12:55 PM, CNA #1 removed the plate of approximately 50% of the remaining food from the table. Interview with the Director of Nursing (DON) on 6/24/15 at 5:30 PM, in the education room, the DON was asked what she expected the nursing staff to do for hospice residents related to feeding assistance. The DON stated, They are to provide all of that (assistance). The DON was asked if Resident #252 should always receive feeding assistance. The DON stated, Off the top of my head, I can't remember. The DON confirmed a new plate of food should have been provided when the cognitively impaired resident poured tea onto her pureed food.",2018-10-01
5955,"NHC HEALTHCARE, DICKSON",445004,812 CHARLOTTE ST,DICKSON,TN,37055,2015-06-25,323,D,0,1,M5UR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to implement falls interventions for 1 of 3 (Resident #144) sampled residents of 5 residents reviewed with falls. The findings included: The facility's FALLS policy documented, .PURPOSE . To reduce patient risk of falling . Post falls nursing assessment to be completed when patient incident occurs. Intervention to prevent further falls to be put in place at the time of the incident . Interventions will be added to the multidisciplinary (multidisciplinary) note and Care Plan Coordinator notified of intervention. Staff will be notified of intervention . Medical record review revealed Resident #144 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] documented Resident #144 had a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment, and that Resident #144 required extensive staff assistance for activities of daily living. The MDS documented the resident was not steady and required human assistance to stabilize when moving from a seated to a standing position, and with surface-to-surface transfers. The MDS documented no falls since the prior assessment. The care plan dated 6/5/15 documented, .PROBLEM . Safety risk . at high risk for falls . does not often recognize her limitations . APPROACHES . Keep Wheelchair out of patients (patient's) sight when she is in bed . A Post Falls Nursing assessment dated [DATE] documented, .6/19/2015 9:20 PM . PT (patient) WAS FOUND SITTING IN THE FLOOR NEXT TO HER BED. PT STATED THAT SHE WAS GETTING UP TO USE THE BATHROOM AND SLIPPED. PT WAS PLACED BACK INTO HER WC (wheelchair) . fell from bed to go bathroom . Observations on 6/22/15 at 4:43 PM, and 6/23/15 at 7:23 AM and 3:35 PM, in Resident #144's room revealed Resident #144 lying in the bed with the wheelchair at bedside within her sight. Interview with Licensed Practical Nurse (LPN) #2 on 6/23/15 at 3:27 PM, at the unit 4 nurses' station, LPN #2 was asked to explain the care plan intervention related to keeping the wheelchair out of Resident #144's sight while she is was in bed. LPN #2 stated, That is because when she sees it, she thinks she can get up and go by herself. But, she is not safe to go by herself. Interview with LPN #2 on 6/23/15 at 3:35 PM, in Resident #144's room, LPN #2 was asked if the wheelchair was in the resident's sight at this time while she is in bed. LPN #2 stated, Yes. Right now it is. Interview with the Director of Nursing (DON) on 6/24/15 at 5:30 PM, in the education room, the DON was asked whether she expected the staff to follow fall interventions. The DON confirmed that she did.",2018-10-01
5956,"NHC HEALTHCARE, DICKSON",445004,812 CHARLOTTE ST,DICKSON,TN,37055,2015-06-25,463,D,0,1,M5UR11,"Based on observation and interview, the facility failed to ensure all call systems were functioning properly in 1 of 4 (100 hall shower room) common shower areas. The findings included: Observations during the initial tour of the 100 hall on 6/22/15 at 9:35 AM, revealed the emergency call light in the 100 hall shower room would not sound an alarm and there was no light above the door. Interview with Registered Nurse (RN) #1 on 6/23/15 at 7:53 AM, in the 100 Hall, RN #1 was asked if the shower room was used by residents. RN #1 stated Yes. RN #1 was asked if the call light was functioning. RN #1 stated, No, it is not.",2018-10-01
7755,"NHC HEALTHCARE, DICKSON",445004,812 CHARLOTTE ST,DICKSON,TN,37055,2014-02-05,278,D,0,1,KG8011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to accurately assess hospice care for 1 of 18 (Resident #201) sampled residents of the 37 residents included in the stage 2 review. The findings included: Medical record review for Resident #201 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Resident #201's Minimum Data Set (MDS) documented the following: a. Annual MDS dated [DATE] - receiving hospice care. b. Quarterly MDS dated [DATE] - not receiving hospice care. c. Quarterly MDS dated [DATE] - receiving hospice care. Review of the January recertification orders dated 1/18/14 documented, .06/08/2012 Hospice Services . Review of the care plan dated 11/12/13 documented, .receiving Hospice services for End stage late effects [MEDICAL CONDITION]. During an interview in the education room on 2/5/14 at 3:05 PM, Nurse #1 was asked about the 8/3/13 quarterly MDS which documented Resident #201 was not receiving hospice. Nurse #1 stated, .was an error . I did check the life expectancy of less than 6 months on it (MDS) .",2017-10-01
7756,"NHC HEALTHCARE, DICKSON",445004,812 CHARLOTTE ST,DICKSON,TN,37055,2014-02-05,280,D,0,1,KG8011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interviews, it was determined the facility failed to revise the comprehensive care plan to address behaviors for 1 of 20 (Resident # 203) sampled residents of the 37 residents included in the stage 2 Review. The findings included: Medical record review for Resident #203 documented an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE], documented that Resident #203 exhibited hallucinations, delusions, other behavioral symptoms not directed toward others and rejection of care on 1 to 3 days during the 30 days after admission. Review of physician orders [REDACTED].(Increase) [MEDICATION NAME] to 25mg (milligrams) po (by mouth) BID (twice per day) . Review of a physician's progress notes documented the following: a. 12/24/14 - .Patient is being seen this day for agitation and restlessness. She has had some delusional thought as well as thinking that her family has abandoned her here. She has been very disruptive to her peers as well . IMPRESSION . Dementia with delusions and behavioral problems . b. 12/26/13 - .The patient is being seen today per family request reported that she has had increased sedation. Apparently the patient had a bad day on Monday with excessive crying and tearfulness . The care plan dated 12/13/13 had not been updated to address the behavioral problems of crying, agitation and restlessness. During an interview at the nurse's station on 1/4/14 at 5:00 PM, Nurse #4 was asked what type of behaviors were displayed by Resident #203. Nurse #4 stated, She's crying out a lot and fights staff. Nurse #4 was asked what type of behavioral management the staff uses. Nurse #4 stated, Diversional activities and calls daughter.",2017-10-01
7757,"NHC HEALTHCARE, DICKSON",445004,812 CHARLOTTE ST,DICKSON,TN,37055,2014-02-05,282,D,0,1,KG8011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, it was determined the facility failed to follow the care plan intervention of a bed alarm for 1 of 20 (Resident #233) sampled residents reviewed of the 37 residents included in the stage 2 review. The findings included: Review of the facility's Post Falls Intervention policy documented, .Bed Alarm . Medical record review for Resident #233 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a High-Risk Patient Selection Form dated 12/1/13 documented the resident was at risk for falls. Review of the care plan dated 12/6/13 and updated 1/10/14 documented, .PROBLEM PRIORITY . Falls, at risk for as evidenced by . is assisted with ambulation . APPROACHES . Bed alarms placed . Observations in Resident #233's room on 2/4/14 at 2:33 PM and 3:00 PM and on 2/5/14 at 7:25 AM and 8:50 AM, revealed Resident #233 lying in bed, with no bed alarm in place as care planned. During an interview in Resident #233's room on 2/5/14 at 8:50 AM, Nurse #2 was asked to locate Resident #233's bed alarm. After checking the bed, Nurse #2 stated, I will, embarrassingly, tell you it's not there .",2017-10-01
7758,"NHC HEALTHCARE, DICKSON",445004,812 CHARLOTTE ST,DICKSON,TN,37055,2014-02-05,314,D,0,1,KG8011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, it was determined the facility failed to provide appropriate care and treatment for [REDACTED].#330) sampled residents of the 8 residents with pressure ulcers. The findings included: Review of the facility's PRESSURE ULCER PREVENTION policy documented, .PATIENT CARE PLAN; STRATEGIES FOR INTERVENTION . Orders are implemented promptly and the physician is kept informed of wound progress and/or the lack there of . Review of the facility's SKIN INTEGRITY PREVENTION AND MANAGEMENT policy documented, ASSESSMENT GUIDELINES . Current treatment and a patient's response to treatment and progress toward healing . Medical record review for Resident #330 documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the interim care plan dated 1/13/14 and updated 1/28/14 documented, .Alteration in skin integrity . potential (marked) . Stage: Coccyx . Wound/skin/surgical wound care as ordered (marked) . 1/28 ordered wound care . Review of the Admission Nursing assessment dated [DATE] documented Resident #330 with redness to the coccyx. Review of the weekly wound assessment dated [DATE] documented Resident #330 with a stage 1 pressure ulcer to the coccyx. Review of the weekly wound assessment progress note dated 1/14/14 documented, .Wound assessment complete. Stage I to coccyx . Red, non- blanchable area . Cleansed buttocks, pat dry, apply [MEDICATION NAME] BID (twice a day) et (and) PRN (as needed). Keep pt (patient) turned side to side . Will cont (continue) to monitor et tx (treatment) as indicated . Review of the Discontinued Medication Order documented, .CLEAN BUTTOCKS, PAT DRY. APPLY [MEDICATION NAME] TO BUTTOCKS QID . Stage I to coccyx effective 1/13/14 . Review of the Treatment Administration Record (TAR) for January 2014 documented, .CLEAN BUTTOCKS, PAT DRY, APPLY [MEDICATION NAME] TO BUTTOCKS QID (four times a day) . Diagnosis . stage 1 to coccyx . effective 1/13/14 . Signed out 1/20/14. There were no orders for wound care until 1/20/14 and no documentation wound care was performed other than on 1/14/14 and 1/20/14. Resident #330 was hospitalized from [DATE] through 1/28/14 due to decreased oxygen saturations. Review of the 1/28/14 Admission Nursing Assessment (readmission from hospital) documented Resident #330 with redness to the coccyx. Review of the weekly wound assessment dated [DATE] documented Resident #330 with a unstageable pressure ulcer to the coccyx and the left upper thigh. Review of the Ancillary Orders documented, .CLEAN COCCYX AND LEFT UPPER THIGH (BACK), PAT DRY. APPLY SKIN PREP TO PERIWOUND AREA, THEN APPLY [MEDICATION NAME] TO WOUND BED AND COVER WITH ALLEVYN DRESSING . Every 3 days . Start: 02/01/2014 . Diagnosis . stage II effective 1/28/14 . Review of the Medication Order documented, .CLEAN COCCYX AND LEFT UPPER THIGH (BACK), PAT DRY. APPLY SKIN PREP TO PERIWOUND AREA, THEN APPLY [MEDICATION NAME] TO WOUND BED AND COVER WITH ALLEVYN DRESSING Q (every) 3 DAYS AND PRN (as needed) unstageables to coccyx and left thigh effective 1/28/14 . Review of the February 2014 TAR documented the following: a. .CLEAN COCCYX, PAT DRY. APPLY SKIN PREP TO PERIWOUND AREA, THEN APPLY [MEDICATION NAME] TO WOUND BED AND COVER WITH ALLEVYN DRESSING. CHANGE Q (every) 3 DAYS AND PRN (as needed) . Start: 02/01/2014 DC (discontinue) Date: 02/04/2014 . Diagnosis . stage II effective 1/28/14 . and signed out as done 2/1/14. b. .CLEAN COCCYX AND LEFT UPPER THIGH (BACK), PAT DRY. APPLY SKIN PREP TO PERIWOUND AREA, THEN APPLY [MEDICATION NAME] TO WOUND BED AND COVER WITH ALLEVYN DRESSING. CHANGE Q 3 DAYS AND PRN . Start: 02/01/2014 . Diagnosis . unstageables to coccyx and left thigh effective 1/28/14 . and signed out as done 2/4/14. Resident #330 returned from the hospital on [DATE], but there was no order for wound care until 2/1/14 and no documentation wound care was performed from 1/28/14 until to 2/1/14. Observations in Resident #330's room on 2/5/14 at 9:35 AM, the Treatment Nurse changed the dressings for the wounds to the left upper thigh (back) and the left coccyx of Resident #330. The wound to the left upper thigh (back) was pink to the edges, with a yellow wound bed. The wound to the left coccyx was pink to the edges, with the wound bed yellow and approximately 40 percent necrosis noted. No redness or [MEDICAL CONDITION] was noted to either wound. During an Interview at the 100 Hall nurses' station on 2/4/14 at 3:30 PM, Nurse #3 was asked about the wound to the coccyx area documented as redness/stage 2 on 1/28/14 return from hospital and as unstageable 1/29/14 on the wound care assessment. Nurse #3 stated, .I was not here when the resident returned from the hospital . assessed the wound the next day after he came back from hospital it was necrotic . the nurses are not supposed to assess/stage the wounds . because they are not always correct . I am supposed to do that . the first order was incorrect that stated stage 2, that is why I had to modify it . Nurse #3 confirmed there was no documentation of the wound care being performed to the coccyx until 2/1/14 and to left thigh until 2/4/14. During an Interview in the education room on 2/4/14 at 4:20 PM, Nurse #3 was asked about the stage 1 wound to coccyx effective 1/13/14 and no orders for wound care until 1/20/14. Nurse #3 confirmed there should have been orders for a stage 1 wound, and stated, should have called doctor and written wound care orders, cannot find until this date .",2017-10-01
7759,"NHC HEALTHCARE, DICKSON",445004,812 CHARLOTTE ST,DICKSON,TN,37055,2014-02-05,319,D,0,1,KG8011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interviews, it was determined the facility failed to ensure appropriate treatment and services were provided to correct the assessed behaviors of crying, agitation and restlessness for 1 of 3 (Resident #203) sampled residents with behavioral problems of the 37 residents included in the stage 2 Review. The findings included: Medical record review for Resident #203 documented an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of a behavior assessment dated [DATE] documented, .Antipsychotic Drug Use . [MEDICATION NAME] 25mg (milligram) . Reason for Use Dementia . behavioral disturbance Hx (history) of hallucinations . Notify the drug review committee or consulting pharmacist that the resident is in the Fall Prevention Program and their use of antipsychotic medication should be reevaluated . Review of the care plan dated 12/13/13 revealed the care plan had not been updated to address the behavioral problems of crying, agitation and restlessness. Review of the Minimum Data Set ((MDS) dated [DATE], documented that Resident #203 exhibited hallucinations, delusions, other behavioral symptoms not directed toward others and rejection of care on 1 to 3 days during the 30 days after admission. Review of physician orders [REDACTED].(Increase) [MEDICATION NAME] to 25mg (milligrams) po (by mouth) BID (twice per day) . Review of physician's orders [REDACTED].(Decrease) [MEDICATION NAME] 0.5mg Q (every) 6 (hours) PRN (as needed) notify if sedation does not improve . Physician orders [REDACTED].Hold [MEDICATION NAME] until further order, (due to) lethargy, (increased) weakness . Physician orders [REDACTED].[MEDICATION NAME] 25mg (milligrams) at bedtime . Review of physician's orders [REDACTED].[MEDICATION NAME] 25 mg . TAKE 1 TABLET BY MOUTH TWICE DAILY AS NEEDED . Diagnosis: [REDACTED]. [MEDICAL CONDITION] . Diagnosis: [REDACTED]. Review of a physician's progress notes documented the following: a. 12/24/14 - .Patient is being seen this day for agitation and restlessness. She has had some delusional thought as well as thinking that her family has abandoned her here. She has been very disruptive to her peers as well . IMPRESSION . Dementia with delusions and behavioral problems . b. 12/26/13 - .The patient is being seen today per family request reported that she has had increased sedation. Apparently the patient had a bad day on Monday with excessive crying and tearfulness. She was placed on a milligram of [MEDICATION NAME] q4 as needed and [MEDICATION NAME] was increased from 25 mg q.h.s. (every hour of sleep) to 25 mg b.i.d. She was also given a loading dose of 25 mg. Prior to going to her daughter's house, she received a milligram of [MEDICATION NAME] and 2 doses of [MEDICATION NAME]. Today, family reports that she has been more alert though she is not participating as well in therapy. She is acting like she is having more difficulty moving her legs and leaning somewhat to the right . Impression . Lethargy most likely medication related . c. 12/28/13 - .dementia occasionally with behavior disturbances . During an interview at the 200 hall nurse's station on 1/4/14 at 5:00 PM, Nurse #4 was asked what type of behaviors were displayed by Resident #203. Nurse #4 stated, She's crying out a lot and fights staff. Nurse #4 was asked what type of behavioral management the staff uses. Nurse #4 stated, Diversional activities and calls daughter. Nurse #4 was asked if Resident #203's behavior warranted an increase in her [MEDICATION NAME]. Nurse #4 stated, No, not really. Nurse #4 was asked if she thought Resident #203 would benefit from social services. Nurse #4 stated, Probably. During an interview in the Director of Nursing's (DON) office on 1/4/14 at 6:10 PM, the DON was asked what were her expectations of the staff after a resident falls. The DON stated, They should assess the resident, identify the cause if possible, identify immediate interventions and apply to care plan, notify the physician and family. The DON was asked what type of behavioral management does your staff use beyond drugs. The DON stated, We have diversional activities, and we call the families to get involved. We have a psychologist and social service involvement. The DON was asked why this resident's [MEDICATION NAME] was increased on 12/24/13. The DON stated, .increased confusion and agitation . The DON was asked if she thought this resident would benefit from social services. The DON stated, Yes. The DON was asked if the resident had a psychology (psych) consult. The DON stated, I don't think so . to be honest with you. I think we should have had psych services review resident .",2017-10-01
7760,"NHC HEALTHCARE, DICKSON",445004,812 CHARLOTTE ST,DICKSON,TN,37055,2014-02-05,323,D,0,1,KG8011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, it was determined the facility failed to ensure a bed alarm intervention to prevent accidents/falls was implemented for 1 of 3 (Resident #233) sampled residents reviewed of 7 residents with falls of the 37 residents included in the stage 2 review. The findings included: Review of the facility's Post Falls Intervention policy documented, .Bed Alarm . Medical record review for Resident #233 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the High-Risk Patient Selection Form dated 12/1/13 documented the resident was at risk for falls. Review of the care plan dated 12/6/13 and updated 1/10/14 documented, .PROBLEM PRIORITY . Falls, at risk for as evidenced by . is assisted with ambulation . APPROACHES . Bed alarms placed . Observations in Resident #233's room on 2/4/14 at 2:33 PM and 3:00 PM, and on 2/5/14 at 7:25 AM and 8:50 AM, revealed Resident #233 lying in bed, with no bed alarm in place. During an interview in Resident #233's room on 2/5/14 at 8:50 AM, Nurse #2 was asked to locate Resident #233's bed alarm. After checking the bed, Nurse #2 stated, I will, embarrassingly, tell you it's not there .",2017-10-01
10112,"NHC HEALTHCARE, DICKSON",445004,812 CHARLOTTE ST,DICKSON,TN,37055,2012-02-15,246,D,0,1,KPFB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, it was determined the facility failed to ensure the call light was within a resident's reach for 2 of 24 (Residents #10 and 17) sampled residents. The findings included: 1. Review of the facility's CALL LIGHTS policy documented, .8. Be sure the call light is always within easy reach of the patient . 2. Medical record review for Resident #10 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 1/6/12 documented, .Call light within reach and answer promptly . Observations in Resident #10's room on 2/13/12 at 10:23 AM, 3:30 PM and 5:25 PM, revealed Resident #10 lying in bed with bilateral hand and arm contractures. The call light was under the pillow and out of Resident #10's reach. Observations in Resident #10's room on 2/14/12 at 7:55 AM, 9:00 AM and 10:00 AM, revealed the call light was lying between the headboard and the mattress out of Resident #10's reach. Observations in Resident #10's room on 2/14/12 at 4:20 PM, revealed Resident #10 resting in bed with the call light clipped to her gown at chest level. Resident #10 was unable to reach up to where the call light was clipped. During an interview in the 100 hall on 2/14/12 at 4:20 PM, Nurse #1 confirmed the call light was out of Resident #10's reach. 3. Medical record review for Resident #17 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 1/30/12 documented, .Call light within reach and answer light promptly . Observations in Resident #17's room on 2/14/12 at 5:00 PM, revealed Resident #17 resting in bed with bilateral hand and elbow contractures. The call light was clipped to the overbed light string out of Resident #17's reach. During an interview in Resident #17's room on 2/14/12 at 5:05 PM, Nurse #2 confirmed the call light was clipped to the light string and out of Resident #17's reach.",2016-07-01
10113,"NHC HEALTHCARE, DICKSON",445004,812 CHARLOTTE ST,DICKSON,TN,37055,2012-02-15,272,D,0,1,KPFB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to initiate an accurate initial Minimum Data Set (MDS) assessment for 1 of 27 (Resident #19) sampled residents. The findings included: Medical record review for Resident #19 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].[MEDICAL TREATMENT] MWF (Monday Wednesday Friday) . Review of the initial 5 day scheduled MDS dated [DATE] did not documented [MEDICAL TREATMENT] under Section O Special Treatments, Procedures, and Programs. During an interview in the education room on 2/15/12 at 11:00 AM, Nurse #4 was asked about the [MEDICAL TREATMENT] not being documented on the MDS. Nurse #4 stated, .It ([MEDICAL TREATMENT]) should have been marked . I'll have to correct that .",2016-07-01
10114,"NHC HEALTHCARE, DICKSON",445004,812 CHARLOTTE ST,DICKSON,TN,37055,2012-02-15,278,E,0,1,KPFB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to ensure the accuracy of the Minimum Data Set (MDS) related to the pneumonia vaccine requirement for 9 of 27 (Residents #1, 2, 4, 10, 11, 12, 17, 19 and 24) sampled residents. The findings included: 1. Medical record review for Resident #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Influenza / Pneumococcal Record labeled with an admission date of [DATE] documented, .Pneumoccocal Immunization . X Refused . Review of the admission 5-day MDS dated [DATE] and the 30-day MDS dated [DATE] documented, .O0300. Pneumococcal Vaccine . A. Is the resident's Pneumococcal vaccination up to date? .0 . O. NO . If Pneumococcal vaccine not received, state reason . B. If Pneumococcal vaccine not received, state reason: - (symbol for dash) . The MDS was not coded as to the reason why vaccine not received. 2. Medical record review for Resident #2 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Influenza/Pneumococcal Record labeled with admission date of [DATE] documented, .Pneumoccocal Immunization . X Refused . Review of the admission 5-day MDS dated [DATE] and the 30-day MDS dated [DATE] documented, .O0300. Pneumococcal Vaccine . A. Is the resident's Pneumococcal vaccination up to date? .0 . O. NO . If Pneumococcal vaccine not received, state reason . B. If Pneumococcal vaccine not received, state reason: - (symbol for dash) . The MDS was not coded as to the reason why vaccine not received. 3. Medical record review for Resident #4 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the medical record contained no documentation of the Influenza and Pneumococcal Immunization history or education provided. Review of the admission MDS dated [DATE] documented, .O0300. Pneumococcal Vaccine . A. Is the resident's Pneumococcal vaccination up to date? .0 .O. NO . If Pneumococcal vaccine not received, state reason . B. If Pneumococcal vaccine not received, state reason: - (symbol for dash) . The MDS was not coded as to the reason why vaccine not received. 4. Medical record review for Resident #10 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Influenza / Pneumococcal Record labeled with an admission date of [DATE] documented, .Influenza and Pneumoccocal Immunization History . Pneumococcal 2009 . Review of the annual MDS dated [DATE] and the quarterly MDS dated [DATE] documented, .O0300. Pneumococcal Vaccine . A. Is the resident's Pneumococcal vaccination up to date? .0 . O. NO . If Pneumococcal vaccine not received, state reason . B. If Pneumococcal vaccine not received, state reason: - (symbol for dash) . The MDS should have been coded as up to date as the pneumococcal vaccine had been given in 2009. 5. Medical record review for Resident #11 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] documented, O0300. A. Is the resident's Pneumococcal vaccination up to date? No. B. If Pneumococcal vaccine not received, state reason: - (symbol for dash) . The MDS was not coded as to the reason why vaccine not received. 6. Medical record review for Resident #12 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS dated [DATE] documented the resident's Pneumococcal Vaccine was not up to date and had not been offered. 7. Medical record review for Resident #17 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Influenza / Pneumococcal Record labeled with admission date of [DATE] documented, .Pneumoccocal Immunization . X Refused . Review of the annual MDS dated [DATE] and the quarterly MDS dated [DATE] documented, .O0300. Pneumococcal Vaccine . A. Is the resident's Pneumococcal vaccination up to date? .0 . O. NO . If Pneumococcal vaccine not received, state reason . B. If Pneumococcal vaccine not received, state reason: - (symbol for dash) . The MDS was not coded as to the reason why vaccine not received. 8. Medical record review for Resident #19 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Influenza/Pneumococcal Record labeled with admission date of [DATE] documented, .Pneumoccocal Immunization . X Refused . Review of the admission 5-day MDS dated [DATE] documented, .O0300. Pneumococcal Vaccine . A. Is the resident's Pneumococcal vaccination up to date? .0 . O. NO . If Pneumococcal vaccine not received, state reason . B. If Pneumococcal vaccine not received, state reason: - (symbol for dash) . The MDS was not coded as to the reason why vaccine not received. 9. Medical record review for Resident #24 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE] documented, O0300. A. Is the resident's Pneumococcal vaccination up to date? No. B. If Pneumococcal vaccine not received, state reason: - (symbol for dash) . The MDS was not coded as to the reason why vaccine not received. 10. During an interview in the education room on 2/15/12 at 9:20 AM, Nurse #5 confirmed the MDS Section O concerning Pneumococcal vaccination was inaccurate Residents #1, 2, 4, 10, 11, 12, 17, 19 and 24.",2016-07-01
10115,"NHC HEALTHCARE, DICKSON",445004,812 CHARLOTTE ST,DICKSON,TN,37055,2012-02-15,279,E,0,1,KPFB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, it was determined the facility failed to develop an interim plan of care upon admission to address the immediate needs of the resident for 5 of 27 (Residents #1, 2, 4, 11 and 19) sampled residents. The findings included: 1. Review of the facility's care plan development policy documented, .Time Frames for Care Plans: Interim plan of care within 24 hours of admission addressing the immediate needs of the patient . 2. Medical record review for Resident #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the interim plan of care documented a start date of 12/30/11. The care plan was initiated greater than 24 hours after admission. During an interview in the education room on 2/15/12 at 10:25 AM, Nurse 34 was asked when the interim care plan should be initiated on new admissions. Nurse #4 stated, .In first 24 hours . Nurse #4 confirmed the interim care plan for Resident #1 had not been initiated within 24 hours of admission. 3. Medical record review for Resident #2 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the interim plan of care documented a start date of 1/7/12. The care plan was initiated greater than 24 hours after admission. During an interview in the education room on 2/15/12 at 10:25 AM, Nurse #4 was asked when the interim care plan should be initiated on new admissions. Nurse #4 stated, .In first 24 hours . Nurse #4 confirmed the interim care plan for Resident #2 had not been initiated within 24 hours of admission. 4. Medical record review for Resident #4 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the interim plan of care was dated 1/10/12 and was not initiated within the 24 hour time frame as per the facility's policy. During an interview in the education room on 2/15/12 at 9:20 AM, the Assistant Director of Nursing (ADON) confirmed Resident #4's interim plan of care was not initiated within 24 hours of admission. 5. Medical record review for Resident #11 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the interim plan of care dated 2/2/12 did not contain documentation of contact isolation related to the [DIAGNOSES REDACTED]. During an interview in the education room on 2/15/12 at 10:30 AM, Nurse #8 confirmed there was no documentation of contact isolation on Resident #11's interim plan of care. 6. Medical record review for Resident #19 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the interim plan of care documented a start date of 2/1/12. The care plan was initiated greater than 24 hours after admission. During an interview in the education room on 2/15/12 at 10:25 AM, Nurse #4 was asked when the interim care plan should be initiated on new admissions. Nurse #4 stated, .In first 24 hours . Nurse #4 confirmed the interim care plan for Resident #19 had not been initiated within 24 hours of admission.",2016-07-01
10116,"NHC HEALTHCARE, DICKSON",445004,812 CHARLOTTE ST,DICKSON,TN,37055,2012-02-15,280,E,0,1,KPFB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, it was determined the facility failed to revise the comprehensive care plan to reflect the current status for elevating legs, [MEDICAL CONDITION]-embolic device (TED) hose, bleeding precautions, bed alarm, ortho boot, orastretcher, hand splint, a roll guard, feeding a resident at each meal and/or not to obtain weights for 6 of 27 (Residents #1, 5, 6, 10, 13 and 14) sampled residents. The findings included: 1. Review of the facility's care plan development policy documented, .9. Problems: a. Problems are patient conditions, needs, or weaknesses which currently do, or potentially could, prevent the patient from achieving or maintaining the highest practicable level of well being . 2. Medical record review for Resident #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].Keep legs elevated when possible . Review of a physician's orders [REDACTED].Measure for TED hose, below knee, on Q (every) AM, off at HS (hour of sleep) . The care plan dated 1/12/12 was not updated to reflect interventions for elevating legs and TED hose. During an interview in the education room on 2/15/12 at 10:30 AM, Nurse #4 was asked if the interventions for elevating legs and TED hose were on the care plan. Nurse #4 stated, Its's (interventions for elevating legs and TED hose) not on there (care plan) because I haven't updated the care plan . 3. Review of the Nursing 2012 Drug Handbook, Lippincott Williams & (and) Wilkins documented, .[MEDICATION NAME] Sodium [MEDICATION NAME] Nursing Considerations: Regularly inspect patient for bleeding gums, bruises on arms or legs, petechiae, nosebleeds, melena, tarry stools, hematuria and hematemesis . Medical record review for Resident #5 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].[MEDICATION NAME] 60 mg (milligram) sq (subcutaneous) q (every) day x (times) 6 w (weeks) . The care plan updated 1/31/11 was not revised to reflect care for bleeding precautions for the use of an anticoagulant medication [MEDICATION NAME]. During an interview in the education room on 2/15/12 at 8:55 AM, Nurse #5 reviewed Resident #5's medical record and stated, .There is nothing on the care plan related to bleeding precautions and [MEDICATION NAME] . 4. Medical record review for Resident #6 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the POS [REDACTED].INTERVENTIONS: BED ALARM PLACED UNDER PATIENT . The care plan initiated on 1/9/12 to the present had not been revised to reflect the intervention of a bed alarm. Observations in Resident #6's room on 2/14/12 at 8:10 AM and at 3:00 PM, revealed a bed alarm on Resident #6's bed. During an interview in the unit 1 nurses' station on 2/14/12 at 3:30 PM, the Assistant Director of Nursing (ADON) confirmed the bed alarm should be on the care plan. 5. Medical record review for Resident #10 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of an order dated 9/28/09 documented, .Remove ortho Boot daily during Bath and to assess skin integrity . Review of an order dated 8/1/11 documented, .Orastretch to be performed 5x (times)/ (per) week by restorative/nursing @ (at) 7 second hold @ 20- (to) 25 . Review of an order dated 8/3/11 documented, .provide training to caregivers, family & (and) restorative nursing/nursing staff on orastretcher device and how to use . Review of the physician's recertification orders dated 2/29/11 documented, .(R) (right) HAND SPLINT: ON AT 1ST (first) ROUND, OFF AT 2ND (second), ON AT 3RD (third), OFF AT 4TH (fourth), ON AT 5TH (fifth), OFF AT 6TH (sixth) . Review of the November 2011, December 2011 and January 2012 treatment records documented, .Stretch mouth using oral stretcher @ 20-25 level for 7 seconds daily . Remove ortho boots daily (during bath) & check for skin irritation. Review of the care plan dated 1/6/12 was not revised to reflect interventions for ortho boot, orastretcher and right hand splint. During an interview in the education room on 2/15/12 at 10:40 AM, Nurse #4 was asked if the ortho boot, right hand splint and the orastretcher were on the care plan. Nurse #4 stated, .No, I don't see it . 6. Medical record review for Resident #13 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a post falls assessment completed on 8/5/12 documented the resident was found on the floor beside the bed with the intervention to prevent further falls was to have roll guards placed on the bed. Review of the care plan dated 1/2/12 documented, .Falls, at risk for as evidenced by Dementia w/ (with) poor safety awareness; inability to self transfer, Severe [MEDICAL CONDITION] with risk of fractures PMH (past medical history); UE (upper extremity) & (and) LE (lower extremity) fractures . The care plan was not revised to reflect the intervention for roll guards on the bed. During an interview on in the education room on 2/15/12 at 8:00 AM, the Assistant Director of Nursing (ADON) was asked about the roll guards on the care plan. The ADON stated, That one (roll guard intervention) is not on there. Review of a nurses note dated 2/4/12 documented Resident #13 spilled coffee in her lap during a breakfast meal with the intervention to prevent any further spills to always feed the resident. Review of the care plan dated 1/2/12 was not revised to reflect that Resident #13 is to be fed at each meal. During an interview in the education room on 2/15/12 at 9:45 AM, the ADON was asked about the intervention to feed the resident at each meal documented in the nurses notes dated 2/14/12. The ADON stated, It (intervention to be fed at each meal) hasn't been added on here (care plan). 7. Medical record review for Resident #14 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. The care plan dated 12/16/11 documented, .Weigh: weekly X (times) 4 and then monthly . The care plan was not revised to reflect the intervention not to weigh Resident #14. During an interview in the Minimum Data Set Coordinator's office on 2/16/12 at 3:15 PM, Nurse #7 was asked if weights should be on the care plan after the physician had ordered no weights. Nurse #7 stated, .weighing should have been taken off of the care plan .",2016-07-01
10117,"NHC HEALTHCARE, DICKSON",445004,812 CHARLOTTE ST,DICKSON,TN,37055,2012-02-15,328,D,0,1,KPFB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, it was determined the facility failed to ensure oxygen (O2) was administered at the rate prescribed by the physician for 2 of 7 (Residents #14 and 17) sampled residents receiving O2. The findings included: 1. Review of the facility's inhalation therapy policy documented, .Oxygen therapy will be initiated . on the order of a physician . 2. Medical record review for Resident #14 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].O2 @ (at) 4 L (liters) PER NC (nasal cannula) CONTINUOUS . Observations in Resident #14's room on 2/13/12 at 11:30 AM, 3:30 PM and 5:30 PM, revealed Resident #14 receiving O2 per binasal cannula at a rate of 3.5 L. 3. Medical record review for Resident #17 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].O2 @ 4 L/M (liters per minute) NC (nasal cannula) . Observations in Resident #17's room on 2/14/12 at 3:15 PM and 5:00 PM and on 2/15/12 at 7:50 AM and 8:25 AM, revealed Resident #17 receiving O2 at 2 L/M. During an interview in Resident #17's room on 2/15/12 at 8:25 AM, Nurse #3 was asked if Resident #17 was receiving O2 at 2 L/M. Nurse #3 stated, .yes . and confirmed the oxygen should be administered at 4 L/M per physician's orders [REDACTED].>",2016-07-01
10118,"NHC HEALTHCARE, DICKSON",445004,812 CHARLOTTE ST,DICKSON,TN,37055,2012-02-15,334,E,0,1,KPFB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, it was determined the facility failed to provide the required components of the Influenza and Pneumococcal immunization program for 11 of 27 (Residents #1, 2, 4, 6, 7, 11, 12, 17, 19, 23 and 24) sampled residents. The findings included: 1. Review of the facility's Pneumonoccal Vaccination Policy documented, .A medical history of [REDACTED]. A Vaccine Information Sheet will be provided to the patient or Responsible Party . Pneumococcal Immunization will be kept in the patients medical record for patients receiving Pneumococcal Vaccine and will include: Immunization history, Education Provided, Administration of Vaccine, Name of person refusing vaccine for the patient, Post Immunization monitoring . Review of the facility's Influenza Vaccination Policy documented, .Each patient will be offered immunization against influenza October 1 through March 31 annually . A history will be obtained from the patient or responsible party to determine patient ability to receive the influenza vaccine and history of adverse reactions . A Vaccination Information Sheet will be provided to the patient or responsible party . Influenza Immunization Record will be kept in the patient's chart containing Immunization History, Education provided, Administration of vaccine, name of person refusing vaccine for patient, and Post Immunization Monitoring for patients receiving influenza injection . 2. Medical record review for Resident #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Influenza / Pneumococcal Immunization Record documented, .Administration Record: Vaccine Information Pneumococcal Immunization: Refused (marked with an X) . Review of the Influenza/Pneumococcal Immunization record contained no documentation of the name of the patient or responsible party refusing the Pneumococcal Vaccine for the patient and no documentation of vaccine information sheet education provided or explained. 3. Medical record review for Resident #2 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Influenza/Pneumococcal Immunization Record documented, .Administration Record: Vaccine Information Pneumococcal Immunization: Refused (marked with an X) . Review of the Influenza / Pneumococcal Immunization record contained no documentation of the name of the patient or responsible party refusing the Pneumococcal Vaccine for the patient and no documentation of vaccine information sheet education provided or explained. 4. Medical record review for Resident #4 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The facility was unable to provide documentation of the Influenza or Pneumococcal Immunization history or education provided. During an interview in the education room on 2/15/12 at 9:10 AM, Nurse #5 was asked to review Resident #4's medical record for Influenza and Pneumococcal immunization record. Nurse #5 stated, .There is no flu or pneumonia immunization record on the chart, therefore not documented, so we did not do it, we have a broken system . During an interview in the education room on 2/15/12 at 9:20 AM, Nurse #4 was asked to review Resident #4's medical record for Influenza and Pneumococcal immunization record. Nurse #4 stated, .There is no documentation on the chart but on my work sheet it says family said unknown, he should have gotten the flu vaccine because during flu season . 5. Medical record review for Resident #6 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The facility was unable to provide documentation of the Influenza or Pneumococcal Immunization history or education provided. 6. Medical record review for Resident #7 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The facility was unable to provide documentation of the Influenza or Pneumococcal Immunization history or education provided. 7. Medical record review for Resident #11 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The facility was unable to provide documentation of the Influenza or Pneumococcal Immunization history or education provided. 8. Medical record review for Resident #12 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The facility was unable to provide documentation of the Influenza or Pneumococcal Immunization history or education provided. 9. Medical record review for Resident #17 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Influenza / Pneumococcal Immunization Record documented, .Administration Record: Vaccine Information Pneumococcal Immunization: Refused (marked with an X) . Review of the Influenza/Pneumococcal Immunization Record contained no documentation of the name of the patient or responsible party refusing the Pneumococcal Vaccine for the patient. 10. Medical record review for Resident #19 documented and admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Influenza/Pneumococcal Immunization Record documented, .Administration Record: Vaccine Information Pneumococcal Immunization: Refused (marked with an X) . Review of the Influenza / Pneumococcal Immunization Record contained no documentation of the name of the patient or responsible party refusing the Pneumococcal Vaccine for the patient and no documentation of vaccine information sheet education provided or explained. 11. Medical record review for Resident #23 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The facility was unable to provide documentation of the Influenza or Pneumococcal Immunization history or education provided. 12. Medical record review for Resident #24 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The facility was unable to provide documentation of the Influenza or Pneumococcal Immunization history or education provided. 13. During an interview in the education room on 2/15/12 at 8:55 AM, Nurse #5 was asked to discuss the Influenza and Pneumococcal immunization program. Nurse #5 stated, .I have not seen the education vaccine sheet in the admission packs, the patients are not getting them . Nurse #5 and the Assistant Director of Nursing (ADON) reviewed an admission pack and confirmed there was no immunization education sheets in the admission packet to be given during admission. During an interview in the education room on 2/15/11 at 9:25 AM, the ADON was asked to discuss the Influenza and Pneumococcal immunization program. The ADON stated, .The MDS (minimum data set) nurse should tell me (ADON) that a vaccine is needed for the patient, they (MDS nurse) have not been . I should be tracking and have not been . During an interview in the Unit 1 nurses' station on 2/15/12 at 10:10 AM, the Director of Nursing (DON) confirmed the Influenza or Pneumococcal Immunization history or education provided was not documented in the residents' charts. The DON stated, .It's policy . if vaccinations are done here . we'll put them on the form and put it in the chart .",2016-07-01
10119,"NHC HEALTHCARE, DICKSON",445004,812 CHARLOTTE ST,DICKSON,TN,37055,2012-02-15,441,D,0,1,KPFB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, review of a Certified Nursing Assistant (CNA) information form, observation and interview, it was determined the facility failed to ensure practices to prevent the potential spread of infection were maintained by failing to institute consistent isolation practices for 1 of 1 (Resident #11) sampled residents and by failing to ensure sanitary hand hygiene practices during 1 of 2 (Lunch 2/14/12) dining observations. The findings included: 1. Review of the facility's Multidrug-Resistant Microorganisms policy documented, .Use Contact Precautions: for patients with known or suspected Clostridium difficile associated disease . Medical record review for Resident #11 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the admitting orders dated 2/1/12 documented, .c-diff (Clostridium difficile) . as diagnosis. There was no order for isolation documented. Review of the Admission Nursing Assessment Report dated 2/1/12 did not document Clostridium difficile illness or initiation of isolation. Review of the interim plan of care dated 2/2/12 did not include isolation precautions. Review of the facility's CNA information form for Resident #11 did not document isolation precautions. During an interview in the education room on 2/16/12 at 10:30 AM, Nurse #8 was unable to locate documentation for isolation and could not verify that CNAs were informed of contact isolation precautions for Resident #11. 2. Review of the facility's Handwashing policy documented, .Turn water off with paper towel used to dry hands . During dining observations in room [ROOM NUMBER] on 2/14/12 at 11:38 AM, CNA #1 washed her hands with soap and water and turned off the water faucet with her bare hand. During dining observations in room [ROOM NUMBER] on 2/14/12 at 11:50 AM, CNA #2 moved the chair to the bedside and moved the overbed table then prepped the meal tray without washing her hands. During an interview in the education room on 2/15/12 at 5:10 PM, the Director of Nursing (DON) was asked what is the expectation of infection control practices during the meal tray pass. The DON stated, .I expect the staff to use a paper towel to turn off the water faucet . I expect if the staff touches the patient's environment they are to wash their hands before preparing the meal tray .",2016-07-01
10120,"NHC HEALTHCARE, DICKSON",445004,812 CHARLOTTE ST,DICKSON,TN,37055,2012-02-15,502,D,0,1,KPFB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to ensure laboratory testing was obtained as ordered for 1 of 27 (Resident #3) sampled residents. The findings included: Medical record review for Resident #3 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physicians order dated 1/12/12 documented, .Stool for C (,[MEDICAL CONDITION].) Diff (Difficile) . The facility was unable to provide documentation that a stool sample for[DIAGNOSES REDACTED] was obtained as ordered. During an interview at Unit 1 nurses' station on 2/15/12 at 10:45 AM, the Assistant Director of Nursing (ADON) stated, .we are not able to produce the[DIAGNOSES REDACTED] results .",2016-07-01
10121,"NHC HEALTHCARE, DICKSON",445004,812 CHARLOTTE ST,DICKSON,TN,37055,2012-02-15,514,D,0,1,KPFB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, it was determined the facility failed to ensure physician's orders were accurate for 2 of 27 (Residents #2 and 10) sampled residents. The findings included: 1. Review of the facility's DOCUMENTATION GUIDELINES documented, .A nurse reviews all current orders for content and clarity, deletes discontinued orders, signs the orders as recopied/reprinted . The nurses's signature indicates accountability for the accuracy of the updated orders as of the date signed . 2. Medical record review for Resident #2 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's admitting orders dated 1/3/12 documented, .Diet: Mechanical NAS (no added salt) .Labs ordered: BMP (basic metabolic panel), CBC (complete blood count), Thurs (Thursday) then q (every) 3 mo (months) . Review of the physician's recertification orders dated 2/8/12 documented, .DIET: MECHANICAL . BOTH HEELS: APPLY ALLEVYN HEELS AND [MEDICATION NAME] EVERY 3 DAYS & (and) PRN (as needed) . The physician's recertification orders did not include orders for the BMP and CBC to be done q 3 months or include NAS to the diet order. Review of the weekly wound assessment record dated 2/9 (2012) documented, .Lt (left) Hel (heel) . Healed . Review of all physician's orders documented no order to discontinue left heel dressing changes due to that the area had healed. During an interview in the education room on 2/15/12 at 10:10 AM, Nurse #5 confirmed the order for NAS diet and the CBC and BMP q 3 months had not been added to the current recertification orders. Nurse #5 was asked if there was an order to discontinue the dressing change to the left heel. Nurse #5 stated, .I don't see an order . During an interview in the education room on 2/15/11 at 4:35 PM, Nurse #6 confirmed an order should have been written to discontinue the dressing change to the left heel as it was healed on 2/9/12. 3. Medical record review for Resident #10 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of an order dated 9/28/09 documented, .Remove ortho Boot daily during Bath and to assess skin integrity . Review of an order dated 8/1/11 documented, .Orastretch to be performed 5x (times)/ (per) week by restorative/nursing @ (at) 7 second hold @ 20- (to) 25 . Review of an order dated 8/3/11 documented, .provide training to caregivers, family & restorative nursing/nursing staff on orastretcher device and how to use . Review of the physician's recertification orders dated 12/29/11 did not include an order for [REDACTED].>Review of the November 2011, December 2011 and January 2012 treatment records documented, .Stretch mouth using oral stretcher @ 20-25 level for 7 seconds daily . Remove ortho boots daily (during bath) & (and) check for skin irritation. During an interview in the education room on 2/15/12 at 10:10 AM, Nurse #5 confirmed the ortho boot and orastretcher were not on the recertification orders and should have been. During an interview in the education room on 2/15/12 at 2:35 PM, Nurse #1 was asked when the ortho boot and orostretch had been left off the recertification orders. Nurse #1 stated, .they were never carried over .",2016-07-01
10122,"NHC HEALTHCARE, DICKSON",445004,812 CHARLOTTE ST,DICKSON,TN,37055,2013-08-13,157,D,1,0,R0PB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Intakes: TN 209 Based on policy review, medical record review and interview, it was determined the facility failed to notify the responsible party of a change in medication for 1 of 5 (Resident #1) sampled residents. The findings included: Review of the facility's POLICIES AND PROCEDURES REGARDING CHANGE IN PATIENT STATUS documented, .The patient or decision maker is encouraged to be involved in all decision-making regarding changes in the plan of care . Medical record review for Resident #1 documented an admission date of [DATE] and a discharge date of [DATE] with [DIAGNOSES REDACTED]. Review of the Nutritional Assessment Report dated 6/28/13 documented, .CBW (current body weight) 181 # (pounds); some variation since admit 16# (pound) (8.1% (percent)) compared to the stated UBW (usual body weight) 197# . Review of the physician's progress notes dated 7/1/13 documented, .This patient was referred by the dietician due to having trigger for malnourishment on a recent assessment. He has a significant weight loss due to poor intake and has chronic [DIAGNOSES REDACTED]. Add [DIAGNOSES REDACTED].o. (by mouth) q.h.s. (every hour of sleep) . Review of the physician's orders [REDACTED].[MEDICATION NAME] 15 mg po QHS . Review of the nurses' notes dated 7/1/13 documented, .N.O. (new order) rec'd (received) r/t (related to) wt (weight) loss . There was no documentation the family was notified of this change. During an interview in the Director of Nursing's (DON) office on 8/13/13 at 3:00 PM, the DON was asked what is the responsibility of staff in relation to family when a resident has a change in condition or medication. The DON stated, Family should be notified. The DON confirmed the responsible party was not notified of the new medication on 7/1/13 and stated, I did become aware of this . that nurse was educated .",2016-07-01
10123,"NHC HEALTHCARE, DICKSON",445004,812 CHARLOTTE ST,DICKSON,TN,37055,2013-08-13,282,D,1,0,R0PB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to follow the care plan interventions for bowel movement (BM) protocol for 1 of 5 (Resident #1) sampled residents. The findings included: Medical record review for Resident #1 documented an admission date of [DATE] and a discharge date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].MILK OF MAGNESIA SUSPENSION Start Date: 7/11/2013 . IF NO BM IN 2 DAYS GIVE MOM (Milk of Magnesia) 30 ML (milliliters) AFTER BREAKFAST . [MEDICATION NAME] 10 MG (milligrams) SUPPOSITORY . Start Date: 7/11/2013 . IF NO BM AFTER MOM GIVE [MEDICATION NAME] . FLEET ENEMA . Start Date: 7/11/2013 . IF NO BM AFTER [MEDICATION NAME] GIVE FLEET ENEMA . Review of the physician's orders [REDACTED].SOAP SUD ENEMA . Start Date: 7/15/2013 . 1X (time) NOW . Review of the care plan dated 7/12/13 documented, .PROBLEM . Constipation, potential for . APPROACHES . Follow BM protocol if no BM is noted > (greater) (3) days . Review of Activities of Daily Living (ADL) tracking sheets for July, 2013 documented Resident #1 had no BM on 7/11/13, 7/12/13, 7/13/13 or 7/14/13. Review of the Medication and Treatment Administration Record Report documented Resident #1 did not receive anything to assist his bowels to move until 7/15/13, when he received MOM, a [MEDICATION NAME] Suppository, a Fleet Enema, and a Soap Sud Enema. Review of the ADL tracking sheets for July, 2013 documented Resident #1 did have a BM 7/15/13, then had no BM on 7/16/13, 7/17/13, 7/18/13 or 7/19/13, and did have a BM 7/20/13. Review of the Medication and Treatment Administration Record Report documented Resident #1 did not receive anything to assist his bowels to move from 7/16/13 through 7/20/13. During an interview in the Director of Nurses's (DON) office on 8/13/13 at 3:00 PM, the DON was asked what the process for the BM protocol was. The DON stated, On day 3, if no BM, give MOM, then if no BM, give a [MEDICATION NAME] tablet or suppository, then if no results, give fleets enema, then if no results, would notify the doctor . The DON confirmed the BM protocol was not followed and stated, .was aware of this at that point after it happened. I have started the inservices .",2016-07-01
10124,"NHC HEALTHCARE, DICKSON",445004,812 CHARLOTTE ST,DICKSON,TN,37055,2013-08-13,309,D,1,0,R0PB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, it was determined the facility failed to follow physician's orders or the bowel movement (BM) protocol for 1 of 5 (Resident #1) sampled residents. The findings included: Review of the facility's .Admitting Orders documented, .Bowel Protocol: If no BM in 2 days give MOM (Milk of Magnesia) 30 cc (cubic centimeters) po (by mouth) p (after) breakfast. If no BM following MOM give [MEDICATION NAME] Suppository rectally p evening meal. If no BM p [MEDICATION NAME] give Fleets enema @ (at) H.S. (Hour of Sleep) . The Director of Nursing stated this was their policy for the BM protocol. Medical record review for Resident #1 documented an admission date of [DATE] and a discharge date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders dated 7/17/13 documented, .MILK OF MAGNESIA SUSPENSION Start Date: 7/11/2013 . IF NO BM IN 2 DAYS GIVE MOM 30 ML (milliliters) AFTER BREAKFAST . [MEDICATION NAME] 10 MG (milligrams) SUPPOSITORY . Start Date: 7/11/2013 . IF NO BM AFTER MOM GIVE [MEDICATION NAME] . FLEET ENEMA . Start Date: 7/11/2013 . IF NO BM AFTER [MEDICATION NAME] GIVE FLEET ENEMA . Review of the physician's orders dated 7/18/13 documented, .SOAP SUD ENEMA . Start Date: 7/15/2013 . 1X (time) NOW . Review of the care plan dated 7/12/13 documented, .PROBLEM . Constipation, potential for . APPROACHES . Follow BM protocol if no BM is noted > (greater) (3) days . Review of Activities of Daily Living (ADL) tracking sheets for July, 2013 documented Resident #1 had no BM on 7/11/13, 7/12/13, 7/13/13 or 7/14/13. Review of the Medication and Treatment Administration Record Report documented Resident #1 did not receive anything to assist his bowels to move until 7/15/13, when he received MOM, a [MEDICATION NAME] Suppository, a Fleet Enema and a Soap Sud Enema. Review of the ADL tracking sheets for July, 2013 documented Resident #1 did have a BM 7/15/13, then had no BM on 7/16/13, 7/17/13, 7/18/13 or 7/19/13, and did have a BM 7/20/13. Review of the Medication and Treatment Administration Record Report documented Resident #1 did not receive anything to assist his bowels to move from 7/16/13 through 7/20/13. During an interview in the Director of Nurses's (DON) office on 8/13/13 at 3:00 PM, the DON was asked what the process for the BM protocol was. The DON stated, On day 3, if no BM, give MOM, then if no BM, give a [MEDICATION NAME] tablet or suppository, then if no results, give fleets enema, then if no results, would notify the doctor . The DON confirmed the BM protocol was not followed and stated, .was aware of this at that point after it happened. I have started the inservices now .",2016-07-01
12348,"NHC HEALTHCARE, DICKSON",445004,812 CHARLOTTE ST,DICKSON,TN,37055,2010-11-17,328,D,0,1,9SDV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations and interviews, it was determined the facility failed to ensure oxygen (O2) was administered at the physician's prescribed rate for 1 of 12 (Resident #2) sampled residents receiving oxygen. The findings included: Medical record review for Resident #2 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's telephone orders dated 10/29/10 documented, ""...change O2 to 2 (liters) PRN (as needed) for SOB (shortness of breath)..."" Observations in Resident #2's room on 11/15/10 at 10:30 AM and 2:10 PM, revealed Resident #2 was receiving O2 at 3 liters per minute (LPM) per binasal cannula (BNC). Resident #2 was not receiving oxygen at the physician's prescribed rate of 2 LPM. Observations in Resident #2's room on 11/16/10 at 7:45 AM, revealed Resident #2 was receiving O2 at 3 1/2 LPM per BNC. Resident #2 was not receiving oxygen at the physician's prescribed rate of 2 LPM. During an interview in Resident #2's room on 11/16/10 at 7:45 AM, Nurse #7 was asked what rate was Resident #2's oxygen set on. Nurse #7 bent down and looked at the oxygen concentrator and stated, ""It is on 3 and 1/2 liters."" During an interview at the nurse's station on 11/16/10 at 9:55 AM, Nurse #8 was asked what rate was Resident #2's O2 ordered for. Nurse #8 stated, ""2 Liters.""",2015-08-01
12349,"NHC HEALTHCARE, DICKSON",445004,812 CHARLOTTE ST,DICKSON,TN,37055,2010-11-17,441,E,0,1,9SDV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy reviews, observations and interviews, it was determined the facility failed to ensure practices to prevent the potential spread of infection were maintained by 2 of 2 (Nurses #9 and 10) nurses observed during wound care; 4 of 7 (Nurses #1, 2, 3 and 4) nurses observed during medication administration; and 6 of 14 Certified Nursing Assistants (CNAs #1, 2, 3, 4, 5 and 6) and Occupational Therapist (OT #1) obsered during dining observations. The findings included: 1. Review of the facility's ""HANDWASHING"" policy documented, ""PURPOSE: To decrease the number of microorganisms, preventing cross contamination... ...Procedure wash hands after contact with each patient, after toileting, smoking or eating, and after removal of gloves..."" 2. Observations during wound care in Resident #3's room on 11/16/10 at 9:00 AM, Nurse #9 pushed the paper towel dispenser handle for a paper towel, washed her hands, dried her hands with the paper towel, took the same paper towel and dispensed more paper towel, then dried her hands with the fresh paper towel and the towel she had used on the dispenser. Nurse #9 dried her hands in this same way three times during observation of the wound care. Nurse #9 cross contaminated her hands when she use the dirty paper towel to dry her hands. During an interview in the biohazard room on 11/16/10 at 9:15 AM, Nurse #9 stated, ""...I should not have dried with the dirty paper towel..."" Observations during wound care in Resident #11's room on 11/26/10 at 11:08 AM, revealed Nurse #10 dispensed some paper towel, washed her hands, dried her hands with that towel, used her bare index finger on her clean right hand to dispense more paper towel to turn the water off. Nurse #10 used this same technique contaminating her right hand 4 times during observation of her wound care. During an interview in the Director of Nursing's (DON) office on 11/16/10 at 11:35 AM, the DON stated, ""...She (Nurse #9) should not have dried her hands with dirty towel... She (Nurse #10) should have used the paper towel to get the other papers down..."" 3. Observations in room [ROOM NUMBER] on 11/15/10 at 4:45 PM, Nurse #1 removed her gloves after checking the resident's blood sugar. Nurse #1 did not wash her hands immediately after removing gloves and prior to cleaning the glucometer. 4. Observations in room [ROOM NUMBER] on 11/15/10 at 5:20 PM, Nurse #2 pulled the resident's gown up with gloved hands and repositioned the resident on her back. Nurse #2 continued to check placement of a Percutaneous Endoscopy Gastrostomy (PEG) tube and administer medications through the PEG tube. Nurse #2 did not remove her gloves or wash her hands after resident contact or prior administering medications per the PEG tube. 5. Observations in room [ROOM NUMBER] on 11/16/10 at 6:20 AM, Nurse #3 removed gloves after checking the resident's blood sugar. Nurse #3 donned gloves and applied a medication patch to the resident's chest wall. Nurse #3 removed gloves, donned clean gloves, cleaned the glucometer and removed her gloves. Nurse #3 did not wash her hands after removing gloves. 6. Observations at the medication cart in front of room [ROOM NUMBER] on 11/16/10 at 9:30 AM, Nurse #4 applied gloves, opened a medication capsule, emptied the contents of the capsule into the medication cup, mixed the medication with pudding and then removed her the gloves. Nurse #4 entered room [ROOM NUMBER], applied gloves, repositioned the resident in bed, then administered the medications to the resident. Nurse #4 did not wash her hands after removing gloves, after resident contact or prior to administering the medications. 7. Observations in room [ROOM NUMBER] on 11/16/10 at 7:40 AM, CNA #1 opened the straw and touched the straw with her bare hand. 8. Observations in room [ROOM NUMBER] on 11/16/10 at 7:23 AM, CNA #2 placed the breakfast tray on the overbed table, assisted the resident to a sitting position, covered the resident's legs with a blanket, pulled the overbed table by the resident and proceeded to set up the tray removing tops from liquids and foods and opened the silverware without washing her hands. Observations in the Independent dining room on 11/16/10 at 7:30 AM, CNA #2 dropped a piece of paper on the floor, picked up the paper, placed the paper in the trash and pulled a tray from the clean cart for another resident without washing her hands. 9. Observations in room [ROOM NUMBER] on 11/26/10 at 7:35 AM, CNA #3 placed the tray on the overbed table, turned the light switch on, then proceeded to open and set up the residents food tray without washing her hands. 10. Observations in the Independent dining room on 11/16/10 at 7:18 AM, CNA #4 touched a resident's straw with her bare hands. Observations in room [ROOM NUMBER] on 11/16/10 at 7:38 AM, CNA #4 touched the biscuit and sausage with her bare hands while serving the breakfast tray. Observations in the Independent dining room on 11/16/10 at 11:00 AM, CNA #4 touched a resident's straw with her bare hands, pushed a resident's wheelchair and pulled a tray from the clean cart for another resident without washing her hands. Observations in the Independent dining room on 11/16/10 at 11:35 AM, CNA #4 touched the resident's bread with her bare hands. 11. Observations in room [ROOM NUMBER] on 11/16/10 at 7:30 AM, CNA #5 washed her hands and turned the water off with her bare hands. CNA #5, then delivered a breakfast tray to room [ROOM NUMBER]B, set the tray on the overbed table, applied gloves, emptied the bedpan and removed her gloves. CNA #5 did not wash her hands. CNA #5 went back into the resident's room, positioned the resident in the bed and proceeded to set up the residents meal tray. CNA #5 then washed her hands and turned off the water with her bare hands instead of using a paper towel. Observations in room [ROOM NUMBER] on 11/16/10 at 7:50 AM, CNA #5 touched the resident, manually raised the head of bed, opened and touched the straw with her bare hand and began to feed the resident without washing her hands. Observations in the dining room on 11/16/10 at 11:20 AM, CNA #5 washed her hands and turned off the water with her bare hands, then touched a resident on the back, touched a staff member and proceeded to obtain a cup of coffee for a resident without washing her hands. Observations in the dining room on 11/16/10 at 11:50 AM, CNA #5 served 2 meal trays, touched a resident then continued to serve the trays. CNA #5 removed an ink pen from her pocket then washed her hands and turned the water off with her bare hands. Observations in the dining room on 11/16/10 at 12:05 PM, CNA #5 assisted a resident to sit down in the wheelchair, took a plate from the table and scraped it off, cleaned up a spill from the floor, took the towels to the soiled utility room, then washed her hands and turned off the water with her bare hands. 12. Observations in room [ROOM NUMBER] on 11/16/10 at 8:05 AM, CNA #6 opened the straw and touched the straw with her bare hand. Observations in room [ROOM NUMBER] on 11/16/10 at 8:10 AM, CNA #6 washed her hands and turned the faucet off with her bare hand. 13. Observations in room [ROOM NUMBER] on 11/16/10 at 7:30 AM, OT #1 entered room [ROOM NUMBER] and placed the breakfast tray on the overbed table. OT #1 repositioned the resident in the bed, raised the head of the bed and washed the resident's hands with a Sani-Hands cloth. OT #1 continued to serve the tray and feed the resident. OT #1 did not wash her hands after direct resident contact. 14. During an interview in the Director of Nursing office on 11/17/10 at 10:45 AM, The Director of Nursing stated, ""Would expect them (staff) to wash hands after removing gloves as well as after emptying bedpan."" During an interview at the unit 4 nurses' station on 11/17/10 at 1:45 PM, Nurse #8 stated, ""I expect the bare hand not to touch the straw once the wrapper is removed.""",2015-08-01
12350,"NHC HEALTHCARE, DICKSON",445004,812 CHARLOTTE ST,DICKSON,TN,37055,2010-11-17,282,D,0,1,9SDV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews, observations and interviews, it was determined the facility failed to follow interventions on the care plan for Reddy shakes or hand splints for 2 of 24 (Residents #3 and #9) sampled residents. The findings included: 1. Medical record review for Resident #3 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive care plan dated 10/29/10 documented, ""Significant nutritional risk... Malnutrition... Supplement Use between meals... 1 (one) 4 oz (ounce) Reddy Shake c (with) each meal for add (additional) /Calories/Prot. (protein)."" Observations in Resident #3's room on 11/16/10 at 8:00 AM and on 11/17/10 at 7:40 AM, revealed no Reddy Shake on Resident #3's meal tray as care planned. During an interview in the Director of Nursing's (DON) office on 11/17/10 at 8:00 AM, the DON was asked about the Reddy Shakes. The DON stated, ""It would be between dietary and nursing to make sure the supplement is on the tray."" During an interview in the education room on 11/17/10 at 10:00 AM, Dietician #1 was asked about the Reddy Shakes. Dietician #1 stated, ""...The CNA (Certified Nursing Assistant) just didn't put it (Reddy shake) on her tray, it wasn't that she (Resident #3) refused it."" 2. Medical record review for Resident #9 documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive care plan dated 8/23/10 and updated 8/25/10 documented, ""...ADL's (Activities of Daily Living), Dependent on staff for ADLS... Bilateral hand splints to both hands: On while facing the door and off while facing the window..."" Observations in Resident #9's room on 11/15/10 at 5:10 PM, on 11/16/10 at 10:15 AM and 12:00 PM and on 11/17/10 at 7:35 AM, revealed Resident #9 lying in bed facing the door, with no bilateral hand splints on as care planned. During an interview in the 100 hall on 11/17/10 at 8:15 AM, Nurse #2 was asked about Resident #9 not having the hand splints on. Nurse #2 stated she was not aware Resident #9 should have hand splints on.",2015-08-01
12351,"NHC HEALTHCARE, DICKSON",445004,812 CHARLOTTE ST,DICKSON,TN,37055,2010-11-17,280,D,0,1,9SDV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews, observations and interviews, it was determined the facility failed to revise the comprehensive care plan to address range of motion (ROM) and/or oxygen (O2) for 4 of 27 (Residents #4, 5, 19 and 22) sampled residents. The findings included: 1. Medical record review for Resident #4 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an assessment reference date of 10/16/10 documented Resident #4 had impairment on both sides of the upper and lower extremities for ROM. Review of the care plan dated 11/6/10 revealed no documentation to address ROM limitations. During an interview in the care plan office on 11/16/10 at 3:50 PM, MDS Coordinator #1 confirmed there was no care plan to address ROM and stated, ""I am going to add it right now."" 2. Medical record review for Resident #5 documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the MDS with an assessment reference date of 10/4/10 documented Resident #5 had impairment on both sides of the upper and lower extremities for ROM. Review of the care plan dated 10/5/10 revealed no documentation to address ROM limitations. During an interview at the unit 2 nurses' station on 11/17/10 at 8:30 AM, MDS Coordinator #1 stated, ""No, it's (ROM) not in the ADL's (activities of daily living) where it (ROM) should be..."" 3. Medical record review for Resident #19 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #19's physician's orders [REDACTED].@ (at) 3L (liters) PER NC (nasal cannula) CONTINUOUS..."" Review of the nurse's notes dated 11/15/10 documented Resident #19 was receiving O2 continuous at 2 liters per minute (LPM). Review of the care plan dated 9/22/10 revealed no care plan for O2 therapy. Observations in room [ROOM NUMBER] on 11/15/10 at 10:15 AM, on 11/16/10 at 4:00 PM and on 11/17/10 at 9:25 AM, revealed Resident #19 lying in bed with O2 in use. During an interview at the unit 4 nurses' station on 11/17/10 at 9:35 AM, Nurse #8 stated, ""I don't see oxygen on here (care plan). It should be. Looks like there's a problem with the care plan."" 4. Medical record review for Resident #22 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].@ 2L PER NC..."" Review of the care plan dated 9/18/10 revealed no care plan for O2 therapy. Observations in room [ROOM NUMBER] on 11/16/10 at 4:10 PM and on 11/17/10 at 8:30 AM, revealed Resident #22 lying in bed receiving O2 at 2 LPM per NC. During an interview in the care plan office on 11/17/10 at 10:20 AM, MDS Coordinator #1 confirmed there was no care plan for O2 therapy and stated, ""It looks like I need to make some updates, I will add it (O2 to care plan) now.""",2015-08-01
12352,"NHC HEALTHCARE, DICKSON",445004,812 CHARLOTTE ST,DICKSON,TN,37055,2010-11-17,371,E,0,1,9SDV11,"Based on policy reviews, observations and interviews, it was determined 4 of 8 (dietary staff members #1, 2, 3 and 4) dietary staff members failed to ensure food was prepared or stored under sanitary conditions as evidenced by rice stored in an open bag; a Teflon skillet had scratches and a carbon build up; dirty towels and cloths on counters and carts; improper storage of a broom; cover their hair and beards or follow the handwashing policy. The findings included: 1. Review of the facility's ""DRY STORAGE"" policy documented, ""...GUIDELINES... 6. Foods will be stored in their original packages, if possible. If opened, packages should be closed securely to protect product..."" Observations in the kitchen on 11/15/10 at 10:00 AM and 4:18 PM and on 11/16/10 at 3:35 PM, revealed a large open bag of rice stored on a shelf in the food preparation area. During an interview in the kitchen on 11/16/10 at 3:35 PM, the Dietary Manager stated, ""It (rice) should be in a closed container to keep something from getting in it."" 2. Observations in the kitchen on 11/15/10 at 4:18 PM, revealed the cook preparing a grilled cheese sandwich in a skillet that had missing Teflon, multiple scratches on the inside and large amounts of carbon buildup along the top edge and bottom. During an interview in the Dietary Manager's (DM) office on 11/16/10 at 8:15 AM, the DM held the Teflon skillet and stated, ""It has too much carbon. This one should have been taken out. It shouldn't be used."" 3. Observations in the kitchen on 11/15/10 at 10:00 AM, revealed a dirty dry towel on the food preparation counter and on 11/15/10 at 4:38 PM revealed a dirty wet towel on the floor next to the racks of clean cups and bowls. Observations in the kitchen on 11/16/10 at 8:20 AM, revealed a dirty wet cloth hanging on top of the clean dish rack. Observations in the kitchen on 11/16/10 at 3:15 PM, revealed 2 dirty towels hanging on the end of a utility cart. During an interview in the kitchen on 11/16/10 at 3:15 PM, the DM was asked what he would expect staff to do with towels and cloths that have been used. The DM stated, ""They should put the towels in the bin for dirty and the wet cloths in the sanitizing solution in a bucket."" After looking at the dirty towels on the utility cart the DM confirmed the towels should not be left in the kitchen. 4. Observations in the kitchen on 11/16/10 at 8:15 AM, revealed a broom with the bristles up resting on the end of the clean dish counter. 5. Review of the facility's ""PERSONAL HYGIENE"" policy documented, ""...3. Hair restraints... Dietary partners shall wear hair restraints such as hats, hair coverings, or nets, beard restraints... and worn to effectively keep hair from contacting exposed food; clean equipment, utensils, and linens..."" Observations in the kitchen on 11/15/10 at 10:05 AM, revealed dietary staff member #2 placed eating utensils in napkins and moved a cart of prepared desserts with his beard uncovered. Observations in the kitchen on 11/15/10 at 10:15 AM, revealed dietary staff member #1 went throughout the kitchen wearing a cap. Her hair was not covered. Observations in the kitchen on 11/16/10 at 8:15 AM and 8:40 AM, revealed dietary staff member #3 was cooking at the stove and was working at the prep table wearing a cap. His hair and beard was not covered. Observations on the 400 unit on 11/16/10 at 11:35 AM, revealed dietary staff member #1 served food from the steam table wearing a cap. Her hair was not covered. Observations in the kitchen on 11/16/10 at 3:15 PM, revealed dietary staff member #4 was working in the food prep area. His beard was not covered. Observations in the kitchen on 11/17/10 at 9:30 AM, revealed dietary staff member #3 was cooking at the stove and was working at the prep table wearing a cap. His hair was not covered. During an interview in the DM's office on 11/17/10 at 9:30 AM, the DM was asked if the dietary staff was expected to have their hair and beards covered. The DM stated, ""They wear nets or caps and a beard cover."" The Regional Registered Dietician stated, ""They wear the caps, but their hair in the back is short and not covered."" 6. Review of the facility's ""HAND WASHING"" policy documented, ""...All partners handling food products or contacting equipment used in food preparation should wash their hands... 1. Hands should be washed... after leaving and returning to a food preparation area..."" Observations in the kitchen on 11/15/10 at 4:20 PM, revealed dietary staff member #2 left the department to take a cart out and returned to the department. Dietary staff member #2 did not wash his hands after returning to the department or before beginning to roll silverware. During an interview in the kitchen on 11/15/10 at 4:25 PM, dietary staff member #2 was asked if he had washed his hands. dietary staff member #2 stated, ""No, I did not wash my hands.""",2015-08-01
12353,"NHC HEALTHCARE, DICKSON",445004,812 CHARLOTTE ST,DICKSON,TN,37055,2010-11-17,514,D,0,1,9SDV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews and interviews, it was determined the facility failed to ensure physician's orders were accurate for 2 of 27 (Residents #11 and 16) sampled residents. The findings included: 1. Medical record review for Resident #11 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's telephone order dated 9/29/10 documented, ""Dec (decrease) [MEDICATION NAME] to 25mg (milligrams) po (by mouth) every hs (bedtime)."" The physician's recertification orders dated 10/6/10 failed to reflect the decrease of [MEDICATION NAME]. During an interview at the unit 4 nurses' station on 11/16/10 at 12:15 PM, Nurse #8 and Nurse #7 reviewed Resident #11's chart. Nurse #7 stated, ""The PPOC (recertification orders) has [MEDICATION NAME] 50mg and she is receiving [MEDICATION NAME] 25mg."" 2. Medical record review for Resident #16 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's telephone order dated 11/9/10 documented, ""Increase O2 (oxygen) BNC (binasal cannula) to 4 LPM (liters per minute)..."" The physician's recertification orders dated 11/11/10 failed to reflect the increase of oxygen. During an interview at the unit 4 nurses' station on 11/17/10 at 10:05 AM, Nurse #8 stated, ""PPOC is wrong means they did not pick up the order. Pharmacy generates the PPOC from the supplemental (orders).""",2015-08-01
12354,"NHC HEALTHCARE, DICKSON",445004,812 CHARLOTTE ST,DICKSON,TN,37055,2012-08-29,253,D,1,0,SINC11,"Intakes: TN 160 Based on observations and interviews, it was determined the facility failed to provide maintenance services as evidenced by the presence of a ? to ? inch open air space between the frame of an air conditioner and the air conditioner in 1 of 5 (Resident #1) sampled residents' rooms. The findings included: Observations in Resident #1's room on 8/20/12 at 9:51 AM, revealed a ? to ? inch open space between the room's air conditioner and the frame around the air conditioner which allowed light and outside air to come through to the inside of the room. During an interview in Resident #1's room on 8/20/12 at 9:51 AM, Nurse #1 was shown the open space between the air conditioner and the frame of air conditioner. Nurse #1 stated, ""...Oh, my, that's not good..."" During an interview in Resident #1's room on 8/20/12 at 9:53 AM, following an inspection of the area around the air conditioner on the outside of the building and inside of the room, Maintenance worker #1 stated, ""...The light is coming through the vent on the outside. Inside is this 1 by (x) 4 inch trim but it is sticking out too far and won't allow the air conditioner to completely close (around the unit...""",2015-08-01
12355,"NHC HEALTHCARE, DICKSON",445004,812 CHARLOTTE ST,DICKSON,TN,37055,2012-08-29,315,D,1,0,SINC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Intakes: TN 160 Based on policy review, observations, and interview, it was determined the facility failed to provide appropriate care of the catheter tubing or catheter drainage bag for 3 of 5 (Residents #1, 2, and #4) sampled residents observed with Foley catheters. The findings included: 1. Review of the facility's ""CATHETER DRAINAGE SYSTEM, CLOSED"" policy documented, ""...POINTS TO REMEMBER... Never allow the drainage bag to touch the floor... PROCEDURE: 1. Attach drainage bag to bed frame..."" 2. Medical record review for Resident #1 documented an admission date of [DATE] and readmission date of [DATE] with [DIAGNOSES REDACTED]. Observations in the dependent dining room outside the 300 hall on 8/20/12 at 10:50 AM and on 8/20/12 at 11:00 AM, approximately 4 inches of Resident #1's Foley catheter tubing was laying on the floor underneath the wheelchair in which Resident #1 was sitting. Observations in the activity room on 8/20/12 at 1:35 PM, on 8/21/12 at 12:05 PM, and on 8/22/12 at 10:30 AM, approximately 4 inches of Resident #1's Foley catheter tubing was laying on the floor underneath the wheelchair in which Resident #1 was sitting. 3. Medical record review for Resident #2 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #2's room on 8/20/12 at 1:10 PM, revealed the Foley catheter drainage bag was laying on the bed, beside Resident #2's right leg. The tubing contained yellow colored urine. The catheter tubing was not positioned below Resident #2's bladder. During an interview in Resident #2's room on 8/20/12 at 1:45 PM, Nurse #2 was shown the position of the Foley catheter drainage bag. Nurse #2 took the catheter drainage bag off the bed and secured it to the bed frame, moving the catheter bag below Resident #2's bladder. 4. Medical record review for Resident #4 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #4's room on 8/21/12 at 1:15 PM, revealed the tubing from her Foley catheter was laying on the floor beside the bed in which she was laying. During an interview in Resident #4's room on 8/21/12 at 1:32 PM, Nurse #5 was shown the tubing of the Foley catheter laying on the floor beside the bed of Resident #4. Nurse #5 stated, ""...This (catheter tubing) does not need to be laying on the floor..."" During an interview in the in-service education room on 8/22/12 at 5:00 PM, the Director of Nurses (DON) was asked what should be the position of the Foley catheter drainage bag. The DON stated, ""The Foley (catheter drainage) bag and tubing should be kept up off of the floor.""",2015-08-01
12356,"NHC HEALTHCARE, DICKSON",445004,812 CHARLOTTE ST,DICKSON,TN,37055,2012-08-29,441,D,1,0,SINC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Intakes: TN 308 Based on policy review, observation, and interview, it was determined 2 of 2 (Nurse #4 and Nurse #5) nurses failed to perform a dressing change to prevent the potential spread of infection by not placing a barrier on the over-bed table prior to placing supplies on the overbed table; not cleansing a wound in a circular motion from inside to outside; and not washing hands or regloving after handling a soiled dressing. The findings included: 1. Review of the facility's ""DRESSING: WOUND CHANGES"" policy documented, ""...PROCEDURES... 14. Remove soiled dressing... NOTE: do not use scissors to cut soiled dressings 15. Remove gloves, wash hands, and reglove 16. Using prescribed cleanser, cleanse wound from center out... Remove gloves dispose in red bag, wash hands and reglove 17. Apply prescribed treatment/ dressing, secure the dated, initialed tape 18. Remove gloves and wash hands 19. Reglove and dispose of red bag in biohazard room [ROOM NUMBER]. Remove gloves and wash hands..."" 2. Observations in Random Resident (RR) #1's room (on the 100 hall) on 8/20/12 at 4:10 PM, Nurse #4 performed a dressing change on a wound on RR #1's right leg. Using a saline saturated 4 by (x) 4, Nurse #4 cleaned the lower half of the wound, ending the cleansing with up and down motions over the length of the lower half of the wound. Using a different, saline soaked 4x4, Nurse #4 cleaned the upper half of the wound and then dabbed up and down the length of the entire wound which at this point was bleeding. Nurse #4 then used a new, dry 4x4 and dabbed the entire length of the wound with up and down strokes. During the up and down motions taken, part of the 4x4 veered off onto the skin area, lateral to the middle of the wound. After the [MEDICATION NAME] was applied to the wound, a non-adhesive dressing was placed over the wound; as the non-adhesive dressing was applied, it touched the stuffed arm of the recliner in which RR #1 was sitting. After the wound care was completed, no dated tape was put on the dressing. Nurse #4 washed her hands and carried the red bag with the soiled dressings into the biohazard room without gloves. Nurse #4 did not wash her hands before returning to the nurses' station to document her care. 3. Observations in RR #1's room (on the 100 hall) on 8/21/12 at 4:10 PM, Nurse #5 performed a dressing change on the wound on RR #1's right leg. Nurse #5 took all of the dressing supplies into the room and put them on RR #1's over-bed table without first putting down a barrier on the over-bed table. After Nurse #5 washed her hands and put on gloves, she handled the knee rest of the chair in which RR #1 was sitting. RR #1's right foot was now on the floor without a barrier. Nurse #5 took the ace bandage off of the resident's right leg and then took her scissors and cut the Kerlix off of RR #1's leg. The dressing was taken off of RR #1 and Nurse #5 put her scissors on RR #1's over-bed table. Nurse #5 did not wash her hands and reglove, but began to clean the wound. Nurse #5 applied saline to RR #1's wound and caught the excess saline draining down the wound with a 4x4 held at the bottom of the wound. Nurse #5 then dabbed up and down the leg wound. After [MEDICATION NAME] and a non-adhesive dressing were applied to the wound, Nurse #5 wrapped a Kerlix over the wound, lifted the foot off of the bare floor and wrapped the Kerlix around the foot and back up the leg. An ace bandage was wrapped over the Kerlix that was over the wound and down over the foot after the foot was lifted off of the bare floor. No dated tape was put onto the dressing after the dressing was completed. Nurse #5 put the soiled scissors into her pocket without cleaning them. Nurse #5 put a glove around the top of the red bag in which the soiled dressings had been placed, and carried the red bag to the biohazard room holding onto the glove around the neck of the bag. There were no towels in the biohazard room so Nurse #5 used the sanitizer to cleanse her hands. 4. During an interview in the Director of Nurse's (DON) office on 8/21/12 at 1:25 PM, the DON was asked if she expected a barrier to be placed on the over-bed table, what motions should be used to clean a wound, and if the nurse should wash her hands and reglove after handling the soiled dressing. The DON stated, ""... I expect (nurses) to use a circular motion, from inside out, to clean a wound... There should be a barrier on the over-bed table (before placing the clean supplies on it)... She (the nurse) should wash her hands after taking off the (soiled) dressing...""",2015-08-01
12357,"NHC HEALTHCARE, DICKSON",445004,812 CHARLOTTE ST,DICKSON,TN,37055,2012-08-29,514,D,1,0,SINC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Intakes: TN 160 Based on medical record review, observations, and interviews, it was determined that the facility failed to ensure the accuracy of documentation in the record for 1 of 5 (Resident #1) sampled residents. The findings included: Medical record review for Resident #1 documented an admission date of [DATE] and readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. During an interview in the education classroom on 8/22/12, Nurse #3 was asked if there should be nursing documentation concerning the condition of Resident #1's eyes since there was an order for [REDACTED].#3 stated, ""...Yes, you would expect documentation..."" Observations in the activity area off of the 100 hall on 8/22/12 at 10:30 AM, revealed Resident #1 with a soft brace on her right knee and a metal leg brace attached to a shoe on her left leg. Observations in Resident #1's room on 8/22/12 at 3:15 PM, during a skin assessment revealed Resident #1 with a soft brace on her right knee and a metal leg brace attached to a shoe on her left leg. The braces were taken off for the assessment and reapplied after the assessment was done. Review of physician's orders [REDACTED]. [REDACTED]. [REDACTED]. During an interview in the education classroom on 8/22/12 at 3:40 PM, Nurse #3 was asked if there should be orders for the braces. Nurse #3 stated, ""...If they have them (braces) on, they should have orders..."" During an interview in the education classroom on 8/23/12 at 10:30 AM, Nurse #3 was asked about orders for the braces observed on Resident #1. Nurse #3 stated, ""...she (Resident #1) came back from the hospital on 2/13/(12). There was no order (for the brace) but kept doing it (applying the brace)..."" During an interview during a phone conversation on 8/24/12 at 2:05 PM, the Director of Nurses (DON) stated, ""After (Resident #1) came in (back from hospitalization ), there were no new orders written for leg brace or knee splint or arm splint. I talked to therapy; they should have done a re-eval (evaluation) and gotten orders..."" During an interview during a phone conversation on 8/27/12 at 3:55 PM, the DON stated, ""There is no order for the arm splint. There is no order for the leg brace. The knee brace has never been reordered since '06. I talked with the Certified Nursing Assistants (CNA) and asked why they were putting on the knee brace. They (CNAs) said that (named Resident #1's daughter) wanted (Resident #1) to have it (knee brace) on, so we put it on..."" Review of the May 2012 weekly skin assessment record revealed the following: a. ""[MEDICAL CONDITION] present"" - May 7, 14, 21, and 28 - marked ""Y"" (indicating yes) with no narrative note on the back. b. ""Redness, Pallor, Cyanosis, or Demarcation"" - May 14, 21, and 28 - marked ""Y"" with no narrative note on the back. c. ""Narrative Note is required if answered yes."" Review of the June 2012 weekly skin assessment record revealed the following: a. ""Alteration in Skin integrity"" - June 24 - Marked ""Y"" with no narrative note on the back. b. ""Redness, Pallor, Cyanosis, or Demarcation"" - June 3 and 24 - Marked ""Y"" with no narrative note on the back. c. ""Narrative Note is required if answered yes."" Review of the July 2012 weekly skin assessment record revealed the following: a. ""Alteration in Skin integrity"" - July 8, 15, and 29 - Marked ""Y"" with no narrative note on the back. b. ""Redness, Pallor, Cyanosis, or Demarcation"" - July 8 and 15 - Marked ""Y"" with no narrative note on the back. c. ""Narrative Note is required if answered yes."" Review of the August (Aug) 2012 weekly skin assessment record revealed the following: a. ""Alteration in Skin integrity"" [DATE] - no entry. b. ""Redness, Pallor, Cyanosis, or Demarcation"" August 5 and 19 - Marked ""Y"" with no narrative note on the back. c. ""Narrative Note is required if answered yes."" During an interview in the education classroom on 8/23/12 at 10:50 AM, Nurse #3 was asked about the documentation expected on the weekly skin assessment record. Nurse #3 stated, ""...if the areas are answered with a yes, there should be documentation (about) what they are seeing...""",2015-08-01
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
3623,ST BARNABAS AT SISKIN HOSPITAL,445008,1 SISKEN PLAZA,CHATTANOOGA,TN,37403,2017-01-25,279,D,0,1,BSB511,"**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 a specific care plan for allergies and non- pressure related skin conditions that included measurable goals and interventions to ensure that Resident #30's skin concerns would be addressed in a timely fashion for 1resident (#30) of 21 residents reviewed. The findings included: Review of the facility's policy, Nursing Plan of Care, undated, revealed the following information: .1. Registered nurses initiate Nursing Plans of Care to identify teaching and discharge needs. Both RNs (Registered Nurses) and LPNs (Licensed Practical Nurses) may maintain/update Nursing Plan of Cares. RNs are to supervise LPN care and documentation on the Nursing Plan of Care. 2. Nursing Plans of Care reflect the nursing process of assessment, planning, implementing and evaluating of care. The Care Plan is to be reassessed no less than weekly and updated or resolved by assigned nurse. 3. The Nursing Plan of Care is initiated within the first 24 hours of admission. It reflects nursing care provided and discharge planning. 4. The Nursing Plan of Care reflects nursing interventions and responses . Review of the medical record for Resident #30 revealed that she was readmitted to this facility on 3/2/12 with [DIAGNOSES REDACTED]. Review of the medical record and the physician's orders [REDACTED].#30 had allergies to antibiotics such as, [MEDICATION NAME], Cephalosporin, Cipro, and Carbapenems. She was also allergic to vaccines such as Tetanus and [MEDICATION NAME]. Per the physician's orders [REDACTED]. The order was dated 6/22/15. Review of the plans of care for Resident #30 revealed a care plan for allergies which was dated 3/15/12. The Goal &Target Date included Will have no allergic reactions during review period which was revised on 9/13/16 and 12/23/16. The target date was 3/20/17. The Approaches included: List of all know allergies will be kept on physician order [REDACTED]. Allergy list will be reviewed and updated prn (as needed). Communication to dietary and housekeeping of known allergies when appropriate. The allergy plan of care did not include the PRN (as needed) order for [MEDICATION NAME] 0.5% cream. Continued review revealed it did not include a skin assessment with a directive to document any signs and symptoms of allergies, and it did not include direction to staff to communicate Resident #30's skin condition with nursing to ensure that Resident #30 would not have to experience episodes of scratching, itching, and picking at her skin unnecessarily. Observation of Resident #30 on 1/24/17 at 8:37 AM, revealed the resident lying in bed ,eating her breakfast. Resident #30 had several large red blotches, approximately the size of a quarter on her neck. In addition, she had red scaly areas all over her face and scalp. Continued observation revealed Resident #30 continuously scratched and picked at her head, neck and face. An interview with Resident #30 on 1/24/17 at 8:37 AM revealed that she had some kind of allergic reaction that caused her to scratch and pick at her skin continuously. When interviewed about if she had shared her symptoms with the nursing staff, Resident #30 stated that she thought that she had but she could not be sure. Resident #30 stated that she would like for the red, scaly blotches on her face, neck and scalp to go away. An interview with the Care Plan Coordinator on 1/24/17 at 1:30 PM confirmed the care plan for Resident #30 ' s skin condition and allergies did not include the appropriate interventions and directives. When interviewed about how staff would know what to do to prevent Resident #30 from suffering unnecessarily if the medication was not included on the TAR and if the care plan did not provide direction to staff, the Care Plan Coordinator stated, they would not.",2020-04-01
3624,ST BARNABAS AT SISKIN HOSPITAL,445008,1 SISKEN PLAZA,CHATTANOOGA,TN,37403,2017-01-25,309,D,0,1,BSB511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide the necessary care and services for one resident (#30), of one resident reviewed for non-pressure related skin conditions of 21 residents reviewed. The findings included: Review of the medical record for Resident #30 revealed the resident was readmitted to this facility on 3/2/12 which [DIAGNOSES REDACTED]. Review of the medical record and the physician's orders [REDACTED].#30 had allergies [REDACTED]. She was also allergic to vaccines such as Tetanus and [MEDICATION NAME]. Per the physician's orders [REDACTED]. The order was dated 6/22/15. Review of the Treatment Administration Record (TAR) dated 10/15/16 - 1/24/17 revealed the PRN order for [MEDICATION NAME] 0.5% cream had not been added to the TAR. Review of the Medication Administration Record [REDACTED]. Observation of Resident #30 on 1/24/17 at 8:37 AM revealed the resident was lying in bed eating her breakfast. Resident #30 had several large red blotches, approximately the size of a quarter on her neck. In addition, she had red scaly areas all over her face and scalp. Resident #30 continuously scratched and picked at her head, neck and face. An interview with Resident #30 on 1/24/17 at 8:37 AM, revealed she had some kind of allergic reaction that caused her to scratch and pick at her skin continuously. When interviewed about if she had shared her symptoms with the nursing staff, Resident #30 stated that she thought that she had but she could not be sure. Resident #30 stated that she would like for the red, scaly blotches on her face, neck and scalp to go away. An interview on 1/24/17 at 1:00 PM with Certified Nursing Assistant (CNA) #1 who was assigned to Resident #30, revealed that while she was providing activities of daily living with Resident #30 she had noticed that she had a rash on her neck, face and scalp. When interviewed about what she had done relative for Resident #30's skin rash, CNA #1 stated that she told the nurse about the concern. CNA #1 added that she noticed Resident #30's skin rash the day previously but she did not document her concern; she stated again that she had just shared the concern with the nurse. An interview on 1/24/17 at 1:15 PM with the Licensed Practical Nurse (LPN) #3 revealed she was assigned to Resident #30's daily care for the past few days, however she had not completed a thorough skin assessment. Consequently, she had not noticed the rash on Resident #30's face, neck or scalp. When asked if CNA #1's had told her about Resident #30's skin condition, LPN #3 stated that she had not.",2020-04-01
3625,ST BARNABAS AT SISKIN HOSPITAL,445008,1 SISKEN PLAZA,CHATTANOOGA,TN,37403,2017-01-25,362,F,0,1,BSB511,"Based on facility policy and procedure review, dish machine log review, personnel file review, observation, and interview, the facility failed to employee sufficient kitchen staff and provide them with the appropriate training to ensure they could perform their duties and responsibilities effectively. This deficient practice had the potential to affect all of the residents who resided in this Long-Term Care (LTC) facility. The findings included Review of the facility's policies and procedures revealed a document titled, HACCP (hazard analysis critical control points)/Food Safety Program. Food Safety Standards & Requirements dated 8/17/16 which provided the following information: .Employee Training: Employees must be trained in safe food handling practices, per company policy, when hired and must complete on-going training during the course of their employment. The Unit Manager is responsible to ensure food safety training programs are in place and properly conducted . Review of the Dishwashing/Warewashing Machine Temperature Log(s) dated from (MONTH) (YEAR) through (MONTH) (YEAR) revealed the water temperature during the wash cycle was documented below the manufacturer's recommendations for safe water temperatures on most of the days of the month. In (MONTH) (YEAR), the temperature of the water during the wash cycle reached the minimum of 160 degrees F only on 8 days of the month; 11/1/16, 11/6/16, 11/7/16, 11/8/16, 11/10/16, 11/14/16, 11/24/16, and on 11/27/16. The remaining days in the month of (MONTH) (YEAR), the temperature of the water during the wash cycle averaged about 155 degrees F (Fahrenheit) which was below the manufacturers recommendation. Review of the temperature log for the month of (MONTH) (YEAR), revealed that the temperature of the water during the wash cycle only reached the minimum temperature of 160 degrees F on 5 days of the month. Review of the temperature log for the month of (MONTH) (YEAR), revealed the temperature of the water during the wash cycle only reached the minimum temperature of 160 degrees F on 7 days of the month. The average water temperature for both (MONTH) (YEAR) and (MONTH) (YEAR) was approximately 155 degrees F. Review of the personnel file for UW #1 revealed that he had not completed the facility's general orientation when he was hired on 6/25/14. Review of the in-service trainings that were provided to the kitchen staff during (YEAR), (YEAR) and in (MONTH) (YEAR) revealed there was no training provided relative to operating the dish machine safely and effectively while ensuring good infection control practices. Observation of the kitchen and the dish room on 1/24/17 at 11:00 AM revealed 2 employees were operating the dish machine, a Utility Worker (UW#1) and a temporary agency employee. UW #1was working on the dirty side of the dish machine and the agency employee was working on the clean side of the dish machine. Observation of the dish machine on 1/24/17 at 12:05 PM, revealed a metal label which was affixed to the underside of the dish machine. The metal label contained information about the use of the dish machine including the manufacturer's minimum temperature for the water during the wash cycle. It was 160 degrees F. An interview with the agency employee on 1/24/17 at 11:05 AM, revealed he was asked to do dishes for this LTC facility on a temporary basis and this was his first day. He added that his previous working experience was as a construction worker. He stated that he had no experience operating a dish machine and the facility had not trained him how to operate the dish machine safely and effectively. When interviewed about his knowledge relative to the water temperatures in the dish machine for both the wash and the rinse (sanitizing) cycles, he stated he was unsure. When interviewed about what were some good infection control techniques to use while operating a dish machine, the temporary agency employee was unable to answer the question. An interview with the kitchen's General Manager of the Food Service Department (GM) on 1/24/17 at 11:15 AM confirmed the facility was short staffed and consequently they had to reach out to the temporary agency for additional staff. When interviewed about how the facility had prepared and trained the temporary employee to complete his duties and responsibilities effectively, the GM stated they had not. The GM stated they had spoken to him briefly before he started his work, but nothing formal or in writing. An interview with UW #1 on 1/24/17 at 11:30 AM revealed he was hired in (MONTH) 2014 and he had some basic training at that time. When interviewed about his training as it pertained to operating the dish machine safely and effectively, UW #1 stated he could not remember. When interviewed about what the manufacturer's recommended safe water temperatures were for both the wash and the rinse cycles, UW #1 stated he was unsure. However, he added that he believed the temperature during the wash cycle needed to be a minimum of 150 degrees Fahrenheit (F). He stated that it was his responsibility to monitor the dish machine water temperatures and document his findings on the temperature log. An interview with the GM on 1/24/17 at 1:30 PM confirmed UW #1 had not completed his general orientation when he was first hired, and the facility had not had any continuing education relative to the operation of the dish machine. She added that the facility also did not have a policy and procedure relative to the use of the dish machine. When interviewed about how the kitchen employees would perform their duties and responsibilities safely and effectively if they did not provide the training and develop a policy and procedure on the topic, the GM stated she was unsure.",2020-04-01
3626,ST BARNABAS AT SISKIN HOSPITAL,445008,1 SISKEN PLAZA,CHATTANOOGA,TN,37403,2017-01-25,371,F,0,1,BSB511,"Based on observation and interview, the facility failed to ensure food safety when they failed to clean and sanitize the meat slicer after use and when they failed to discard potentially hazardous food in a timely fashion. This deficient practice had the potential to affect all of the residents (57) who consume food orally in this Long-Term Care (LTC) facility. The findings include: 1. Observation of the kitchen on 1/23/17 at 9:30 AM revealed a kitchen employee, Cook #1, was preparing lunch for the residents. He was preparing sandwiches on the Cook's preparation counter. At the end of the Cook's preparation counter there was a large meat slicer. When interviewed about the use of the meat slicer, Cook #1 stated the slicer was clean and ready for use. Observation of the metal blade on the meat slicer revealed it was covered with food debris. There was a thick continuous line of debris around the entire edge of the blade. The line of debris was orange in color and was easily wiped off. An interview with the General Manager of the Food Service Department (GM) on 1/23/17 at 9:35 AM confirmed the slicer had been used the previous day and had not been cleaned and sanitized effectively. 2. Observation of the 3rd floor nursing unit on 1/25/17 at 3:00 PM revealed a nourishment room that contained a refrigerator. The refrigerator was observed to have 40 individual health shakes that were defrosted and ready for use. An interview with the GM, at that time, revealed the health shakes were used for those residents who had a nutritional concern. Review of the manufacturer's recommendations, which were posted under the spout on each health shake, revealed the health shakes needed to be stored frozen and discarded 14 days after defrost. The 40 defrosted health shakes did not contain a defrost date or a use by date. Review of the undated LTC Patient /Diets list that was provided by the GM revealed the facility had 3 residents who were ordered health shakes on a daily basis. An interview with the GM and the Assistant Director of Nursing (ADON) on 1/25/17 at 3:15 PM revealed they were unsure when the milk shakes were defrosted or if the milk shakes were safe for consumption.",2020-04-01
3627,ST BARNABAS AT SISKIN HOSPITAL,445008,1 SISKEN PLAZA,CHATTANOOGA,TN,37403,2017-01-25,456,F,0,1,BSB511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure their essential kitchen equipment specifically, the [NAME]ot Coupe blades and the dish machine, were maintained in a safe operating fashion. The deficient practice had the potential to affect each of the 62 residents who resided in the facility. The findings included: 1. Observation of the kitchen on 1/23/17 at 10:15 AM, revealed the kitchen staff utilized 2 [NAME]ot Coupes (blenders) to grind and puree food for residents who had a physician ordered therapeutic diet. Closer inspection of the inside of the blender revealed the metal blade was chipped and missing pieces of metal. Observation of the counter above the [NAME]ot Coupes revealed 2 more metal blades that were used as spares. They were also chipped and missing small pieces of metal. When the smooth-edged metal blades became chipped, there was a potential for small pieces of metal to become dislodged and enter the resident's food. An interview with the General Manager of the Food Service Department (GM) on 1/23/17 at 10:20 AM confirmed the facility utilized the [NAME]ot Coupes to grind and puree food for those residents who had difficulties chewing and swallowing. The GM stated she was unaware the blades were chipped and missing metal pieces. Review of the undated, LTC Patients/Diets list that was provided by the GM revealed that the facility had 10 residents who had a physician's orders [REDACTED]. 2. Observation of the kitchen on 1/24/17 at 11:15 AM, revealed the dish machine was in operation. During observation of five separate trials revealed the water temperature during the wash cycle only reached 143.9 degrees F. Observation of the dish machine on 1/24/17 at 12:05 PM, revealed a metal label which was affixed to the underside of the dish machine. The metal label contained information about the use of the dish machine and it included the manufacturer's minimum water temperature for wash cycle of 160 degrees Fahrenheit (F). Review of the Dishwashing/Warewashing Machine Temperature Log(s) dated from (MONTH) (YEAR) through (MONTH) (YEAR) revealed that the water temperature during the wash cycle was documented below the manufacturer's recommendations for safe water temperatures on most of the days of the month. In (MONTH) (YEAR), the temperature of the water during the wash cycle reached the minimum of 160 degrees F only on 8 days of the month; 11/1/16, 11/6/16, 11/7/16, 11/8/16, 11/10/16, 11/14/16, 11/24/16, and on 11/27/16. The remaining days in the month of (MONTH) (YEAR), the temperature of the water during the wash cycle averaged about 155 degrees F. Review of the temperature log for the month of (MONTH) (YEAR), revealed that the temperature of the water during the wash cycle only reached the minimum temperature of 160 degrees F on 5 days of the month. Review of the temperature log for the month of (MONTH) (YEAR), revealed that the temperature of the water during the wash cycle only reached the minimum temperature of 160 degrees F on 7 days of the month. The average water temperature for both (MONTH) (YEAR) and (MONTH) (YEAR) was approximately 155 degrees F. An interview with the GM on 1/24/17 at 2:00 PM revealed they had a service contract with a local vendor who serviced the dish machine. She stated they had relied on that company to maintain the dish machine in good working condition. The GM provided a document that was given to the facility by the contractor which indicated they had not been out to service the dish machine for the past two months. Per the GM, the contractor failed to review the water temperature logs to ensure the dish machine was operating in a safe fashion.",2020-04-01
5462,ST BARNABAS AT SISKIN HOSPITAL,445008,1 SISKEN PLAZA,CHATTANOOGA,TN,37403,2015-12-16,242,D,0,1,69C911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure personal choices were honored for 1 resident (#29) of 35 residents reviewed for choices. The findings included: Medical record review revealed Resident #29 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Interview with Resident #29 on 12/15/15 at 9:53 AM, in the residents room revealed don't put me to bed when I want to go to bed .I asked to go back to bed Friday (12/11/15) around 5:30 PM .they came in and told me they would put me back as soon as they could .the shift changed and second shift put back to bed after 7 .I called and I went out in the hall a couple of timesl .they were at the desk .I called my brother and he called them .they just didn't come put me back to bed .they were just sitting at the desk . Medical record review of the 30 day Minimum Data Set ((MDS) dated [DATE] revealed the resident was cognitively intact and requires assist with tranfers to be from the wheelchair. Interview with Certified Nurse Aide (CNA) #2/Unit Clerk on 12/15/15 at 2:00 PM at the 300 nursing station confirmed when the call light rings .I tell whoever the person is that is working with the resident or find someone to go take care of the problem, or I do it myself .I work 8-4:30 (8 AM-4:30 PM) Monday through Friday .after that everyone answers the call lights .shifts change at 7:00 PM . Interview with Licensed Practical Nurse (LPN) #2 Nursing Supervisor for 300 hall on 12/15/15 at 4:35 PM at the 300 nursing station confirmed (resident) had requested to go to bed Friday at approximately 5:30 PM and wasn't assisted to bed until after 7 PM when night shift came on . Continued interview confirmed .my expectation is within 30 minutes of the request depending on what is going on, on the unit or if there is extenuating circumstances .any staff certified or licensed can put residents to bed or get them up . Interview with CNA #1 on 12/16/15 at 12:40 PM in the 300 hall nursing station revealed .came back from [MEDICAL TREATMENT] and the ambulance people always put him back to bed after [MEDICAL TREATMENT] . Interview with LPN #1 on 12/16/15 at 12:45 PM in the 300 hallway confirmed .I helped the ambulance people put him in the wheelchair, he wanted to stay up so his brother could shave him and cut his hair .I was finishing up my last med (medication) pass, the CNA's were passing trays and feeding residents, he wasn't hurting, he just wanted to go to bed .I think I told (CNA #1) .I told him we would put him to bed as soon as possible .I can see the perception of us not putting him back to bed as soon as possible if he saw us at the desk or in the hall . Interview with the Director of Nursing (DON) on 12/16/15 at 1:46 PM, in the conference room confirmed there was no specific policy regarding timeliness of honoring requests and just consider it a nursing judgment .have to focus on feeding and passing trays .it's a judgment call .My expectation is within an hour depending on what is happening on the floor .this is not acceptable to make him wait and I understand the perception that we weren't helping him .His choice was not honored to go back to bed in a timely manner .",2019-02-01
5463,ST BARNABAS AT SISKIN HOSPITAL,445008,1 SISKEN PLAZA,CHATTANOOGA,TN,37403,2015-12-16,329,D,0,1,69C911,"**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, or document the reason the [MEDICAL CONDITION] medication should not be reduced for 1 (#23) resident of 5 residents reviewed for unnescessary medications. The findings included: Medical record review revealed Resident #23 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician's Rcapitulation Orders dated from 9/1/14 to present revealed Resident #23 received [MEDICATION NAME] (antidepressant) 60 milligrams (mg) daily, and on 9/12/14, the dosage for the [MEDICATION NAME] was changed to 60 mg in the morning and 30 mg at bedtime. Continued review revealed the [MEDICATION NAME] was changed again on 10/23/15, to 60 mg in the morning and 60 mg at bed time, no other changes noted for the [MEDICATION NAME]. Medical record review of the Psych Services note dated 9/11/14 revealed the Psych Services Nurse Practitioner (NP) recommended to increase the [MEDICATION NAME] to 60 mg in the morning and 30 mg at bedtime due to the resident had increased Depression and was verbally aggressive with staff at times. Continued review of the Psych Services NP notes dated 10/5/15 revealed .Patients' current Status: Stable/Manageable w/o (without) Clinical Complications .Reason for this Encounter: Maintenance Medication Monitoring .remains sad and irritable at times. Verbally aggressive with staff. Presently alert, oriented X 2 (times 2 knows; her name and where she is). Compliant with meds . Continued review of the Psych Services notes dated from 11/2014 to present revealed no recommendations for reducing the dosage of [MEDICATION NAME] or documentation of the reason to not reduce the dosage of the [MEDICATION NAME]. Medical record review of the Consultant Pharmacist Progress Notes dated 1/6/15 to 12/2/15 revealed the Consultant Pharmacist reviewed Resident #23's medication monthly, and the only recommendation the Consultant Pharmacist made was for the 10/2015 review to discontinue the resident's vitamin c and Cranberry capsules with no recommendations to attempt to reduce the dosage of [MEDICATION NAME]. Observation and interview with Resident #23 on12/15/15, at 3:25 PM, in her room revealed Resident #23 was lying in the bed with the head of the bed elevated, watching tv, and when asked how she was feeling she replied better than usual. Interview with the Psych Services NP on 12/16/15 at 1:30 PM, by telephone confirmed the NP had not made a recommendation for the reduction of the dosage of the [MEDICATION NAME] or written an explanation as to why the dosage should not be reduced. Continued interview revealed the Consultant Pharmacist usually will suggest a dosage reduction of [MEDICAL CONDITION] medications and was unsure if the Consultant Pharmacist had made any recommendations to reduce the [MEDICATION NAME] Interview and review of Resident #23's medical record, with Resident #23's Physician, on 12/16/15 at 2:33 PM, in the conference room confirmed no documentation exists for an explanation why to not reduce the [MEDICATION NAME] and no attempts to reduce the dosage of the [MEDICATION NAME] had been attempted.",2019-02-01
7242,ST BARNABAS AT SISKIN HOSPITAL,445008,1 SISKEN PLAZA,CHATTANOOGA,TN,37403,2014-10-22,333,D,0,1,UNTM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure significant medication errors did not occur for one resident (#18) of four residents reviewed for medications. The findings included: Resident #18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician order [REDACTED]. Medical record review of a communication form from the [MEDICAL TREATMENT] center dated October 8, 2014, revealed the [MEDICAL TREATMENT] center desired the Phoslo 667 mg be increased to two tablets three times a day to lower the phosphorus level of 7.4 to a goal of 3.5-5.5. The recommendation was noted by the physician on October 9, 2014, but the order was not written until October 10, 2014. Further medical record review of a physician order [REDACTED]. Medical record review of a Medication Administration Record (MAR) for October 2014, revealed Phoslo 667 mg 1 tablet was being given three times a day with meals from October 1, 2014, through October 14, 2014. Further review of the MAR revealed the Phoslo 667 mg was not increased to 2 tablets three times a day until October 14, 2014, at 5:00 p.m. Interview with Licensed Practical Nurse (LPN) #1 on October 22, 2014, at 1:40 p.m., at the 300 nursing station, confirmed the resident was receiving Phoslo 1 tablet since September 5, 2014. Further interview confirmed the LPN noticed a lot of pills in the medication drawer, checked the physician's orders [REDACTED]. Interview with the Director of Nursing on October 22, 2014, at 2:45 p.m., in the conference room, confirmed the order was not documented on the MAR and the patient did not receive the medication as was ordered for four days.",2018-02-01
7243,ST BARNABAS AT SISKIN HOSPITAL,445008,1 SISKEN PLAZA,CHATTANOOGA,TN,37403,2014-10-22,371,F,0,1,UNTM11,"Based on observation, interview, review of facility policy, an review of manufacturer's recommendations, the facility dietary department failed to maintain food temperatures on the steam table for two of three tray lines observed during one of two meal times; failed to sanitize dishes according to manufacturer's recommendations for one of one three compartment sink; and failed to maintain a sanitary environment in the food service area and the dish room. The findings included: Observation and interview on October 20, 2014, at 11:37 a.m., of the Third Floor Resident Dining Room, revealed the food temperatures were obtained by a dietary staff member (DA) #1 with a calibrated thermometer. The following temperatures were obtained: 1. Marinated Chicken Breasts were 130 degrees Fahrenheit (F). 2. Country Fried Steaks were 112 degrees F. 3. Chopped Country Fried Steak was 118 degrees F. 4. Mashed Potatoes were 128 degrees F. 5. Gravy was 133 degrees F. Interview with the Certified Dietary Manager (CDM) on October 20, 2014, at 11:50 a.m., at the Third Floor Dining Room tray line, confirmed the foods were not at or greater than 135 degrees F and the Ground Chicken temperature was not obtained due to the pan was barely warm to touch. Further observation revealed the following: 1. All hot foods less than 135 degrees F were removed from the steam table at 11:53 a.m., and transported to be reheated. 2. The reheated food items were delivered to the Third Floor Dining Room from the main kitchen at 12:48 p.m., (55 minutes from the time the food left the floor). The reheated food temperatures obtained by the CDM on October 20, 2014, at 12:52 p.m., revealed the Ground Chicken was 129 degrees F and was not in the appropriate temperature range. Interview with the CDM on October 20, 2014, at 12:55 p.m., at the Third Floor Dining Room tray line, confirmed the reheated Ground Chicken was not at an appropriate temperature. Observation on October 20, 2014, at 11:58 a.m., of the Second Floor Resident Dining Room, revealed the food temperatures were obtained by dietary staff member #2 with a calibrated thermometer. The following temperatures were obtained: 1. Marinated Chicken Breasts were 124 degrees F. 2. Chopped Marinated Chicken Breast was123.5 degrees F. 3. Ground Chicken was 109 degrees F. 4. Pureed Marinated Chicken Breast was 120 degrees F. 5. Country Fried Steaks were 82 degrees F. 6. Chopped Country Fried Steak was 119 degrees F. 7. Mashed Potatoes were 118 degrees F. 8. Gravy was 132 degrees F. 9. Pimento Cheese Sandwich, stored in the reach-in refrigerator, was 47 degrees F. Interview with the CDM on October 20, 2014, at 12:00 p.m., at the Second Floor Dining Room tray line, confirmed the foods were not at or greater than 135 degrees F and the Ground Chicken temperature was not obtained due to the pan was barely warm to touch. Further interview confirmed the Pimento Cheese Sandwich was not at an appropriate temperature and needed to be returned to the kitchen. Further observation revealed the following: 1. The hot food less than 135 degrees F and cold food greater than 41 degrees F were transported to the main kitchen at 12:15 p.m., in a transport cart containing the Second and Third Floor Dining Room foods. 2. The reheated foods were returned to the Second Floor Dining Room and temperatures were obtained at 12:55 p.m. 3. The Second Floor Dining Room reheated Marinated Chicken Breasts were 133.6 degrees F. 4. The reheated Country Fried Steaks were 76 degrees F. Further observation revealed the following foods remained on the original steam table (while the other foods were sent down to the main kitchen to be reheated), and the following temperatures were obtained at 12:55 p.m.: 1. Turnip Greens were 124 degrees F (decreased 24 degrees F). 2. Squash was 130 degrees F (decreased 20 degrees) 3. Gumbo was 129 degrees F (decreased 23 degrees). Further observation revealed dietary staff member #2 served the Turnip Greens, Squash, and the Gumbo to the residents. Interview with dietary staff member #2 while obtaining the temperatures of the reheated food at 12:55 p.m., on October 20, 2014, in the Second Floor Dining Room, confirmed the Marinated Chicken Breasts, Country Fried Steak, Turnip Greens, Squash and the Gumbo were less than 135 degrees Fahrenheit. Review of the facility policy for Food Safety Program, with the revision date of August 12, 2013, revealed .foods held cold for service must be 40 degrees F or below .foods held hot for service must be at 140 degrees F or above . Interview with the Food Service Director on October 22, 2014, at 10:30 a.m., in the conference room, confirmed the facility failed to follow the facility policy to serve cold food 40 degrees F or less and hot food 140 degrees F or above. Observation and interview with the Food Service Director and the Sub-Acute Service Director on October 20, 2014, at 10:50 a.m., of the dietary department dish room in operation, confirmed nine dish racks were sitting on the dish room floor. Observation and interview with the Food Service Director on October 20, 2014, at 11:15 a.m., confirmed the three compartment sink was in operation. Further observation and interview confirmed the dietary staff member sanitizing the pots and pans was dipping the pans into and out of the sanitizer solution and placing the items on the drying rack in three consecutive observations. Further observation revealed the dietary staff member washing the pots and pans, held the sanitizer test strip in the sanitizer solution for ten seconds, and the result was 100 parts per million (ppm). Further observation revealed thirty-two items on the drying rack. Review of the posted three compartment sink sanitizer directions revealed .submerge in sanitizer solution one minute . Review of the posted manufacturer's recommended sanitizer range was .150-400 ppm . Review of the posted sanitizer test strip directions revealed .dip strip into (sanitize) solution to be tested for 1-2 seconds. Compare strip to color within 10 seconds. Interview with the Food Service Director on October 20, 2014, at 11:15 a.m., confirmed items processed in the three compartment sink had not been sanitized per the posted directions, the staff failed to submerge items in the sanitizing solution for at least a minute, and the sanitizer range was not in compliance with the manufacturer's recommendation. Observation and interview with the facility dietary department Chef and District Manager on October 20, 2014, at 1:15 p.m., revealed the dish room in operation and eight dish racks were sitting on the dish room floor. Observation and interview with the Food Service Director and Sub-Acute Service Director on October 21, 2014, at 2:44 p.m., in the dietary department, confirmed the following: 1. The floor mixer was covered with a plastic wrap with dried splattered white and brown debris. Further observation and interview confirmed the floor mixer underside of the beater arm, stem, and legs had an accumulation of dried splattered debris. 2. The warmer next to the convection oven interior rungs had a brown colored accumulation of debris. 3. The range top lower storage unit had sticky debris on the interior side and floor and the doors. 4. The exterior of one of three food storage bins had a dried brown stain. 5. The food slicer blade base and slide grip prongs had dried food debris present. 6. Two ceiling vents in the dish room, one on the dirty side and one on the clean side of the dish machine, the surrounding ceiling tiles and lighting fixture, had an accumulation of blackened debris hanging off which could contaminate the cleaned dishes.",2018-02-01
7244,ST BARNABAS AT SISKIN HOSPITAL,445008,1 SISKEN PLAZA,CHATTANOOGA,TN,37403,2014-10-22,431,E,0,1,UNTM11,"Based on observation and interview, the facility failed to ensure expired medications and supplies were removed from the shelves and not available for resident use in one (second floor) of two medication storage rooms. The findings included: Observation of the medication storage room on the second floor on October 21, 2014, at 3:00 p.m., revealed nine Intravenous Start Kits (all supplies needed to start an intravenous line) in the Intravenous start basket had an expiration date of February 2014, and were available for resident use. Observation of a basket containing lancets (used to test blood glucose) revealed a screwdriver, three batteries, a 20 milliliter syringe, an insulin syringe, and rubber bands in the same basket, and the lancets were available for resident use. Observation of the stock medication cabinets revealed: 1. one bottle of Bisacodyl (laxative) with an expiration date of January 2014. 2. one bottle of Pain Reliever Plus with an expiration dated of September 2014. 3. one tube of Desitin (used for diaper rash) with an expiration date of October 2013. 4. one tube of 1% Hydrocortisone with an expiration date of April 2014. 5. one tube of Itch Relief Cream with an expiration date of August 2014. 6. one tube of Miconazole 2% (used for yeast infections) with an expiration date of November 2013. 7. three packets of Hemorrhoidal suppositories with an expiration date of January 2014. 8. one tube of Muscle and Joint Ointment with an expiration date of November 2013. Interview with Licensed Practical Nurse #2, who was administering medications, on October 21, 2014, at 3:30 p.m., in the second floor medication room, confirmed the medications and supplies were expired and were still available for resident use.",2018-02-01
9108,ST BARNABAS AT SISKIN HOSPITAL,445008,1 SISKEN PLAZA,CHATTANOOGA,TN,37403,2013-09-11,221,D,0,1,3NWZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to complete a restraint assessment and attempt restraint reduction for one resident (#48) of thirty residents reviewed. The findings included: Resident #48 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data Set, dated dated dated [DATE], revealed the resident had severely impaired cognitive skills for daily decision making and used a trunk restraint daily. Medical record review of the Physical Restraint Reduction assessment dated [DATE], revealed Instructions: Restrained individuals should be reviewed at least quarterly to determine whether or not they are candidates for restraint reduction, less restrictive restraining measures, or total restraint elimination. For each category listed below, assess the resident by circling the corresponding score(s) that best describe his/her current status in the appropriate assessment column. Add the column of numbers to obtain the total score. Continue evaluation and review on the reverse . Medical record review of the Physical Restraint Reduction assessment dated [DATE], revealed the resident scored a 25 (21-35 Good Candidate). Medical record review of the reverse side of the Physical Restraint Reduction Assessment revealed no documentation of the continued evaluation and review of the restraint assessment on August 18, 2013. Medical record review of a physician's orders [REDACTED].soft self release velcro belt while up in chair .check restraint and release per facility protocol . Observation and interview on September 10, 2013, at 7:45 a.m., with Licensed Practical Nurse (LPN) #3, in front of the nursing station, revealed the resident seated in a tilt/recline chair, with a soft velcro seat belt in place. Continued observation revealed the resident was unable to self release the seat belt when asked by LPN #3. Observation on September 11, 2013, at 7:45 a.m., revealed the resident seated in the chair in front of the nursing station, with a soft self release velcro belt in place. Interview on September 9, 2013, at 3:45 p.m., with the Director of Nursing (DON), in the DON's office confirmed the resident was unable to self release the soft belt restraint. Interview on September 11, 2013, at 9:15 a.m., with the DON, in the conference room confirmed the restraint assessment was not completed on August 18, 2013, the resident scored as a good candidate for attempted reduction of the restraint on August 18, 2013, and no attempt to reduce the restraint had been completed.",2017-02-01
9109,ST BARNABAS AT SISKIN HOSPITAL,445008,1 SISKEN PLAZA,CHATTANOOGA,TN,37403,2013-09-11,246,D,0,1,3NWZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure the call light was within reach for one resident (#58) of thirty residents reviewed. The findings included: Resident #58 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the admission Minimum Data Set, dated dated dated [DATE], revealed the resident scored fourteen on the Brief Interview for Mental Status (BIMS) indicating the resident was independent with daily decision making and was able to be understood, and understood others. Observation and interview with the resident on September 9, 2013, at 2:10 p.m., revealed the resident seated in a wheelchair on the left side of the bed and the call light was wrapped around the assist bar on the right side of the bed. Interview with the resident at the time of the observation revealed the resident needed the call light to ask for assistance with transfers. Continued interview revealed the resident had previously asked the staff to ensure the call light was within reach. Observation and interview with Licensed Practical Nurse (LPN) #2 on September 9, 2013, at 2:15 p.m., confirmed the resident's call light was not within the resident's reach.",2017-02-01
9110,ST BARNABAS AT SISKIN HOSPITAL,445008,1 SISKEN PLAZA,CHATTANOOGA,TN,37403,2013-09-11,279,D,0,1,3NWZ11,"**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 one (#118) of thirty residents reviewed. The findings included: Resident #118 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the [MEDICAL CONDITION] Medical Management Progress Note dated July 25, 2013, revealed .Long and short term memory impaired, chronic (scored 5 on a scale with 10 indicating the most severe impairment); Recall impaired, chronic with a score of 5; Attention and Judgement impaired; and Appetite - Decreased with a score of 7, Acute . Record review of the Monthly Weight Record revealed a weight of 137 pounds in March 2013 and 124 pounds in August 2013 with the weight decreasing each month. Review revealed the September weight of 123 pounds represented a 10% weight loss over the previous six months. Review of the Certified Dietary Manager (CDM) Dietary Notes for May 8, 2013, revealed .Weight showing a trending down x (for) 90 days. Review of the CDM's Dietary Notes dated August 9, 2013, revealed Recommendation placed in MD (doctor) communication book for [MEDICATION NAME] for increased appetite due to poor intake and weight decline . Review of the resident's Care Plan Meeting held on August 7, 2013, revealed the family .concerned .weight. Noted Ensure seems to give (resident) diarrhea. Review of the Care Plan approaches to address the Problem/Need of a Therapeutic Diet on admission in June 2012 revealed Offer foods high in protein, Praise resident's attempts to follow diet, and Provide calculated diabetic diet, including snack. Review of the Care Plan dated May 8, 2013, at the annual review after the resident had been identified with significant weight loss revealed no approaches were developed to address the weight loss. Review of the quarterly Care Plan update of August 8, 2013, revealed no new approaches to address the continued weight loss. Review revealed an approach was added on August 23, 2013, Add to assist to feed at meals. Observation and interview of the resident on September 10, 2013, at 8:45 a.m., revealed the resident was unable to recall any information about what was served or eaten for breakfast. Interview on September 11, 2013, at 8:10 a.m., with the CDM at the third floor nursing station, confirmed Ensure (a protein supplement) was not included in the care plan, although the resident had received at intervals and the family stated it caused diarrhea; an alternative to Ensure had not been added to the Care Plan during the previous month after the Ensure was stopped; and dementia prevented the resident from knowingly increasing their protein intake as planned for in the CDM's May 2013 Dietary Notes .Will encourage increased intake of protein . Observation of the resident on September 11, 2013, at 8:25 a.m., revealed the resident was resting in bed and breakfast had not been served. Continued observation revealed the resident had a breakfast tray taken to their room at 9:15 a.m. Interview on September 11, 2013, at 10:10 a.m., with the Certified Nursing Assistant (CNA #4) revealed .usually in bed for breakfast .if you wake up too early gets upset and won't eat anything .will usually take cereal with help .took cereal today. Interview on September 11, 2013, at 12:25 p.m., with CNA #2 revealed (the resident) went to the bathroom .does that a lot after begins to eat . Observation on September 11, 2013, at 12:35 p.m., revealed the resident ambulated from the bathroom to the foyer area of the nursing unit and set down. Observation revealed the nursing staff redirected the resident back to the dining room to eat lunch and LPN #1 began cueing the resident to eat. Interview by telephone on September 11, 2013, at 2:15 p.m., with the Registered Dietician (RD), confirmed the RD did not attend or contribute to the care plan meetings. Interview with the Director of Nurse's (DON), in the DON's office at 4:55 p.m., on September 10, 2013, confirmed neither the RD or Registered Nurses (RN) attended the annual or quarterly care plan meetings for the resident in 2013. Interview with the DON, in the DON's office at 3:40 p.m., on September 11, 2013, confirmed the resident's Care Plan did not include the following: where the resident desired to take meals; a protein supplement; or the approach verbally shared by both the DON and the CDM related to finger foods and sandwiches being most appropriate for the resident. Interview confirmed the resident did not have a comprehensive care plan to address the weight loss.",2017-02-01
9111,ST BARNABAS AT SISKIN HOSPITAL,445008,1 SISKEN PLAZA,CHATTANOOGA,TN,37403,2013-09-11,312,D,0,1,3NWZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide adequate grooming assistance for one resident (#64) of thirty residents reviewed. The findings included: Resident #64 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review of the Care Plan revealed under the problem of .decreased functional status .approaches .Nail care done weekly .Assist with dressing .grooming as needed. Observation and interview with the resident on September 9, 2013, at 12:10 p.m., in the resident's room revealed the resident remained in the bed, had a beard, and dirt under long fingernails on each hand. Observation revealed the resident's glasses were on the bedside table and the lenses were visibly dirty. Continued interview revealed the resident stated shaving was done on shower days. Interview with the Certified Nursing Assistant (CNA #3) on September 9, 2013, at 12:30 p.m., after the CNA prepared the lunch tray for the resident (who remained in the bed) and began to exit the room confirmed the resident usually wore glasses during the day and confirmed they were dirty and had not been cleaned or provided for the resident. Interview with the Interim Charge Nurse at the third floor nursing station on September 11, 2013, at 9:30 a.m., confirmed the resident required assistance with all activities of daily living, had a beard on Monday, September 9, 2013, and on that day the Charge Nurse had requested (the resident) be shaved. Interview confirmed residents should be shaved even on days they are not showered. Continued interview confirmed the resident had long fingernails and dirt under the nails of both hands. Interview confirmed the expectation for assistance with daily care needs included nail care and shaving if needed.",2017-02-01
9112,ST BARNABAS AT SISKIN HOSPITAL,445008,1 SISKEN PLAZA,CHATTANOOGA,TN,37403,2013-09-11,325,D,0,1,3NWZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to prevent weight loss for two residents (#118, #79) of thirty residents reviewed for weight loss. The findings included: Resident #118 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review of the Monthly Weight Record revealed a weight of 137 pounds in March 2013. Review of the Certified Dietary Manager's (CDM) Dietary Notes dated May 8, 2013, revealed .Weight showing a trending down x (for) 90 days. Medical record review of the [MEDICAL CONDITION] Medical Management Progress Note dated July 25, 2013, revealed .Long and short term memory impaired, chronic (scored 5 on a scale with 10 indicating the most severe impairment); Recall impaired, chronic with a score of 5; Attention and Judgement impaired; and Appetite - Decreased with a score of 7, Acute . Review of the resident's Care Plan Meeting held on August 7, 2013, revealed the family .concerned .weight. Noted Ensure (liquid dietary supplement) seems to give (resident) diarrhea. Review of the CDM's Dietary Notes dated August 9, 2013, revealed Recommendation placed in MD (doctor) communication book for [MEDICATION NAME] (medication) for increased appetite due to poor intake and weight decline . Record review of the Monthly Weight Record revealed the resident weighed 124 pounds in August 2013. Continued review revealed the September weight was 123 pounds. Observation and interview of the resident on September 10, 2013, at 8:45 a.m., revealed the resident was unable to recall any information about what was served or eaten for breakfast. Interview with the Director of Nurse's (DON), in the DON's office at 4:55 p.m., on September 10, 2013, confirmed the resident had experienced significant weight loss. Interview confirmed the Registered Dietitian (RD) had not provided evaluation or input on the resident's weight loss. Continued interview confirmed the resident's labwork results on May 9, 2013, revealed two nutritional indicators, total protein and [MEDICATION NAME], had below normal values at 5.8 (range 6.0 - 8.5) and 3.2 (range 3.5 - 5.0). Interview confirmed the resident did not have a protein supplement prescribed by the physician after the nutritional indicators were identified as below normal. Interview included a review of the Physician's Progress note dated August 12, 2013, and confirmed the progress note stated trial appetite stimulant and monitor response and confirmed the trial of an appetite stimulant had not been initiated as of September 10, 2013. Continued interview confirmed the Nursing staff had noted the resident frequently had difficulty focusing on a meal and would get up and wander off. Interview revealed the resident had been added to the feeder list and was to be assisted at meals since August 23, 2013. Observation of the resident on September 11, 2013, at 8:25 a.m., revealed the resident was resting in bed and breakfast had not been served. Continued observation revealed the resident had a breakfast tray taken to their room at 9:15 a.m. Interview on September 11, 2013, at 10:10 a.m., with the Certified Nurse Aide (CNA #1) revealed, .usually in bed for breakfast .if you wake up too early gets upset and won't eat anything .will usually take cereal with help, but won't eat much else at breakfast .took cereal today. Observation on September 11, 2013, at 12:25 p.m., revealed the resident was not in the dining room eating. Continued observation revealed the resident exited their room and ambulated to the foyer area of the nursing unit. Observation revealed the nursing staff redirected the resident back to the dining room to eat lunch. Observation revealed the resident began to eat slowly and alone at a table with no feeding assistance. Interview with the RD by telephone on September 11, 2013, at 2:15 p.m., confirmed the RD had not been asked to review the resident for weight loss from March 2013 to the present and was unaware of the resident's weight loss. Interview with the Director of Nurse's (DON), in the DON's office at 4:00 p.m., on September 11, 2013, confirmed the following: the resident did not have any additional labwork checked since May 2013, the DON had not been able to locate any evaluation by the RD that defined the resident's Ideal Body Weight range, and the Nutritional at Risk committee reviewed the Monthly Weight Record for all the resident's, but had not identified the resident's monthly decline in weight prior to August 23, 2013. Resident #79 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Departmental Notes dated May 3, 2013, revealed .wt (weight) 135 (pounds) had a recent diet change receives Puree meat with soft veggies . Review of the weight record revealed the resident's weight was 133 pounds on June 3, 2013, and 120 pounds on September 2, 2013, (10 percent weight loss in 3 months) Medical record review of the Dietitian's Recommendations dated May 31, 2013, revealed .recommendation .Nepro 1 can po (by mouth) bid (twice a day) between meals . Medical record review of the physician's progress note dated June 11, 2013, revealed .dietary noncompliance-pt. (patient) eats what .wants (and) refuses what .doesn't want . Medical record review of a physician's orders [REDACTED].D/C (discontinue) shake (with) meals .begin Nepro 1 can BID between meals . Medical record review of the Medication Record dated June 17, 2013, revealed the Nepro 1 can bid was implemented on June 17, 2013. (seventeen days after the dietary recommendation) Medical record review of the Departmental Notes dated July 13, 2013, revealed .Poor diet, Ensure offered and taken well . Medical record review of the Departmental Notes dated August 1, 2013, revealed .wt. 125 (pounds) .continues to receive Puree Meat with soft vegetables diet as ordered .Weight down 4 (pounds) x 90 days due to reduction in doughnuts and sweets family would bring to facility. Family has stopped bringing these items, intake of meals 80 (percent) . Medical record review of the Departmental Notes dated August 23, 2013, revealed .NAR (nutrition at risk) weight trending down will provide shake tid (three times a day) with meals. Weekly weight . Review of the NAR meeting minutes dated August 30, 2013, revealed .Family not providing as many snacks . Observation on September 11, 2013, at 8:50 a.m., revealed the resident sitting on the bed eating breakfast, consisting of oatmeal, eggs, yogurt, milk, and mighty shake with a staff member sitting next to the resident to offer the resident encouragement to eat. Interview with the Registered Dietitian (RD) on September 11, 2013, at 1:20 p.m., by telephone confirmed the RD was not aware of the resident's continued weight loss and would have increased the nepro to three or four times a day. Interview with the Certified Dietary Manager (CDM) on September 11, 2013, at 3:00 p.m., in the conference room, confirmed a delay in starting the RD recommendation for the Nepro 1 can BID.",2017-02-01
9113,ST BARNABAS AT SISKIN HOSPITAL,445008,1 SISKEN PLAZA,CHATTANOOGA,TN,37403,2013-09-11,327,D,0,1,3NWZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, observation, and interview, the facility failed to ensure a physician's order for fluid restriction was being maintained for one (#13) of thirty sampled residents. The findings included: Resident #13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Physician's order dated October 10, 2012, revealed 1500 ml (milliliters) fluid restriction per day. Medical record review of the Care Plan revealed, 10/10/12 Fluid restriction 1500 ml/day. Medical record review of Dietary notes revealed no documentation of the breakdown of fluids to be provided by dietary and or nursing for the the resident each shift. Review of facility policy, Restricted Fluids, revealed .1. Licensed Nurse will note the Physician's order in regard to fluid restriction and develop and/or follow a plan for the amount of fluids to be consumed by the resident each shift .3. The resident with an order for [REDACTED]. A door identifier will be placed on the resident's door to identify resident's on fluid restriction .8. If the resident is not consuming the amount of fluid ordered (under or over the amount ordered), the Licensed Nurse will notify the physician and document further orders. Observation of the resident's room, on September 11, 2013, at 10:05 a.m., revealed a water pitcher at bedside and no door identifier to indicate the resident was on restricted fluids. Interview on September 11, 2013, at 10:10 a.m., with the Certified Nursing Assistant (CNA #1) providing the resident's care revealed CNA #1 was unaware of how much fluid the resident was allowed per shift. Interview Licensed Practical Nurse (LPN #1) on September 11, 2013, at 10:15 a.m., in the 200 hallway revealed LPN #1 was unaware of the breakdown of fluid to be given by dietary and nursing. Further interview revealed LPN #1 was unaware how many milliliters the resident was allowed each shift. Interview with the Dietary Manager on September 11, 2013, at 11:00 a.m., in the Director of Nursing's (DON) office revealed the resident is on a select diet which means the resident chooses liquids to be provided by dietary for each meal. Further interview confirmed in a twenty-four hour period no more than 960 ml was to be provided by dietary for the resident. Interview with the DON in the DON's office on September 11, 2013, at 2:40 p.m., confirmed the facility's Restricted Fluids policy had not been followed for developing a plan for the amount of fluids to be provided by dietary and nursing. Further interview confirmed the resident was not to have a water pitcher at bedside and a fluid restriction identifier had not been placed on the resident's door.",2017-02-01
9114,ST BARNABAS AT SISKIN HOSPITAL,445008,1 SISKEN PLAZA,CHATTANOOGA,TN,37403,2013-09-11,332,D,0,1,3NWZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure a five percent or less medication error rate in 4 of 32 opportunities observed. The findings included: Medical record review of the physician's orders [REDACTED].#119 revealed .[MEDICATION NAME] [MEDICATION]) 250 mg (milligram) tablet Take 1 tab by mouth twice daily .Aspirin EC ([MEDICATION NAME] coated) take 1 tab by mouth every day . Observation with Licensed Practical Nurse (LPN) #3 of a medication pass for resident #119 on September 10, 2013, at 8:00 a.m., revealed LPN #3 omitted [MEDICATION NAME] 250 mg and Aspirin 81 mg. Medical record review of the physician's orders [REDACTED].Vitamin D (D3) 1000 IU (international units) cap take 1 by mouth every day .[MEDICATION NAME] (gastric acid pump inhibitor) (20 mg) take 1 cap by mouth every day . Observation with LPN #4 of a medication pass for resident #4, on September 10, 2013, at 8:40 a.m., revealed LPN #4 administered Vitamin D 400 IU and omitted [MEDICATION NAME] 20 mg. Interview with LPN #3 on September 10, 2013 at 8:20 a.m., in the hall confirmed the [MEDICATION NAME] and Aspirin had not been administered to resident #119. Interview with LPN #4 on September 10, 2013, at 8:45 a.m., in the hall confirmed vitamin D 400 IU was administered to resident #4 and the [MEDICATION NAME] had not been administered.",2017-02-01
9115,ST BARNABAS AT SISKIN HOSPITAL,445008,1 SISKEN PLAZA,CHATTANOOGA,TN,37403,2013-09-11,431,D,0,1,3NWZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure medications were secured on one of five medication carts. The findings included: Observation on September 11, 2013, at 8:57 a.m., revealed an unattended medication cart in the hallway outside of room [ROOM NUMBER]. Further observation revealed a plastic cup containing approximately 60 ml. (milliliters) of a watery mixture. Continued observation revealed the cart remained unattended for three minutes until the nurse returned. Interview with Licensed Practical Nurse #1 at that time revealed the cup contained a Carafate tablet mixed in water. Continued interview confirmed the medication had been left unsecured for a period of time and had not been properly stored.",2017-02-01
9116,ST BARNABAS AT SISKIN HOSPITAL,445008,1 SISKEN PLAZA,CHATTANOOGA,TN,37403,2013-09-11,502,D,0,1,3NWZ11,"**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 for one resident (#22) of thirty residents reviewed. The findings included: Resident #22 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].TSH ([MEDICAL CONDITION] Stimulating Hormone) every six months. First draw to be done 9-2-13 . Medical record review revealed no laboratory report for the TSH level on September 2, 2013. Interview with Licensed Practical Nurse #5 on September 11, 2013, at 8:30 a.m., at the nursing station confirmed the TSH level had not been obtained.",2017-02-01
11429,ST BARNABAS AT SISKIN HOSPITAL,445008,1 SISKEN PLAZA,CHATTANOOGA,TN,37403,2012-03-07,166,D,0,1,51I011,"Based on review of the resident council meeting minutes and group interview, the facility failed to resolve grievances regarding staffing shortages and not enough linen on weekends. The findings included: Review of the Resident Council Meeting minutes dated August 3, 2011, September 9, 2011, October 6, 2011, November 10, 2011, December 2, 2011, January 5, 2012, and February 3, 2012, revealed residents complained of not enough nursing staff and the continued need for more help. Continued review revealed resident complaints of not enough linen on the weekends. Interview with residents at a group meeting on March 5, 2012, at 2:30 p.m., in the chapel room, revealed complaints of the facility not addressing the issue of needing more staff during meal trays time, and answering call lights. Continued interview revealed the residents had complained of not having enough linen on the weekends. Continued interview revealed the residents' complaints had not been addressed. Interview with the Activities Director on March 5, 2012, at 3:30 p.m., in the Activities Director office, revealed if concerns during the resident council meetings are identified, the information is given to the respectful department. Interview with the Director of Nursing and Administrator on March 7, 2012, at 9:30 a.m., in the Administrator's office, confirmed there was no documentation of the investigation for the resident council complaints or follow up for the grievances.",2016-01-01
11430,ST BARNABAS AT SISKIN HOSPITAL,445008,1 SISKEN PLAZA,CHATTANOOGA,TN,37403,2012-03-07,221,D,0,1,51I011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to assess for restraint reduction for three residents (#3, #15 & #10) of twenty residents reviewed. The findings included: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].self releasing belt . Observation on March 5, 2012, at 10:02 a.m., in the resident room, revealed resident #3 in bed. Continued observation revealed the resident's wheelchair in the bathroom had a self releasing belt in place available for use. Medical record review of a Physical Restraint Reduction Assessment last completion date May 1, 2011, revealed no quarterly restraint assessments where completed for the months of August 2011, November 2011, and February 2012. Interview with the Director of Nursing (DON) on March 5, 2012, at 2:20 p.m., in the facility conference room, confirmed the resident was not assessed quarterly for a least restrictive device. Resident # 15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physicians order dated April 8, 2009, revealed .lap belt while up out of bed . Observation on March 7, 2012, at 7:48 a.m., revealed resident #15 sitting in front of the third floor nurse's station in a gerichair (type of wheelchair) with a lap belt (restraint) in place. Medical record review of a Physical Restraint Reduction Assessment last completion date August 1, 2011, revealed no quarterly restraint assessments where completed for the months of November 2011, and February 2012. Interview and medical record review, with the Director of Nursing on March 7, 2012, at 8:03 a.m., in the facility conference room, confirmed the resident was not assessed quarterly for a less restrictive device. Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed a physician's orders [REDACTED]. Review of the Physical Restraint Reduction Assessment revealed the last quarterly assessment was completed on August 25, 2011. Interview with the 300 Hall Unit Manager in the manager's office on March 6, 2012, at 11:00 a.m., confirmed assessments are to be completed quarterly and the resident had not been assessed since August 2011.",2016-01-01
11431,ST BARNABAS AT SISKIN HOSPITAL,445008,1 SISKEN PLAZA,CHATTANOOGA,TN,37403,2012-03-07,281,D,0,1,51I011,"**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 one (#7) and failed to obtain psych services timely for two (#10 & #14) of twenty residents reviewed. The findings included: Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical Record review of a physician's order dated March 2, 2012, revealed order for [MEDICATION NAME] written as follows: [MEDICATION NAME] .5, TID prn (three times per day as needed). Medical record review of Medication Record from March 2012, revealed the resident was receiving [MEDICATION NAME] 0.5 mg (milligrams) three times per day at the following times: 6:00 a.m., 2:00 p.m., 10:00 p.m., and [MEDICATION NAME] 0.5 mg as needed for anxiety. Further review of Medication record revealed the resident received the [MEDICATION NAME] on March 2, 2012 at 10:00 p.m., March 3, 2012, at 6:00 a.m. and 2:00 p.m., and received another dose March 3, 2012, with no time indicated. Interview with the second floor Charge Nurse March 5, 2012, at 2:20 p.m. at the second floor nurse's station confirmed the physician's order was [MEDICATION NAME] 0.5 mg three times a day as needed. Further interview confirmed the medication had been incorrectly transcribed to the Medication Record and incorrectly administered three times per day on a routine basis instead of an as need basis. Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed a physician's order dated December 27, 2011, for psych (psychological) eval (evaluation) related to refusal of meds. Medical record review revealed a physician's order for [MEDICATION NAME] (antidepressant) 50 mg. to be given at bedtime. Further review revealed the resident had been refusing the medication at night. Psych services evaluated the resident on January 17, 2012, (twenty-one days later) increasing the dosage of [MEDICATION NAME] to 100 mg. to be given at 9:00 a.m., because the resident did not want to be awakened for medications at night. Interview with the Director of Nursing on March 6, 2012, at 10:00 a.m., in the conference room, confirmed the twenty-one day delay in obtaining psych services. Further interview confirmed when the medication time was changed to morning, the resident did not refuse the medication. Resident # 14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed a physician's order dated February 3, 2012, to refer to psych for AIMS testing for use of [MEDICATION NAME] (antipsychotic). Medical record review revealed no documentation psych services had been obtained. Interview with the Director of Nursing, in the conference room on March 6, 2012, at 3:15 p.m., confirmed psych services had seen the resident on December 16, 2011, and was due to see the resident in four to six week, however, psych services had not been back and the physician ordered testing had not been completed.",2016-01-01
11432,ST BARNABAS AT SISKIN HOSPITAL,445008,1 SISKEN PLAZA,CHATTANOOGA,TN,37403,2012-03-07,323,D,0,1,51I011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure safety devices were in place for one resident (#3) of twenty residents reviewed. The findings included: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the resident current care plan revealed .Problem Potential for Injury .June 24, 2011 status [REDACTED].Approaches .pressure sensitive mat while in bed . Medial record review of a facility fall investigation report dated November 22, 2011, revealed .pt (patient) slid self out of bed .alerted by patient calls .no injury noted . Continued review of the fall investigation revealed .educated CNA (certified nurse assistant) to utilize alarms in place and make sure they are on and working . Interview on March 7, 2012, at 8:42 a.m., with Licensed Practical Nurse (LPN) #3 the nurse present at the time of the fall, on the 200 hall, confirmed the alarm was not on at the time of the fall.",2016-01-01
11433,ST BARNABAS AT SISKIN HOSPITAL,445008,1 SISKEN PLAZA,CHATTANOOGA,TN,37403,2012-03-07,329,D,0,1,51I011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to ensure unnecessary medications were not administered for one resident (#7) of 20 residents reviewed. The findings included: Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of the resident and interview with residents Power of Attorney (POA) on March 5, 2012, at 10:40 a.m. in resident's room revealed resident was in bed awake and confused. Further interview with POA revealed the resident had received [MEDICATION NAME] (anti-anxiety medication) on a routine schedule over the weekend which caused resident to be oversedated and family thought the [MEDICATION NAME] was only to be administered as needed. Medical record review of the facility's Medication Record from March 2012, revealed the resident was receiving [MEDICATION NAME] 0.5 mg (milligrams) three times per day scheduled for the following times: 6:00 a.m., 2:00 p.m., 10:00 p.m., and [MEDICATION NAME] 0.5 mg as needed for anxiety. Further review of Medication Record revealed resident received the [MEDICATION NAME] on March 2, 2012, at 10:00 p.m.; March 3, 2012, at 6:00 a.m., and 2:00 p.m.; and received another dose March 3, 2012, with no time indicated. Further review of the Medication Record revealed the [MEDICATION NAME] was held March 3, 2012, at 10:00 p.m., for drowsiness and family requested the [MEDICATION NAME] be held on March 4, 2012, at 6:00 a.m., 2:00 p.m., and 10:00 p.m. and March 5, 2012, at 6:00 a.m. Medical Record Review of a physician's orders [REDACTED]. [REDACTED]. Further interview confirmed the medication had been incorrectly administered three times per day routinely.",2016-01-01
11434,ST BARNABAS AT SISKIN HOSPITAL,445008,1 SISKEN PLAZA,CHATTANOOGA,TN,37403,2012-03-07,368,D,0,1,51I011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide breakfast for one resident (#13) leaving the facility early for [MEDICAL TREATMENT] treatment of [REDACTED]. The findings included: Resident #13 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident scored 15 on the Brief Interview for Mental Status (BIMS) (score of 15 indicates cognitive intact). Continued review of the medical record revealed the resident received [MEDICAL TREATMENT] treatment three times per week at an outpatient clinic. Interview with the resident on March 5, 2012, at 2:30 p.m., in the chapel room, revealed the resident left the faciity on [MEDICAL TREATMENT] treatment days at approximately 5:30 a.m. to 6:00 a.m. Continued interview revealed the resident was not offered any breakfast or provided a snack to take to the outpatient [MEDICAL TREATMENT] clinic. Further interview revealed the resident did not return to the facility until 10:30 a.m. to 11:00 a.m., and stated was very hungry when returned to facility. Review of the resident meal times revealed the dinner meal was provided between 4:30 p.m. and 6:30 p.m. Eleven hours between resident's dinner meal and lunch meal provided after returning to the facility from the [MEDICAL TREATMENT] treatment. Interview with the Charge Nurse on March 7, 2012, at 9:30 a.m., in the Assistant Director of Nursing office, confirmed the resident was not provided a meal before leaving the facility and was not provided any snack to take to the clinic. The Charge Nurse confirmed the resident was not provided a meal from the dinner meal until the lunch meal (over 16 hours).",2016-01-01
11435,ST BARNABAS AT SISKIN HOSPITAL,445008,1 SISKEN PLAZA,CHATTANOOGA,TN,37403,2012-03-07,428,D,0,1,51I011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to notify the physician timely of a pharmacy consultant report for one resident (#15) of twenty residents reviewed. The findings included: Resident # 15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Pharmacy Consultant Recommendation to the Physician dated January 5, 2012, revealed .has taken Risperidal (antipsychotic) .since February 3, 2010 .please consider a trial discontinuation . Continued review of the Pharmacy Recommendation revealed the Physician was not notified until January 29, 2012 (a twenty-four day delay). Interview with the Director of Nursing (DON) on March 7, 2012, at 8:03 a.m., in the facility conference room, confirmed the facility failed to ensure that the Pharmacy Recommendation was acted upon timely.",2016-01-01
13579,ST BARNABAS NURSING HOME,445008,950 SISKIN DRIVE,CHATTANOOGA,TN,37403,2010-10-21,280,D,0,1,HTP811,"**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 one (#5) of twenty-six residents reviewed. The findings included: Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Talked to spouse..."" Medical record review of the current Care Plan, reviewed on [DATE], revealed ""...CPR (Cardiopulmonary Resuscitation) Full Treatment...Will abide by resident and family's wishes...Perform Cardiac [MEDICAL CONDITION] Resuscitation (CPR)...Use intubation, advanced airway interventions, mechanical ventilation and cardioversion as indicated..."" Observation on [DATE], at 10:15 a.m., revealed the resident lying on the bed receiving oxygen, with bilateral fall mats in place on the floor. Interview on [DATE], at 1:55 p.m., with Minimum Data Set Coordinator #1, in the nursing station, confirmed the current Care Plan was not revised to indicate the correct DNR status as ordered by the physician on [DATE].",2014-11-01
13580,ST BARNABAS NURSING HOME,445008,950 SISKIN DRIVE,CHATTANOOGA,TN,37403,2010-10-21,328,D,0,1,HTP811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, observation, and interview, the facility failed to obtain podiatry services for one (#5) of twenty-six residents reviewed. The findings included: Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident required extensive assistance with personal hygiene and bathing. Medical record review of a physician's progress note dated July 26, 2010, revealed ""...toenail(s) need trimming..."" Observation on October 19, 2010, at 10:15 a.m., revealed the resident lying on the bed with the feet exposed. Observation revealed a dressing covered the right foot, and the toenails of the left foot were long. Observation and interview on October 19, 2010, at 2:05 p.m., with MDS Coordinator #2 revealed the resident lying on the bed, and the great toenail on the left foot was described as extending approximately 1/4 inch past the fat pad of the toe, the third and fourth toenails on the left foot described as extending approximately 1/2 inch beyond the fat pads of the toes. Continued interview with MDS Coordinator #2 confirmed the toenails were in need of trimming. Review of the facility's policy Fingernails/Toenails, Care of revealed ""...do not trim the nails of diabetic residents or residents with circulatory impairments..."" Interview on October 19, 2010, at 2:15 p.m., with the Director of Nursing, in the nursing station, revealed a podiatrist would be required to trim the toenails due to the resident's [DIAGNOSES REDACTED].",2014-11-01
13581,ST BARNABAS NURSING HOME,445008,950 SISKIN DRIVE,CHATTANOOGA,TN,37403,2010-10-21,514,D,0,1,HTP811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to maintain an accurate clinical record for one (#5) of twenty-six residents reviewed. Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Medical record review of the physician's recapitulation orders dated October 2010, revealed the resident was to receive level 2 sliding scale insulin protocol for blood glucoses. Medical record review of the Sliding Scale Diabetic Monitoring Log dated September 2010, revealed the following scale for level 1 coverage of blood glucoses: 60-110=0 units of insulin; 111-150=2 units of insulin; 151-200=2 units of insulin; 201-250=4 units of insulin; 251-300=4 units of insulin; 301-350=6 units of insulin; 351-400=6 units of insulin; and >400=8 units of insulin and notify provider. Medical record review of the Sliding Scale Diabetic Monitoring Log dated September 2010, revealed the following scale for level 2 coverage of blood glucoses: 60-110=0 units of insulin; 111-150=2 units of insulin; 151-200=4 units of insulin; 201-250=4 units of insulin; 251-300=6 units of insulin; 301-350=8 units of insulin; 351-400=8 units of insulin; and > (greater than) 400=10 units and notify provider. Medical record review of resident #5's September 15-30, 2010, and the October 1-18, 2010, Sliding Scale Diabetic Monitoring Log revealed the resident received the sliding scale insulin with level 1 coverage. Interview on October 20, 2010, at 9:10 a.m., with the Assistant Director of Nursing, at the nursing station, confirmed the October 2010, physician's recapitulation orders indicated the resident was to receive sliding scale insulin by the level 2 insulin protocol was not accurate.",2014-11-01
13582,ST BARNABAS NURSING HOME,445008,950 SISKIN DRIVE,CHATTANOOGA,TN,37403,2010-10-21,226,D,1,1,HTP811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, and interview, the facility failed to implement the abuse policy for one resident #9 with an injury of unknown origin of twenty-six residents reviewed. The findings included: Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Nurse's note dated December 4, 2009, (late entry for December 1, 2009) revealed ""pt (patient) OOB (out of building) with family at 1400(2:00 p.m.)...Family brought pt back at 1445 (2:45 p.m.) daughter states (resident) is 'complaining of L(left) hand pain so we brought (resident) back early'..."" Medical record review of the Nurse Practitioner note dated December 2, 2009, revealed ""...L hand swollen (and) red..."" Medical record review of the X-Ray report of the left hand dated December 2, 2009, revealed ""...Diffuse soft tissue swelling with no evidence for acute osseous changes..."" Medical record review revealed no investigations for the incident on December 1, 2009. Review of the facility Abuse Prevention policy revealed ""...All incidents are reviewed as to source of origin..."" Telephone interview with Licensed Practical Nurse (LPN) #2 on October 20, 2010, at 1:15 p.m., confirmed on December 1, 2009, the resident's daughter reported to LPN #2 the resident complained of pain in left hand. Continued interview revealed LPN #2 recalls the resident's left hand was examined and some redness was noted. Interview with LPN #3 (on duty on December 2, 2009) on October 20, 2010, at 1:35 p.m, in the Director of Nursing Office, confirmed on December 2, 2009, some swelling was noted to the resident's left hand. Continued interview revealed LPN #3 received a call from the resident's daughter and after discussion with the daughter LPN #3 requested an X-ray. Interview with the Director of Nursing on October 20, 2010, at 1:40 p.m. in the Director of Nursing office, confirmed on December 1, 2009, upon returning the resident to the facility, the resident's daughter reported to LPN #2 the resident had complained of left hand pain, on December 2, 2009; the x-ray revealed soft tissue swelling, and confirmed no investigation was completed to determine the origin of the injury. c/o TN 616",2014-11-01
13583,ST BARNABAS NURSING HOME,445008,950 SISKIN DRIVE,CHATTANOOGA,TN,37403,2010-10-21,323,D,1,1,HTP811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to investigate and implement new interventions after a fall for one resident (#9) and failed to ensure a restraint was applied correctly for one resident (#8) of twenty-six residents reviewed. The findings included: Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the care plan updated on October 22, 2009, revealed the resident had a history of [REDACTED]. Medical record review of the Nurse's note dated December 4, 2009, (late entry for December 1, 2009) revealed ""...CNA's called Nurse to room pt (patient) states 'I slipped out of my w/c (wheelchair)...I didn't hurt anything..."" Medical record review revealed no investigation was completed or new interventions implemented after the fall. Telephone interview with Licensed Practical Nurse (LPN) #2 (on duty December 1, 2009) on October 20, 2010 at 1:15 p.m., confirmed on December 1, 2009, the resident slid out of the wheelchair and no injury was noted. Continued interview revealed LPN #2 was unsure if the above occurance were reported. Interview with the Director of Nursing on October 20, 2010, at 1:40 p.m. in the Director of Nursing office, confirmed on December 1, 2009, the resident slid out of wheelchair and no investigation was completed or new interventions implemented after the fall on December 1, 2009. c/o TN 616 Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short/long term memory problems, with severely impaired cognitive skills for daily decision making. Medical record review of the careplan dated September 21, 2010, revealed, ""...self-release soft belt while up w/c (wheelchair) to remind not to attempt rising (second to) lack safety awareness..."" Medical record review of the physician's recapitulation orders dated October 1, 2010, through October 31, 2010, revealed, ""...10/23/08-continue self release belt..."" Medical record review of the manufacturer's instructions for the self release soft belt revealed, ""...The Patient-Release Soft Belts are intended to act as ""gentle reminders "" for patients to ask for assistance when leaving the wheelchair...They are designed to be easily opened and removed by most patients...place the belt at the patient's waist and bring the straps directly behind the patient. Thread the straps through the space between the space between the wheelchair seat and backrest..."" Observation on October 19, 2010, at 11:30 a.m., revealed the resident seated in the wheelchair with the self release soft belt in place with the left strap wrapped around the outer upper leg of the wheelchair and looped over the right kickspur and the right strap between the leg of the wheelchair and backrest of the wheelchair and looped over the left kickspur. Interview on October 19, 2010, at 11:30 a.m., on the hall, with LPN #6 confirmed the resident was not able to self release the belt when asked and confirmed the self release soft belt was applied incorrectly.",2014-11-01
13584,ST BARNABAS NURSING HOME,445008,950 SISKIN DRIVE,CHATTANOOGA,TN,37403,2010-10-21,281,D,1,1,HTP811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to complete and Interim Care Plan for one (#16), and failed to follow physician's orders [REDACTED].#23) of twenty-six residents reviewed. The findings included: Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Admission Evaluation and Interim Care Plan form dated October 7, 2010, revealed the portion of the form ""...Screen for Fall Risk..."" was not completed. Continued review of the Admission Evaluation and Interim Care Plan form revealed there was no Interim Care Plan completed for the resident. Observation on October 20, 2010, at 3:20 p.m., revealed the resident propelling self in a wheelchair, in the hallway, with a self-releasing soft safety belt in place. Interview on October 20, 2010, at 3:35 p.m., with the Minimum Data Set (MDS) Coordinator, at the nursing station, revealed the Interim Care Plan was to be documented on the Admission Evaluation and Interim Care Plan form dated October 7, 2010. Continued interview with MDS Coordinator #1 confirmed an Interim Care Plan was not completed for resident #16. Resident # 23 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had no problems with memory or decision making. Medical record review revealed the resident was admitted to the facility on [DATE], at 3:45 p.m. Medical record review of the Physician's admission orders [REDACTED] Medical record review of the Medication Administration Record [REDACTED]. Interview with the Admission Nurse at 2:30 p.m., in the conference room, confirmed the resident did not receive the medications on December 4, 2009, as ordered by the Physician. C/O #",2014-11-01
13585,ST BARNABAS NURSING HOME,445008,950 SISKIN DRIVE,CHATTANOOGA,TN,37403,2010-10-21,502,D,0,1,HTP811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to obtain laboratory results as ordered by the physician for one resident (#11) of twenty-six residents reviewed. The findings included: Resident #11 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Medical record review of a physician's orders [REDACTED]. Medical record review revealed no documentation the lab specimens had been obtained as ordered on August 25, 2010, or August 30, 2010 as ordered. Interview with the Assistant Director of Nursing (ADON), on October 21, 2010, at 7:55 a.m., at the Second Floor Nursing Station, confirmed the facility failed to obtain the lab specimens as ordered on August 25, and August 30, 2010.",2014-11-01
13586,ST BARNABAS NURSING HOME,445008,950 SISKIN DRIVE,CHATTANOOGA,TN,37403,2010-10-21,314,G,0,1,HTP811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility policy, observation, and interview, the facility failed to perform weekly wound care assessments that resulted in a pressure ulcer not being identified resulting in harm to resident #3 of twenty-six residents reviewed. The findings included: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short/long term memory problems, moderately impaired cognitive skills for daily decision making, usually continent of bowel and bladder, and required extensive assistance for transfers and positioning. Medical record review of the Braden Scale for Predicting Pressure Sore Risk dated March 6, 2010, revealed the form was blank. Review of the facility policy, Skin and wound Care Program, revealed, ""...The skin assessment must be completed by a licensed nurse on every resident within two (2) hours of admission...A licensed nurse must complete this skin assessment weekly on all residents..."" Medical record review of the careplan reviewed on May 26, 2010, and September 15, 2010, revealed, ""...Turn and position resident every 2 hours as indicated by individual turning schedule posted in resident's room...ensure shower, shampoo, nail care and oral care per facility policy...weekly skin assessment...Dress in clothing comfortable for season and for therapy, ensure non skid footwear..."" Medical record review of the Quarterly Assessment documentation by the dietician, dated June 27, 2010, revealed, ""Noted stage III L. (left) ankle...Alb ([MEDICATION NAME]) 2.7 (L) (low) Hgb (hemaglobin) 9.6 L (low) ...Added [MEDICATION NAME] (protein supplement) 1 carton bid (twice a day) po (by mouth) x 21 d (days) for enhanced wound healing..."" Medical record review of the Resident/Wound Skin assessment dated [DATE], August 16, 2010, and August 25, 2010, revealed, ""Tx (treatment) to LLE (left lower extremity)."" Medical record review of documentation by treatment nurse #1 on the the physician's progress notes dated August 30, 2010, revealed, ""Wound Care: PU (pressure ulcer) to (L) (left) ankle healing has stalled, wound bed is bulging from wound edges exposing muscle (and) tendon...new orders to send pt. (patient) to wound clinic for evaluation. cont. (continue) Iodosorb to aid in decreasing microbial load (and) remove exudate..."" Medical record review of the Regional Wound Center Report dated September 7, 2010, revealed, ""...The patient was noted to have a left lateral ankle wound that started in late May secondary to pressure...Patient was noted to have progressive ulceration of the wound with retained necrotic tissue and was sent to the Wound Care Center for evaluation...reviewing the nursing home records, the patient preferred to lie on...left side in a fetal position, but has been switched to the right side...Past Medical History: Positive for right transmetatarsal amputation secondary to [MEDICAL CONDITION] of the right lateral ankle shows ulceration measuring approximately 0.9 (centimeters) x (by) 0.8 (centimeters) with no drainage, with black eschar in this wound bed...attention was then turned to the right lateral ankle...The patient underwent a full-thickness skin debridement...the ulcer bed approximately 1 cm (centimeter) by 1 cm, down to yellow fibrous tissue underneath...this patient represents a very difficult patient to heal secondary to [MEDICAL CONDITION] and secondary to age and poor nutrition and dependent status of nonambulatory..."" Medical record review of the facility Skin/Wound Assessment for Pressure Ulcers dated September 7, 2010, revealed, ""...Wound #2 (right outer ankle) stage III 0.9 (cm) (x) 0.8 (cm) (x) 0.2 yellow serous..."" Medical record review of documentation by the treatment nurse #1 on the physician's progress notes dated September 7, 2010, revealed, ""...back from (named) wound care center. (L) (left) lateral ankle PU (pressure ulcer) 3.0 (cm) x 3.0 (cm) x 1.5 (cm) (with) serous drainage. red/yellow wound bed (with) exposed tendon area was debrided at clinic...(R) (right) ankle lateral new open area. 0.9 x 0.8 x 0.2 serous drainage-yellow wound bed, will apply santyl drsg (dressing) (change) daily..."" Medical record review of the wound care clinic physician's orders dated September 7, 2010, revealed, ""...Barrier periwound...(R) (right) lateral wound-santyl 4x4's roll gauze..."" Medical record review of the Quarterly assessment dated [DATE], revealed, ""...St. (stage) 3 (right) ankle improved to 1.0 (cm)x 1.0 x 0.1 (cm) (and) pink..."" Medical record review of the Treatment Record for the month of September, 2010, revealed, ""...Cleanse PU (pressure ulcer) (R) (right) ankle NS (normal saline), pat dry, apply barrier cream to periwound, santyl to wound bed, 4x4 gauze conform wrap (change) daily..."" Continued review revealed no documentation the treatment was provided to the right ankle pressure ulcer on September 11, 12, 25, and 26, 2010. Observation on October 21, 2010, at 9:15 a.m., of the pressure ulcer on the right outer ankle, described by treatment nurse #1 as 3.0 cm x 2.0 cm unstageable with black eschar. Interview on October 21, 2010, at 9:30 a.m., at the nursing station, with the treatment nurse #1, confirmed...was not aware of the pressure ulcer on the right outer ankle until September 7, 2010, after the resident returned from the wound care center. Interview on October 21, 2010, at 1:15 p.m., in the conference room, with treatment nurse #1, confirmed the treatment nurse did not remove the sock on the right foot when treatment was provided to the left ankle on August 30, 2010. Interview on October 21, 2010, at 1:30 p.m., with the Director of Nursing, in the conference room, confirmed there was no documentation the treatment was provided to the right ankle pressure ulcer on September 11, 12, 25, and 26, 2010. Further interview with the Director of Nursing confirmed there was no documentation the pressure ulcer on the right ankle had been identified prior to September 7, 2010. Interview on October 21, 2010, at 2:15 p.m., in the conference room, with Licensed Practical Nurse (LPN) #6, confirmed a skin assessment was done on August 25, 2010, but ""did not see right ankle well"", continued interview confirmed LPN #6 was unsure if...looked at the right ankle, may have ""peeked"" at it; LPN #6 stated the resident was resistant, and did not obtain help to complete the skin assessment.",2014-11-01
13587,ST BARNABAS NURSING HOME,445008,950 SISKIN DRIVE,CHATTANOOGA,TN,37403,2010-10-21,253,D,0,1,HTP811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain safety floor mats in clean condition for one (#5) of twenty-six residents reviewed. The findings included: Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Observation on October 19, 2010, at 12:20 p.m., and October 20, 2010, at 7:35 a.m., revealed the resident sitting on the side of the bed with the feet resting on a safety floor mat on the right side of the bed. Continued observation revealed a dressing was on the right foot, and the left foot was bare. Observation of the safety floor mat located on the left side of the bed revealed the floor mat was soiled with various shades and sizes of a black/gray stain. Observation on October 21, 2010, at 9:05 a.m., with the Housekeeping Supervisor, in resident #5's room, revealed the resident lying on the bed with bilateral safety floor mats in place, beside the bed. Interview with the Housekeeping Supervisor, at the time of the observation, in the resident's room, revealed the floor mats were described as ""bad"" and dirty with areas of dark colored dirt, and confirmed the floor mats were not clean.",2014-11-01
13588,ST BARNABAS NURSING HOME,445008,950 SISKIN DRIVE,CHATTANOOGA,TN,37403,2010-10-21,221,D,0,1,HTP811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, facility policy review, and interview, the facility failed to complete a restraint assessment for two (#16, #8) of twenty-six residents reviewed. The findings included: Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]."" Medical record review revealed no documentation a pre-restraint assessment had been completed prior to application of the safety belt. Observation on October 20, 2010, at 3:20 p.m., revealed the resident propelling self in a wheelchair, in the hallway, with a self-releasing soft safety belt in place. Observation on October 20, 2010, at 3:40 p.m., with Minimum Data Set (MDS) Coordinator #1, revealed the resident seated in a wheelchair in the resident's room. Continued observation revealed MDS Coordinator #1 instructed the resident to remove the self-releasing soft safety belt. Continued observation revealed the resident could not remove the self-releasing soft safety belt. Review of the facility's policy Restraints, Physical, General Guidelines for the Use of revealed ""...The resident must be physically and cognitively able to self-release devices such as velcro lap trays or tables, seat belts with Velcro...If a resident cannot mentally and physically self-release, then the device is considered a restraint...The interdisciplinary restraints committee will review and monitor all residents with restraints. Attachments...Pre-restraining assessment...Quarterly restraint assessment..."" Interview on October 20, 2010, at 3:45 p.m., with MDS Coordinator #1, in the hallway, confirmed resident #16's self-releasing soft safety belt was a restraint and a pre-restraining assessment had not been completed. Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short/long term memory problems, with severely impaired cognitive skills for daily decision making. Medical record review of the careplan dated September 21, 2010, revealed, ""...self-release soft belt while up w/c (wheelchair) to remind not to attempt rising (secondary to) lack safety awareness..."" Medical record review of the physician's recapitulation orders dated October 1, 2010, through October 31, 2010, revealed, ""...10/23/08-continue self release belt..."" Medical record review revealed no assessment for the continued use of the self-release soft belt. Observation on October 19, 2010, at 11:30 a.m., revealed the resident seated in the wheelchair with the self release soft belt in place. Interview on October 19, 2010, at 11:30 a.m., on the hall, with LPN #6 confirmed the resident was not able to self release the belt when asked. Interview on October 20, 2010, at 11:00 a.m., in the conference room, with the Director of Nursing, confirmed no restraint assessments had been done to determine the appropriateness of the restraint.",2014-11-01
13589,ST BARNABAS NURSING HOME,445008,950 SISKIN DRIVE,CHATTANOOGA,TN,37403,2010-10-21,315,E,0,1,HTP811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to initiate bladder training for one (#16), and failed to assess three (#4, #11, #15) for a bladder retraining program of twenty-six residents reviewed. The findings included: Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Admission Evaluation and Interim Care Plan form dated October 7, 2010, revealed the resident had a urinary catheter upon admission to the facility. Medical record review of a physician's note dated October 12, 2010, revealed ""...Plan: D/C (discontinue) foley (urinary catheter)..."" Medical record review of a physician's orders [REDACTED]. Medical record review revealed no documentation the bladder training had been initiated. Observation on October 21, 2010, at 7:45 a.m., revealed the resident seating in a wheelchair, in the resident's room, with a urinary catheter draining yellow urine into a drainage bag. Interview on October 21, 2010, at 8:00 a.m., with the Assistant Director of Nursing, in the nursing station, confirmed the bladder training had not been initiated. Interview on October 21, 2010, at 8:35 a.m., with the Director of Nursing, in the conference room, confirmed there was no medical justification for the resident to require a urinary catheter. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short and long term memory problems, was moderately impaired with cognitive skills for daily decision making, and was frequently incontinent of bowel and bladder. Medical record review revealed no documentation a bladder assessment had been completed to develop an individualized bladder retraining program. Interview on October 20, 2010, at 3:00 p.m., with the Director of Nursing, in the conference room, confirmed the resident had not been assessed for a bladder retraining program. Resident #11 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short and long term memory problems, was moderately impaired with cognitive skills for daily decision making, and was incontinent of bowel and bladder. Medical record review revealed no documentation a bladder assessment had been completed to develop an individualized bladder retraining program. Interview on October 20, 2010, at 3:00 p.m., with the Director of Nursing, in the conference room, confirmed the resident had not been assessed for a bladder retraining program. Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short and long term memory problems, was moderately impaired with cognitive skills for daily decision making, and was frequently incontinent of bowel and incontinent bladder. Medical record review revealed no documentation a bladder assessment had been completed to develop an individualized bladder retraining program. Interview on October 20, 2010, at 4:15 p.m., with the Director of Nursing, in the conference room, confirmed the resident had not been assessed for a bladder retraining program.",2014-11-01
13590,ST BARNABAS NURSING HOME,445008,950 SISKIN DRIVE,CHATTANOOGA,TN,37403,2011-07-28,153,D,1,0,UMD211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to allow access to the medical record for one resident #3 of 8 residents reviewed. The findings included: Resident #3 was admitted to the facility on [DATE], from the hospital, with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had difficulty with long and short term memory and the resident's decision making skills were not able to be scored. Continued review of the MDS revealed the resident was non-ambulatory and required assistance for all activities of daily living. Interview with the Durable Power of Attorney (DOPA) on July 27, 2011, at 4:15 p.m., by phone revealed the facility would not allow the DOPA for health care, to review the medical records for Resident #3. Continued interview with the DOPA revealed there had been a difference of opinion about the resident's care which was provided by the resident's physician. Interview with the Director of Nursing (DON) on July 26, 2011, at 3:30 p.m., in the conference room confirmed the DOPA, who is a Physician, had asked to review the medical record. When the DON heard the DOPA wanted to review the chart, there was hesitation about allowing the DOPA (Physician) to review the chart alone. This was later accomplished after receiving a phone call from the POA's attorney. The DOPA was allowed to review the resident's medical record with a staff present but failed to meet the within 24 hour request time frame. C/O #",2014-11-01
13591,ST BARNABAS NURSING HOME,445008,950 SISKIN DRIVE,CHATTANOOGA,TN,37403,2011-07-28,315,D,1,0,UMD211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to discontinue an indwelling urinary catheter for one resident #3 of eight residents reviewed. The findings included: Resident #3 was admitted to the facility on [DATE], from the hospital, with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had difficulty with long and short term memory and the resident's decision making skills were not able to be scored. Continued review of the MDS revealed the resident was non ambulatory and required assistance for all activities of daily living. Review of the physician's orders [REDACTED]. Observation of the resident on July 25, 2011, at 1:45 p.m., revealed the resident in the bed, eyes closed, with a Foley catheter present to bed side drainage. Interview with the Director of Nursing on July 25, 2011, at 1:30 p.m., in the conference room, confirmed the resident did not have a pressure sore, at this time, and the indwelling catheter was not discontinued as ordered. C/O #",2014-11-01
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
4237,"NHC HEALTHCARE, CHATTANOOGA",445013,2700 PARKWOOD AVE,CHATTANOOGA,TN,37404,2016-10-26,371,F,1,0,8EON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of pest control records, observation, and interview, the facility failed to maintain sanitary conditions and failed to safely store canned foods in the dietary department in 1 of 1 observations made. The findings included: Review of the facility policy Safety and Sanitation, last revised 10/2014, revealed .if dent is not on side seam top or bottom .no leakage .before placing .acceptable dented cans back on the storeroom shelf for usage, label 'OK' at the site of acceptable dent, date and initial . Review of pest control records revealed the dietary department was serviced for a roach infestation in the dishwasher drain in (MONTH) (YEAR) and was serviced by the pest control company for treatment of [REDACTED]. Observation of the dietary department on 10/25/16 between 1:40 PM and 2:15 PM, in the food preparation areas and dishwashing areas, revealed the following: 1. A dead roach atop the edge of the wall trim on the south wall adjacent to the stored cereals and steam kettle. 2. A dead roach on the floor behind the reach in cooler near the stove. 3. Food debris atop the floor drain grate behind the steam kettle. 4. Damp dry wall between the faucet and sink adjacent to the ice maker. 5. Dirt and debris on the floors in the food prep areas at the corners, behind, and beneath large appliances. Continued observation of the dietary department on 10/25/16 between 2:15 PM and 2:25 PM, in the dry storage area, revealed: 1. A 106 ounce can of whole corn dented and stored available for resident use, unmarked as reviewed for safety. 2. A 112 ounce can of chocolate pudding dented and stored available for resident use, unmarked as reviewed for safety. 3. Two 6 pound 9 ounce cans of crushed tomatoes stored dented available for resident use, unmarked as reviewed for safety. 4. A 112 ounce can of tomato ketchup stored dented and available for resident use, unmarked as reviewed for safety. 5. A 28 ounce can of unpeeled tomatoes stored dented and available for resident use, unmarked as reviewed for safety. 6. A 49.75 ounce can of clam chowder stored dented and available for resident use, unmarked as reviewed for safety. 7. Four steam table lids stored with brown debris and food residue on the inner and outer surfaces available and ready for use. Continued observation of the dietary department on 10/25/16 at 2:25 PM, in the walk in cooler, revealed a loose aluminum floor panel located on the floor of the cooler. Further observation revealed when stepped on, the distal end of the panel arose from the floor of the cooler. Continued observation of the dietary department at 2:30 PM, revealed a resident water pitcher labeled with the room and bed number lying in the floor behind the utensil rack. Further observation revealed 2 #16 scoops stored ready for use, stored wet with visable food debris inside the scoops. Interviews with 4 dietary staff members during tour of the kitchen on 10/25/16 between 1:40 PM and 2:15 PM, in the dietary department, revealed the 4 staff members confirmed they had seen live roaches in the kitchen on 10/23/16. Futher interview confirmed the staff had seen roaches near the dishwasher drain, on the floor near the stove, and on the wall near the walk in freezer. Continued observation revealed Dietary Worker #1 confirmed he saw live roaches on 10/22/16 emerge from the wall behind the soap dispenser and paper towel dispenser, located beside the ice maker. Interview with the Kitchen Supervisor on 10/25/16 at 2:35 PM, outside the dietary department, revealed the facility's contracted pest control service had implemented a regimen to eliminate roaches in the dietary department in (MONTH) (YEAR) and efforts were ongoing. Continued interview revealed roaches continued to be present in the dietary department. Further interview revealed on two occasions, after power washing food service carts outside the building, the Kitchen Supervisor and dietary staff found roaches on the carts themselves when they were brought back inside the kitchen. Continued interview confirmed the roach infestation was not resolved. Further interview confirmed the dented cans were stored and available for use, the facility failed to properly inspect the dented cans, and the facility failed to follow facility policy.",2019-10-01
4238,"NHC HEALTHCARE, CHATTANOOGA",445013,2700 PARKWOOD AVE,CHATTANOOGA,TN,37404,2016-10-26,431,D,1,0,8EON11,"**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 maintain control of the controlled substance inventory for 1 resident (#3) of 3 residents reviewed for controlled substance use reviewed. The findings included: Review of the facility Controlled Substance policy, effective date 6/2016, revealed .Accurate accountability of all controlled drugs is maintained at all times .when a dose of a controlled medication is removed from the container for administration .or not given for any reason .it must be destroyed in the presence of two licensed nurses and the disposal documented on the accountability record on the line representing that dose .when a controlled medication is administered .the licensed nurse immediately enters the following information on the accountability record .date and time of administration .amount administered .signature of the nurse . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Medication Administration Record [REDACTED].Lorazepem (Ativan) 2 mg (milligrams per) ml (milliliter) .inject . 2 mg .every 4 hours as needed . Medical record review of the Narcotic Inventory Record (documentation of narcotic administration and waste) dated 9/13/16 at 7:30 PM, revealed Licensed Practical Nurse (LPN) #12 documented waste of 2 ml of Ativan (2 doses) on a single line on the document. Continued review revealed the waste was countersigned by LPN #2. Review of the facility investigation dated 9/13/16 revealed during the 7:00 PM narcotic reconciliation count LPN #2 determined Resident #3 had 2mls of injectable Ativan was unaccounted for. Continued review of the facility investigation revealed LPN #12 reported to LPN #2 the missing Ativan had been wasted though no Nurse had witnessed the waste and LPN #12 documented both doses of the missing Ativan as wasted on a single entry into the record. Continued review of the facility investigation revealed on 9/13/16 around 8:30 PM, LPN #12 (who was off duty and had remained in the facility in a nursing office adjacent to the nursing station) exhibited symptoms of altered mental status, slurred speech, and a brief period of unresponsiveness witnessed by a number of the Nurses on duty. Further review revealed EMS was called to the facility, LPN #12 refused EMS assessment or to undergo compulsory urine drug screening, and LPN #12 fled the facility. Continued review of the facility investigation revealed the facility determined LPN #12 had diverted the missing doses of Ativan and LPN #2 had failed to follow the Controlled substances policy, which required two nurses to witness narcotic waste, to immediately document wasted narcotic doses, and to document each wasted dose individually on the applicable controlled substance inventory documents. Interview with LPN #2 on 10/25/16 at 5:20 PM, by telephone, revealed on 9/13/16 around 7:30 PM, LPN #2 discovered the irregularity in the narcotic count for Resident #3's Ativan and initially refused to accept control of the medication cart. Continued interview revealed LPN #12 corrected the narcotic count and informed LPN #2 the missing Ativan had been wasted, at which time LPN #12 documented the waste in a single entry on the Narcotic Control Inventory and LPN #2 the waste. LPN #2 confirmed she did not witness waste of the missing Ativan and confirmed she accepted control of the medication cart. Further interview confirmed she did not immediately notify her supervisor of the irregularity in the medication count, but did report the situation after she and a number of other nurses on duty witnessed LPN #12 become impaired with symptoms consistent with drug ingestion a short time later. Interview with LPN #12 on 10/26/16 from 3:22 PM to 4:28 PM, by telephone, confirmed she informed LPN #2 she wasted the missing Ativan during the narcotic reconciliation count on 9/13/16. Continued interview revealed LPN #12 confirmed she had deliberately documented the alleged waste via a single entry into the record in violation of facility policy and no licensed nurse witnessed the waste of the missing Ativan in violation of facility policy. Further interview revealed LPN #12 denied diversion of the medication. Interview with the Administrator and Director of Nursing (DON) on 10/25/16 at 6:10 PM, in the conference room, confirmed LPN #2 and LPN #12 failed to follow the facility controlled substances policy for waste of narcotics and failed to report irregularities in narcotic reconciliation counts immediately to the nursing supervisor. Further interview confirmed the facility investigation determined the missing Ativan from Resident #3 was diverted by LPN #12 and the facility failed to maintain control of the controlled substance inventory for Resident #3.",2019-10-01
5202,"NHC HEALTHCARE, CHATTANOOGA",445013,2700 PARKWOOD AVE,CHATTANOOGA,TN,37404,2016-03-30,323,D,0,1,F23O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to prevent a fall for 1 resident (#350) of 3 residents reviewed for falls of 34 residents reviewed. The findings included: Medical record review revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 3/19/15 revealed the resident was at risk for falls due to a history of falls, weakness, abnormality of gait, osteoarthritis, cervical and thoracic [DIAGNOSES REDACTED], with goals of (Resident #350) will be kept safe AEB (as exhibited by) no falls with injury resulting in hospitalization . Review of the resident's Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident needed extensive assistance with bed mobility, transfers, toilet use, and personal hygiene, with the assistance of 2+ persons. The MDS rated the resident needed total assistance with locomotion on unit with the assistance of one person. Review of a facility fall investigation dated 4/12/16 revealed the resident had been toileted in his bathroom on the evening of 4/8/16 with the assistance of CNA #1. The CNA stated . she was transferring the resident from the commode to the wheelchair when the wheelchair tipped backward into her body . she lowered the resident onto the floor of the bathroom . She said that he did not hit anything and stated she thought he was fine . The CNA opened the bathroom door and asked the roommate's family member to help her return the resident to his wheelchair .the family member assisted the CNA to transfer the resident back into his wheelchair and back to his bed. The CNA intended to report the fall to the Nurse on duty Licensed Practical Nurse (LPN) #5, got busy with other residents and forgot to report the fall . Review of a note from the Director of Nursing on 3/29/16 at 9:10 AM, in the conference room revealed .the facility had no falls policy, the facility had guidelines they use to keep patients safe, and the patients are individually assessed . Interview with the Administrator on 3/29/16 at 4:18 PM, in the Administrator's office confirmed CNA #1 should have prevented the fall and reported the resident's fall to her superior immediately after the fall, did not report it until questioned about it at a later date.",2019-04-01
5203,"NHC HEALTHCARE, CHATTANOOGA",445013,2700 PARKWOOD AVE,CHATTANOOGA,TN,37404,2016-03-30,371,F,0,1,F23O11,"Based on review of facility policy, review of temperature logs, observation, and interview, the facility failed to monitor and record freezer temperatures for 8 of 8 resident freezers for 4 of 4 nursing stations, monitor a thermometer for 1 of 10 resident refrigerators for 1 of 4 nursing stations, and to complete temperature logs for 2 of 10 nourishment refrigerators/freezers for 2 of 4 nursing stations that could have affected 178 residents. The findings included: Review of facility policy, Safety and Sanitation Best Practice Guidelines, Refrigerator and Freezer Storage, revised 1/2011 revealed .thermometers .recorded upon opening and in the late afternoon .temperatures not within these ranges, 32 degrees F (Fahrenheit) to 41 degrees F or less .for refrigerator and between - (symbol for negative) 10 degrees F to 0 degrees F .for freezer, should be reported . Observation with Licensed Practical Nurse #1 on 3/29/16 at 9:05 AM in the Station 4 Kitchen/Ice Machine Room in the Non-NHC Refrigerator/Freezer, revealed no thermometer in the freezer. Observation with Registered Nurse #1 on 3/29/16 at 9:20 AM in the Station 3 Kitchen Room in the Non-NHC Refrigerator/Freezer, revealed no thermometer in the freezer. Observation with the Registered Dietician (RD) on 3/29/16 at 9:25 AM, at the Station 2 Non-NHC Refrigerator/Freezer revealed no thermometer in the freezer. Further review in the NHC Secured Refrigerator revealed 24, 4 oz (ounce) dairy snacks with no thermometer and no posted temperature control log sheet. Observation with the RD on 3/29/16 at 9:30 AM, at the Station 1 Refrigerator/Freezer at the Secured Refrigerator revealed 24, 4 oz dairy desserts (high calorie ice creams) with no freezer thermometer. Further review revealed no posted temperature control log sheet. Continued review of the Station 1 Non-NHC Refrigerator revealed no freezer thermometer. Observation with the RD on 3/29/16 at 9:40 AM,at the Station 3 Secured Refrigerator/Freezer revealed 27, 4 oz dairy desserts with no freezer thermometer. Observation with the RD on 3/29/16 at 9:50 AM, at the Station 4 Secured Refrigerator/Freezer revealed no freezer thermometer. Interview with the RD on 3/29/16 at 10:30 AM, in the RD office confirmed the facility failed to maintain and monitor freezer temperatures for 8 freezers, maintain a thermometer for 1 refrigerator, and to maintain temperatures logs for 2 refrigerators.",2019-04-01
6878,"NHC HEALTHCARE, CHATTANOOGA",445013,2700 PARKWOOD AVE,CHATTANOOGA,TN,37404,2015-02-11,309,D,0,1,PJXT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, [MEDICAL TREATMENT] clinic flow sheets, observation, and interview, the facility failed to assess the correct [MEDICAL TREATMENT] site and update the care plan to reflect the current [MEDICAL TREATMENT] in use for one resident (#186) of thirty-seven residents reviewed. The finding included: Resident #186 was admitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set, dated dated dated [DATE], revealed the resident was independent in cognitive skills for decision making. Medical record review of the nurse's notes and [MEDICAL TREATMENT] clinic flow sheets revealed the nurses documented post [MEDICAL TREATMENT] assessments of the left upper extremity and check of the bruitt & thrill dated January 31, 2015, February 2, 2015, and February 3, 2015. Review of the [MEDICAL TREATMENT] flow sheets obtained from the [MEDICAL TREATMENT] center dated January 29, 2015, January 31, 2015, and February 3, 2015, indicated use of the venous [MEDICAL TREATMENT] catheter access in right chest wall instead of the left upper arm access. Medical record review of the care plan dated December 29, 2014, revealed the residents [MEDICAL TREATMENT] access was located in the left upper extremity. Interview with Registered Nurse (RN) #1 on February 10, 2015, at 8:30 a.m., in the nurses station 2 hallway, confirmed RN #1 was not aware of which access was being used for [MEDICAL TREATMENT]. Interview with the Assistant Director of Nursing (ADON) on February 10, 2015, at 8:45 a.m., at nurses station 2, confirmed the ADON was not sure which site was in use for [MEDICAL TREATMENT]. Interview with Licensed Practical Nurse (LPN) #1, on February 10, 2015, at 9:00 a.m., in the nurses station 2 unit manager's office, confirmed the right chest wall [MEDICAL TREATMENT] access was being used. Coninued interview with LPN #1 revealed the [MEDICAL TREATMENT] clinic had notified LPN #1 by telephone of the use of the right chest wall catheter for [MEDICAL TREATMENT]. Interview with the ADON on February 10, 2015, at 9:00 a.m., in the station 2 unit manager's office, confirmed the care plan was incorrect. Observation and interview with the resident on February 11, 2015, at 8:00 a.m., in the resident's room confirmed the right wall [MEDICAL TREATMENT] catheter was present and used for [MEDICAL TREATMENT].",2018-04-01
8906,"NHC HEALTHCARE, CHATTANOOGA",445013,2700 PARKWOOD AVE,CHATTANOOGA,TN,37404,2014-01-29,309,D,0,1,2L2R11,"**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 medication administration for one resident (#250) of forty residents reviewed. The findings included: Resident #250 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 15 (indicating cognitively intact) on the Brief Interview for Mental Status (BIMS). Review of a physician's telephone order dated December 30, 2013, revealed, .[MEDICATION NAME] eye gtt (drops) (1) gtt (L) (left) eye Q (every) a.m. & (and) both eyes Q HS (hour of sleep) . Review of the physician's recapitulation orders for January 1-31, 2014, revealed, .[MEDICATION NAME] 0.005% (percent) eye gtt (1) gtt (L) eye Q am .[MEDICATION NAME] 0.005% eye gtts (1) gtt Q hs . with no indication if the evening eye drops were to be instilled in one eye or both eyes. Medical record review of a Medication Administration Record [REDACTED].[MEDICATION NAME] 0.005% eye gtts (drops) (1) gtt Q hs . with no indication if the drops in the evening were to be instilled in one eye or both eyes. Observation of a medication administration on January 28, 2014, at 7:58 a.m., in the resident's room, with Licensed Practical Nurse (LPN) #1, revealed LPN #1 administered one eye drop in the resident's left eye. After administering the eye drop, the resident asked LPN #1 why am I not getting my eye drops in both of my eyes at night, that is how I take them at home and the hospital was putting them in both eyes at night before I came here. LPN #1 advised the resident a note would be left for the doctor about the eye drops at night. Interview on January 28, 2014, at 8:31 a.m., with Unit Manager #1, at the nurses' station, revealed, (the resident) is pretty with it, if .says .hasn't been getting them, I am sure .hasn't . Continued interview with Unit Manager #1 confirmed the physician's recapitulation orders and the MAR indicated [REDACTED].",2017-03-01
8907,"NHC HEALTHCARE, CHATTANOOGA",445013,2700 PARKWOOD AVE,CHATTANOOGA,TN,37404,2014-01-29,371,F,0,1,2L2R11,"Based on observation, review of facility policy, and interview, the facility failed to follow proper food storage in one of one walk-in freezer in the dietary department. The findings included: Observation of the walk-in freezer in the dietary department on January 27, 2014, at 10:06 a.m., revealed seven pans of dressing, one pan of cornbread, and five slices of cake, all unlabeled and undated. Review of the facility policy Safety and Sanitation Best Practice Guidelines, revised January 2011, revealed, .once cooled, the food should be covered, dated, and labeled . Interview with the Dietary Manager in the kitchen on January 27, 2014, at the time of observation, confirmed the facility failed to label and date the frozen prepared foods.",2017-03-01
10807,"NHC HEALTHCARE, CHATTANOOGA",445013,2700 PARKWOOD AVE,CHATTANOOGA,TN,37404,2012-11-15,157,D,0,1,XL5611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to notify the family of an appointment for one resident (#307) and failed to notify the family after a fall for one resident (#236) of three residents reviewed for accidents of forty three residents reviewed. The findings included: Resident #307 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. (3) Referral to urology . Medical review of a physician's orders [REDACTED].obtain Nephrologists .dx (diagnosis) Persistent Hematuria, Chronic [MEDICAL CONDITION] . Review of the appointment log book revealed on November 6, 2012, an apppointment with a urologist was made for November 14, 2012, at 12:45 p.m. Interview on November 13, 2012, at 4:49 p.m., in the resident's room, with the resident's Power of Attorney (POA) revealed the resident was scheduled for an appointment with the urologist on November 14, 2012. Continued interview revealed .was not notified of the appointment until today (one day before the appointment and if .had not came to visit today .would have never known about the appointment . Interview with the 100 Wing Unit Manager on November 14, 2012, at 3:45 p.m., in the nurses station, revealed the appointment was made on November 6, 2012, for November 14, 2012 at 12:45 p.m. Continued interview confirmed, .we usually call the family and let them know and we failed to notify the POA .spoke with the POA yesterday and told .this was an oversight .another nurse made the appointment and the nurse failed to call the POA . Resident #236 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a nurse's note dated November 13, 2012, revealed .resident found on knee kneeling at bedside facing bed with no apparent injury noted . Medical record review of the Nursing Care Plan dated November 13, 2012, revealed .at risk for falls r/t (related to) fracture and anxiety .ensure call light within reach, scoop mattress (7/24/12), ghost alarm and bed alarm . Review of the POS [REDACTED].patient was on knee kneeling at bedside facing bed .then patient turned over onto mat .Family Notified: No . Observation on November 14, 2012, at 4:20 p.m., in the resident's room, revealed the resident lying on the bed, falls mat in place, and a scoop mattress in place. Interview with Licensed Practical Nurse (LPN) #3 on November 14, 2012, at 4:11 p.m., at the 100 Wing nurses station, confirmed .resident rolled out of the bed on November 13, 2012, was found on .knees on the falls mat .we call the family after any incident . Interview with the Resident Care Coordinator (RCC) on November 15, 2012, at 8:55 a.m., in the coordinator's office, confirmed the family was not notified after the resident's fall on November 13, 2012.",2016-04-01
10808,"NHC HEALTHCARE, CHATTANOOGA",445013,2700 PARKWOOD AVE,CHATTANOOGA,TN,37404,2012-11-15,164,D,0,1,XL5611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to protect privacy during care of one resident (#78) of forty-three residents reviewed. The findings included: Resident #78 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation of resident #78 on November 15, 2012, at 1:31 p.m., in the resident's room, after entering the room during a medication pass, revealed the resident was in bed, lying on the resident's right side with the gown pulled up to the waist and the bed covers pulled down to the ankles. Further observation revealed the incontinent pad was bunched together under the coccyx area, also exposed, the privacy curtains were not drawn, and no staff were present in the room. Interview with Licensed Practical Nurse (LPN) #2 on November 15, 2012, at 1:35 p.m., in the hallway directly outside the resident's room, revealed the resident was receiving incontinence care when left uncovered in the room. Interview with Certified Nursing Assistant (CNA) #1 on November 15, 2012, at 1:35 p.m., outside the resident's room, confirmed the resident was left uncovered while the CNA went to assist another resident. When questioned why this was done, the CNA said There is no excuse. I thought I could get back in time to finish. Further interview with LPN #2 confirmed the facility failed to protect the privacy of the resident during incontinence care.",2016-04-01
10809,"NHC HEALTHCARE, CHATTANOOGA",445013,2700 PARKWOOD AVE,CHATTANOOGA,TN,37404,2012-11-15,176,D,0,1,XL5611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and interview the facility failed to assure one resident (#225) was assessed for self-administration of a medication of forty- three residents reviewed. The findings included: Resident #225 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Physician's Recapitulation Order for November 2012, revealed .[MEDICATION NAME] .5 - 3mg (milligram) .give 1 unit per aerosol 4 times daily . Observation on November 14, 2012, at 8:27 a.m., in the resident's room, revealed the resident was resting in bed in an isolation room, with the door closed. Continued observation revealed the resident was receiving an [MEDICATION NAME] nebulizer treatment with no staff present. Observation revealed the resident's nurse was not in view of the resident. Interview on November 14, 2012, at 8:29 a.m.,on the 400 hallway, with Licensed Practical Nurse (LPN) #1 confirmed the [MEDICATION NAME] nebulizer was started and the nurse left the resident unattended. Interview on November 14, 2012, at 9:53 a.m., at the unit 4 nurse's station, with unit manager #1, confirmed the resident had not been assessed for self administration of the [MEDICATION NAME] breathing treatment.",2016-04-01
10810,"NHC HEALTHCARE, CHATTANOOGA",445013,2700 PARKWOOD AVE,CHATTANOOGA,TN,37404,2012-11-15,241,D,0,1,XL5611,"Based on observation and interview, the facility failed to provide one resident (#158) a meal tray while the roommate was eating of forty-three residents sampled. The findings included: Observation on November 14, 2012, at 8:50 a.m., in the resident's room, revealed the roommate of resident #158 was self feeding their breakfast. Further observation revealed resident #158 had not received a tray. Further observation revealed resident #158 pressed the call light and the responding Certified Nurse Aide (CNA) #2 asked resident #158 what (resident) needed. Resident #158 pointed to the roommate and questioned the CNA why (resident #158) had not received their tray. Further observation at 9:01 a.m., revealed CNA #2 delivered resident #158's tray and resident #158 proceeded to self feed their breakfast. Interview with CNA #2 on November 14, 2012, at 9:01 a.m., in the residents' room, revealed both residents, #158 and the roommate, breakfast trays were delivered on the same cart. Further interview confirmed both residents were to receive their breakfast at the same time.",2016-04-01
10811,"NHC HEALTHCARE, CHATTANOOGA",445013,2700 PARKWOOD AVE,CHATTANOOGA,TN,37404,2012-11-15,253,D,0,1,XL5611,"Based on observation and interview, the facility failed to maintain three ceiling vents and twelve ceiling tiles in the main dining room in a sanitary manner; failed to maintain resident fans in a sanitary manner for two (#40 and #94) of forty-three residents reviewed; and failed to maintain two soiled linen carts and one clean linen rack in a sanitary manner on the 100 hall. The findings included: Observation on November 13, 2012, at 11:41 a.m., in the main dining room during the mid-day meal service, revealed two ceiling vents and surrounding ceiling tiles, located on either end of the steam table; and one ceiling vent and surrounding ceiling tiles, located closest to the clock and over dining tables, had a heavy black accumulation of debris. Further observation revealed twelve stained ceiling tiles. Interview on November 13, 2012, at 11:43 a.m., with the facility Registered Dietitian, in the main dining room, confirmed three ceiling vents and surrounding ceiling tiles had a heavy accumulation of black debris and twelve ceiling tiles were stained. Observation on 100 hall, outside room 115, on November 14, 2012, at 8:25 a.m., revealed two soiled linen carts with stained exteriors and a heavy accumulation of dust and debris. Further observation revealed a covered clean linen rack containing linen, between the two soiled linen carts, with a heavy accumulation of dust on the frame of the rack. Interview on November 14, 2012, at 8:30 a.m., with the Housekeeping Director, outside room 115, confirmed the two soiled linen carts had soiled exteriors and had a heavy accumulation of dust and debris. Further interview confirmed the clean linen rack had a heavy accumulation of dust on the frame of the rack. Observation on November 15, 2012, at 8:22 a.m., of resident #40's fan on the floor at the foot of the bed, revealed the fan grate and blades had a heavy accumulation of dust and debris. Further observation revealed resident #94 in bed with a fan in operation on the bed-side table and pointed directly at the resident. Further observation revealed a heavy accumulation of debris hanging from the fan grate. Interview in the room of residents #40 and #94, on November 15, 2012, at 8:26 a.m., with Licensed Practical Nurse (LPN) #5, confirmed both fans had a heavy accumulation of dust and debris on the grates. Observation revealed LPN #5 turned off resident #94's fan. Further observation revealed resident #94's fan blades were also covered with a heavy accumulation of debris. Further interview with LPN #5 confirmed both resident's fans had blades with a heavy accumulation of dust and debris.",2016-04-01
10812,"NHC HEALTHCARE, CHATTANOOGA",445013,2700 PARKWOOD AVE,CHATTANOOGA,TN,37404,2012-11-15,272,D,0,1,XL5611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to complete the Minimum Data Set (MDS) accurately for one resident (#281) of twenty-nine residents reviewed of forty-three residents sampled. The findings included: Resident #281 was admitted to the facility on [DATE], with diagnosed including: [DIAGNOSES REDACTED]. Medical record review of the admission MDS dated [DATE], revealed no behavior issues addressed and no [DIAGNOSES REDACTED]. Medical record review of the Pre-Admission Screening and Resident Review (PASRR) dated September 26, 2012, revealed .Mental Illness: Yes .Diagnosis: [REDACTED]. Medical record review of a Social Service Note dated October 4, 2012, revealed .Pt (patient) very guarded and suspicious .Pt very abrupt .Pt cursed .PT refused assess (assessment) .pt has been uncooperative/cursing at other staff as well . Medical record review of a Social Service Note dated October 23, 2012, revealed .Pt's sister .brought in documentation dated 6/25/11 .eval'd (evaluated) by a psyc (psychiatrist) diag (diagnosis) [MEDICAL CONDITION] .[MEDICAL CONDITION] Type .Borderline Personality D/O (disorder) .signed (named psychiatric service) Consult . Interview with the Director of Nursing (DON) on November 14, 2012, at 4:30 p.m., in the DON office, confirmed the MDS was not accurate.",2016-04-01
10813,"NHC HEALTHCARE, CHATTANOOGA",445013,2700 PARKWOOD AVE,CHATTANOOGA,TN,37404,2012-11-15,280,D,0,1,XL5611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to evaluate and update the care plan for one resident (#21) for behaviors, and for one resident (#40) for dental needs of twenty-nine residents reviewed of forty-three residents sampled. The findings included: Resident #21 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a quarterly Minimum Data Set (MDS) dated [DATE], revealed memory impairment, no behaviors, and required extensive assistance with all Activities of Daily Living (ADL's.) Medical record review of a care plan dated August 30, 2012, revealed no care plan for behaviors and the use of [MEDICATION NAME]. Medical record review of a Nurse's Note dated September 11, 2012, revealed .can become combative with care . Medical record review of a Nurse's Note dated September 25, 2012, revealed .increased agitation noted . Medical record review of the Physician's Recapitulation orders dated November 1, 2012, through February 1, 2013, revealed .[MEDICATION NAME] 1mg (milligram) SQ (subcutaneous) every morning at 6:30 a.m. or PO (per mouth) . Observation on November 14, 2012, at 8:30 a.m., in the resident's room, revealed the resident lying on the bed. Interview with Unit Manager #1 on November 11, 2012, at 9:42 a.m., at the Nurse's Station, revealed the [MEDICATION NAME] was given subcutaneously, the resident refuses to take medications orally, refuses care, and becomes combative with personal care. Interview with the Director of Nursing (DON) on November 15, 2012, at 10:00 a.m., at the Nurses Station, revealed the care plan had not been updated to reflect the resident's behaviors and the use of [MEDICATION NAME]. Resident #40 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the annual Minimum Data Set, dated dated dated [DATE], revealed the resident scored a fourteen out of fifteen for cognition; had broken or loosely fitting full or partial denture; and had no mouth or facial pain, discomfort or difficulty with chewing. Medical record review of the Dental Progress Notes revealed: October 12, 2012, Exam: Periodic Oral Evaluation, Consultation; Other procedures: Can not wear new dentures, No ridge; October 19, 2012, alignment impression made for a new lower complete denture with a permanent cushion liner; October 23, 2012, Wax bite registration; and October 30, 2012, Delivery of new lower complete denture w (with) a permanent cushion liner. Attending nurse and administrator informed. Medical record review of the Social Services Progress Note dated October 31, 2012, revealed .Got (resident) new dentures yesterday. (Resident) is real excited and says they fit good . Medical record review of a physician phone order dated November 13, 2012, revealed Dental Consult loose fitting dentures. Medical record review of the nurse's note dated November 13, 2012, revealed .Spoke w (named dentist) and informed him that (Resident) was c/o (complaining of) loose fitting dentures. (Named dentist) informed writer that only thing you can do is have (resident) to apply adhesive to (resident's) dentures. There is nothing else I can do to the dentures to adjust them. Writer stated OK . Medical record review of the care plan dated October 30, 2012, revealed no documentation of the use of adhesive. Interview with Certified Nurse Aide #3, working the 3:00 p.m. to 11:00 p.m. shift, on November 14, 2012, at 4:21 p.m., at the station one nursing station, confirmed resident #40 .has false teeth, at night take them out and place (false teeth) in cup .(resident) does not use adhesives . Interview with Certified Nurse Aide #4 on November 15, 2012, at 8:39 a.m., at the station one nursing station, confirmed the resident . has dentures .does not need adhesive and if (resident) needed adhesive I would apply it . Interview with Unit Manager #3 on November 15, 2012, at 9:20 a.m., at the station one nursing station, confirmed the nurse failed to update the care plan to address the use of a dental adhesive.",2016-04-01
10814,"NHC HEALTHCARE, CHATTANOOGA",445013,2700 PARKWOOD AVE,CHATTANOOGA,TN,37404,2012-11-15,371,F,0,1,XL5611,"Based on observation and interview, the facility dietary department failed to maintain the walk-in refrigerator condenser grates, ceiling area in front of the condenser unit, and the ceiling vents and surround ceiling tiles in the dietary department in a sanitary manner. The findings included: Observation on November 13, 2012, at 11:27 a.m., with the facility Registered Dietitian present, revealed the walk-in refrigerator condenser grates and ceiling area in front of the condenser had a heavy accumulation of debris present. Interview with the Registered Dietitian, present during the observation on November 13, 2012, at 11:27 a.m., confirmed the walk-in refrigerator condenser grates and ceiling area in front of the condenser had a heavy accumulation of debris present. Observation on November 15, 2012, beginning at 7:45 a.m., with the regional representative present, of the resident morning meal tray line service in the dietary department, revealed a ceiling vent and surrounding ceiling tiles located above the steam table service area, were covered with a heavy accumulation of debris. Further observation revealed a ceiling vent and surrounding ceiling tiles in the area between the steam jacketed kettle and the tray line were covered with a heavy accumulation of debris. Interview on November 15, 2012, at 8:10 a.m., in the dietary department by the steam table, with the facility regional representative, confirmed the ceiling vents and surrounding ceiling tiles over the steam table service area and between the steam jacketed kettle and steam table had heavy accumulations of debris.",2016-04-01
10815,"NHC HEALTHCARE, CHATTANOOGA",445013,2700 PARKWOOD AVE,CHATTANOOGA,TN,37404,2012-11-15,428,D,0,1,XL5611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to notify the physician timely of pharmacy consultant reports for one resident (#225) of forty-three residents reviewed. The findings included: Resident #225 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Consultant Pharmacist's Recommendation dated August 9, 2012, revealed .Sulfasalazine (drug used for ulcerative colitis) .consider decreasing dose to 1 gm (gram) in the morning and 500 mg (milligram) in the evening . Continued review of the recommendation revealed the Physician/ Prescriber response was not addressed until August 21, 2012 (12 days after recommendation). Interview with Unit Manager #1 on November 14, 2012, at 4:05 p.m., at the station 4 nurse's station, confirmed the facility failed to act upon the pharmacy consultant reports timely.",2016-04-01
10816,"NHC HEALTHCARE, CHATTANOOGA",445013,2700 PARKWOOD AVE,CHATTANOOGA,TN,37404,2012-11-15,441,D,0,1,XL5611,"Based on observation, review of facility policy, and interview, the facility failed to follow infection control practices during medication administration for one resident (#281) of ten medication administrations observed and failed to assure that the biohazard trash was secure on one of four stations. The findings included: Observation on November 13, 2012, at 7:45 a.m., revealed Licensed Practical Nurse (LPN) #4 prepared resident #281's medication, entered the resident's room, placed the inhaler chamber on the resident's bedside table, and the resident self administered the inhaler. Further observation at this time revealed LPN #4 placed the inhaler chamber on the bathroom sink, washed the hands, exited the room, placed the inhaler chamber on the medication cart, unlocked the medication cart, and placed the inhaler chamber in the medication cart. Interview with LPN #4 on November 13, 2012, at 7:50 a.m., on the 300 hallway, confirmed infection control practice was not followed during medication administration. Observation on November 13, 2012, at 11:38 a.m., across from the station 3 nurse's station, revealed a housekeeping door was left unlocked leading to a biohazard trash closet, also left unlocked. Continued observation revealed multiple isolation boxes half full and a visible sharps container. Observation and interview on November 13, 2012, at 11:40 a.m., with the Director of Nursing, confirmed the doors were to be locked and secured.",2016-04-01
10817,"NHC HEALTHCARE, CHATTANOOGA",445013,2700 PARKWOOD AVE,CHATTANOOGA,TN,37404,2012-11-15,463,D,0,1,XL5611,"Based on observation and interview, the facility failed to have operational call lights in two of two whirlpool rooms. The findings included: Observation on November 15, 2012, beginning at 1:00 p.m., with the Maintenance Director present, revealed the call lights were not working in the whirlpool rooms located on station 3 and station 4. Interview with the Maintenance Director present during the observation on November 15, 2012, beginning at 1:00 p.m., confirmed the call lights were not working in stations 3 and 4. Further interview confirmed the residents did use the whirlpool rooms.",2016-04-01
10818,"NHC HEALTHCARE, CHATTANOOGA",445013,2700 PARKWOOD AVE,CHATTANOOGA,TN,37404,2012-11-15,520,D,0,1,XL5611,"Based on review of Quality Committee sign in sheets, Quaility Committee member list, and interview, the facility failed to maintain a quality assessment committee that met at least quarterly. The findings included: Review of sign in sheets with Assistant Director of Nursing (ADON) #1 on November 15, 2012, at 1:00 p.m., in the ADON office on station three, revealed the physician designated by the facility had only attended two meetings from October 2011 to October 2012. Interview with ADON #1 on November 15, 2012, at 1:10 p.m., in the ADON office at station three, revealed the designated physician had been informed about the requirement to attend meetings at least quarterly. Further interview confirmed the physician was on the committee but not an active participant, and had not attended the Quality Assurance meetings at least quarterly.",2016-04-01
13159,"NHC HEALTHCARE, CHATTANOOGA",445013,2700 PARKWOOD AVE,CHATTANOOGA,TN,37404,2015-02-11,371,B,0,1,PJXT11,"Based on observation and interview, the facility failed to store food in a sanitary manner to prevent cross-contamination between resident food items and non-food items for three of seven refrigerator/freezers designated for resident snacks, on two of four units observed. The findings included: Observation with Licensed Practical Nurse (LPN) #4 on February 10, 2015, at 12:55 p.m., of the station 1 nourishment refrigerator/freezer, revealed individual servings of ice cream for resident use stored in the freezer. Continued observation revealed three ice packs had been stored on the door rack of the freezer (one freezer gel pack and two solid ice packs). Observation with LPN #3 on February 10, 2015, at 1:00 p.m., of the station 4 nourishment refrigerator/freezer located in the Kitchen/Ice Machine room, revealed individual servings of ice cream for resident use had been stored in the freezer. Continued observation revealed one solid ice pack had been stored on the door rack of the freezer. Observation with LPN #3 on February 10, 2015, at 1:05 p.m., of the station 4 nourishment refrigerator/freezer located in the Med (medication) Prep (preparation) Room, revealed individual servings of ice cream for resident use had been stored in the freezer. Continued observation revealed one gel freezer pack had been stored in the freezer next to the resident's ice cream. Interview with LPN #2 on February 10, 2015, at 2:15 p.m., at nurse's station 4, confirmed the ice packs were not to be stored with the food items. Interview with the Registered Dietician on February 10, 2015, at 4:15 p.m., in the Parkwood Dining Room, confirmed non-food items were not to be stored with the resident's snacks.",2015-04-01
13287,"NHC HEALTHCARE, CHATTANOOGA",445013,2700 PARKWOOD AVE,CHATTANOOGA,TN,37404,2011-05-19,159,F,0,1,F82G11,"Based on review of resident trust accounts and interview, the facility failed to apply interest to eighty-eight of eighty-eight resident trust accounts reviewed. The findings included: Review of eighty-eight pooled resident trust accounts revealed no interest was applied to the trust accounts January 1, 2011, through April 30, 2011. Review of the bank account statement for the trust account for the statement period from March 1-31, 2011, revealed the average balance was $45,382.93. Interview on May 18, 2011, at 1:00 p.m., with the Business Office Manager (BOM), in the BOM's office, confirmed interest was not applied to the resident trust accounts from January 1, 2011, through April 30, 2011.",2015-02-01
13288,"NHC HEALTHCARE, CHATTANOOGA",445013,2700 PARKWOOD AVE,CHATTANOOGA,TN,37404,2011-05-19,323,D,0,1,F82G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to ensure a safety device was in place for one (#22) of twenty-eight residents reviewed. The findings included: Resident #22 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 assistance with transfers, limited assistance with walking, and had experienced a fall since the prior assessment. Medical record review of the Complete Patient Care Plan reviewed on April 21, 2011, revealed the resident was at risk for falls and a tab alarm was to be applied when in the chair or bed. Observation on May 18, 2011, at 4:53 p.m., revealed the resident seated in a wheelchair in the resident's room. Continued observation revealed the alarm box was located on the back of the wheelchair, however, the tab alarm was not attached to the resident. Observation and interview, on May 18, 2011, at 4:57 p.m., with Licensed Practical Nurse (LPN) #3, revealed the resident seated in the wheelchair, and confirmed the tab alarm was not attached to the resident.",2015-02-01
13289,"NHC HEALTHCARE, CHATTANOOGA",445013,2700 PARKWOOD AVE,CHATTANOOGA,TN,37404,2011-05-19,425,D,0,1,F82G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of pharmacy delivery records, observation, and interview, the facility failed to ensure timely pharmacy services for one (#22) of twenty-eight residents reviewed. The findings included: Resident #22 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]."" Medical record review of the nursing notes revealed the following: February 21, 2011, at 8:00 p.m., ""...ABT (Antibiotic) for conjunctivitis. Gentamycin to begin to Rt. Eye...""; ""February 21, 2011, at 11:00 p.m., ""Med (Medication) from pharmacy Gentamycin ophthalmic did not come in from pharmacy""; February 22, 2011, at 11:00 p.m., ""ABT eye ointment still did not arrive...""; February 23, 2011, at 1:00 p.m., ""ABT eye oint still not in facility. Pharmacy has been notified..."" Review of the pharmacy Delivery Sheets revealed the Gentamicin Ophthalmic Ointment was delivered to the facility February 23, 2011, (no time documented). Observation on May 18, 2011, at 7:15 a.m., revealed the resident lying on the bed sleeping. Interview on May 19, 2011, at 7:35 a.m., with the Director of Nursing (DON), in the conference room, confirmed the delay in obtaining the Gentamicin ophthalmic ointment.",2015-02-01
13290,"NHC HEALTHCARE, CHATTANOOGA",445013,2700 PARKWOOD AVE,CHATTANOOGA,TN,37404,2011-05-19,281,E,0,1,F82G11,"**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 four residents (#18, #20, #15, #25) of twenty-eight residents reviewed. The findings included: Resident #18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed the resident received [MEDICAL TREATMENT] for chronic [MEDICAL CONDITION] at the [MEDICAL TREATMENT] clinic three times a week on Monday, Wednesday, and Friday. Continued medical record review revealed the resident had a vascular catheter (vas cath) placed in the upper right chest wall for [MEDICAL TREATMENT] access. Review of the physician's order dated May 9, 2011, revealed, ""...Monitor for S/S (signs and symptoms) of bleeding at vas cath Q (every) shift..."" Continued review of facility documentation revealed no evidence the facility had followed the physician's order and monitored the catheter site every shift. Interview with Licensed Practical Nurse #1 on May 18, 2011, at 4:00 p.m., at the 200 hall nurses station confirmed the physician's order had not been followed. Resident #20 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed the resident received [MEDICAL TREATMENT] treatment three days a week on Tuesday, Thursday and Saturday. Review of the physician's order dated May 9, 2011, revealed, ""...Obtain BP (blood pressure) prior to leaving for [MEDICAL TREATMENT] & (and) upon return from [MEDICAL TREATMENT] on Tues (Tuesday), Thur (Thursday), Sat (Saturday)."" Review of the resident's [MEDICAL TREATMENT] treatment schedule revealed the first [MEDICAL TREATMENT] treatment after the order had been written was on May 10, 2011. Review of the facility's documentation for May 10, 2011, revealed no evidence the blood pressures had been obtained. Interview with RN #1 on May 19, 2011, at 8:30 a.m., at the 300 hall nurses station confirmed the physician's order had not been followed. Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician's orders dated April 1, 2011, through April 30, 2011, and May 1, 2011, through May 31, 2011, revealed, ""...Obtain v/s (vital signs) before [MEDICAL TREATMENT] and upon returning from [MEDICAL TREATMENT]..."" Medical record review of the vital signs record revealed no documentation vital signs were obtained upon return from [MEDICAL TREATMENT] on April 8, 2011, April 18, 2011, April 20, 2011, April 22, 2011, May 4, 2011, and May 9, 2011. Interview on May 18, 2011, at 9:10 a.m., with the Assistant Director of Nursing, in the conference room, confirmed the vital signs had not been obtained upon return from [MEDICAL TREATMENT] on April 8, 18, 20, 22, 2011, May 4, and May 9, 2011. Resident #25 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Physician's Telephone Order dated May 10, 2011, revealed ""...1.) Stop HCTZ ([MEDICATION NAME]-a diuretic medication used to control blood pressure) 2.) [MEDICATION NAME] (a medication used to control blood pressure) 0.1 mg. (milligram) TID (three times per day) PO (by mouth); hold for SBP (systolic blood pressure) <100 (less than 100)..."" Medical record review of the May, 2011, Medication Administration Record [REDACTED]. Interview with LPN #2 on May 18, 2011, at 3:50 p.m., in nursing station three, confirmed the blood pressure had not been checked prior to [MEDICATION NAME] administration.",2015-02-01
13291,"NHC HEALTHCARE, CHATTANOOGA",445013,2700 PARKWOOD AVE,CHATTANOOGA,TN,37404,2011-05-19,502,D,0,1,F82G11,"**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 as ordered for three residents (#21, # 25, #27) of twenty - eight residents reviewed. The findings included: Resident #21 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of Physician's Telephone Orders dated April 1, 2011, revealed ""...CBC (Complete Blood Count) in 1 week..."" Continued review revealed an order on April 6, 2011, ""...Hgb A1c (blood test done to assess blood sugar levels over a three month period) to be obtained (with) CBC see order 4/1/11..."" Medical record review of the resident's chart revealed no documentation the CBC and Hgb A1c were completed on April 8, 2011. Interview with the Director of Nursing on May 19, 2011, at 8:45 a.m. in nursing station three, confirmed the CBC and Hgb A1c were not completed on April 8, 2011. Resident #25 was admitted to the facility with [DIAGNOSES REDACTED]. Medical record review of Physician's Telephone Orders dated March 10, 2011, revealed ""...BMP (Basic Metabolic Profile-blood test to assess blood chemistry) Dx.(Diagnosis) HCTZ ([MEDICATION NAME]-diuretic drug used to treat Hypertension) Rx. (prescription)..."" Medical record review of the Medication Administration Record [REDACTED]. Continued medical record review revealed a BMP had not been completed on March 11, 2011. Interview with the Assistant Director of Nursing on May 19, 2011, at 10:05 a.m., in the conference room, confirmed the BMP ordered on March 10, 2011, was not completed. Resident #27 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed the resident was discharged on [DATE]. Medical record review of a Nurse Practitioner's order dated March 7, 2011, revealed ""1. increase [MEDICATION NAME] (anticoagulant) 6 mg (milligrams) PO (by mouth) daily. 2. PT/INR (test to check coagulopathy) on 3-11-11"" Medical record review revealed no documentation the PT/INR was completed on March 11, 2011. Medical record review of the Nurse Practitioner's (NP) orders dated March 14, 2011, revealed ""1. Discharge to...4. Home Health to manage [MEDICATION NAME] therapy...5. PT/INR now before discharge. 6. Call NP with results before discharge for PT/INR/[MEDICATION NAME] orders..."" Medical record review of the PT/INR results dated March 14, 2011, revealed the PT was 12.6 and the INR was 1.3 (no reference range noted). Continued review of the PT/INR results revealed the Nurse Practitioner was notified of the results and an order was obtained to increase the [MEDICATION NAME] to 7 mg daily. Interview on May 18, 2011, at 8:40 a.m., with the Assistant Director of Nursing, in the conference room, confirmed the PT/INR was not completed as ordered on March 11, 2011. Interview on May 18, 2011, at 9:55 a.m., with the Nurse Practitioner, in the conference room, revealed the resident received the [MEDICATION NAME] due to [MEDICAL CONDITION] Fibrillation and the optimal range for the resident's INR was 2.0-3.0. Continued interview revealed the Nurse Practitioner had discovered the PT/INR was not completed as ordered on March 11, 2011, and re-ordered the PT/INR on the day of discharge (May 14, 2011).",2015-02-01
13292,"NHC HEALTHCARE, CHATTANOOGA",445013,2700 PARKWOOD AVE,CHATTANOOGA,TN,37404,2011-05-19,287,D,0,1,F82G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure timely submission of the MDS (Minimum Data Set) information for one resident (#11) of twenty-eight residents reviewed. The findings included: Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed no MDS available to review after December 30, 2010. Interview with the MDS Coordinator on May 17, 2011, at 4:30 p.m. at nursing station three, revealed the MDS with an assessment reference date of March 25, 2011, had not been locked or submitted to the state.",2015-02-01
13915,"NHC HEALTHCARE, CHATTANOOGA",445013,2700 PARKWOOD AVE,CHATTANOOGA,TN,37404,2009-02-12,157,D,1,1,XMN911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, and interview, the facility failed to notify the physician and the family of a fall for one resident (#15) of thirty-two residents reviewed. The findings included: Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had modified independence with daily decision making (new situations only) and required assist of one person for transfers and ambulation. Review of the nurse's notes dated March 21st through April 1, 2008, revealed the resident had fallen on Easter Sunday (March 23, 2008), complained of pain on March 26, 2008, and was sent to the emergency room for evaluation on March 31, 2008, and was admitted with the [DIAGNOSES REDACTED]. Review of the nurses note dated March 31, 2008, revealed the nurse failed to notify the physiscian and the resident's family at the time of the fall. Review of the documentation provided by the facility dated April 4, 2008, revealed, "" Pt. found on floor at bed ...no apparent injury. Nurse never notified anyone ... "" Review of the facility's policy, Protocol for Falls, revealed, "" After a fall staff will: ...3. Notify family and MD (Medical Doctor) ... "" Interview with the Director of Nurses on February 11, 2009, at 1:30 p.m., in the Director's office, confirmed the physician and the family had not been notified of the resident's fall. Entity reported incident #TN",2014-07-01
13916,"NHC HEALTHCARE, CHATTANOOGA",445013,2700 PARKWOOD AVE,CHATTANOOGA,TN,37404,2009-02-12,514,D,1,1,XMN911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure a medical record was complete for two (#14, #15) of thirty-two residents reviewed. The findings included: Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. intake. Interview on February 11, 2009, at 7:35 a.m., with Licensed Practical Nurse (LPN) #2, responsible for the resident's care, in the hallway, revealed the resident was on a 1500cc fluid restriction Interview on February 12, 2009, at 7:15 a.m., with the Registered Dietician, in the nursing station, revealed the dietary department provided 750cc of fluid daily, to the resident, with meals, and nursing provided an additional 750cc of fluid. Interview on February 12, 2009, at 7:30 a.m., with LPN #3, in the hallway, revealed dietary provides 740cc of fluids, the resident received approximately 240cc of water with the morning medications, and the Certified Nursing Assistants (CNA) notified LPN #3 of the resident's fluid intake daily. Interview with CNA #1 on February 12, 2009, at 7:35 a.m., (CNA responsible for the resident's care), in the hallway revealed an awareness of the resident's fluid restriction. Continued interview revealed the resident was provided one cup (120cc) of water on the day shift, in addition to fluids provided with meals. Interview on February 12, 2009, at 7:40 a.m., with CNA #2, in the hallway, revealed the resident was provided one cup (120cc) of water on the day shift, in addition to fluids provided with meals. Interview on February 11, 2009, at 8:00 a.m., with the Director of Nursing, in the conference room, confirmed there was no documentation of the amount of the resident's daily fluid intake. Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had modified independence with daily decision making, and required assist of one person for transfers and ambulation. Review of the nurse's notes dated March 31, and April 1, 2008, revealed the resident had fallen on Easter Sunday (March 23, 2008). Review of the facility's investigation dated April 4, 2008, revealed, ""Pt. found on floor at bed...no apparent injury. Nurse never notified anyone..."" Review of the nurse's notes dated March 21st through March 30th, 2008, revealed no documentation the resident had fallen. Review of the facility's policy, Protocol for Falls, revealed, ""After a fall staff will: ...3. Notify family and MD (Medical Doctor); 4. Place on alert charting for 72 hours;...6. Print out Post Fall Assessment; 7. Start in depth investigation, after printing Post Fall Investigation; 8. Notify staff of changes in Patient Care Plan by oral report, written intervention on assignment sheet..."" Observation on February 10, 2009, at 3:00 p.m., in the resident's room, revealed the resident seated in a wheelchair at the bedside. Resident was alert, oriented, able to recall events of childhood and family history. Interview with the resident at this time revealed the resident recalled, ""...had been up to bathroom, fell and broke hip..."" Interview with the Director of Nurses on February 11, 2009, at 1:30 p.m., in the Director's office, confirmed no documentation had been made in the clinical record at the time of the resident's fall.",2014-07-01
14255,"NHC HEALTHCARE, CHATTANOOGA",445013,2700 PARKWOOD AVE,CHATTANOOGA,TN,37404,2010-04-28,323,D,,,FSYY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide supervision to prevent a fall for one (#21) of twenty-eight residents reviewed. The findings included: Resident #21 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had no short/long term memory problems, moderately impaired cognitive skills for daily decision making, required extensive assistance for transfers, and was not able to attempt balance test for standing or sitting without physical help. Medical record review of the High Risk Patient Selection Form dated March 30, 2010, revealed the resident was at risk for falls. Medical record review of the post falls nursing assessment dated [DATE], revealed, ""...CNA entered bathroom to find (resident) sitting on the bathroom floor...leaning against the shower chair that was over the toilet...4/12/10 staff reports pt. (patient) was...reaching for the sink ...placed on CNA sheet ""do not leave alone in bathroom...was assessed for injury (with) no apparent injury noted...new intervention Do not leave unattended in BR-shower chair has seat belt and wheels that lock ..."" Medical record review of the post falls nursing assessment dated [DATE], revealed, "" ...CNA reported ...needed to get a washcloth for patient and no linen cart in hallway had to go to front hall to get washcloth off linen cart and upon returning to patient in bathroom ...found patient sitting on floor leaning to left side patient had stood up to get paper towel forgot that CNA had gone to get washcloth...patient not to be left alone in bathroom...assessed for injury (with) no apparent injury noted..."" Observation on April 27, 2010, at 3:15 p.m., in the resident's room, revealed the resident lying on the low bed with mats on the floor beside the bed, and a tab alarm attached to the resident's shirt. Interview on April 27, 2010, at 3:55 p.m., with LPN #2, in the Director of Nursing office, confirmed the resident was not to be left alone in the bathroom.",2014-02-01
14256,"NHC HEALTHCARE, CHATTANOOGA",445013,2700 PARKWOOD AVE,CHATTANOOGA,TN,37404,2010-04-28,226,D,,,FSYY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, and interview, the facility failed to implement the Abuse Protection and Response Policy for one (#28) of twenty-eight residents reviewed. The findings included: Resident #28 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed the resident was discharged from the facility to the hospital on February 15, 2010. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had short term memory problems, moderately impaired cognitive skills, had repetitive health and anxious complaints, was verbally abusive, and was resistive to care. Medical record review of a nursing note dated December 28, 2009, at 1:00 a.m., revealed ""Writer went into pt's (patient's) room to give meds. Pt was upset and started crying. When asked what was wrong pt stated, 'I've got to tell you something and I want it reported. The CNA (Certified Nursing Assistant) threw my call light where I could not reach it and all I wanted was her to turn my fan."" The pt continued to repeat this over and over. The CNA had been in to pts room to answer the call light once since the shift started, and pt wanted (her/him) to ask writer if...could have...meds. After CNA had came out of pts room, the pt rang the call light again, and this is when the writer answered it and gave pt...meds. After several minutes of care per writer, the pt stated, 'and (she/he) told me that I was going to hell, and that I was the worst pt in the whole facility.' I want this reported because nobody is going to talk to me like this. I do not want the CNA to come back into this room and take care of me. Writer asked pt if...knew where...tissues were so writer could wipe pts face off. Pt stated, 'I don't have any, I've been asking everybody for some for two days and nobody will bring me any. Pt's tissues were by...cooler. Writer explained to pt that if...wanted someone reported, that...would also need to talk to whomever...wanted to report the CNA to. All needs were met for pt by writer before leaving the room, however pt has on the light again within 15 minutes. Pt's call light is in reach."" Review of documentation provided by the facility revealed Licensed Practical Nurse (LPN) #1 had been in charge of the resident's care on December 28, 2009, and had received the complaint from the resident regarding allegations related to Certified Nursing Assistant (CNA) #1. Continued review of the documentation revealed LPN #1 had talked to CNA #1 after receiving the allegations from the resident and CNA #1 had denied the allegations. Telephone interview on April 27, 2010, at 9:30 p.m., with LPN #1, (LPN in charge of the resident on December 28, 2009, at the time of the incident) revealed resident #28 had reported CNA #1 had placed the call light out of the resident's reach, had told the resident (he/she) was the worst patient in the facility, and told the resident to go to hell. Continued interview revealed the resident had a touch pad call light, and when LPN #1 had entered the resident's room on December 28, 2009, at approximately 1:00 a.m., it appeared the call light had slid from the resident's chest. Continued interview with LPN #1 revealed the resident had requested CNA #1 to not return to the resident's room to provide care to the resident. Continued interview revealed LPN #1 and another LPN provided care to the resident for the remainder of the shift, with the exception of two times when LPN #1 needed help providing care to the resident, and CNA #1 assisted LPN #1 with the resident's care. Review of the facility's Abuse Protection and Response Policy revealed ""...Any patient event that is reported to any partner by patient, family, other partner or any other person will be considered an allegation of abuse if it meets any of the following criteria...Any patient or family complaint of physical or verbal harm, pain or mental anguish resulting from the actions of others...Partner(s) suspected of abuse will be immediately placed on administrative leave pending result of investigation..."" Interview on April 27, 2010, at 8:25 a.m., with the Administrator, in the Administrator's office, revealed CNA #1 was not immediately placed on administrative leave after the allegation of verbal abuse, and confirmed the facility's policy was not followed. C/O #",2014-02-01
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
3705,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2017-03-16,225,D,1,0,1BX111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of facility investigations, and interview, the facility failed to notify the state of an allegation of abuse in a timely manner for 1 resident (#7) of 8 residents reviewed. The findings included: Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of facility documentation dated 1/24/17 revealed on 1/24/17 at 12:20 PM, Resident #7 informed Registered Nurse (RN) #1 a staff member on the night shift .came into my room and was hitting my back and spanking my rear end . Review of a facility investigation revealed the facility conducted a thorough investigation of the allegation and did not substantiate abuse had occurred. Interview with the RN #1 on 3/13/17 at 10:09 AM, in the Director of Nursing (DON) office, confirmed Resident #7 reported the allegation to RN #1 on 1/24/17 at 12:20 PM. Interview with Social Worker #1 on 3/13/17 at 10:45 AM, in the DON's office, confirmed Social Worker #1 was notified by Resident #7 of the alleged abuse on 1/24/17 at 2:40 PM. Interview with the Administrator on 3/15/17 at 2:59 PM, in the DON's office, and again by telephone on 3/16/17 at 2:24 PM, confirmed the facility became aware of the allegation of abuse on 1/24/17 and did not notify the state of the alleged abuse until 3 days later on 1/27/17.",2020-03-01
3897,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2017-01-05,431,D,1,0,UY2G11,"**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 secure a controlled substance to prevent diversion for 1 resident (#6) of 8 residents reviewed. The findings included: Review of the facility policy, Medication-Controlled Medication, with a revised date of 3/23/15, revealed, .Controlled substances must be stored in a locked medication room in a locked container separate from containers for any non-controlled medications, or in a double locked compartment of the medication cart . Medical record review revealed Resident #6 was admitted to the facility for respite hospice care on 11/20/16, discharged on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Hospice Physician Verbal Order dated 11/17/16, with an effective date of 11/20/16, revealed an order for [REDACTED]. Medical record review of the Controlled Drug Receipt/Record/Disposition Form received 11/20/16, revealed Resident #6 brought in a home medication of liquid Oxycodone 5mg/5ml containing 55 ml. Continued review revealed on 11/25/16 at 8:30 AM, the bottle contained 30 ml and there was no documentation the resident had received any doses of the medication. Review of an email from the Director of Nursing (DON) to the Pharmacist dated 11/25/16 at 8:24 AM, revealed .We have a narcotic issue that we found this morning .Also, we need lock boxes for the fridge narcotics. Is that something that we can get from you all? . Review of an email from the Pharmacist to the DON dated 11/25/16 at 11:18 AM revealed, .We can order fridge lock boxes for you. I will get you something asap (as soon as possible) . Interview with License Practical Nurse (LPN) #1 on 1/4/17 at 10:38 AM, in the 3rd floor chartroom, revealed at shift change on 11/25/16 at 7:00 AM, while counting Resident #6's oxycodone with off-going LPN #3, a discrepancy was noted in the amount of medication left in the bottle. Continued interview confirmed, according to Resident #6's Controlled Drug Receipt/Record/Disposition Form, the resident had 55 ml of oxycodone in the bottle, but during the count with LPN #3, she observed 30 ml of medication in the bottle. Continued interview revealed there was no documentation the resident had received the medication. Continued interview revealed Resident #6's liquid Oxycodone 5mg/5ml bottle was stored in the medication room refrigerator on a shelf and was not stored in a locked container. Interview with LPN #2 on 1/4/17 at 3:00 PM, in the 3rd floor chartroom, confirmed Resident #6's liquid Oxycodone was stored in the refrigerator on a shelf and not in a locked container. Continued interview revealed the facility had no locked containers to secure narcotics in the refrigerator at that time. Interview with the Pharmacist on 1/4/17 at 4:00 PM, by phone, confirmed narcotics have to be stored in a special lock box. Interview with the DON on 1/4/17 at 4:34 PM, in the 3rd floor chartroom, confirmed Resident #6's Oxycodone was not stored in a locked container in the medication refrigerator.",2020-01-01
3989,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2016-11-02,203,D,1,0,G65O11,"**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 timely notify a family member or legal representative of a resident's discharge plans, including the reason for the discharge, effective date of the discharge, and right of appeal for 1 resident (#7) of 3 residents reviewed for Admission, Transfer, and Discharge. Review of the Admission, Transfer, and Discharge Policy dated 8/6/04 revealed .When a resident is transferred or discharged , for reasons other than nonpayment or facility closure, the clinical record shall contain documentation by the resident's physician of the medical reason for the transfer or discharge. Ancillary departments will also document pertinent and appropriate involvement in the decision, transfer, and discharge process . Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed the resident scored 02/15 (severely cognitive impaired) on the Brief Interview for Mental Status (BIMS). Review of Resident #7's admission care plan revealed the resident was care planned for discharge plans with goals to go home and short term memory impairment. Review of a discharge progress note by the Nurse Practitioner (NP) dated 8/29/16 revealed .plan of care was reviewed with the patient. No equipment needed for home setting. Patient with verbal understanding of discharge plan . Review of the NP progress note dated 8/30/16 revealed the discharge plan was discussed with the resident who verbalized understanding and was agreeable. The NP noted the resident was to be discharged [DATE] home with son. Review of a Social Worker (SW) note dated 8/31/16 revealed the SW spoke with the resident's son regarding discharge on 9/1/16. The son stated he was not ready for the resident yet. The son reported the resident no longer had a hospital bed or oxygen as he returned it to the company when his dad was admitted to the hospital. The SW advised the discharge could be delayed until 9/2/16 due to we had not given a 48 hour notice. Review of the Physical Therapy (PT) discharge summary revealed the resident was discharged from PT on 8/31/16. Resident #7 did progress in therapy and became more independent in gait and transfers. However, his progress was limited secondary to his poor mental status and he had plateaued in progress. Review of the Occupational Therapy (OT) discharge summary revealed Resident #7 was discharged from therapy on 9/1/16. Patient had made little progress with OT plan secondary to safety awareness, decreased mental status, and resistance for education. Review of the Notice of Medicare Non-Coverage revealed skilled services will end 9/1/16 with discharge date [DATE]. Continued review of a handwritten note written on the back of the notice revealed .8/31/16 Social Worker spoke with the resident's son who requested d/c (discharge) be extended to 9/2/16 . Review of clinical note dated 9/3/16 revealed Resident #7 went home with family in private care with discharge instructions completed. Interview with the SW on 11/1/16 at 3:30 PM, in the 3 North (3N) Mentor Office, confirmed there was no documentation of discharge planning prior to 8/31/16. Interview with the SW on 11/2/16 at 10:00 AM, in the 3N Mentor Office, confirmed she did not mail the Notice of Medicare Non-Coverage to Resident #7's family and .It's on me . The SW further confirmed she did not call the resident's responsible party to advise of the tentative discharge date of [DATE]. The SW confirmed the first conversation held with the son related to the resident's discharge occurred on 8/31/16, at which time, the son told the SW of the need for the hospital bed and stated there was no way he could get everything ready for his father to go home tomorrow (9/1/16). The discharge date was extended to 9/2/16 and then to 9/3/16 at the family's request. The SW further confirmed she or someone from Rehab should have called and discussed the discharge plans with the responsible party prior to 8/31/16. The SW then stated .we need to work on our communication . Interview with the Rehab Manager on 11/2/16 at 11:00 AM, in the 3N Mentor Office, confirmed there was no documentation of any communication between family/responsible party and therapy staff regarding the resident's progress or any discharge plans. The Rehab Director stated .we need to work on that . Interview with the SW on 11/2/16 at 12:10 PM, in the 3N Mentor Office, confirmed the Notice of Medicare Non-Coverage for Resident #7 was placed in the discharge folder which contained the discharge orders and instructions and was not mailed prior to the discharge date . The SW confirmed no communication in writing, by phone, or in person with Resident #7's family/responsible party was conducted by the facility after the 8/25/16 Utilization Review Meeting of the tentative discharge date of [DATE] until the SW spoke with the son on 8/31/16, the day before discharge.",2019-11-01
4435,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2016-06-22,226,D,0,1,H28V11,"**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 failed to implement the abuse policy timely for 2 residents (#135 and #3) of 3 residents reviewed for an allegation of abuse of 32 residents reviewed. The findings included: Review of the facility's Abuse Policy revised 7/1/10 revealed It is the policy of Asbury, Inc. that no abuse, neglect mistreatment of [REDACTED].'Misappropriation of Resident Property' The deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent .While the investigation is in progress, steps will be taken to prevent further potential abuse. Staff suspected of involvement in the incident will be placed on administrative leave . Medical record review revealed Resident #135 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission Minimum (MDS) data set [DATE] revealed the resident scored a 1 on the Brief Interview for Mental Status (BIMS) indicating the resident had severely impaired cognitive skills. Medical record review of the (MONTH) (YEAR) Physician order [REDACTED].[MEDICATION NAME] HCL ([MEDICATION NAME]) 4 mg (milligrams) (1 tab) tablet oral as needed for nausea and vomiting . Review of facility documentation revealed on 5/21/16 Licensed Practical Nurse (LPN) #1 notifed the Director of Nursing (DON) of not feeling well and wanted to take a [MEDICATION NAME]. Interview with the DON on 6/21/16 at 9:55 AM, in the DON's office revealed the DON received a text message from LPN #1 on 5/21/16 at approximately 6:30 PM stating LPN #1 didn't feel well and was going to take a [MEDICATION NAME]. Continued interview revealed by the time I got back to (LPN #1) it was too late. Continued interview revealed LPN #1 had taken a [MEDICATION NAME] from Resident #135's supply. Continued interview revealed the DON had traveled to the facility to speak with LPN #1 and LPN #1 had stated the [MEDICATION NAME] was taken from Resident #135's supply. Continued interview with the DON revealed on 5/21/16 after LPN #1 confirmed taking the [MEDICATION NAME] from Resident #135's supply, LPN #1 was allowed to complete working the shift at the facility. Continued interview confirmed the facility's Abuse Policy was not followed and LPN #1 was not placed on administrative leave after LPN #1 confirmed taking the [MEDICATION NAME] from Resident #135's supply. Telephone interview with LPN #1 on 6/22/16 at 12:55 PM confirmed LPN #1 had taken the [MEDICATION NAME] from the resident's supply. 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 severely impaired cognitive skills for daily decision making. Review of the facility investigation dated 2/12/16 revealed LPN (Licensed Practical Nurse) heard resident yelling out from his room. CNA (Certified Nursing Assistant) went into the room. The LPN states the resident was cursing and using words such as '[***] ' and 'whore' to the nursing assistant. The LPN claims the nursing assistant was agitating the patient by cursing and telling (resident #3) she needs to change (resident). The LPN then instructed the nursing assistant to wait until the patient was calmer, The CNA refused and went back into the room after gathering supplies. The LPN went to get help from another nurse at 0250 (2:50 AM). The Registered Nurse (RN) came to the unit and removed the staff member from the unit for the remainder of the shift . Interview with the Administrator on 6/22/16 at 10:05 AM, in the Administrator's office confirmed would expect the LPN to stop the CNAs alleged abuse immediately and then get assistance.",2019-09-01
4436,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2016-06-22,441,D,0,1,H28V11,"Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure infection control standards were followed during a skin check for 1 Resident (#124) of 32 sampled residents. The findings included: Review of facility policy Handwashing/Hand Hygiene, dated 9/5/05 revealed .regards handwashing/Hand hygiene as the single most important means of preventing the spread of infection .All personnel will follow the handwashing procedure .to prevent the spread of infection and disease to other personnel, residents and visitors .before and after each resident contact .Before and after using protective equipment used in Standard Precautions .Using gloves does not replace handwashing/hand hygiene . Observation of Licensed Practical Nurse #4 (LPN) on 6/21/16 at 2:53 PM, outside resident's room revealed LPN #4 retrieved alcohol preps, a mirror from treatment cart, walked into Resident #124's room, retrieved gloves, explained to resident that was going to look at the foot, and without washing the hands donned gloves, picked up resident's foot from the wheelchair, removed the resident's sock, cleaned the mirror with an alcohol prep, held the mirror under the foot to see the skin, placed resident's sock back on, removed gloves, then washed the hands. Interview with LPN #4 on 6/21/16 at 3:03 PM, in the hallway outside Resident #124's room confirmed did not wash the hands prior to donning gloves to ensure infection control standards were followed during a skin check. Interview with the Director of Nursing (DON) on 6/22/16 at 1:45 PM, in the DON's office, confirmed the facility failed to ensure infection control standards were followed.",2019-09-01
4437,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2016-06-22,514,D,0,1,H28V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to ensure complete documentation of the medical record specifically the Psychoactive Medication Monthly Flow Record, for 2 residents (#103 and #161) of 32 residents reviewed. The findings included: Medical record review revealed Resident #103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Episodic Mood Disorders, and [MEDICAL CONDITION]. Medical record review of the Psychoactive Medication Monthly Flow Record dated (MONTH) (YEAR) revealed no documentation of behaviors on the following dates: 6/1, 6/2, 6/6, 6/7, 6/10, 6/11, 6/12, 6/15, 6/16, or 6/20. Continued review revealed documentation of the behavior assessment for one shift only on the following dates: 6/3, 6/4, 6/5, 6/8, 6/9, 6/13, 6/14, 6/17, 6/18, 6/19 or 6/20. Interview and medical record review with Licensed Practical Nurse (LPN) #6 on 6/22/16 at 9:15 AM at the 1 South Nurses Station revealed the Psychoactive Medication Monthly Flow Sheet (form used for monitoring resident target behaviors) was to be filled out each shift and confirmed the documentation of the Psychoactive Medication Monthly Flow Sheet dated (MONTH) (YEAR) for Resident #103 was incomplete. Interview and medical record review with the Director of Nursing (DON) on 6/22/16 at 9:30 AM in the Inservice Room confirmed the documentation of the Psychoactive Medication Monthly Flow Sheet dated (MONTH) (YEAR) for Resident #103 was not complete. Continued interview revealed the nursing staff was expected to document the assessment of the resident's behaviors on each shift on a daily basis. Resident #161 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Psychoactive Medication Monthly Flow Record for (MONTH) (YEAR) revealed no documentation of behaviors on the following dates: 5/1, 5/2, 5/3, 5/4, 5/5, 5/6, 5/7, 5/8, 5/9, 5/10, 5/13, 5/14, 5/15, 5/18, 5/19, 5/23, 5/28, and 5/29. Continued review revealed documentation for one shift only on the following dates: 5/11, 5/12, 5/16, 5/17, 5/20, 5/21, 5/22, 5/24, 5/25, 5/26, 5/27, 5/30, and 5/31. Continued medical record review of the Psychoactive Medication Monthly Review Flow Record dated (MONTH) (YEAR) revealed no documentation on the following dates: 6/1, 6/2, and 6/21. Continued review revealed documentation for one shift only on the following dates: 6/3, 6/4, 6/5, 6/6, 6/7, 6/8, 6/9, 6/10, 6/11, 6/12, 6/13, 6/14, 6/15, 6/16, 6/17, 6/18, 6/19, and 6/20. Interview and medical record review of the Psychoactive Medication Monthly Flow Records dated (MONTH) and (MONTH) (YEAR) for Resident #161 with the DON on 6/22/16 at1:20 PM, in the DON's office, confirmed the Psychoactive Medication Monthly Flow Record Forms were incomplete and the faciility had failed to ensure complete documentation of the medical record.",2019-09-01
6158,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2015-06-17,278,D,0,1,B48Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of employee written statement, and interview, the facility failed to accurately reflect the aggressive behavior on the Minimum Data Set (MDS) for 1 resident (#81) of 38 residents reviewed. The findings included: Medical record review revealed Resident #81 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed .Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing .). Behavior not exhibited . Record review of a written statement by Certified Nursing Assistane (CNA #3) dated 5/15/2015 revealed .at 1:00 (AM) (CNA #1) & I went into (Resident #81) room because her alarm was going off as we were trying to help her in bed she was very agitated & was swinging and kicking at (CNA #1). Interview with Registered Nurse #2 on 6/17/2015 at 9:20 AM, at the 100 South nurse's desk revealed .it is not unusual for the resident to be combative .it is how you approach her. Interview with MDS/Care Plan Licensed Practical Nurse #1 on 6/17/15 at 2:20 PM, in the MDS office confirmed the quarterly MDS dated [DATE] failed to reflect the resident's aggressive behavior on 5/15/2015.",2018-09-01
6159,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2015-06-17,280,D,0,1,B48Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of employee written witness statement, and interview, the facility failed to revise the care plan for 1 resident (#81) of 38 residents reviewed. The findings included: Medical record review revealed Resident #81 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #81's current care plan dated 5/7/15 revealed no problems or approaches to intervene when Resident #81 is being aggressive and hitting people or how to approach her to reduce instances of combativeness. Record review of the Written Statement of Certified Nurse Assistant (CNA) #3 dated 5/15/2015 revealed .at 1:00 (AM) (CNA #1) & I went into (Resident #81) room because her alarm was going off as we were trying to help her in bed she was very agitated & was swinging and kicking at (CNA #1) . Interview with Registered Nurse #2 on 6/17/2015 at 9:20 AM, at the 100 South nurse's desk revealed .it is not unusual for the resident to be combative .it is how you approach her. Interview with Minimum Data Set/Care Plan Licensed Practical Nurse on 6/17/15 at 2:20 PM, in the MDS office confirmed the care plan had not been revised for the resident's aggressive behavior.",2018-09-01
8405,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2014-03-20,225,D,0,1,9CN111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, and interview, the facility failed to report an allegation of possible abuse to the proper authorities for one resident (#4), of three residents reviewed for abuse or neglect. The findings included: Resident #4 was admitted to the facility March 15, 2013, with [DIAGNOSES REDACTED]. Medical record review of the annual assessment from the Minimum Data Set (MDS) dated [DATE], revealed the resident was born March 28, 1922, had a Brief Interview of Mental Status (BIMS) score of 6 out of a possible 15, (which indicated severe cognitive impairment) usually understood and usually understands staff, and required extensive assistance to transfer to the wheelchair for locomotion. Review of the facility's investigation file of an allegation of abuse from January 2014, revealed a written statement, dated January 14, 2014, was included. Review of the written statement revealed the allegation of abuse included two residents being abused. Review of the information included in the report sent to the State's incident reporting system (IRS) revealed only one of the two residents had their medical record number and complete information submitted in the report. Review of the facility's Abuse Policy, last revised July of 2010, revealed, Alleged violations .reported .to other officials in accordance with State law . Interview with the facility Administrator on March 18, 2014, at 1:20 p.m., in the conference room, revealed the Administrator was the facility's Abuse Officer. Further interview confirmed the allegation of possible abuse of resident #4 had not been reported to the appropriate State Agency. Complaint #",2017-06-01
8406,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2014-03-20,281,D,0,1,9CN111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, and interview, one of three nurses failed to follow the facility's policy and provide services that met professional standards. The findings included: Review of the March 2014, Medication Administration Record [REDACTED]#1 had initialed the following medications as administered on March 18, 2014 at 9:00 a.m.: 1. Pot Chloride (potassium chloride - mineral) Liq (liquid) 10% scheduled for administration at 9:00 a.m. 2. Acetylcyst Sol (solution) (reduces mucous secretions) scheduled for administration at 9:00 a.m. and 9:00 p.m. 3. [MEDICATION NAME] Tab (tablet) (inhibits gastric acid) 20 mg (milligram) scheduled for administration at 9:00 a.m. and 9:00 p.m. 4. [MEDICATION NAME] Cap (capsule) 40 mg (antidepressant) scheduled for administration at 9:00 a.m. 5. [MEDICATION NAME] Tab 20 mg (diuretic) scheduled for administration at 9:00 a.m. 6. Ipratropin/ Sol Albuter (aerosol treatment to aid with breathing) scheduled for administration at 9:00 a.m. and 9:00 p.m. Review of the facility policy Medication Administration revealed .medications shall be administered as prescribed .in accordance with Professional Standards of Care .7. Medications may not be set up in advance and must be administered within one (1) hour before or after their prescribed time . Interview with RN #1 on March 18, 2014, at 7:45 a.m., at the 2 South Nurse's station revealed the medications had been administered more than one hour before the administration time and the facility policy had not been followed.",2017-06-01
8407,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2014-03-20,431,D,0,1,9CN111,"Based on observation and interview, the facility failed to properly label and store medications in one medication cart of three medication carts observed of the eight medication carts in the facility. The findings included: Observation on March 20, 2014, at 1:20 p.m., at the 2 North Nurse's Medication Cart, with the Director of Nursing, revealed an open clear plastic medication cup in the drawer of the medication cart with four unknown, unlabeled medications inside. Interview with the Director of Nursing, at the time of the observation, confirmed the medication had not been labeled or stored correctly.",2017-06-01
8408,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2014-03-20,441,F,0,1,9CN111,"Based on review of the facility's Infection Control Line Listings, facility policy and inservice review, observation, and interview, the facility failed to: 1) maintain aseptic technique when disinfecting blood glucose meters; 2) maintain a functioning Infection Control Coordinator; 3) maintain an accurate record of identified infective organisms; and 4) failed to follow the facility's policy for reporting to local or county health officers. The findings included: 1) Review of the March 2014 Inservice states, .Glucometer .Clean the glucometer between residents: Apply gloves Wipe glucometer then place the saniwipe around the glucometer, leaving the glucometer wet for 2 minutes. Set timer Remove saniwipe Remove gloves . Interview with Licensed Practical Nurse (LPN) #1 on March 20, 2014, at 1:20 p.m., at the 2 North Nurse's Station, with the Director of Nursing present, revealed the glucometer on the medication cart was cleaned with a Sani-cloth and allowed to set for thirty seconds then it was ready to be used. Interview with LPN #2 on March 20, 2014, at 1:30 p.m., at a medication cart on 1 South, with the Director of Nursing present, revealed the glucometer on the cart was cleaned with an alcohol wipe and then was ready for use for the next resident. Interview with the Interim Director of Nursing at the time of the interviews with LPN #1 & LPN #2 confirmed neither one of the cleaning routines described by LPN #1 & #2 followed the criteria of the inservice and neither cleaning routine would disinfect the glucometers appropriately. Review of the facility's policy Infection Control-Identification of Infection revealed, .2. c. To identify and treat epidemiologically important organisms .4. The Infection Control Coordinator will report surveillance information to the Infection Control Committee performing infection control oversight functions . Review of the facility's policy Infection Control-Reportable Diseases revealed, .4. The occurrence of outbreaks or clusters of any illness which may be of public concern whether or it is known to be communicable in nature, shall be reported to the local health officer of the county in which it occurs. 2) Interview with the facility Administrator on March 19, 2014, at 9:10 a.m., in the conference room, revealed the Administrator named Licensed Practical Nurse (LPN) #3 as the Infection Control Nurse for the facility. Interview with LPN #3 at 9:30 a.m., on March 19, 2014, in the conference room, revealed LPN #3 denied functioning as an Infection Control Nurse and stated, I am only responsible for data entry. Interview with the Interim Director of Nurses (DON) at 9:50 a.m., on March 19, 2014, in the conference room, revealed the previous DON had been the Infection Control Coordinator, the Interim DON had not been assigned to the position, and the facility presently did not have a functioning Infection Control Coordinator. 3) Interview with the Interim DON at 3:00 p.m., on March 19, 2014, in the conference room, revealed the Infection Control Line Listing for the facility from October 2013, through to the present time did not consistently list Organisms Identified (If known) in the required column of the month to month line log. Interview continued and confirmed the staff routinely, and incorrectly, entered the disease in the column provided for the infective organisms if known. Further interview confirmed the facility presently had three residents on one nursing unit identified with pneumonia, there were no infecting organisms identified, there was no indication of whether the pneumonia was viral or bacterial, but all three residents were being treated with antibiotics. 4) Interview with the facility administrator on March 19, 2014, at 9:10 a.m., in the conference room, confirmed the facility had an outbreak of communicable diseases as follows: the Lakeview Terrace unit from October 9, 2013, through October 28, 2013, of nausea/vomiting and/or diarrhea; the Village unit from October 10, 2013, through October 24, 2013, of a respiratory illness; and the Smokey's View unit from October 21, 2013, to November 1, 2013, of both a diarrhea and respiratory illness. Further interview revealed the public was not allowed on these units during these intervals. Continued interview revealed the facility had not followed their policy and notified the local health officer.",2017-06-01
9896,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2013-09-20,155,D,1,0,Y2MX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's Resident's Rights, medical record review, review of a facility investigation, and interview, the facility failed to permit a resident to refuse treatment for one resident (#1) of eight sampled residents. The findings included: Review of the facility's Resident's Rights provided by the Director of Nursing (DON) on September 13, 2013, revealed, .Each resident has at least the following rights .To refuse treatment. The resident must be informed of the consequences of that decision. The refusal and its reason must be reported to the physician and documented in the resident's file . Medical record review revealed Resident #1 was readmitted to the facility on [DATE], and [DIAGNOSES REDACTED]. Medical record review of a Minimum Data Set, dated dated dated [DATE], revealed the resident's cognition was intact and the resident required total assistance with bed mobility, transfers, dressing, and hygiene. Medical record review of a physician's orders [REDACTED].DC PO (discontinue oral) [MEDICATION NAME] - refuses to take. [MEDICATION NAME] 9.75 mg IM (milligrams intramuscular) for acute [MEDICAL CONDITION] repeat in 2 hrs prn (hours as needed) .Maximum 30 mg daily . Medical record review of a nurse's note dated February 14, 2013, at 4:00 p.m., revealed, .c/o (complained of) chest pain. Called (Medical Doctor - M.D. #1) and adv (advised) of complaints. (M.D. #1) .stated to give PRN dose of [MEDICATION NAME] IM. Adv (advised) had been refusing meds (medications) daily .' IM injection given in L (left) thigh. Medical record review of the next nurse's note dated February 14, 2013, at 6:30 p.m., revealed no documentation regarding refusal of the medication, informing the patient of the consequences of the decision to refuse, and/or notification of the physician of the patient's refusal prior to the injection. Continued review revealed, Follow-up from injection. Calm . Review of a witness statement (Director of Nursing's) in the facility's investigation dated February 15, 2013, revealed, I spoke with (resident) per telephone about .(7:00 p.m.) .informed me (resident) was upset about something that happened yesterday .(M.D. #1) .had the nurse give .injection of [MEDICATION NAME] last night and that (resident) did not want the medication .was given to (resident) by the nurse (Licensed Practical Nurse - LPN #1) and (Registered Nurse - RN#1) made the nurse give it . Telephone interview with LPN #1 on September 17, 2013, at 10:00 a.m., revealed LPN #1 administered the injection on February 14, 2013, and LPN #1 stated, .I called (M.D. #1) .(M.D. #1) said to give injection of [MEDICATION NAME] .(RN #1) and I went in there. (Resident) refused. (RN #1) told me to put it in the top of (resident's) leg .I let .somebody talk me into doing something I knew was wrong. Interview with the DON on September 17, 2013, at 3:00 p.m., in the facility's family room, revealed she learned of the patient's refusal of the injection from the patient on February 15, 2013. She stated, .violated patient's rights. C/O: #",2016-09-01
9897,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2013-09-20,157,D,1,0,Y2MX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's Resident Rights, review of facility policy, medical record review, review of a facility investigation, and interview, the facility failed to notify the physician of a resident's refusal of medication for one resident (#1) of eight sampled residents. The findings included: Review of the facility's Resident's Rights provided by the Director of Nursing (DON) on September 13, 2013, revealed, .Each resident has at least the following rights .To refuse treatment .The refusal and its reason must be reported to the physician . Review of facility Policy Number: RS-NSG-022 titled Physician Notification and dated July 13, 2012, revealed, .the physician will be notified about any change in resident condition according to Federal and State guidelines .Licensed personnel will convey the situation .in a concise and complete manner .Chief complaint of resident . Medical record review revealed Resident #1 was readmitted to the facility on [DATE], and [DIAGNOSES REDACTED]. Medical record review of a Minimum Data Set, dated dated dated [DATE], revealed the resident's cognition was intact and the resident required total assistance with bed mobility, transfers, dressing, and hygiene. Medical record review of a physician's orders [REDACTED].DC PO (discontinue oral) [MEDICATION NAME] - refuses to take. [MEDICATION NAME] 9.75 mg IM (milligrams intramuscular) for acute [MEDICAL CONDITION] repeat in 2 hrs prn (hours as needed) .Maximum 30 mg daily . Medical record review of a nurse's note dated February 14, 2013, at 4:00 p.m., revealed, .c/o (complained of) chest pain. Called (Medical Doctor - M.D. #1) and adv (advised) of complaints. (M.D. #1) .stated to give PRN dose of [MEDICATION NAME] IM. Adv (advised) had been refusing meds (medications) daily .IM injection given in L (left) thigh. Medical record review of the next nurse's note dated February 14, 2013, at 6:30 p.m., revealed, Follow-up from injection. Calm, but still upset . Medical record review of a Nurse Practitioner's note dated February 15, 2013, revealed, .is upset that .received IM [MEDICATION NAME] yesterday and says .did not want it even though (physician) ordered . Medical record review of nurse's notes dated February 14, 2013, revealed no documentation the physician was notified regarding the patient's refusal of the medication prior to the injection. Review of facility investigation documentation (Director of Nursing's witness statement) dated February 15, 2013, revealed, I spoke with (resident) per telephone about .(7:00 p.m.) .informed me (resident) was upset about something that happened yesterday .injection of [MEDICATION NAME] last night and that (resident) did not want the medication .was given to (resident) by the nurse (Licensed Practical Nurse - LPN #1) and (Registered Nurse - RN#1) made the nurse give it . Telephone interview with LPN #1 on September 17, 2013, at 10:00 a.m., revealed LPN #1 administered the injection on February 14, 2013, and LPN #1 stated, .I called (M.D. #1) .(M.D. #1) said to give injection of [MEDICATION NAME] .(Registered Nurse RN #1) and I went in there. (Resident) refused. (RN #1) told me to put it in the top of (resident's) leg .I gave injection (resident) told me (resident) did not want . Interview with the DON on September 16, 2013, at 12:37 p.m., in the facility's family room, revealed the resident refused the injection of Ability on February 14, 2013. She stated, .The resident was in (resident's) right mind .They did not let the doctor know the resident was refusing and gave it anyway. C/O: #",2016-09-01
9898,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2013-09-20,226,D,1,0,Y2MX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based review of facility policy, medical record review, review of a facility investigation, and interview, the facility failed to implement the abuse policy for one resident (#1) of eight sampled residents. The findings included: Review of facility Policy Number: RS-NSG-041 most recently revised July 1, 2010, revealed, .When a person witnesses or suspects abuse, neglect or mistreatment of [REDACTED]. Medical record review revealed Resident #1 was readmitted to the facility on [DATE], and [DIAGNOSES REDACTED]. Medical record review of a Minimum Data Set, dated dated dated [DATE], revealed the resident's cognition was intact and required total assistance with bed mobility, transfers, dressing, and hygiene. Medical record review of a physician's orders [REDACTED].DC PO (discontinue oral) [MEDICATION NAME] - refuses to take. [MEDICATION NAME] 9.75 mg IM (milligrams intramuscular) for acute [MEDICAL CONDITION] repeat in 2 hrs prn (hours as needed) .Maximum 30 mg daily . Medical record review of a nurse's note dated February 14, 2013, at 4:00 p.m., revealed, .c/o (complained of) chest pain. Called (Medical Doctor M.D. #1) and adv (advised) of complaints. (M.D. #1) .stated to give PRN dose of [MEDICATION NAME] IM. Adv (advised) had been refusing meds (medications) daily .IM injection given in L (left) thigh. Medical record review of the next nurse's note dated February 14, 2013, at 6:30 p.m., revealed, Follow-up from injection. Calm, but still upset . Review of facility investigation documentation (statement of the Director of Nursing) dated February 15, 2013, revealed, I spoke with (resident) per telephone about .(7:00 p.m.) .(resident)informed me (resident) was upset about something that happened yesterday .the nurse give .injection of [MEDICATION NAME] last night and that (resident) did not want the medication .was given to (resident) by the nurse (Licensed Practical Nurse - LPN #1) and (Registered Nurse - RN #1) made the nurse give it . Review of facility investigation documentation (an e-mail from RN #1 to the DON and a statement signed by Licensed Practical Nurse (LPN #1)) dated February 16, 2013, revealed LPN #1 administered an IM injection despite the patient's refusal on February 14, 2013, and RN #1 was present when the injection was administered. Telephone interview with Licensed Practical Nurse (LPN #1) on September 17, 2013, at 10:00 a.m., revealed LPN #1 administered the injection on February 14, 2013, and LPN #1 stated, .(M.D. #1) said to give injection of [MEDICATION NAME] .(Registered Nurse RN #1) and I went in there. (Resident) refused. (RN #1) told me to put it in the top of (resident's) leg .I gave injection (resident) told me (resident) did not want .I let .somebody talk me into doing something I knew was wrong. Interview with the Director of Nursing on September 17, 2013, at 3:00 p.m., in the facility's family room, revealed LPN #1 nor RN #1 reported the incident to her. Continued interview revealed she learned the resident was administered an injection on February 14, 2013, despite the resident's refusal, from the patient on February 15, 2013. Continued interview confirmed the facility failed to implement the abuse policy for Resident #1 on February 14, 2013. C/O: #",2016-09-01
10125,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2013-01-10,272,D,0,1,SX6Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, facility policy review, and interview, the facility failed to assess the bladder continence needs for one resident (#191) of thirty-nine residents reviewed. The findings included: Resident #191 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 required supervision with set-up help only for bed mobility, transfers, and walking in room. Continued review of the same MDS revealed the resident required extensive assistance of one person for dressing, toilet use, personal hygiene and was .frequently incontinent of bladder and bowel . Medical record review of the quarterly MDS dated [DATE], revealed the resident was always incontinent of bladder and bowel, indicating a decline from the admission MDS. Review of the facility's Incontinence Monitoring Record dated August 2 through August 8, 2012, revealed the resident's voiding pattern (toileting habits) had been monitored for seven days. Continued review of the Incontinence Monitoring Record revealed the resident's voiding pattern had been categorized as voided, wet, and dry. Review of the Bladder Incontinence assessment dated [DATE], revealed the document was blank. Review of facility policy, Instructions for Patterning Tool, revealed, 1. Select residents first who have the greatest chance of going from incontinence to continence. 2. Begin patterning at midnight; check on resident every hour and enter a x in the appropriate box. 3. Once patterning is complete; notify nurse so she/he can complete the nursing assessment . Interview in the conference room on January 10, 2013, with the Unit Manager of the secured unit on January 10, 2013, at 2:30 p.m., confirmed the bladder assessment had not been completed for the resident as per the facility's policy.",2016-07-01
10126,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2013-01-10,315,D,0,1,SX6Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, facility policy review, and interview, the facility failed to ensure treatment and services were provided to prevent decline in bladder continence for one resident (#191) of thirty-nine residents reviewed. The findings included: Resident #191 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 required supervision with set-up help only for bed mobility, transfers, and walking in room. Continued review of the same MDS revealed the resident required extensive assistance of one person for dressing, toilet use, personal hygiene, and was frequently incontinent of bladder and bowel. Medical record review of the quarterly MDS dated [DATE], revealed the resident was always incontinent of bladder and bowel, indicating a decline from the admission MDS. Review of the facility's Incontinence Monitoring Record dated August 2 through August 8, 2012, revealed the resident's voiding pattern (toileting habits) had been monitored for seven days. Continued review of the monitoring record revealed the resident's voiding pattern had been categorized as voided, wet, and dry. Review of the Bladder Incontinence assessment dated [DATE], revealed the document was blank. Review of facility policy, Instructions for Patterning Tool, revealed, 1. Select residents first who have the greatest chance of going from incontinence to continence. 2. Begin patterning at midnight; check on resident every hour and enter a x in the appropriate box. 3. Once patterning is complete; notify nurse so she/he can complete the nursing assessment . Interview with the Unit Manager of the secured unit in the conference room on January 10, 2013, at 2:30 p.m., confirmed the facility had failed to provide treatment and services to address the resident's decline in bladder continence.",2016-07-01
10127,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2013-01-10,333,G,0,1,SX6Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a facility investigation, facility policy review, and interview, the facility failed to ensure residents were free of significant medication errors for one resident (#124) of thirty-nine residents reviewed. The medication error resulted in an emergent hospitalization and harm for resident #124. The findings included: Resident #124 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 severely cognitively impaired and required extensive staff assistance for all activities of daily living. Medical record review of a Physician's Progress Note dated January 4, 2013, revealed the resident had been administered the following medications prescribed for the resident's roommate: [MEDICATION NAME] 100 milligrams (mg) (anithypertensive medication), [MEDICATION NAME] 5 units (insulin/diabetic medication), [MEDICATION NAME] 500 mg (anticonvulsant), Tylenol, Aspirin, [MEDICATION NAME], Carvedilol 25 mg (antihypertensive), [MEDICATION NAME] 20 mg (antidepressant), and [MEDICATION NAME] 60 mg (cardiac medication/lowers blood pressure and heart rate). Continued review of the Physician's Progress Note dated January 4, 2013, revealed the medication error resulted in a sharp decrease in blood pressure (72/40) and heart rate (48) for the resident, and required emergent transport to the local hospital, and a three day admission to the intensive care unit. The resident was returned to the facility by ambulance on January 7, 2013. Review of an undated facility policy, Medication Administration, revealed .before giving a resident any medication: validate the medication: right resident, right medication, right dose, right route, right time .identify the resident by using one of the following: photo identification, resident's identification bracelet, or have the resident state their name .no medication will be given if the resident cannot be identified . Review of a facility investigation dated January 4, 2013, revealed a Medication Error Report which stated .Description of error: resident rec'd (received) ASA 81 mg (aspirin), [MEDICATION NAME] 25 mg, [MEDICATION NAME] 20 mg, [MEDICATION NAME] 60 mg, [MEDICATION NAME] 100 mg, [MEDICATION NAME] 500 mg, MPAP 500 mg .nurses will be more careful to identify correct resident .pictures of residents put (with) MAR (Medication Administration Record) and ID (identification) bracelets applied to each resident . The facility investigation included a statement by the Director of Nursing (DON), who responded at the time of the medication error. The DON assisted the LPNs in attempts to stabilize the resident's blood pressure with IV (intravenous) fluids, and obtained physician's orders [REDACTED]. Interview with Licensed Practical Nurse (LPN #2) on January 10, 2013, at 10:25 a.m., in the third floor nurse's station, confirmed on January 4, 2013, during the morning medication pass, the facility policy regarding medication administration and resident identification had not been followed. Continued interview confirmed a medication error occurred when resident #124 received the roommate's medications (listed above). The LPN provided a signed statement, to the DON, as a part of the facility investigation into the medication error. The LPN's signed statement revealed a new nurse/orientee had administered the medications, in the third floor dining area, without correctly identifying the two residents. The error was discovered and reported when the roommate's family member, familiar with both residents, recognized resident #124 had received an insulin injection prescribed for the roommate. During the interview LPN #2 confirmed the signed statement was complete regarding the details of the incident. Interview with the DON and Administrator on January 10, 2013, at 2:00 p.m., in the Administator's office, confirmed on January 4, 2013, the facility policy related to medication administration and resident identification had not been followed, and a medication error occurred. This medication error resulted in harm and hospitalization for the resident.",2016-07-01
10128,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2013-01-10,441,D,0,1,SX6Q11,"Based on observation and interview, the facility failed to prevent/minimize the transmission of potential airborne contamination for one resident during a random observation at mealtime. The findings included: Observation of the secured unit dining room on January 7, 2013, at 12:40 p.m., of Certified Nurse Assistant (CNA) #1 assisting the resident with eating revealed the CNA scooped the food onto a spoon from the resident's plate, held the spoon close to the CNA's mouth, blew on the food, and offered the food to the resident to consume. Continued observation revealed the resident opened the mouth and easily accepted the food. Continued observation revealed the process was repeated four times during the observation. Interview with CNA #1 on January 7, 2013, at 1:30 p.m., confirmed blowing on the resident's food to ensure a safe temperature was not an acceptable method of testing the food temperature. Interview with the Unit Manager on January 7, 2013, at 1:35 p.m., in the Unit Manager's office confirmed blowing on the resident's food was not an acceptable means of infection control.",2016-07-01
11718,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2012-11-05,225,D,1,0,JIW311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, review of facility investigation, observation, and interview, the facility failed to thoroughly investigate an allegation of abuse for one resident (#2) of thirteen sampled residents. The findings included: Review of facility policy Number RS-NSG-041 most recently revised on April 3, 2005, revealed, .Topic: Abuse/Neglect/Mistreatment.Alleged violations will be thoroughly investigated by the Director of Nursing (DON). Medical record review revealed the resident (#2) was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a History and Physical dated November 30, 2011, revealed, .closed head injury.alert and oriented answered questions appropriately. Medical record review of a Minimum Data Set, dated dated dated [DATE], revealed the resident was impaired with decision-making skills and dependent on staff for hygiene. Interview with the Director of Nursing (DON) on October 29, 2012, at 9:00 a.m., in the family room, revealed the facility had reported an allegation of verbal abuse regarding sampled Resident #2. Review of facility investigation (statement by Certified Nursing Assistant - CNA) #1 dated October 24, 2012, revealed, .on 10-21-12.(Alleged Perpetrator - AP).telling (resident) that (resident) knew better than to smear (feces).was a grown adult.and when (AP) was getting (resident) out of bed (resident) became combative by kicking.(Resident) started yelling at (AP).(AP) told (resident).if kept that up (Resident's) (expletive) would stay up until 11 p.m. Review of facility investigation (the AP's statement) dated October 24, 2012, revealed, When I clock (clocked) in went to my floor. A housekeeper (#1) stop (stopped) me.said (resident) had (feces) all over.not cleaning (resident's) room until someone clean (cleaned) (resident) up.I clean (cleaned) (resident) up and try to get (resident) up. Continued review of facility investigation revealed no statement from the referenced housekeeper. Observation on November 1, 2012, at 2:56 p.m., revealed the resident utilized the call light, requested toileting assistance, and the assistance was provided. Interview with the resident on November 1, 2012, at 3:25 p.m., revealed the resident was disoriented to time, had never been mistreated, and had no complaints. Continued interview revealed the resident would rely on family to address any complaint that may occur. Interview with the Housekeeper #1 on November 5, 2012, at 1:22 p.m., revealed she was in the room while the AP provided care to the resident. Interview with the DON on November 2, 2012, at 4:00 p.m., in the family room, revealed the facility's investigation did not include a statement from Housekeeper #1. Continued interview confirmed the facility failed to thoroughly investigate an allegation of abuse for Resident #2. C/O: #",2015-11-01
11719,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2012-11-05,323,D,1,0,JIW311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility investigation, observation, and interview, the facility failed to provide adequate supervision and/or safety device to prevent recurrent falls for one resident (#8) of thirteen sampled residents. The findings included: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Minimum Data Set (MDS) dated [DATE], revealed the resident was moderately impaired with decision-making skills and non-ambulatory, required limited assistance with transfers, and had a history of [REDACTED]. Medical record review of a Fall Risk assessment dated [DATE], revealed a score of eight and included, .4 or more.will be.care planned at risk. Medical record review of the current care plan effective through December 12, 2012, revealed the risk for falls was addressed and interventions included a low bed. Medical record review of a care plan revision dated July 11, 2012, revealed, .bed pressure sensor. Medical record review of a nurse's note dated September 2, 2012, at 2:45 p.m., revealed, found.on floor at bedside. Bed low position and bed alarm sounded. No injury.phone call to res (resident's) son.who requests that both siderails be up this evening when res (resident) in bed. Review of facility investigation dated September 2, 2012, revealed the resident fell out of bed and included, .were bed rails present yes.R (right) down.successful fall. Continued review revealed no documentation regarding a new intervention to prevent falls. Medical record review of a nurse's note dated September 3, 2012, at 7:45 p.m., revealed, unwitnessed fall OOB (out of bed).found lying on floor next to bed by CNA (Certified Nursing Assistant) who was right outside of room and heard bed alarm sound.hematoma to R (right) forehead and scant blood R nostril.mat placed on floor at this time. Medical record review of a nurse's note dated September 3, 2012, at 7:50 p.m., revealed, .steristrip to small lac (laceration) underneath right nostril.(son).said doesn't care what state has to say about it. This could have been prevented. order written per (Nurse Practitioner -NP for SR (siderail.) Medical record review of a Nurse Practitioner's (NP) note dated September 3, 2012, revealed, staff report (resident) was in bed with siderail down.heard noise.went.to check on (resident) and found in floor on R side.hematoma R forehead.tiny laceration under R nostril.knew son when he came in.lac cleaned with soap and water skin prep (preparation) steristrip. Medical record of an Interdiscplinary Narrative Note dated September 6, 2012, revealed, .reevaluated for siderail needs.siderail up per drs (doctor's) order. Observations on November 2, 2012, at 3:07 p.m. and November 5, 2012, at 9:10 a.m., revealed the resident in bed and the siderails raised. Interview with the MDS/Care Plan Coordinator on November 5, 2012, revealed she participated with review of the resident's falls and she stated, .under the impression if successful fall with no injury there's nothing else we can do at that point. Continued interview revealed no additional intervention to prevent falls was implemented following the resident's fall on September 2, 2012. Continued interview confirmed the facility failed to provide adequate supervision and/or safety device to prevent a fall with injury for Resident #8 on September 3, 2012. C/O: #",2015-11-01
11720,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2012-11-05,441,D,1,0,JIW311,"**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 a sanitary environment to prevent the development and transmission of infection for one resident (#13) of thirteen sampled residents. The findings included: Review of facility policy titled Equipment and Supplies Used During Isolation dated May, 22, 2003, revealed, .supplies will be used to ensure that sanitary conditions are maintained during isolation.shall be stored and maintained in accordance with appropriate isolation precautions. Resident #13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a laboratory result dated August 10, 2012, revealed, Clostridium Difficile (C-diff) toxin A+B positive (normal is negative). Medical record review of a nurse's note dated August 11, 2012, at 7:00 p.m., revealed, incont (incontinent) bowel @ (at) supper time found stool in floor of room and hallway. Medical record review of a nurse's note dated August 22, 2012, revealed, to (another floor within the facility).new order to dc (discontinue) isolation with[DIAGNOSES REDACTED]. Medical record review of a nurse's note dated August 22, 2012, at 8:00 p.m., revealed, wanders into others rooms.gets in other res beds. Medical record review of a laboratory report dated September 3, 2012, revealed, (C-diff) toxin A+B positive. Medical record review of a Nurse Practitioner (NP) note dated September 3, 2012, revealed, seen due to recurrent diarrhea. had just finished (antibiotic) and now with fever.liq (liquid) stool incont. Medical record review of a physician's progress note dated October 8, 2012, revealed recurrent bout with[DIAGNOSES REDACTED] colitis. has been released from isolation. Medical record review of a NP note dated October 11, 2012, revealed, .still with diarrhea.recurrent[DIAGNOSES REDACTED]. cont (continue) (antibiotic) qid (four times daily).through 10-20, then.tid (three times daily) x 14 d (for 14 days), then.q12h (every 12 hours) x 14 d, then.qd (every day) x 14 d. Observation on November 5, 2012, at 12:48 p.m., revealed a posted sign outside the resident's room advised visitors to report to the nurse's station before entering the room. Observation on November 15, 2012, at 2:33 p.m., revealed the resident seated in a wheelchair and fabric heel protectors (worn while in bed) on the floor in the corner of the room. Observation and interview with Licensed Practical Nurse #1 on November 5, 2012, at 2:36 p.m., revealed fabric heel protectors on the floor in the corner of the resident's room and confirmed the facility failed to maintain a sanitary environment to prevent the development or transmission of infection for Resident #13. C/O: #",2015-11-01
12358,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2012-04-11,205,D,1,0,VEEQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medicall record review and interview the facility failed to provide the family with the required bed hold information for one resident (#2) of nine residents reviewed. The findings included: Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Physician's Progress Note dated January 5, 2012, revealed ""...readmit after a prolong stay at (local hospital) [MEDICAL CONDITION]."" Medical record review of an Admission Resident Data Collection Nursing Assessment Tool dated January 5, 2012, revealed the following pressure ulcers: sacrum- stage IV, right shoulder- stage I, left shoulder and left ankle unstagable. Medical record review of a Readmission Minimum Data Set, dated dated dated [DATE], revealed the resident was ventilator dependent, totally dependent in all activities of daily living and required a feeding tube for nutrition. Medical record review of a Social Service Progress Note dated February 20, 2012, revealed ""...(family member) called...will sign consent to treat... is happy (Resident) is going to (hospital) for wound treatment."" Medical record review of a Nursing Discharge Summary dated February 28, 2012, revealed ""...(Resident) goes into respiratory arrest when turned to right side dressing changes...(primary doctor) wrote orders to send out to (hospital)."" Medical record review of a Physician Discharge Summary revealed ""...Resident) care necessitating transfer back to hospital with a discharge date of [DATE]."" Interview with the Primary Care Physician on April 2, 2012, at 3:55 p.m., in the physician's charting room revealed ""...each time we would do wound care (Resident) would get worse...we could not sustain (Resident) here."" Review of facility policy, Bed Hold, updated on August 2, 2005, revealed ""...Procedure: When a health care center resident leaves the facility for an anticipated temporary absence (e.g. transfer to hospital, therapeutic leave), the nursing supervisor will notify the social worker. The Social Worker will contact the resident or residents respnsible party to determine whether the bed is to be held..."" Interview with the Social Worker on April 2, 2012, in the conference room confirmed that although there was a family discussion the family was not told or given information on a bed hold policy. C/O #",2015-08-01
12359,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2012-04-11,242,D,1,0,VEEQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to consider the resident's choices for one resident (#4) of nine residents reviewed. The findings included: Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Minimum Data Set, dated dated dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of eight. The Resident was unable to recall repeated words after a brief interval and required physical one person assistance with bathing. Review of the facility bathing schedule revealed the resident was to be assisted with a shower twice weekly on Tuesday and Friday. Medical record review of the Activity of Daily Living Flow Sheet for March 2012 revealed the resident received five showers on March 3, 16, (13 days between showers), 21, 23, and 27. Interview with Certified Nursing Assistant #2 on April 4, 2012, at 8:45 a.m. in the staff lounge, revealed Resident #4 ""...often refuses...showers...when it is time (Resident) goes to activities...around 3:00 p.m. (Resident) says...I didn't get a shower...it is too late then."" Interview with Licensed Practical Nurse #2 on April 4, 2012, at the Nurses' Station revealed although Resident #3 did refuse showers it was not on the Plan of Care, nor did the Resident's Plan of Care include interventions to plan showers around the Resident's activities. C/O #",2015-08-01
12360,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2012-04-11,246,D,1,0,VEEQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure reasonable accomodations for inidividual needs for one Resident (#9) of nine residents reviewed. The findings included: Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated February 27, 2012, revealed ""...Diet...Regular...no salt...set-up (able to feed self after setting up food)."" Observation on April 5, 2012, at 1:15 p.m., in the residnet's room revealed the resident with lunch tray and drinking the ice cream from the container. Interview with the resident on April 5, 2012, at 1:15p.m in the Resident's room revealed ""...I like to go to the dining room to eat...I have to go to the bathroom after I eat...they said they have people who need to be fed...I cannot wait (in the dining room) that long...I eat in my room...I had to eat this first (referring to the ice cream) it is already melted and soupy...then my food is medium warm."" C/O #",2015-08-01
12361,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2012-04-11,371,D,1,0,VEEQ11,"Based on observation and interview of the 2 South Resident wing the facility failed to ensure food was served at the correct temperature. The findings included: Review of the 2 South Staffing Schedule and Resident Census for April 10, 2012, revealed a total resident census of twenty-two residents; of those residents fifteen are total care and sixteen require total assistance with feeding. Further review of the staffing schedule revealed ""...ideal staffing ...4.5 CNAs (Certified Nursing Assistants)."" Observation of CNA staffing for 2 South on April 5, 2012, at the Noon meal revealed three CNA's. Continued observation of the Noon meal revealed the food cart for ""feeders"" arrived on the 2 South wing at 11:55 a.m. and was left on the long hall of 2 South. Although the plate of food was covered with an insulated dome covering, the cart itself was open. The trays of food contained pasta salad, drinks and ice cream. The cart remained on the nursing wing from 11:55 a.m. until the last tray was served at 1.25 p.m. Interview with CNA #4 on April 5, 2012, at 1:30 p.m., in the 2 South hallway revealed ""...I get to them (trays) as soon as I can...you know some people eat faster than others..."" Interview with the Dietary Manager and food temperature test at 1:05 p.m. at the 2 South food cart revealed ""...we do not have any more squash or pasta salad...not sure about the meat."" Observation and interview with the Dietary Manager confirmed the ice cream temperature was 51.8 degrees Farhenheit. continued observation and interview with teh dietary Manager confirmed the ice cream was warm and liquid and when the thermometer was removed from the liquid ice cream the temperature dropped to 50.3 degrees Farenheit. Interview with Resident #9 on April 5, 2012, at 1:15 p.m., in the Resident's room revealed ""...I like to go to the dining room to eat...I have to go to the bathroom after I eat...they said they have people who need to be fed...I cannot wait (in the dining room) that long...I eat in my room....(resident drinking ice cream from the ice cream contatiner)...I had to eat this first (referring to the ice cream) it is already melted and soupy...then my food is medium warm. C/O #",2015-08-01
12362,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2012-04-11,514,D,1,0,VEEQ11,"**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 for one resident (#1) of nine residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medcial record review of Physician order [REDACTED]. Interview with the Director of Nursing on April 2, 2012, at 2:00 p.m., at the Nursing Station revealed no facility policy could be located that was specific for documenting oxygen saturation levels. Interview with the Medical Director on April 2, 2012, at 2:10 p.m., revealed Resident #1's oxygenation saturation levels, when required to maintain saturation percentage, should be checked by a pulse ox at least twice daily. Review of the Vital Sign Chart (Oxygen Sat. column) revealed the facility failed to record the O2 pulse ox reading twenty (20) times during the month of February 2012 and zero (0) were recorded for the month of March 2012. Interview and review of the medical record with the Director of Nursing on April 2, 2012, at 2:30 p.m., at the Nurses' Station confirmed the Vital Sign Chart Record did not consistently record Resident #1's oxygen saturation levels. C/O #",2015-08-01
12363,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2012-07-23,441,D,1,0,5ZTE11,"**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 implement isolation precautions to prevent the development and/or transmission of infection for three residents (#5, #7, #8) of nine sampled residents. The findings included: Review of facility policy titled ""Initiating Isolation"" dated May 20, 2003, revealed, ""Isolation precautions will be initiated when there is reason to believe that a resident has an infectious or communicable disease...nurse shall notify the resident's attending physician for appropriate isolation instructions...enter the physician's orders [REDACTED]. Review of facility policy titled ""Infection Control Policies/Practices"" dated June 26, 2002, revealed, ""...This facility's infection control policies and practices apply equally to all personnel, consultants...residents, visitors, volunteer workers, and the general public alike...The objectives of our infection control policies and practices are...Establish guidelines to follow in the implementation of Isolation precautions..."" Medical record review revealed a hospital discharge summary, for resident #5, dated May 25, 2012 which revealed, ""...pneumonia...has grown a multi-drug resistant acinetobacter from sputum culture..."" Medical record review of a Nurse Practitioner (NP) note dated June 29, 2012, revealed, ""history acinetobacter from bronchus...sputum pending...hold treatment for [REDACTED]. Medical record review revealed Resident #5 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a hospital discharge summary dated May 25, 2012, revealed, ""...pneumonia...has grown a multi-drug resistant acinetobacter from sputum culture..."" Medical record review of a Nurse Practitioner (NP) note dated June 29, 2012, revealed, ""history acinetobacter from bronchus...sputum pending...hold treatment for [REDACTED]. Medical record review of a physician's orders [REDACTED]."" Medical record review of a Result Form dated July 2, 2012, revealed, ""Lower Respiratory Culture...Specimen Description Tracheal Aspirate...Culture Oropharyngeal Flora Present 3+ Acinetobacter...(Multiple Antibiotic Resistant Organism)...3+ Methicillin Resistant Staphylococcus Aureus..."" Observation on July 12, 2012, at 3:45 p.m., revealed the resident in bed, a tracheotomy tube (to facilitate breathing) was used and a bio-hazard trash can and a regular trash can were in the resident's room. Continued observation revealed the door to the resident's room fully opened into the resident's room and a posted sign on the door (not visible from outside the resident's room) instructed visitors to see a nurse before entering the resident's room. Continued observation revealed an isolation cart across the hall from the resident's room. Interview with Licensed Practical Nurse (LPN) #1 on July 12, 2012, at 4:07 p.m., in the third floor day room, revealed isolation carts were placed on one side of the hall as a safety measure. Continued interview revealed staff had been inserviced regarding acinetobacter and instructed posting of isolation signs violated a resident's right to privacy. Interview with the Assistant Director of Nursing (ADON) on July 23, 2012, at 3:50 p.m., in the third floor family room, confirmed the facility failed to implement isolation precautions for Resident #5. Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of admission orders [REDACTED] Observation on July 20, 2012, at 3:15 p.m., revealed the resident in bed, a tracheotomy tube was used, and another resident was in the room. Continued observation revealed a visitor in the room (in the roommate's side of the room) without gloves or a gown and a sign posted outside the room instructed visitors to see a nurse before entering the room. Interview with LPN #3 on July 20, 2012, at 3:23 p.m., at the third floor nurse's station, revealed a gown, gloves, and a mask were to be donned before entering the room and the resident's mother was non-compliant with isolation precautions. Interview with the Assistant Director of Nursing (ADON) on July 23, 2012, at 3:50 p.m., in the third floor family room, revealed the Medical Director instructed staff isolation precautions continued until a resident had no symptoms of infection. Continued interview confirmed the facility failed to implement isolation precautions for Resident #7. Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Result Form dated July 11, 2012, revealed, ""...Wound Culture...Specimen Description...trach (tracheostomy) stoma...Organism 1 3+ Pseudomonas Aeruginosa...Organism 2 2+ Acinetobacter..."" Medical record review of a Hepatitis Panel report dated July 5, 2012, revealed, ""...Reactive Reference Range Non-reactive..."" Continued review revealed the resident had Hepatitis C. Observation on July 20, 2012, at 3:17 p.m., revealed the resident in bed, a tracheotomy tube was used, and a female (visitor) held the siderail of the resident's bed. Continued observation revealed a sign posted on the door instructed visitors to check with a nurse before entering the room. Continued observation revealed the female did not wear gloves or a gown, removed a mask as she left the room, and did not wash her hands. Interview with LPN #3 on July 20, 2012, at 3:23 p.m., at the third floor nurse's station, revealed a gown, gloves, and a mask were to be donned before entering the room. Interview with the ADON on July 23, 2012, at 1:30 p.m., in the third floor family room, confirmed the facility failed to implement isolation precautions for Resident #8.",2015-08-01
12364,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2012-06-25,157,D,1,0,52UQ11,"Based on facility policy review, medical record review, review of facility investigation documentation, and interview, the facility failed to notify the physician in a timely manner of an allegation of sexual abuse for one resident (#10) of eleven sampled residents. The findings included: Review of facility policy RS-NSG -022 most recently revised January 5, 2005, revealed, ""...Topic: Physician Notification...It is the policy of (facility), that the physician will be notified about any change in resident condition according to Federal and State guidelines...If the physician does not respond to the phone call after two attempts (30 minutes apart), the Medical Director will be contacted. Messages will not be left on the physician's answering machine...when a prompt response is indicated..."" Medical record review of a Skilled Daily Nurses Note authored by Licensed Practical Nurse (LPN) #2 dated May 24, 2012, at 5:00 a.m., revealed, ""CNA's (Certified Nursing Assistants) informed this nurse resident was upset and stating (resident) had been raped...This nurse called resident's daughter...Also message left for social worker."" Continued review revealed no documentation regarding physician notification. Medical record review of a nurse's note (LPN #2) dated May 24, 2012, at 6:30 a.m., revealed no documentation regarding physician notification. Medical record review of a nurse's note (LPN #3) dated May 24, 2012, at 10:45 a.m., revealed, ""Rec'd (received) new order to send to (hospital)..."" Medical record review of a nurse's (Director of Nursing) note dated June 4, 2012, revealed, ""Late entry for 5/24/12: Received call from RN (registered nurse) supervisor at 5:15 (a.m.)...resident stated (resident ) had been raped...Daughter declined sending to ER...(6:15 a.m.)...daughter in room...Staff reported (resident's physician) was not the on-call MD (medical doctor) and daughter agreed to wait until (resident's physician's) office opened at (8:00 a.m.)...10:30 (a.m.) Advised (resident's physician) returned phone call and wanted the resident sent to the ER (emergency room ) for evaluation...(1:30 p.m.) Medical Director advised of allegation..."" Review of facility investigation documentation dated May 24, 2012, revealed, ""...Time of incident/accident 5:00 a.m...Name of physician notified (space was blank) Time of notification (space was blank)..."" Telephone interview with LPN #2 on June 14, 2012, at 11:20 p.m., revealed the resident's physician was not on call, the resident's daughter preferred the resident's physician be notified of the allegation, and LPN did not notify a physician of the allegation. Interview with LPN #3 on June 25, 2012, at 9:50 a.m., in a conference room, revealed LPN #3 left a message on the resident's physician's answering machine on May 24, 2012, at approximately 8:30 a.m. and did not make another attempt to notify the physician. Continued interview revealed the physician called and LPN #3 received an order to send the resident to a hospital at 10:45 a.m. Continued interview confirmed physician notification was delayed and the facility failed to implement the Physician Notification policy for Resident #10 on May 24, 2012.",2015-08-01
12365,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2012-06-25,225,D,1,0,52UQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, review of facility investigation documentation, observation, and interview, the facility failed to thoroughly investigate and timely report an allegation of abuse for one resident (#10) of eleven sampled residents. The findings included: Review of facility policy number RS-NSG-041most recently revised April 3, 2005, revealed, ""...Topic: Abuse/Neglect/Mistreatment...When a person witnesses or suspects abuse...the person must report it immediately to the DON (Director of Nursing) and Administrator...will thoroughly investigate and promptly report to proper authorities all allegations or incidents of resident abuse...will notify the Administrator of the facility immediately that an incident has been alleged or occurred and other officials in accordance with State law including the state survey and recertification agency...within 5 working days of the incident..."" Medical record review revealed Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Skilled Daily Nurses Note dated May 24, 2012, at 5:00 a.m., revealed, ""CNA's (Certified Nursing Assistants) informed this nurse resident was upset and stating (resident) had been raped..."" Medical record review of a physician's orders [REDACTED]."" Medical record review of a hospital History and Physical dated May 24, 2012, revealed, ""...Here for examination of alleged sexual assault..."" Medical record review of hospital nurses' notes dated May 24, 2012, revealed, ""...(11:48 a.m.) arrived from (facility). Complaints (complains) of sexual assault this a.m., in (resident's) room, at facility...12:01 p.m.)...police here to see patient...(1:00 p.m.) Pt (patient) in with sane (Sexual Assault Nurse Examiner) nurse..."" Medical record review of a hospital nurse's note dated May 24, 2012, at 3:10 p.m., revealed, ""...discharged to home (facility)..."" Review of facility investigation documentation dated May 24, 2012, revealed, ""...Report...Resident stated...was raped and couldn't get out of bed because he would kill (resident)..."" Review of facility investigation documentation (a single handwritten statement signed by two CNAs) (#3 and #4) dated May 24, 2012, revealed, ""...(resident) stated 'I can't get up that man said he would kill me because he raped me...I tried to explain...that there wasn't any men in...room...I went and told (House Supervisor)..."" Continued review revealed no documentation regarding the identity of the CNA responsible for notification of the House Supervisor. Review of facility investigation documentation (a single statement signed by two Licensed Practical Nurses (LPN) (#1 and #2), dated May 24, 2012, revealed, ""CNA reported resident states, '...has been raped and if (resident) gets out of bed he is in (resident's) room and will kill (resident)' this nurse and another nurse working the floor entered the room...supervisor notified message left for Social Worker and call to D.O.N. (Director of Nursing). Roommate and floor staff also questioned, no male has been seen entering room this shift..."" Continued review revealed no documentation regarding the identity of the LPN responsible for notification of the supervisor, Social Worker, or the DON. Continued review revealed no documentation regarding the identify of staff responsible for questioning staff and/or statement of the resident's roommate. Review of facility investigation documentation (House Supervisor's statement) dated May 24, 2012, revealed, ""CNA's (CNAs) reported to nurse on the floor...resident...made the statement that a man had raped (resident) when they were in...changing (resident)...The 2 LPN's on the floor...examined the resident...then came back to the desk and called (resident's) daughter...daughter changed her (resident) again...mother kept saying it's on me. Don't know what (resident) was referring to...Social Worker notified of alleged in incident..."" Continued review revealed no documentation regarding the identify of the CNAs or two LPNs working the floor or the LPN responsible for notification of the resident's daughter. Review of facility investigation documentation dated June 4, 2012, revealed, ""Late Entry for 5/24/12: Received call from RN (Registered Nurse) supervisor at 5:15 (a.m.)...(6:15 a.m.) I spoke with RN supervisor and reviewed statements of staff. Sitter on floor asked for name and contact information..."" Continued review revealed no documentation regarding a statement from the sitter. Review of facility reporting documentation dated June 6, 2012, revealed, ""...Date of Occurrence: 05/28/2012...staff interviewed the resident, the resident's daughter, the roommate...After completing internal investigation we have found this allegation of abuse to be unsubstantiated..."" Observation on June 13, 2012, at 9:20 a.m., revealed the resident seated in a chair and the resident's son-in-law at the bedside. Continued observation and interview revealed the resident was alert, disoriented, and without complaint of mistreatment. Telephone interview with Police Detective #1 on June 1, 2012, at 2:03 p.m., revealed the facility did not report the allegation to local law enforcement. Interview with the Director of Nursing on June 13, 2012, at 12:34 p.m., in a conference room, revealed a thorough investigation included individual statements from staff, and confirmed the facility failed to complete a thorough investigation of Resident #10's allegation of sexual abuse. Telephone interview with an Adult Protective Services caseworker on June 25, 2012, at 9:30 a.m., revealed the facility did not report the allegation to Adult Protective Services. Telephone interview with the Administrator on June 25, 2012, at 10:20 a.m., confirmed the facility failed to accurately and/or timely report Resident #10's allegation of sexual abuse.",2015-08-01
12366,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2012-06-25,312,D,1,0,52UQ11,"**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 hygiene for one resident (#3) of eleven sampled residents. The findings included: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Minimum Data Set, dated dated dated [DATE], revealed the resident had no cognitive impairment or mood or behavioral problems. Continued review revealed the resident was frequently incontinent of bowel and bladder and totally dependent on staff for toileting and hygiene. Medical record review of a care plan effective through July 25, 2012, revealed, ""...keep clean and dry...wing brief..."" Observation on June 12, 2012, at 9:20 a.m., revealed the resident in bed and the resident's left leg was amputated below the knee. Interview with the alert, oriented resident on June 12, 2012, at 9:20 a.m., revealed a concern about the staff's response time to call lights and the resident's brief had been changed after breakfast. The resident stated, ""They don't come prompt, I''ll tell you. Sometimes I lay wet."" Observation on June 12, 2012, at 9:24 a.m., revealed the resident's call light was activated and staff inquired (via the call system), ""Can I help you?"" Continued observation revealed the resident stated, ""I need changed. I'm wet."" Continued observation revealed staff did not verbally acknowledge the resident's request. Observation on June 12, 2012, at 9:40 a.m., revealed four staff stood in the corridor at the nurse's station. Interview with Certified Nursing Assistant (CNA) #2 on June 12, 2012, at 9:50 a.m., in the second floor corridor, revealed the facility had no method for monitoring residents' requests for assistance and/or response to requests. Observation on June 12, 2012, from 9:24 a.m.through 9:55 a.m., revealed staff did not respond to the resident's request for assistance. Interview with the Administrator on June 12, 2012, at 9:55 a.m., at the nurse's station, confirmed the facility failed to provide the requested assistance with activities of daily living for Resident #5 on June 12, 2012. C/O: #",2015-08-01
12367,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2012-06-25,323,G,1,0,52UQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility investigation documentation, observation, and interview, the facility failed to ensure safety devices were in place to prevent falls with injury for one (#5) of eleven residents reviewed, resulting in harm to Resident #5 who was transferred to the Emergency Department for sutures for a head laceration. The findings included: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Psychiatric Note dated March 15, 2012, revealed, ""...confused...Orientation: self...Insight:poor...Judgment: poor..."" Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident was severely impaired with decision-making skills, non-ambulatory, totally dependent on staff for all activities of daily living, and required the assistance of two staff for transfers. Medical record review of a Fall Risk assessment dated [DATE], revealed a score of seven and included, "" ...Requires aid with transfers...and is unwilling/unable to ask for assistance...If resident score 4 or more a fall leaf will be placed outside the door and care planned at risk."" Medical record review of the care plan effective through June 21, 2012, revealed, ""...at risk for falls related to history of fall...safety unawareness...Full side rails with padding to bed..."" Medical record review of a nurse's note dated April 30, 2012, at 8:50 p.m., revealed, ""Heard alarm sounding, upon entering room resident noted lying on floor beside bed. Laceration freely bleeding noted to R (right) forehead. Pressure applied to stop bleeding. R siderail down ...Sent to (Hospital #1)..."" Medical record review of a physician's orders [REDACTED]."" Medical record review of a nurse's note dated April 30, 2012, at 8:50 p.m., revealed, ""...Sent to (hospital)..."" Medical record review of a hospital emergency room record dated April 30, 2012, revealed, "" ...Chief Complaint: Fall ...presents via EMS (Emergency Medical Services) from nursing home secondary to sustaining a head laceration. Apparently the patient was placed in bed and bed rails were not put in place and the patient slid out of bed striking the floor ...laceration noted on the forehead ...pertinent history ...Left side weakness Dementia ...Insomnia ...total of ten ...sutures were placed ...Diagnosis: [REDACTED]. Review of facility investigation documentation dated April 30, 2012, revealed, ""...Describe exactly what happened...Resident found lying on floor next to bed. Alarm was sounding. Laceration to forehead. Pressure applied to stem bleeding. Side rail x 1 down...Nursing applied pressure to head wound. Paramedic applied head bandage..."" Continued review revealed, ""...What was the resident doing prior to the fall? Placed into Bed for HS (bedtime)...Resident activity prior to fall: in bed...Medication: Ativan 0.5 mg (milligrams) @ 8 PM...aware of own limitations: no...Environmental factors...Side rails: up x 1..."" Medical record review of a nurse's note dated May 1, 2012, at 12:15 a.m., revealed, ""Resident returned to facility ...DRSGS (dressings) applied to forehead, forearm, and bil (bilateral) elbows ..."" Medical record review of a Therapy Screen dated May 2, 2012, revealed, ""...Diagnosis/Condition/Problem: fell [DATE] OOB (out of bed). siderail down on bed...Comments: Pt (patient) has been in bed or Jeri-chair (geri-chair) @ all times. Lift use to get pt OOB..."" Observation on June 12, 2012, at 9:30 a.m., revealed the resident asleep in bed, siderails raised, and mats on both sides of the bed. Observation on June 13, 2012, at 9:58 a.m. revealed the resident awake, in bed, and a Certified Nursing Assistant (CNA) #1 shaved the resident. Continued observation and interview with the resident revealed siderails raised, mats on the floor on both sides of the bed; the resident was unable to respond appropriately to questions and unaware of (resident's) fall. Interview with CNA #1 on June 13, 2012, at 9:58 a.m., in the resident's room, revealed the resident did not attempt to get out of bed, and the CNA stated, ""(Resident) does scoot around..."" Interview with the Director of Nursing (DON) on June 13, 2012, at 3:00 p.m., in a conference room, confirmed the facility failed to ensure siderails were in place to prevent a fall with injury for Resident #5 on April 30, 2012.",2015-08-01
12368,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2012-08-08,281,D,1,0,52UQ12,"**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 one resident (#5) of six sampled residents. The findings included: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a recapitulation (short summary) of physician's orders effective through August 31, 2012, revealed, ""...padded siderail...to decrease risk of injury...Mats at bedside for protection..."" Observation on August 8, 2012, at 9:18 a.m., revealed the resident asleep on a low bed, the right siderail was raised and unpadded, a mat on the floor on the left side of the bed, and no mat on the right side of the bed. Observation with Licensed Practical Nurse (LPN) #1 on August 8, 2012, at 9:20 a.m., revealed the right siderail was raised and unpadded and no mat on the floor on the right side of the bed. Observation on August 8, 2012, at 10:23 a.m., revealed the resident on a low bed, the right siderail was raised and unpadded, a mat on the floor on the left side of the bed, and no mat on the right side of the bed. Interview with Registered Nurse (RN) #1 on August 8, 2012, at 9:55 a.m., in the family room, confirmed the facility failed to follow the physician's orders for Resident #5.",2015-08-01
12369,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2012-08-08,272,D,1,0,52UQ12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to assess the use of siderails for one resident (#4) and reassess the use of siderails for one resident (#5) of six sampled residents. The findings included: Review of the facility's Plan of Correction with a correction date of July 13, 2012, revealed, ""...Side rails have been raised x (times) 2 with mats on floor beside bed. Care plan has been updated with current safety precautions. Side rail assessments have been completed on all residents on (resident's floor)..."" Resident #5 (#5 for survey completed June 25, 2012) was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Side Rail Evaluation dated May 15, 2012, revealed the resident was unable to get out of bed safely and included, ""...Interventions utilized...will communicate with family about removing full rails and replace with half rails..."" Medical record review revealed no documentation regarding another Side Rail Evaluation. Medical record review of a Minimum Data Set, dated dated dated [DATE], revealed the resident was impaired with decision-making skills, totally dependent on staff for all activities of daily living, and had a history of [REDACTED]. Medical record review of a care plan dated June 20, 2012, revealed, ""...SAFETY PRECAUTIONS...Floor mats...at risk for falls...safety unawareness...Full side rails with padding to bed..."" Medical record review of a physician's orders [REDACTED]."" Observation on August 8, 2012, at 9:18 a.m., revealed the resident asleep on a low bed, a 3/4 unpadded siderail on the right side of the bed was raised and the siderail on the left side of the bed was lowered. Continued observation revealed a mat on the floor on the left side of the bed and no mat on the right side of the bed. Observation with Licensed Practical Nurse (LPN) #1 on August 8, 2012, at 9:20 a.m., revealed the resident on the bed and the left siderail on the resident's bed was not raised. Observation on August 8, 2012, at 10:23 a.m., revealed the resident on the bed and the left side rail was not raised. Interview with Certified Nursing Assistant (CNA) #1 on August 8, 2012, at 10:30 a.m., in the hallway outside the resident's room, revealed CNA #1 left the siderail down after providing care for the resident. Continued interview revealed the information regarding safety devices required by residents was available in a notebook, and CNA #1 stated, ""...It (left siderail) stays down."" Review of a list in a notebook ""Restraints Bedrails"" with CNA #1on August 8, 2012, at approximately 10:35 a.m., in a nurse's station, revealed, ""...(Resident #5) Bed lowest position - Bedrails Down x 2-Leftside Bedside mat x 1 (Half Rails)..."" Interview with LPN #2 (the resident's nurse) on August 8, 2012, at 10:50 a.m., at a nurse's station, revealed safety precautions to prevent falls for Resident #5 included a low bed with the left siderail lowered. Interview with Nurse Practitioner (NP) #1 on August 8, 2012, at 11:07 a.m., revealed the facility attempted to reduce the number of residents requiring the use of siderails. NP #1 stated, ""...feel like (Resident #5) would benefit from (the use of) two siderails..."" Interview with the Director of Nursing on August 8, 2012, at 9:30 a.m., in the family room, revealed no assessment for use of siderails had been completed since May 15, 2012. Continued interview confirmed the facility failed to ensure safety devices were in place to prevent falls for Resident #5 and/or implement the plan of correction. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a care plan dated May 11, 2012, revealed no documentation regarding the use of siderails. Medical record review of a nurse's note dated August 3, 2012, at 7:00 a.m., revealed, ""...found this morning by nurse hanging on to side rail with body hanging of (off) side of bed..."" Medical record review revealed no documentation regarding assessment for use of siderails. Interview with the Assistant Director of Nursing (ADON) on August 8, 2012, at approximately 3:00 p.m., at the second floor nurse's station, confirmed the facility failed to complete a siderail assessment for Resident #4.",2015-08-01
12370,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2012-08-08,319,D,1,0,52UQ12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to follow a physician's order for a mental health evaluation for one resident (#4) of six sampled residents. The findings included: Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a nurse's note dated July 21, 2012, at 2:00 p.m., revealed, ""...has been roaming the floor all shift. refuses to be laid down...attempts to leave floor...all attempts @ (at) intervention...have failed..."" Medical record review of a nurse's note dated July 25, 2012, at 6:00 p.m., revealed, ""...spit out part of meds (medications)..."" Medical record review of a nurse's note dated July 26, 2012, at 6:00 p.m., revealed,""...found on ground floor and was wandering on ground floor looking for a way out."" Medical record review of a nurse's note dated July 27, 2012, at 10:00 a.m., revealed, ""N/O (new order) received for psych (psychiatric)..."" Medical record review of a physician's order dated July 27, 2012, revealed, ""Psych eval & treat (evaluation and treatment)."" Medical record review revealed no documentation regarding a psychiatric evaluation. Observation on August 8, 2012, at 12:00 p.m., revealed the resident seated in a wheelchair with the arms crossed across the chest. Observation on August 8, 2012, at 3:50 p.m., revealed the resident seated in a wheelchair near the nurse's station on the secure unit (locked unit) and two nurses attended the resident. Interview with Licensed Practical Nurse (LPN) #3 on August 8, 2012, at approximately 3:52 p.m., at the nurse's station, revealed the resident's behavior during the afternoon of August 8, 2012, had required intervention by the staff. LPN #3 stated, ""...(Resident) has been swinging at everybody the last several hours. It comes and goes..."" Continued interview revealed a nurse usually faxed an order for [REDACTED].#3 had spoken with the Psych Nurse Practitioner (PNP) (regarding another resident) on August 1, 2012, and the PNP planned to be on vacation. Interview with the Director of Nursing (DON) and Administrator on August 8, 2012, at 4:30 p.m., in the family room, revealed PNP made weekly visits to the facility and the facility had alternate providers for the PNP. Continued interview confirmed the facility failed to follow the physician's order for a psych evaluation for Resident #4, and the DON stated, ""...Striking out is a new behavior for (Resident #4)...""",2015-08-01
12739,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2011-06-02,283,D,0,1,P03R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to complete a nursing discharge summary for one discharged resident (#23 - closed record) of three discharged residents (closed records) reviewed. The findings included: Resident #23 was admitted to the facility May 6, 2011, with [DIAGNOSES REDACTED]. Medical record review revealed the resident was discharged home with family on May 17, 2011, and no nursing discharge summary was completed. Interview with the Director of Nursing, in the conference room, on June 2, 2011, at 2:30 p.m., confirmed no nursing discharge summary was completed.",2015-07-01
12740,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2011-06-02,372,C,0,1,P03R11,"Based on observation, review of facility policies and procedures, and interview, the facility failed to dispose of garbage and refuse properly. The finding included: Observation of the dumpster refuse area with the Executive Chef on May 31, 2011, at 9:45 a.m., revealed the following: 1. A side door was fully opened on one (dumpster #1) of four dumpsters. 2. A side door was half-way opened on one (dumpster #2) of four dumpsters. 3. Liquid refuse leaking from dumpster #1, ran onto and accumulated on top of the concrete slab where the four dumpsters were positioned. The dumpster refuse and surrounding area produced a strong, foul, and soured odor. 4. Trash and refuse on the ground surrounding two of four dumpsters, included: disposable latex gloves, empty condiment containers, an empty facial tissue box, scattered pieces of paper, and a milk container. Review of a facility policy and procedure titled ""Garbage and Trash Disposal"" revealed, ""...Poor garbage and trash storage and disposal can lead to other types of problems. Various types of vermin will be attracted to the unit because of poor refuse storage on the outer premises. The vermin can enter and then cause further problems once inside...3. Using dumpsters for refuse disposal. The lids to these should be kept closed and waste should be in tight-closing, sealed, plastic bags. It will reduce odors and keep the dumpster clean..."" Interview with the Executive Chef on May 31, 2011, at 9:50 a.m., at the dumpster refuse area, confirmed the facility failed to ensure the proper disposal of garbage and refuse. .",2015-07-01
12741,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2011-06-02,323,G,0,1,P03R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility provided documentation, observation, and interview, the facility failed to ensure safety devices were functioning and in place to prevent a fall with injury (harm) for one (#3) resident., and failed to ensure safety devices were in place to prevent falls for one (#6) of twenty-five residents reviewed. The findings included: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed resident #3 had impaired short and long term memory, moderate difficulty with decision making, had a history of [REDACTED]. Medical record review of the resident's current care plan updated on November 10, 2010, December 8, 2010, and January 5, 2011, revealed ""...deficits in memory, decision making, communication and judgement R/T (related to) Alzheimer's Dementia...Personal alarm: bed chair 11-10-10 Pressure sensor: bed..."" Medical record review of the nurse's notes dated August 18, 2010, to November 10, 2010, revealed the resident had several falls without injury. Medical record review of the nurse's notes dated November 24, 2010, revealed ""...found sitting in floor beside bed. Res(resident) had removed personal alarm and bed sensor did not alarm. No injuries found..."" Review of the facility documentation dated November 24, 2010, revealed ""...resident removed personal alarm & sensor did not sound. Therapy to screen... Interventions; (no interventions were marked). See Interdisciplinary note..."" Medical record review of the Therapy Screen dated December 1, 2010, revealed ""...Reminded resident to push call button. Pt does have confusion..."" No documentation was found if the function of the alarms was assessed to improve the resident's safety. Review of the facility documentation dated December 4, 2010, revealed resident #3 ""...was lying on the floor next to the bed...Personal alarm hx (history) of taking it off...found in bed unattached to resident...Pressure sensor (pad in the bed that sounds when resident attempts to get out of the bed) on- did not activate until CNA (Certified Nurse Assistant) pushed it to see why it didn't work...Level of Consciousness A (alert) & OX1 (oriented to one {self})"" Continued review revealed no documentation the function of the alarms was assessed to improve the resident's safety. Medical record review of a nurse's note dated December 6, 2010, revealed ""...resident in hospital (transfered to the hospital on December 5, 2010)...X-ray results Fx (fracture) R (right) femur (long bone in the leg connected to the hip)..."" Review of the Falls Interdisciplinary Team Narrative Note dated December 6, 2010, revealed ""...Resident curently in hospital. Screen completed prior to hospitalization with poor safety awareness..."" Medical record review of the resident's careplan revealed the resident was readmitted on [DATE], and no new interventions for safety were put in place upon re-admission. Review of the facility provided documentation dated January 8, 2011, revealed ""...Res found in floor @ (at) FOB (foot of bed)...Personal alarm removed by pt & cord wound up &(and) set on bedside table ..."" Continued review revealed no documentation the use of the alarms was assessed to improve the resident's safety. Observation on June 1, 2011, at 1:30 p.m., in the dining room revealed the resident in the wheel chair with the personal alarm attached to the sweater and the control box in a bag on the back of resident's wheel chair (wc). Continued observation revealed resident #3 heard a beeping noise, reached into the bag on the back of the wheel chair removed the control box, checked if the tab was still attached to the box, and returned it to the bag. Observation and interview on June 2, 2011, at 1:40 p.m., near the 1 South nurse's desk with Licensed Practical Nurse (LPN) #1, CNA #1 and CNA #2, revealed the resident in the wheel chair without the personal alarm attached to the resident. Continued observation revealed LPN #1 searched the resident's bag on the back of the wheel chair, and the bag contained the personal alarm with the string wrapped around the control box. Continued observation revealed CNA #1 and CNA #2 re-attached the personal alarm to the resident and put the control box into the bag on the back of the resident's wheel chair. Interview with LPN #1, CNA #1, and CNA #2 all confirmed resident #3's personal alarm was not attached to the resident to alert staff of unsafe attempts to transfer self. Interview on June 2, 2011, at 1:05 p.m., in the facility conference room with the Director of Nursing (DON) confirmed the resident removed the personal alarm and the bed sensor alarm did not sound on November 24, 2010, resulting in the resident falling with no injury. Continued interview confirmed the resident again removed the personal alarm and the bed sensor did not sound on December 4, 2010, the resident fell fracturing the right femur resulting in harm. Continued interview revealed the DON could not find any documentation the functioning of the alarms, and the positioning of the alarms, was assessed to provide safety for the resident until the January 8, 2011, fall. Resident # 6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Fall Risk Assessment and the care plan dated November 12, 2010, revealed ""... increased risk for falls related to weakness, psychotropic medications, tremors and rigidity associated with Parkinson's Disease, unaware of safety issues, forgetful, and leans forward in wc with history of falls."" Continued review of the care plan revealed the resident required assistance of one, with transfers, positioning, ambulation and toileting. The resident also required a personal safety alarm (psa) while in the chair and in the bed. Medical record review of a nurse's note dated May 6, 2011, as a late entry regarding a May 4, 2011, ""...resident found sitting on floor in front of w/c no apparent injuries ..."" Continued medical record review of facility provided documentation dated May 4, 2011, revealed ""...resident found sitting on floor in front of wc... personal alarm found on top of night stand...not on resident."" Interview with the Assistant Director of Nursing on June 1, 2011, at 2:04 p.m., at the 2 South Nurse's Station, confirmed the resident had fallen forward, out of the wheelchair, and the psa was not on the resident as ordered, to alert the staff of unassisted transfers.",2015-07-01
12742,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2011-06-02,221,D,0,1,P03R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, policy review, and interview, the facility failed to obtain a physician's order and informed consent for restraint use for one resident (#18) of twenty-five residents reviewed. The findings included: Resident #18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed a physical restraint was used daily in a chair. Medical record review of the Restraint Evaluation Form dated February 28, 2011, and March 29, 2011, revealed the resident was being physically restrained when in the wheelchair. Medical record review of the February 2011, May 2011, and June 2011, Physician's Recapitulation Orders and Telephone Orders dated February 1, 2011, through June 2, 2011, revealed no order for a physical restraint. Medical record review revealed no signed informed consent for the use of the physical restraint. Review of the facility's ""Restraints-Physical"" policy revealed, ""...In all cases, a physician's order is necessary for the use of a physical restraint. The order must detail the type of restraint, when it is to be used, and for what reason it is to be used...In all cases, the use of the restraining device must first be explained to the resident, family member, or legal representative and used only after their approval..."" Observation on June 1, 2011, at 12:45 p.m., and 3:00 p.m., and on June 2, 2011, at 9:00 a.m., and 1:00 p.m., in the resident's room, revealed the resident on the bed and the resident's wheelchair with a lap belt restraint in the seat of the wheelchair, setting at the resident's bedside. Interview with Licensed Practical Nurse #3 on June 1, 2011, at 3:25 p.m., at the 2-North Nurse's Station, confirmed the resident is transferred from the bed and placed in the wheelchair daily. Continued interview confirmed the resident is physically restrained with a lap belt when in the wheelchair. Further interview confirmed the lap belt is attached and secured onto the kick spurs of the wheelchair and the resident cannot self-release the lap belt. Continued interview confirmed a physician's order and informed consent for the lap belt had not been obtained. Interview with the Director of Nursing (DON) on June 2, 2011, at 1:30 p.m., in the Conference Room, confirmed the resident is physically restrained with a lap belt when in the wheelchair. Further interview confirmed the lap belt is attached and secured onto the kick spurs of the wheelchair and the resident cannot self-release the lap belt. Continued interview confirmed the lap belt is used as a physical restraint for this resident and the facility failed to obtain a physician's order and informed consent to use the lap belt. .",2015-07-01
12743,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2011-06-02,246,D,0,1,P03R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to provide an environment conducive to the accommodation of resident needs for two (#17, #25) of twenty-five residents reviewed. Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE] revealed the resident is severely cognitively impaired, the resident is bed or chair bound and dependent on staff for all activities of daily living. Observation of the resident on May 31, 2011, at 9:10 a.m., revealed the resident in the bed and the resident's call light was on the floor under the bed and not accessible to the resident. Interview with LPN #2, on May 31, 2011 at 9:20 a.m. confirmed the resident could use the call light, but the resident could not access the call light from the floor to call for assist if needed. Resident #25 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident is severely cognitively impaired and dependent on staff for assistance with all activities of daily living. Medical record review of the facility's care plan dated February 17, 2011, revealed "" ... impairment in ADL functioning ablility:...needs extensive assistance with activities of daily living. Continued care plan review revealed the resident was at an increased risk for falls...had a history of [REDACTED]."" Observation of the resident on May 31, 2011, at 9:25 a.m., revealed the resident in the bed, with head of bed elevated 90 degrees. The resident was slumped to the left side and stated that she was uncomfortable and needed assistance. The resident's call light was across the room and not accessible to the resident in bed. Interview with CNA #3 on May 31, 2011, at 9:28 a.m. in the resident's room, confirmed the resident could not access the call light for staff assistance if needed. Interview with the Administrator on June 1, 2011, at 8:50 a.m., in the resident's room, confirmed the resident was unable to access the call light from the floor.",2015-07-01
12744,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2011-06-02,279,D,0,1,P03R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to follow the care plan, for one (#5) resident of twenty five residents reviewed. The findings included: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], indicated the resident was totally dependent on staff for all activities of daily living, toileting needs, and transfers. Medical record review of the care plan dated April 29, 2009, revealed ""...At risk for falls related to severely impaired cognition/safety awareness ...unable to ambulate and [MEDICAL CONDITION]."" Continued review of the current care plan revealed ""...use (named mechanical) total body lift for transfers"". Review of facility documentation dated January 10, 2011 revealed Certified Nurse Assistant (CNA) #2 stated CNA #4 transferred the resident from the chair to the bed, in the resident's room, on January 4, 2011 without the aid of the total body lift. Interview with the Clinical Staff and Training Coordinator (CSTC), June 2, 2011, at 10:20 a.m., in the 2 North dayroom confirmed CNA #4 transferred the resident from the chair to the bed, in the resident's room, on January 4, 2011 without the aid of the total body lift. Interview with the Administrator on June 2, 2011, at 11:05 a.m., in the conference room, confirmed the resident's care plan was not followed when CNA #4 transferred the resident from the chair to the bed, in the resident's room, on January 4, 2011 without the aid of the total body lift.",2015-07-01
14071,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2010-05-05,431,D,,,M4JO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview, the facility failed to date a medication when opened and failed to discard expired supplies in three of five supply cabinets. The findings included: Observation on [DATE], at 10:30 a.m., with Licensed Practical Nurse (LPN) #2, of the 2 North supply cabinet revealed the following: Four, vacutainer tubes (used for blood specimens) available for resident use, with an expiration date of February, 2009. Two vacutainer tubes available for resident use, with an expiration date of November, 2009. Nine packages of suction swabs (active ingredient hydrogen peroxide 1.5%) available for resident use, with an expiration date of 2007. One 20 milliliter container of Lidocaine 1%, opened and undated. Interview on [DATE], at 10:30 a.m., with LPN #2, on the 2 North Hall confirmed the supplies had expired and the Lidocaine was opened and undated. Observation on [DATE], at 11:10 a.m., with LPN #3, of the 3rd floor supply cabinet revealed the following: Sixteen 40 milliliter containers of Bact/Alert (used for arterial blood gases) available for resident use with an expiration date of [DATE], and sixteen 40 milliliter containers of Bact/Alert available for resident use, with an expiration date of [DATE]. Interview on [DATE], at 11:10 a.m., with LPN #3, on the 3rd floor, confirmed the supplies had expired. Observation on [DATE], at 12:45 p.m., with LPN #4, of the 100 South supply cabinet revealed the following: Five vacutainer tubes available for resident use, with an expiration date of November, 2009. Interview on [DATE]. at 12:45 p.m., with LPN #4, on the 100 South Hall, confirmed the supplies had expired.",2014-04-01
14072,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2010-05-05,314,D,,,M4JO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, manufacture recommendations, observation and interview, the facility failed to ensure the specialty mattress was set accurately for two residents (#11, #1) of twenty- five residents reviewed. The findings included: Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed the residents weight dated May 3, 2010, was131 lbs (pounds). Medical record review of the physician's orders [REDACTED]. Review of the name brand manufacture recommendations revealed ""...The comfort control LED displays the patient comfort pressure levels from 0 to 9 and provides a guide to the caregiver to set approximate comfort pressure levels depending on the patient weight..."" Observation and interview with the Wound Care Nurse on May 5, 2010, at 11.00 a.m., revealed the resident lying supine in the bed on the specialty mattress. Continued observation revealed the control panel set on 5 (for weight of 175 to 210 lbs). Interview with the Wound Care Nurse at the time, confirmed the specialty mattress is set depending on the resident's weight, and the current setting of 5 was not accurate for the resident's current weight. Resident #1 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Medical record review of the care plan dated March 25, 2010, revealed ""...apply air mattress to bed..."" related to the risk of impaired skin integrity due to impaired mobility and [MEDICAL CONDITION]. Medical record review of the Weight Chart dated May 1, 2010, revealed the resident's weight of one hundred seventy-six pounds. Observation on May 3, 2010, at 10:30 a.m., May 4, 2010, at 8:00 a.m., and May 5, 2010, at 7:45 a.m., revealed the resident lying in a bed equipped with a Low Air Loss and Alternating Pressure Mattress. Continued observation revealed a control pump, with a pressure adjust knob and markings to indicate the resident's weight in pounds. Further observation revealed the pressure adjust knob set at two hundred fifty pounds. Interview on May 5, 2010, at 8:35 a.m., in the resident's room with the Central Supply employee revealed ""...mattress should be set by resident's weight, if weight loss or weight gain it should be adjusted accordingly..."" Further interview with the Central Supply employee at 1 South Nurse's Station confirmed the resident's weight of hundred seventy-six pounds. Interview on May 5, 2010, at 8:45 a.m., in the resident's room with LPN (licensed practical nurse) #4 and the Central Supply employee confirmed the facility failed to set the pressure adjust knob according to the resident's weight.",2014-04-01
14073,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2010-05-05,281,D,,,M4JO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to follow a Physician's order for one resident (#16) of twenty five residents reviewed. The findings included: Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Physician's order dated April 21, 2010, revealed clean skin tear area on top of L (left) forearm with normal saline and pat dry. Apply dressing and cover with gauze and change every other day. Medical record review of the Physician's order dated April 25, 2010, revealed clean skin tear on right forearm with normal saline cover with dressing and cover with gauze, change every other day. Observation on May 3, 2010, at 9:10 a.m. revealed the resident seated on the bed. Continued observation revealed dressings to the right and left forearm dated April 29, 2010. Both dressings had been in place for 5 days. Interview with the Wound Care Nurse on May 3, 2010, at 9:15 a.m., confirmed the dressings were dated April 29, 2010, and the Physician's order to change the dressings every other day had not been followed.",2014-04-01
14074,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2010-05-05,166,D,,,M4JO11,"Based on review of the resident council minutes, and interviews, the facility failed to resolve grievances in a timely manner for three of three months reviewed. The findings included: Review of the resident council minutes dated February 5, 2010, March 5, 2010, and April 2, 2010, revealed ""...doesn't receive meds in timely manner...once in awhile late on giving medications...medication/timing issue with shots...medicine is sometimes late...when I ask for pain pill I don't get them..."" Further review, revealed no documentation of follow up addressing the grievances. Interview with the resident council on May 3, 2010, at 2:30 p.m., in the one-south dayroom, revealed three residents voiced grievances of medication not given in a timely manner. Interview on May 5, 2010, at 1:30 p.m., with the Director of Social Services in the ground level in-service room, confirmed, ""...I agree. We need to be more proactive with follow ups...I understand we need something on paper stating how the grievances have been addressed..."" Interview with the DON (Director of Nursing), on May 5, 2010 at 9:30 a.m., in the DON's office confirmed the facility failed to resolve grievances in a timely manner.",2014-04-01
14075,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2010-05-05,502,D,,,M4JO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based of medical record review, and interview, the facility failed to obtain laboratory services for one resident (#1) of twenty-five reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED]."" Medical record review of lab results revealed no documentation for a PT/INR completed on April 26, 2010, as ordered by the physician. Interview on May 5, 2010, at 8:30 a.m., with LPN (Licensed Practical Nurse) #4, at the nurse's station on one south, confirmed the facility failed to obtain the PT/INR as ordered by the physician.",2014-04-01
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
4612,"NHC HEALTHCARE, JOHNSON CITY",445024,3209 BRISTOL HWY,JOHNSON CITY,TN,37601,2016-06-02,441,D,0,1,9TZ711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Centers for Disease Control (CDC) guidelines, medical record review, observation and interview, the facility failed to ensure staff donned appropriate personal protective equipment (PPE) when entering a resident's room and to follow proper infection control standards for 1 resident (#418) of 4 residents reviewed for infection control of 26 residents reviewed. The findings included: Review of the CDC guidelines for residents with Clostridium Difficile dated 2007 revealed, .Use gloves when entering patients' rooms and during patient care .Use gowns when entering patients' rooms and during patient care . Medical record review revealed Resident #418 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a lab dated 05/21/16 revealed Resident #418 had a positive stool culture (Stool specimen tested for toxin) positive for Clostridium difficile (infectious bacteria that can cause symptoms ranging from diarrhea to life threatening inflammation of the colon). Medical record review of a physician's orders [REDACTED]. Observation of Resident #418's room on 5/31/16 at 11:50 AM, revealed a contact precaution sign located outside of the resident's door. Continued observation revealed gowns, gloves, and masks hanging from a plastic apron located on the outside of the resident's door. Observation of a meal tray delivery for Resident #418 on 5/31/16 at 11:52 AM, revealed the Certified Nursing Assistant (CNA) #1 had not donned personnel protective equipment (PPE) which consists of gown and gloves, before entering Resident #418's room to deliver a meal tray. Interview with CNA #1 on 5/31/16 at 11:52 AM, in the 100 hallway, confirmed CNA #1 entered Resident #418's room without donning personal protective equipment. Interview with the Director of Nursing on 6/2/16 at 8:56 AM, in the conference room, confirmed the facility failed to ensure staff donned appropriate PPE when entering Resident #418's room, who was on contact precautions, and failed to follow proper infection control standards for Resident #418.",2019-08-01
6303,"NHC HEALTHCARE, JOHNSON CITY",445024,3209 BRISTOL HWY,JOHNSON CITY,TN,37601,2015-06-24,241,D,0,1,WQDT11,"Based on observation and interview, the facility failed to assist residents with eating at mealtime, in a dignified manner, for 5 residents observed in 1 dining of 3 dining areas observed. The findings included: Observation of the station 2 dining area on 6/22/15 at 12:03 PM revealed Certified Nursing Assistant (CNA) #2 feeding two residents while standing over them. Observation of the station 2 dining area on 6/22/15 at 12:05 PM revealed CNA #3 feeding three residents while standing over them and moving from one resident to another. Interview with CNA#2 on 6/22/15 at 12:16 PM, in the dining room confirmed Don't suppose to stand up and feed residents. Interview with CNA#3 on 6/22/15 at 12:19 PM, in dining room confirmed I'm not to stand and feed residents. Interview with the Director of Nursing (DON) and the Administrator on 6/24/15 at 10:42 AM, in the DON's office confirmed the CNAs are not suppose to stand over the residents when assisting with feeding.",2018-08-01
6304,"NHC HEALTHCARE, JOHNSON CITY",445024,3209 BRISTOL HWY,JOHNSON CITY,TN,37601,2015-06-24,242,D,0,1,WQDT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to honor bathing preferences for 1 resident (#231) of 3 residents reviewed for activities of daily living. The findings included: Medical record review revealed Resident #231 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 15 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact/independent with daily decision making and was totally dependent with one person assist for bathing. Observation on 6/23/15 at 7:45 AM revealed the resident lying awake on the bed. Interview with the resident, at this time, revealed the resident received 2 showers weekly. Continued interview revealed the resident had oily hair and would like a shower daily. Further interview revealed Resident #231 had told her Certified Nursing Assistant (CNA) she would like to receive a shower more often than twice a week. Interview with CNA #1 (CNA usually assigned to care for the resident), in the hallway on 6/23/15 at 1:15 PM confirmed the resident had voiced would like a shower daily. Continued interview revealed the CNA had not reported the resident's request to the nursing supervisor. Interview with Resident Care Coordinator #1 on 6/23/15 at 1:40 PM, at the nursing station confirmed the resident's request/choice to receive a shower more often than 2 times a week had not been honored.",2018-08-01
6305,"NHC HEALTHCARE, JOHNSON CITY",445024,3209 BRISTOL HWY,JOHNSON CITY,TN,37601,2015-06-24,329,D,0,1,WQDT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure an unnecessary medication was not administered to 1 resident (#80) of 5 residents reviewed for unnecessary medications. The findings included: Medical record review revealed Resident #80 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Consultant Pharmacist's Recommendation to Physician form dated 6/2/15 revealed .This resident is receiving the antipsychotic agent [MEDICATION NAME] but lacks an allowable [DIAGNOSES REDACTED]. Continued review of the Consultant Pharmacist's Recommendation to Physician form revealed the physician agreed with the recommendation and the [MEDICATION NAME] was to be discontinued on 6/4/15. Medical record review of a physician's orders [REDACTED].D/C (discontinue) [MEDICATION NAME]. Medical record review of the Medication, Treatment and Task Administration Record Report for (MONTH) (YEAR) revealed the resident received Quetiapine ([MEDICATION NAME]) 25 mg (milligrams) daily at 9:00 PM, 6/1/15 through 6/23/15. Observation on 6/24/15 at 12:20 PM revealed the resident lying on the bed, in the resident's room, talking with a staff member. Interview with Resident Care Coordinator #1 on 6/24/15 at 8:10 AM, at the nursing station confirmed the resident continued to receive the [MEDICATION NAME] through 6/23/15 and the physician's orders [REDACTED].",2018-08-01
6306,"NHC HEALTHCARE, JOHNSON CITY",445024,3209 BRISTOL HWY,JOHNSON CITY,TN,37601,2015-06-24,441,D,0,1,WQDT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation, and interview, the facility failed to administer medications in a sanitary manner for 1 of 4 medication carts and the facility failed to feed residents in a sanitary manner for 1 of 3 dining rooms. The findings included: Review of facility policy, Medicine Handling, undated revealed .1. If oral medicine is dropped from its packaging onto the top of the med cart while being removed for administration, use gloved hand to pick up and discard . Observation on 6/22/15 at 10:30 AM, near the 100 nursing desk revealed Licensed Practical Nurse (LPN) #1 prepared Resident #231's medications. Continued observation revealed LPN #1 dropped a [MEDICATION NAME] Bisulfate 75 mg onto the contaminated medication cart, put gloves on and put the pill into a medication cup, prepared the remaining medications placing them into the same medication cup, and administered the contaminated medications to Resident #231. Interview with LPN #1 on 6/22/15 at 10:45 AM, near room [ROOM NUMBER] confirmed the dropped pill was contaminated and should have been discarded. Review of facility policy, Hand Hygiene, revealed, Hands shall be washed .whenever visibly soiled with dirt, blood, or body fluids, or after direct or indirect contact with such, and before eating .In the absence of visible soiling of hands, alcohol-based hand rubs are preferred for hand hygiene . Observation of the dining area at station 2 on 6/22/15 from 12:05 PM to 12:10 PM, revealed Certified Nursing Assistant (CNA) #3 was feeding 3 residents while standing over them, holding/touching the backs of their chairs. Continued observation revealed CNA #3 moved from one resident to another touching their eating utensils without sanitizing the hands. Interview with CNA #3, on 6/22/15 in the dining room, confirmed I didn't wash my hands after touching the chair. Interview with the Director of Nursing (DON) and the Administrator on 6/24/15 at 10:42 AM, in the DON's office confirmed yes they should have washed their hands between touching the chair and feeding the residents.",2018-08-01
8409,"NHC HEALTHCARE, JOHNSON CITY",445024,3209 BRISTOL HWY,JOHNSON CITY,TN,37601,2014-03-19,221,D,0,1,KE0J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and interview, the facility failed to assess for the use of a restraint prior to starting a potential restraint for two residents (#164,#152) of twenty-six residents reviewed. The findings included: Resident #164 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation on March 17, 2014, at 2:30 p.m., and March 18, 2014, at 3:12 p.m., revealed resident #164 on the 300 hall in a reclined wheelchair. Medical record review of a care plan dated February 5, 2014, revealed .11/27/13 resident placed in gerichair .1/3/14 resident to be up in rocking wheelchair (type of reclined wheelchair) during the day as tolerated . Medical record review of a physical restraint review dated January 28, 2014 revealed, .pt (patient) is up to gerichair daily . Interview on March 18, 2014, at 1:44 p.m., with Resident Care Coordinator (RCC) #1 at the 300 hall nurse's desk, revealed the resident was placed in the gerichair on November 27, 2013, and a restraint assessment was not completed till January 28, 2014, two months later. Continued interview revealed the recline wheelchair was not assessed prior to placing the resident in the wheelchair on January 3, 2014. Interview on March 19, 2014, at 9:23 a.m., in the RCC office confirmed the facility failed to assess the gerichair and rocking wheelchair prior to starting for a potential restraint. Resident #152 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation of the resident in the resident's room on March 17, 2014, at 1:42 p.m., revealed the resident sitting in a Broda chair (type of reclining chair). Review of the Interim Care Plan dated February 12, 2014, revealed .2/21/14, Broda chair d/t (due to) fall . Continued review of the medical record revealed the facility failed to complete a Pre-Restraint Assessment for the Broda chair until March 4, 2014, a delay of eleven days. Interview with the Station one Resident Care Coordinator (RCC) on March 18, 2014, at 11:45 a.m., at the Station one Nurse's Station confirmed the facility failed to perform a Pre-Restraint Assessment prior to initiating use of the Broda chair.",2017-06-01
8410,"NHC HEALTHCARE, JOHNSON CITY",445024,3209 BRISTOL HWY,JOHNSON CITY,TN,37601,2014-03-19,315,D,0,1,KE0J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to evaluate the bladder incontinence status of one resident (#162) of twenty-six residents reviewed. The findings included: Resident # 162 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the current care plan for the resident indicated that the resident was at risk for alteration in skin integrity due to urinary incontinence, with an intervention of assisting the resident with toileting as needed. Medical record review revealed two forms entitled Incontinence Screening, one dated November 8, 2013, and the other dated November 18, 2013. Both forms were complete on page one, Both forms indicated Resident # 162 scored a five on the incontinence screening and is a candidate for a bowel/bladder program at this time and is willing and/or able to participate in a continence program. Further review of the Incontinence Screening form dated November 8, 2013, revealed Resident # 162 actively wants to regain bladder control. Continued review of both Incontinence Screening forms revealed the second page to be blank and the section of the forms Complete the following algorithm to determine the appropriate incontinence management program was not completed. Further review revealed the section After completing the management algorithm, the program best suited to meet the patient's needs was: had not been completed and a bladder training program had not been identified on the form for the resident. Interview with Licensed Practical Nurse (LPN) #1 on March 18, 2014, at 1:57 p.m., at Nurse Station Two, revealed Resident #162 was incontinent of urine mostly at night and occasionally during the day. Continued interview revealed the resident was not on a scheduled toileting program. Further interview revealed We offer to take . to the bathroom at least every two hours. The facility standard for residents who need assistance with toileting is to offer every two hours. Interview with MDS (minimum data set) Coordinator #1 on March 19, 2014, at 10:12 a.m., revealed the incontinence screening form, both page one and two, were to have been completed by the MDS coordinator. An incontinence training program for the resident was to have been identified on the form. The information on the form was then to be relayed to the Resident Care Coordinator at the resident's station. Further interview with the MDS Coordinator #1 confirmed page two of the incontinence screening forms dated November 8, and November 18, 2013, for Resident #162 had not been completed and no incontinence program had been identified.",2017-06-01
8411,"NHC HEALTHCARE, JOHNSON CITY",445024,3209 BRISTOL HWY,JOHNSON CITY,TN,37601,2014-03-19,322,D,0,1,KE0J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure tube feedings were properly labeled for one resident (#169) of twenty-six residents reviewed. The findings included: Resident #169 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation on March 17, 2014, at 2:52 p.m., in the resident's room, revealed the resident lying in the bed with [MEDICATION NAME] 1.5 calorie (tube feeding) infusing at 65 milliliter (ml) per hour per the Percutaneous Endoscopic Gastrostomy (PEG) feeding tube. Continued observation revealed the tube feeding was not labeled with a start date or time. Interview with the Director of Nursing (DON) on March 17, 2014, at 3:22 p.m., in the resident's room, confirmed the facility failed to label the tube feeding with a date or time.",2017-06-01
10496,"NHC HEALTHCARE, JOHNSON CITY",445024,3209 BRISTOL HWY,JOHNSON CITY,TN,37601,2013-01-09,221,D,0,1,7UKE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure residents were free from restraints for one resident (#108) of fifty residents reviewed. The findings included: Resident #108 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical Record Review of the Care Plan dated December 6, 2012, revealed no interventions for restraint use. Further review of the Care Plan dated December 6, 2012, revealed no interventions for siderails and .bed to be in the lowest position with mat on floor . Continued medical record review revealed no documentation of a physician's orders [REDACTED]. Observation on January 9, 2013, at10:40 a.m., revealed four side rails in the up position with siderail covers in place. Further observation revealed the resident lying on the left side against the right upper siderail. Interview with Certified Nurse's Assistant #3 and Certified Nurse's Assistant #4, on January 10, 2012 at 8:10 a.m., confirmed the resident was able to roll in the bed and the siderails prevented the resident from rolling out of the bed. Interview with the Resident Care Coordinator (RCC #2), on January 9, 2013, at 10:40 a.m., in the resident's room, confirmed the four siderails were in the up position and the resident was not able to volunatarily able to get out of the bed. Further interview with RCC #2 confirmed the bed was to be in the low position with a mat on the floor at bedside. RCC #2 confirmed the bed was not in the low position. Interview with the Director of Nursing (DON) in the upstairs conference room on January 10, 2013, at 9:45 a.m., revealed the DON stated .four side rails on the bed were not restraints .the side rails prevented the resident from coming out of the bed .the side rails were split and the resident could get out of the bed between the rails . Continued interview revealed the DON was not able to say how much distance was between the lower and upper rails. Further interview with the DON confirmed when the definition of a restraint according to federal regulations were explained, the DON confirmed the side rails were a restraint.",2016-06-01
10497,"NHC HEALTHCARE, JOHNSON CITY",445024,3209 BRISTOL HWY,JOHNSON CITY,TN,37601,2013-01-09,272,D,0,1,7UKE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to complete a comprehensive assessment for incontinence for one resident (#209) of fifty residents reviewed. The findings included: Resident #209 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Urinary Incontinence Assessment and Evaluation Form dated September 6, 2012, revealed Pt (patient) is frequently incontinent of bladder. Will consult (named incontinence experts). Additional review of the Urinary Incontinence Assessment and Evaluation Form on September 18, 2012, revealed Incontinence Management referral to evaluate and treat as needed . Medical record review revealed a consult was performed on November 1, 2012, by the incontinence group and electronically signed on November 15, 2012. The plan included perform voiding diary, obtain a void volume with post void residual. Medical record review revealed an order to discontinue the incontinence group on November 15, 2012. Medical record review of the monthly Nursing Summary dated November 28, 2012, revealed, unable to retrain d/t (due to) impaired cognition. Interview with Certified Nursing Assistant (CNA# 5), on January 9, 2013, at 12:37 p.m., in nursing station 1, revealed the resident was not capable of physically moving to the bathroom independently, never expressed the need to urinate, and was always incontinent of bowel and bladder. Interview with the Director of Nursing (DON) and the Resident Care Coordinator (RCC #1), on January 9, 2013, at 12:40 p.m., in the conference room, revealed November 1, 2012, was the first visit from the incontinence group and on November 2, 2012, the resident was started on void therapy but there is no record of it with the only note being the one dated November 15, 2012. Interview with the DON and RCC #1 on January 9, 2013, at 1:29 p.m., at the Station 1 nursing station, confirmed a comprehensive assessment for bladder incontinence was not completed.",2016-06-01
10498,"NHC HEALTHCARE, JOHNSON CITY",445024,3209 BRISTOL HWY,JOHNSON CITY,TN,37601,2013-01-09,323,D,0,1,7UKE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to implement interventions including assistive devices to reduce the risks of an accident that were consistent with the needs and plan of care for one resident (#108) of fifty residents reviewed. The findings included: Resident # 108 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated March 31, 2012, revealed .Bed in low position, bed alarm, and mat on floor . Continued medical record review of the Care Plan dated December 6, 2012, revealed .Bed in low position, bed alarm and mat on floor . Medical record review of a Physician's Telephone Order dated April 1, 2012, revealed .Bed/WC (wheel chair) Alarms, low bed (with) floor mat . Observation of the resident in bed on January 9, 2012, at 2:10 p.m., with LPN #1 revealed no bed alarm in place and the bed in a raised position and not in the low position. Continued observation on January 10, 2013, at 8:05 a.m., revealed the resident in bed with the bed in a raised position. Interview with LPN #1 on January 9, 2013, at 2:20 p.m., in the upstairs conference room confirmed the bed alarm was not in place. Interview with LPN #1 on January 10, 2013, at 8:05 a.m., in the resident's room confirmed the bed was not in the low position.",2016-06-01
10499,"NHC HEALTHCARE, JOHNSON CITY",445024,3209 BRISTOL HWY,JOHNSON CITY,TN,37601,2013-01-09,425,D,0,1,7UKE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure the accurate acquiring, receiving, dispensing and administering of a medication for one (#172) of fifty sampled residents. The findings included: Resident #172 was admitted to the facilty on June 25, 2012, with diagoses including Parkinson's Disease, Coronary Artery Disease, Long-Term Coumadin Therapy, Congestive Heart Failure, Chronic Renal Failure, Acute Anxiety, Dementia, Depression, and Insomnia. Medical record review revealed a physician's orders [REDACTED]. every twelve hours for anxiety. Medical record review of a Medical Psychiatry Evaluation dated October 10, 2012, revealed the resident was currently on Clonazepam 0.5 mg. twice daily for anxiety. Further review revealed, .add PRN (as needed) of Clonazepam 0.5 mg. every 12 hours for increased anxiety. Medical record review of the November Physician's Recapitulation (recap) Orders revealed the order for Clonazepam 0.5 mg. every 12 hours as needed (PRN) for acute anxiety however, the physician's orders [REDACTED]. twice daily. Further review of the Physician's Recap Orders for December 2012 and January 2013, revealed no order for the routine order for Clonazepam 0.5 mg. twice daily. Review of the Medication Administration Records (MAR) for October, November, December 2012 and January 2013, revealed the resident continued to receive Clonazepam 0.5 mg. every 12 hour at 8:00 a.m. and 8:00 p.m. documented as every 12 hours as needed with no further dosages given. Medical record review of a physician's orders [REDACTED]. bid PRN due to disuse. Review of the MAR indicated [REDACTED]. on January 4, 2013, at 8:00 a.m., and the medication was then discontinued. Observation on January 9, 2013, at 2:00 p.m., revealed the resident sitting quietly in a broda chair in the resident's room. Interview with the Psychiatric Nurse Practitioner at the 200 Hall Nursing Station on January 9, 2012, at 2:30 p.m., confirmed the resident was to have remained on Clonazepam 0.5 mg. twice daily and only the PRN dosages were to be discontinued. Telephone interview with the Pharmacist on January 10, 2013, at 10:00 a.m., confirmed the Physician's Recap Orders are sent to the facility by the pharmacy and the MARs are printed from the Physician's Recap Orders. Further interview confirmed no order had been received to discontinue the routine Clonazepam 0.5 mg. twice daily, and the order should have been included on the Physician's Recap Orders and the MARS in November and December 2012 and January 2013. Interview with the 300 Hall Resident Care Coordinator on January 10, 2013, at 10:10 a.m., confirmed the resident had not received Clonazepam 0.5 mg. since January 4, 2013, at 8:00 a.m.",2016-06-01
10500,"NHC HEALTHCARE, JOHNSON CITY",445024,3209 BRISTOL HWY,JOHNSON CITY,TN,37601,2013-01-09,441,D,0,1,7UKE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility policy, and interview, the facility failed to ensure staff disinfected hands during the ice pass to the residents. The findings included: Observation on January 9, 2013, revealed on the 200 hall several residents had a virus and the facility was using isolation precautions for everyone. Observation on January 9, 2012, at 9:30 a.m., in the 200 hall, revealed two CNA's (certified nursing assistant) filling the resident's water pitchers with ice. Continued observation revealed CNA #1 entered room [ROOM NUMBER], obtained resident A bed's water pitcher, returned to the ice chest, filled the water pitcher with ice, returned to the resident's room, retrieved B bed's water pitcher, returned to the ice chest, placed the water pitcher on the ice chest, filled the water pitcher with ice, and returned the water pitcher to the B bed's room. Continued observation revealed CNA #2 went into room [ROOM NUMBER], obtained the water pitcher and continued to proceed in the same procedure as CNA #1. Continued observation revealed CNA #1 and #2 entered room [ROOM NUMBER] with one resident and enter 204, with one resident, entered room [ROOM NUMBER], with one resident, entered room [ROOM NUMBER], with two residents. Continued observation revealed the CNA's did not disinfect the hands after each resident's water pitcher was filled with ice. Review of facility policy, Handwashing/Hand Hygiene, revealed .e. before and after entering isolation precaution setting .6. i. after contact with objects (e.g. medical equipment) in the immediate vicinity of the resident . Interview with the CNA #1 and #2 on January 9, 2013, at 9:45 a.m., in the 200 hallway, confirmed the CNA's had not disinfected the hands after each resident's water pitcher was filled with ice. Interview with the Assistant Director of Nursing on January 10, 2013, at 10:15 a.m., in the 400 hallway, confirmed the staff are to disinfect hands after each patient. Continued interview confirmed staff are not to place the resident's water pitchers on the ice chest.",2016-06-01
10501,"NHC HEALTHCARE, JOHNSON CITY",445024,3209 BRISTOL HWY,JOHNSON CITY,TN,37601,2013-01-09,502,D,0,1,7UKE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to obtain a laboratory test as ordered by the physician timely. The findings included: Resident #172 was admitted to the facilty on June 25, 2012, with diagoses including [MEDICAL CONDITIONS], and Long-Term [MEDICATION NAME] Therapy. Medical record review revealed a [MEDICATION NAME] was obtained on November 28, 2012, with INR (International Normalized Ratio) result of 5.3. Orders received were to hold [MEDICATION NAME] for two days and start alternating dosage, every other day of 2.0 mg. and 2.5 mg., and recheck INR in two days. Medical record review revealed no documentation the [MEDICATION NAME] was obtained on November 30, 2012, as ordered. Further review revealed the next [MEDICATION NAME] was obtained on December 5, 2012, (seven days from order received on November 28, 2012). Medical record review of the December 5, 2012, [MEDICATION NAME]/INR result was 2.8, with orders to hold [MEDICATION NAME] for one day and repeat lab in one week. Interview with the 300 Hall Licensed Practical Nurse Supervisor at the 300 Nursing Station on January 9, 2013 at 2:15 p.m., confirmed the [MEDICATION NAME] had not been obtained as ordered by the physician.",2016-06-01
10502,"NHC HEALTHCARE, JOHNSON CITY",445024,3209 BRISTOL HWY,JOHNSON CITY,TN,37601,2013-01-09,514,D,0,1,7UKE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to maintain an accurate clinical record for one (#172) of fifty sampled residents. The findings included: Resident #172 was admitted to the facilty on June 25, 2012, with diagoses including [MEDICAL CONDITIONS], Long-Term [MEDICATION NAME] Therapy, [MEDICAL CONDITIONS], Acute Anxiety, Dementia, Depression, and [MEDICAL CONDITION]. Medical record review revealed a physician's orders [REDACTED]. every twelve hours for anxiety. Medical record review of a Medical Psychiatry Evaluation dated October 10, 2012, revealed the resident was currently on [MEDICATION NAME] 0.5 mg. twice daily for anxiety. Further review revealed, .add PRN (as needed) of [MEDICATION NAME] 0.5 mg. every 12 hours for increased anxiety. Medical record review of the November Physician's Recapitulation (recap) Orders revealed the order for [MEDICATION NAME] 0.5 mg. every 12 hours as needed (PRN) for acute anxiety however, the physician's orders [REDACTED]. twice daily. Further review of the Physician's Recap Orders for December 2012 and January 2013, revealed no order for the routine order for [MEDICATION NAME] 0.5 mg. twice daily. Review of the Medication Administration Records (MAR) for October, November, December 2012 and January 2013, revealed the resident continued to receive [MEDICATION NAME] 0.5 mg. every 12 hour at 8:00 a.m. and 8:00 p.m. documented as every 12 hours as needed with no further dosages given. Medical record review of a physician's orders [REDACTED]. bid PRN due to disuse. Review of the MAR indicated [REDACTED]. on January 4, 2013, at 8:00 a.m., and the medications was then discontinued. Interview with the Psychiatric Nurse Practitioner at the 200 Hall Nursing Station on January 9, 2012, at 2:30 p.m., confirmed the resident was to have remained on [MEDICATION NAME] 0.5 mg. twice daily and only the PRN dosages were to be discontinued. Telephone interview with the Pharmacist on January 10, 2013, at 10:00 a.m., confirmed the Physician's Recap Orders are sent to the facility by the pharmacy and the MARs are printed from the Physician's Recap Orders. Further interview confirmed no order had been received to discontinue the routine [MEDICATION NAME] 0.5 mg. twice daily, and the order should have been included on the Physician's Recap Orders and the MARs in November and December 2012 and January 2013. Interview with the 300 Hall Resident Care Coordinator on January 10, 2013, at 10:10 a.m., confirmed the resident's Physician's Recap Orders and MARs for November and December 2012 and January 2013 were incorrect",2016-06-01
12745,"NHC HEALTHCARE, JOHNSON CITY",445024,3209 BRISTOL HWY,JOHNSON CITY,TN,37601,2011-06-08,323,G,0,1,5FEU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure adequate supervision for two (#12, #21) and failed to ensure safety devices were in place for three residents (#3, #5, #9) of thirty residents reviewed. The facility's failure resulted in actual harm to resident #12. The findings included: Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed, ""...moving on and off toilet...not steady, only able to stabilize with human assistance"" Medical record review of the resident Care Plan dated March 3, 2011, revealed ""...Problem...Impaired mobility and self care deficit with left sided [DIAGNOSES REDACTED] making pt (patient)...increased risk for falls...Approaches...Observe for unsafe actions..."" Medical record review of facility investigation documentation provided by the facility dated April 23, 2011, at 4:00 p.m., revealed, ""...This nurse was alerted by staff that resident was in the floor in the bathroom...sent to ER (emergency department)..."" Medical record review of a hospital Consultation Report dated April 23, 2011, revealed, ""...yesterday...was up to commode nursing apparently stepped away...was complaining of pain in...shoulder and arm...Impression:...left clavicle fracture..."" Interview and statement review completed at the time of the fall with Certified Nursing Assistant (CNA) # 1 on June 8, 2011, at 9:20 a.m., by phone confirmed that CNA #1 turned their back for a few seconds after putting the resident on the toilet. Interview with the Director of Nursing in the facility conference room on June 8, 2011, at 10:30 a.m., confirmed the resident was not to be left unobserved while in the bathroom and confirmed the CNA turned their back away from the resident resulting in a fall/fracture. Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the resident's Care Plan dated May 5, 2011, revealed, ""problem...pt (patient) at risk for falls...approaches...use wedge when pt (patient) in bed for positioning..."" Medical record review of documentaion provided by the facility dated May 28, 2011, at 8:00 p.m., revealed, ""Certified Nursing Assistant (CNA) heard resident's bed alarm sounding...wedge cushion not on bed...found in closet..."" Interview with Resident Care Coordinator #1 on June 7, 2011, at 1:15 p.m., in the station two chart room, confirmed the wedge cushion was not on the bed at the time of the fall on May 28, 2011. Resident #21 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the resident's Care Plan updated January 13, 2011, revealed, ""...problem...Impaired mobility related to Parkinson's with a history of falls and [DIAGNOSES REDACTED]; making patient at risk for falls...Approaches...Provide assistance with transfers..."" Medical record review of a nurse's note dated January 14, 2011, at 3:15 p.m., revealed, ""...Pt (patient) taken to bathroom per CNA. Was left to check on another resident...found resident sitting on buttocks on floor facing...chair...no injuries..."" Continued medical record review of a nurse's note dated February 25, 2011, revealed, ""...resident reported that...was on...way back from the bathroom and fell ...no injuries..."" Medical record review of the January 14, 2011, post fall interventions revealed, ""...intervention after fall...resident not to be left alone in bathroom..."" Interview with the Resident Care Coordinator #2 on June 8, 2011, at 9:45 a.m., confirmed the resident was left unattended at the time of the fall on the January 14, 2011, and February 25, 2011. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident required extensive assistance with two persons physical assist for transfers, and extensive assistance with two persons physical assist for toilet use. Medical record review of the post falls nursing assessment dated [DATE], revealed, ""...CNA (certified nursing assistant) was transferring resident to bathroom when...legs gave way. The CNA lowered...to the floor...(no injuries) Inservice staff on gait belt (and) 2 assist..."" Medical record review of the post falls nursing assessment dated [DATE], revealed, ""...CNA was transferring resident from the toilet to (named brand) chair when...has to slide (resident)...to the floor (until) help came ...(no injuries)"" Observation on June 6, 2011, at 4:15 p.m., revealed the resident lying on the bed. Interview on June 7, 2011, at 4:10 p.m., at the nursing station, with Resident Care Coordinator #1, confirmed a gait belt or two person assistance had not been used when transferring the resident at the time of the fall on April 19, 2011. Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the high risk patient selection form dated March 1, 2011, revealed the resident had three falls in February 2011 and had poor safety awareness. Medical record review of the care plan dated May 26, 2011, revealed, ""...use bed cushion alarm..."" Observation on June 7, 2011, at 12:45 p.m., revealed the resident lying on the bed with the pressure pad alarm cord hanging down the side of the bed with no alarm box. Interview on June 7, 2011, at 12:45 p.m., in the resident's room, with Resident Care Coordinator #1, confirmed the alarm box was not attached to the pressure pad alarm.",2015-07-01
13845,"NHC HEALTHCARE, JOHNSON CITY",445024,3209 BRISTOL HWY,JOHNSON CITY,TN,37601,2011-04-28,465,D,1,0,BYN511,"Based on observation and interview, the facility failed to ensure the ice machines in the pantries on the residents' units were clean and sanitary for three of four ice machines observed. The findings included: Observation and interview on April 25, 2011, at 2:55 p.m., in the Station 3 pantry, with the Director of Nursing (DON) revealed a white colored substance which extended across the front edge of the ice machine, where the lid of the machine rested when closed. Observation revealed the white substance had a powder type consistency when scraped with the fingernail. Interview on April 25, 2011, at 2:55 p.m., with the DON revealed the DON had no knowledge if the machine was in need of cleaning and stated, ""I don't know. It's not nursing's responsibility."" Continued interview with the DON confirmed the DON had no knowledge of who was responsible for cleaning the ice machine or when the machine was last cleaned. Observation and interview on April 25, 2011, at 3:00 p.m., in the Station 2 pantry, with the Resident Care Clinician (RCC) #1 revealed the ice machine had a white colored substance which extended across the front edge of the ice machine, where the lid of the machine rested when closed. Observation revealed the white substance had a powder type consistency when scraped with the fingernail. Observation revealed a portable ice container with wheels had a white substance which extended in streaks from the top to the bottom of the side of the portable container. Interview with the RCC confirmed the ice machine and the portable ice container were in need of cleaning. C/O #",2014-08-01
14076,"NHC HEALTHCARE, JOHNSON CITY",445024,3209 BRISTOL HWY,JOHNSON CITY,TN,37601,2010-07-21,441,D,,,CKRK11,"Based on observation and interview, the facility staff failed to wash the hands during a dressing change for one (#12) of twenty-five residents reviewed. The findings included: Observation on July 20, 2010, at 2:02 p.m., revealed Licensed Practical Nurse (LPN) #1 providing wound care to resident #12. Observation revealed LPN #1 removed a dressing from resident #12's right hand, and described the wound on the right wrist as a Stage III pressure area with a small amount of serous drainage. Observation revealed LPN #1 cleansed the wound with wound cleanser, and without changing the gloves or washing the hands, applied ointment and a dressing to the wound. Interview on July 20, 2010, at 3:15 p.m., with the Director of Nursing, at the nursing station, revealed the hands were to be washed after cleansing a wound prior to applying ointment or a clean dressing. Interview on July 20, 2010, at 2:25 p.m., with LPN #1, in the hallway, confirmed the gloves were not changed and the hands were not washed after cleansing the wound prior to applying ointment and a clean dressing.",2014-04-01
14077,"NHC HEALTHCARE, JOHNSON CITY",445024,3209 BRISTOL HWY,JOHNSON CITY,TN,37601,2010-07-21,280,D,,,CKRK11,"**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 one resident (#9) with a history of falls of twenty-five residents reviewed. The findings included: Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had no problems with memory, required moderate assistance with decision making, and extensive assistance with transfers. Review of the medical record revealed the resident had a history of [REDACTED]. Review of the facility's documentation dated September 22, 2009, revealed, ""PT (Resident) found lying in the floor beside of bed on fall mat...Intervention...Low Bed..."" Review of the facility's documentation dated April 8, 2010, revealed.""PT (Resident) was found lying on floor in room...Intervention...Up in Geri-chair as tolerated."" Review of the current care plan dated November 4, 2009, revealed no documentation for the use of a Geri- chair or a low bed. Observation on July 19, 2010, at 9:30 a.m., 10:30 a.m., and on July 20, 2010, at 8:30 a.m., revealed the resident sitting in a Geri-chair, in the resident's room. Continued observation revealed a low bed in the resident's room. Interview with the unit one risk manager on July 20, 2010, at 10:05 a.m., in the conference room, confirmed the care plan had not been revised until July 19, 2010, to reflect the use of a low bed and a Geri-chair.",2014-04-01
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
4902,NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER,445030,5010 TROTWOOD AVE,COLUMBIA,TN,38401,2016-06-09,156,D,0,1,C1XT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of Notice of Medicare Non-Coverage forms, resident council meeting minutes, medical record review and interview, the facility failed to provide the appropriate liability and appeal notice to 2 of 3 (Residents #26 and 121) sampled residents reviewed for liability and appeal notices, and the facility failed to inform residents of ombudsman information during resident council meetings. The findings included: 1. The Notice of Medicare Non-Coverage form for Resident #26 documented, .The Effective Date Coverage of Your Current Skilled Rehab Therapy Services Will End: 3/9/2016 . The facility was unable to provide any documentation that contact was confirmed by written notice as required. 2. The Notice of Medicare Non-Coverage form for Resident #31 documented, .The Effective Date Coverage of Your Current Skilled Rehab Therapy Services Will End: 05/16/16 . The facility was unable to provide any documentation that contact was confirmed by written notice as required. 3. In an interview with the Social Worker (SW) on 6/9/16 at 11:10 AM, in the conference room, the SW was shown Resident #26 and 121's liability and appeal notices and the SW confirmed they had not been signed. The SW was asked how would she show that the residents had been informed. The SW stated, .I wouldn't . 4. Review of the monthly resident council meeting minutes dated (MONTH) through May, (YEAR) did not reflect any discussion of ombudsman information, where the information was posted or who the ombudsman was. 5. Medical record review revealed Resident #121 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] revealed a BIMS score of 14 which indicated no cognitive impairment. In an interview with Resident #121 on 6/9/16 at 9:18 AM, in Resident #121's room, she was asked are you familiar with where the ombudsman information is posted. Resident #121 stated, No ma'am. Resident #121 was asked are you familiar with the ombudsman? Resident #121 stated, No ma'am.",2019-06-01
4903,NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER,445030,5010 TROTWOOD AVE,COLUMBIA,TN,38401,2016-06-09,164,D,0,1,C1XT11,"**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 privacy during medication administration as evidenced by 2 of 5 (Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #1) nurses that administered medications while leaving the window blinds open in full view of the parking area. The findings included: 1. The facility's PRIVACY policy documented, .we provide .privacy .maintain a dignified existence .inside and outside the center .In your accommodations you will be provided with at least visual privacy . 2. Medical record review revealed Resident #70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #70's room on 6/7/16 at 9:20 AM, revealed LPN #1 exposed Resident #70's abdominal area and administered medications to Resident #70 via a Percutaneous Endoscopic Gastrostomy (PEG) tube while the window blinds were open to the parking lot area. Resident #70's bed was directly in front of the window. 3. Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #9's room on 6/7/16 at 10:18 AM, revealed RN #1 exposed Resident #9's abdominal area and administered medications to Resident #9 via a PEG tube while the window blinds were open to the parking lot area. Resident #9's bed was directly in front of the window. Interview with the Director of Nursing (DON) on 6/9/16 at 7:55 AM, in the conference room, the DON was asked what she expected staff to do related to privacy when administering PEG medications. The DON stated, Close the door, pull the curtains. The DON was asked if the window blinds should be closed if the parking area is visible from the window. The DON stated, Yes.",2019-06-01
4904,NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER,445030,5010 TROTWOOD AVE,COLUMBIA,TN,38401,2016-06-09,167,D,0,1,C1XT11,"Based on review of PATIENT RIGHTS, federal interpretive guidelines, observation and interview, the facility failed to ensure survey results were readily accessible to the residents residing in the facility. The findings included: 1. The facility's PATIENT RIGHTS booklet documented, .8. Survey Results .You will find these reports in one of the public areas of the building. Please ask if you need help . The federal interpretive guidelines documented, The facility must make the results available for examination in a place readily accessible to residents and must post a notice of their availability .Place readily accessible to residents is a place (such as a lobby or other area frequented by most residents) where individuals wishing to examine survey results do not have to ask to see them . Observations in the conference room on 6/7/16 at 2:45 PM, revealed the current survey results binder was in a far-corner shelf, out of plain view and inaccessible to residents in wheelchairs or other assistive devices, due to furniture in the conference room. Observations in the front lobby area on 6/9/16 at 1:50 PM, revealed the notice regarding the location of the survey results were behind a luggage cart and were above eye level for residents in wheelchairs. Interview with Resident #121 on 6/9/16 at 9:16 AM, in her room, Resident #121 was asked if she knew where the survey results were kept. Resident #121 stated, No ma'am. Resident #121 was asked if she was familiar with the state survey results. Resident #121 stated, No ma'am.",2019-06-01
4905,NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER,445030,5010 TROTWOOD AVE,COLUMBIA,TN,38401,2016-06-09,278,D,0,1,C1XT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure the comprehensive assessments were accurate related to hospice services for 1 of 18 (Residents #81) sampled residents reviewed of the 33 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #81 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 5/31/16 revealed no documentation that Resident # 81 received hospice services. The physician's orders [REDACTED]. 03/03/2015 HOSPICE TO TREAT . In an interview with the Assistant MDS Coordinator on 6/8/16 at 10:00 AM, in the MDS Coordinator's office, the MDS Coordinator if hospice was coded on Resident #81's MDS assessment dated [DATE]. The MDS Coordinator stated, .I missed that . The MDS Coordinator was asked should the MDS be coded for hospice. The MDS Coordinator stated, .yes Ma'am .definitely should be .",2019-06-01
4906,NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER,445030,5010 TROTWOOD AVE,COLUMBIA,TN,38401,2016-06-09,280,D,0,1,C1XT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to review and revise the care plan to reflect the current dental status for 1 of 18 (Resident #6) sampled residents with dental problems of the 33 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change Minimum Data Set ((MDS) dated [DATE] documented Resident #6 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment, and had no natural teeth or teeth fragments, or was edentulous. The comprehensive care plan dated 5/18/16 documented, .Self Care deficit .Denture care as needed (when pt (patient) wants to wear; often does not wear) .Has upper and lower partials . Observations in Resident #6's room on 6/6/16 at 5:09 PM, and on 6/8/16 at 7:39 AM, revealed Resident #6 had multiple missing upper and lower teeth. Resident #6 was not seen wearing any dentures, and no dentures were seen in the room during the survey. In an interview with Resident #6 on 6/8/16 at 7:39 AM, in Resident #6's room, He was asked if he has dentures. Resident #6 stated, No . In an interview with Certified Nursing Assistant (CNA) #1 on 6/8/16 at 9:38 AM, at the 100 hall nurses' desk, CNA #1 was asked if she takes care of Resident #6. CNA #1 confirmed that she did. CNA #1 was asked if Resident #6 has dentures. CNA #1 stated, No, not that I'm aware of. In an interview with Registered Nurse (RN) #2 at the 100 hall nurses' desk on 6/8/16 at 9:39 AM, RN #2 was asked if Resident #6 has dentures. RN #2 stated, I'm not sure if he has any, but he never has them on if he does. RN #2 went to Resident #6's room to check for dentures. RN #2 came out of Resident #6's room on 6/8/16 at 9:43 AM, and stated,I didn't find any (dentures). In an interview with RN #3 on 6/8/16 at 2:03 PM, in the MDS office, RN #3 was asked if the care plan should have been updated to reflect that Resident #6 does not have dentures. RN #3 stated,Yes.",2019-06-01
6307,NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER,445030,5010 TROTWOOD AVE,COLUMBIA,TN,38401,2015-05-13,241,D,0,1,25GR11,"Based on observation and interview, the facility failed to maintain residents' dignity during 1 of 2 dining observations when 1 of 16 staff members Certified Nursing Assistant (CNA #3) refered to residents as feeders. The findings included: Observations on the 100 hall on 5/12/15 at 5:25 PM, CNA #3 stated, Start with feeders now. Observations in Resident #8 and 46's room on 5/12/15 at 5:27 PM, CNA #3 stated, Made (named resident) a feeder. Interview with the Director of Nursing (DON) on 5/13/15 at 9:27 AM, in the Social Service's office, the DON was asked if it was acceptable for staff to call residents feeders. The DON stated, No, we like to call them dependent diners.",2018-08-01
6308,NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER,445030,5010 TROTWOOD AVE,COLUMBIA,TN,38401,2015-05-13,280,D,0,1,25GR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure the care plan was updated for a suspected deep tissue injury (SDTI) for 1 of 19 (Resident #118) sampled residents of the 38 included in the stage 2 review. The findings included: Medical record review revealed Resident #118 was admitted on [DATE] with [DIAGNOSES REDACTED]. The weekly wound record dated 5/5/15 documented, .R (right) elbow . SDTI . length . 1.0 . Width . 1.0 . The care plan dated 3/10/15 was not updated to reflect the presence of Resident #118's right elbow SDTI. Interview with Licensed Practical Nurse (LPN) #1 on 5/12/15 at 7:35 AM, in the recreation room, LPN #1 was asked about Resident #118's wound on her right elbow. LPN #1 stated, Has a suspected deep tissue injury on her right elbow, found it last week. Interview with the Director of Nursing (DON) on 5/12/15 at 11:53 AM, in the recreation room, the DON was asked should the care plan reflect residents' current status. The DON stated, Yes, it should. The DON was shown Resident #118's care plan. the DON confirmed there was no care plan for Resident #118's SDTI on her right elbow.",2018-08-01
6309,NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER,445030,5010 TROTWOOD AVE,COLUMBIA,TN,38401,2015-05-13,371,F,0,1,25GR11,"Based on policy review, observation and interview, the facility failed to ensure food was stored and prepared under sanitary conditions as evidenced by opened food stored and not labeled with an opened and use by date. This had the potential to affect 73 of 78 residents residing in the building. Two (2) of 13 Certified Nursing Assistants (CNA #1 and 2) failed to perform hand hygiene during meal service. The findings included: 1. The facility's Safety & (and) Sanitation Best Practice Guidelines documented, .Refrigerated Food Storage Guide Storage Guide . covered securely, date with use by date . Observations in the kitchen on 5/11/15 beginning at 10:40 AM, revealed the following foods with no open date or use by date: a. 3 turkey hot dogs in zip lock bag in the 2 door cooler. b. 1 opened plastic clear bag of french fries in the 2 door freezer. c. 1 opened bag of chuck wagon patties in the walk-in freezer. d. 1 zip lock bag of turkey burgers in the walk-in freezer. e. 1 opened bag of biscuits in the walk-in freezer. f. 1 opened bag of rolls in the walk-in freezer. g. 3 opened zip lock bags of red grapes in the walk-in cooler. Interview with the Dietary Manager (DM) on 5/11/15 at 10:50 AM, in the kitchen, the DM was asked if non-labeled opened food should be labeled in the freezer and cooler. The DM stated, They (the food) should be labeled. 2. Observations in the 100 hall medication room on 5/11/15 at 12:10 PM and on 5/13/15 at 8:50 AM, revealed 1 case of bleach wipes stored on the floor. Interview with the Director of Nursing (DON) on 5/13/15 at 9:27 AM, in the Social Services office, the DON was asked if it was acceptable for items used for patient care to be stored on the floor. The DON stated, No ma'am. Observations in the dining room on 5/11/15 at 12:04 PM, revealed CNA #1 touched her hair when putting her hair behind ears, then set up a resident's lunch without sanitizing her hands. At 12:05 PM, CNA #1 touched her hair again then set up lunch for another resident without sanitizing her hands. Observations in Resident #112's room on 5/11/15 beginning at 12:25 PM, revealed CNA #2 dropped a paper towel on the floor, picked it up, then entered Resident #106's room and set up the resident's tray without hand hygiene. CNA #2 sat to feed Resident #106, touched the chair arms, placed her right hand on her uniform pants leg and then fed the resident without performing hand hygiene. Interview with the Director of Nursing (DON) on 5/12/15 5:58 PM, in the DON's office, the DON was asked if it was acceptable for staff to touch their hair and then serve food without sanitizing their hands. The DON stated, No. Interview with the DON on 5/13/15 at 9:27 AM, in the Social Service's office, the DON was asked what would you expect if a paper towel was dropped on the floor and picked up before serving trays. The DON stated, Wash their hands. The DON was asked if objects were touched while feeding the resident what did she expect. The DON stated, Need to wash their hands.",2018-08-01
6310,NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER,445030,5010 TROTWOOD AVE,COLUMBIA,TN,38401,2015-05-13,441,D,0,1,25GR11,"Based on observation and interview, the facility failed to ensure medical supplies were stored off the floor in 2 of 8 (central supply and the 100 hall medication room) medication storage areas and 2 of 13 Certified Nursing Assistants (CNA #1 and 2) failed to perform hand hygiene during meal service. The findings included: 1. Observations in central supply on 5/13/15 at 8:20 AM, revealed the following were stored on the floor: a. 1 case of Kerlix. b. 8 boxes of Coban 2 Life. c. 1 Case of Two Cal High Nitrogen (HN) tube feeding. d. 1 case of urethral catheter trays. e. 1 case red biohazardous bags. f. 1 case yellow bags. g. 1 case sharps containers. h. 1 box of urinals. i. 1 package of disposable briefs. j. 1 box of back braces. k. 2 cases of Sterile Sodium Chloride. l. 1 case foley catheter trays. m. 1 box natural bags. n. 4 cases of isolation gowns. Observations in the 100 hall medication room on 5/11/15 at 12:10 PM and on 5/13/15 at 8:50 AM, revealed 1 case of bleach wipes stored on the floor. Interview with the Director of Nursing (DON) on 5/13/15 at 9:27 AM, in the Social Services office, the DON was asked if it was acceptable for items used for patient care to be stored on the floor. The DON stated, No ma'am. 2. Observations in the dining room on 5/11/15 at 12:04 PM, revealed CNA #1 touched her hair when putting her hair behind ears, then set up a resident's lunch without sanitizing her hands. At 12:05 PM, CNA #1 touched her hair again then set up lunch for another resident without sanitizing her hands. Observations in Resident #112's room on 5/11/15 beginning at 12:25 PM, revealed CNA #2 dropped a paper towel on the floor, picked it up, then entered Resident #106's room and set up the resident's tray without hand hygiene. CNA #2 sat to feed Resident #106, touched the chair arms, placed her right hand on her uniform pants leg and then fed the resident without performing hand hygiene. Interview with the Director of Nursing (DON) on 5/12/15 5:58 PM, in the DON's office, the DON was asked if it was acceptable for staff to touch their hair and then serve food without sanitizing their hands. The DON stated, No. Interview with the DON on 5/13/15 at 9:27 AM, in the Social Service's office, the DON was asked what would you expect if a paper towel was dropped on the floor and picked up before serving trays. The DON stated, Wash their hands. The DON was asked if objects were touched while feeding the resident what did she expect. The DON stated, Need to wash their hands.",2018-08-01
8050,NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER,445030,5010 TROTWOOD AVE,COLUMBIA,TN,38401,2013-10-29,278,D,0,1,8ORN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the CMS's (Center for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 Manual, medical record review and interview, it was determined the facility failed to accurately assess a resident for a Brief Interview for Mental Status (BIMS) score or hospice care for 2 of 17 (Residents #95 and 120) sampled residents reviewed of the 28 residents included in the stage 2 review. The findings included: 1. Review of the CMS's RAI Version 3.0 Manual, page C-1, documented, .Record whether the cognitive interview should be attempted with the resident. Code 0, no: if the interview should not be attempted because the resident is rarely/never understood or an interpreter is needed but not available . Code 1, yes: if the interview should be attempted because the resident is at least sometimes understood verbally or in writing . Medical record review for Resident #95 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] and 8/16/2013 documented, .Section B Hearing, Speech and Vision . Makes Self Understood . Code 2 (entered) Sometimes understood . Section C Cognitive Patterns . Should Brief Interview for Mental Status . be Conducted? . Code 0 (entered) No (resident is rarely/never understood) . During an interview in the Assistant Director of Nursing's office on 10/29/13 at 3:10 PM, the Social Worker was asked how she determined whether to conduct a BIMS interview on Resident #95. The Social Worker stated, On 5/21/13 the resident scored a 3 (on the BIMS interview), so we did a staff interview. We sort of go by the number 6 (BIMS score) to do a staff interview . on 8/16/13 she scored a 3 again, so I did a staff interview . 2. Medical record review for Resident #120 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the care plan dated 9/24/13 documented, .PROBLEM . Hospice Care . Review of the (Named hospice) COMPREHENSIVE ASSESSMENT AND PLAN OF CARE documented, .SOC (Start of Care) 6/10/13 . Review of the significant change MDS with an assessment reference date of 6/24/13 documented no hospice received while a resident. Review of the quarterly MDS with an assessment reference date of 9/20/13 documented no hospice received while a resident. During an interview in the conference room on 10/29/13 at 10:30 AM, the MDS Coordinator was questioned why the significant change MDS was done for Resident #120. The MDS Coordinator stated, because she went to hospice in June (2013) . The MDS Coordinator confirmed the MDS was not accurate, and stated, .it (hospice) was not checked .",2017-08-01
8051,NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER,445030,5010 TROTWOOD AVE,COLUMBIA,TN,38401,2013-10-29,280,D,0,1,8ORN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, it was determined the facility failed to ensure the care plan was revised to reflect the current ordered pressure ulcer treatment for 1 of 17 (Resident #53) sampled residents reviewed of the 28 residents included in the stage 2 review. The findings included: Review of the facility's SKIN INTEGRITY PREVENTION AND MANAGEMENT . DOCUMENTATION policy documented, .Updates are documented on the Patient Plan of Care as changes occur . Review of the facility's Patient Care Plan policy documented, .The patient care plan . revised as needed to address the prevention, care, and treatment of [REDACTED]. Medical record review for Resident #53 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 8/14/13 documented, APPROACHES . (no date) L (left) heel: clean c (with) NS (normal saline) All Kare edges, apply [MEDICATION NAME] AG (silver) to wound bed, then [MEDICATION NAME] plain & (and) cover c (with) [MEDICATION NAME] + (plus) . Review of the physician's orders [REDACTED].[MEDICATION NAME]-AG W (WITH) -[MEDICATION NAME] ([MEDICATION NAME]) DRESS (dressing) TO LEFT HEEL: CLEAN WITH NS, ALL KARE EDGES, APPLY [MEDICATION NAME] AG AND COVER WITH VERIVA Q (every) DAY AND PRN (as needed) . During an interview in the conference room on 10/29/13 at 10:05 AM, the wound care nurse was asked if the order dated 10/24/13 for the treatment to the left heel was added to the care plan. The wound care nurse stated, No. During an interview in the Director of Nursing's (DON) office on 10/29/13 at 10:40 AM, the DON was asked would you expect new orders pertaining to wound care be on the care plan. The DON stated, Absolutely.",2017-08-01
8052,NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER,445030,5010 TROTWOOD AVE,COLUMBIA,TN,38401,2013-10-29,314,D,0,1,8ORN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, it was determined the facility failed to ensure a treatment was obtained at the time a deep tissue injury was identified for 1 of 3 (Resident #53) sampled residents reviewed with a pressure sore/ulcer. The findings included: Review of the facility's SKIN INTEGRITY PREVENTION AND MANAGEMENT . DOCUMENTATION policy documented, .documentation of other pressure ulcer information will include: 1. Physician contact and specific orders obtained . Medical record review for Resident #53 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Nursing Assessment Report dated 6/8/13 documented a 3.2 by (x) 4.1 centimeter (cm) suspected deep tissue injury to the left heel. Review of the physician's orders [REDACTED].[MEDICATION NAME] PROTECT BARRIER WIPE APPLY TO HEELS BID (two times a day) . Review of the physician's progress note dated 6/13/13 documented, .Left heel with a 3.2 x 4.1 fluid filled blister that is fluctuant. Left lower leg with 2- (to) 3+ (plus) [MEDICAL CONDITION]. Left foot with 3+ [MEDICAL CONDITION] . During an interview in the conference room on 10/29/13 at 11:20 AM, the wound care nurse was asked when treatment was started. The wound care nurse stated, .6/11 (2013) . During an interview in the Director of Nursing's (DON) office on 10/29/13 at 1:45 PM, the DON was asked when would it be expected to obtain an order for [REDACTED].",2017-08-01
8053,NHC-MAURY REGIONAL TRANSITIONAL CARE CENTER,445030,5010 TROTWOOD AVE,COLUMBIA,TN,38401,2013-10-29,371,D,0,1,8ORN11,"Based on policy review, observation and interview, it was determined the facility failed to ensure food was prepared under sanitary conditions as evidenced by baking pans with carbon buildup and greasy vent hood on 3 of 3 days (10/27/13, 10/28/13 and 10/29/13) of the survey. The findings included: Review of the facility's Safety & (and) Sanitation Best Practice Guidelines policy documented, .manual cleaning and sanitizing of pots, pans . Remove all traces of food and detergent . Observations in the kitchen on 10/27/13 at 10:45 AM, revealed 2 large pots being used with a large amount of carbon buildup on the bottoms, 8 stored baking sheets with large amount of greasy carbon buildup on the outside edges, small hood over the gas range with greasy brown buildup and a baking sheet that was laying on surface by the three compartment sink with greasy carbon build up on the outside edges. Observations in the kitchen on 10/28/13 at 3:00 PM and 10/29/13 at 11:40 AM, revealed 8 stored baking pans and 3 stored muffin pans with greasy carbon buildup on the outside of the pans. During an interview in the kitchen on 10/29/13 at 2:30 PM, the Dietary Manager was asked if the baking pans and muffin pans should have carbon buildup on them. The Dietary Manager stated, No, that (carbon build up on pans) shouldn't be .",2017-08-01
9899,"NHC HEALTHCARE, HILLVIEW",445030,2710 TROTWOOD AVE,COLUMBIA,TN,38401,2011-10-26,226,D,0,1,F5D011,"Based on review of the State Operations Manual, policy review and interviews, it was determined the facility failed to ensure the education of residents and families on how and to whom they may report concerns, incidents and grievances without fear of retribution. The findings included: Review of the State Operations Manual, Appendix PP, F226, III. Prevention (483.13(b) and 483.13(c) documented, Provide residents, families and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution. Review of the facility's Patient Protection and Response policy failed to document education to the residents and their families concerning how and to whom residents and families may report concerns, incidents and grievances without fear of retribution. During an interview in the Director of Nursing (DON) office on 10/26/11 at 2:48 PM, the DON was asked if there was anything written in the facility's Abuse policy on educating the residents and their families about how and to whom they may report any abuse. The DON stated, .no, that information isn't in our Abuse policy .",2016-09-01
9900,"NHC HEALTHCARE, HILLVIEW",445030,2710 TROTWOOD AVE,COLUMBIA,TN,38401,2011-10-26,283,D,0,1,F5D011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to develop a complete recapitulation of the resident's stay for 2 of 2 (Residents #14 and 16) sampled discharged residents reviewed. The findings included: 1. Medical record review for Resident #14 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The facility's recapitulation failed to document a complete recapitulation of Resident # 14's stay which included nursing care, physical therapy services and occupational therapy services. 2. Medical record review for Resident #16 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the facility's NHC (National Healthcare) Discharge Summary dated 9/22/11 documented, .pt. (patient) admitted c (with) dx (diagnosis) of r (right) TKA (total knee arthroplasty), has progress, but need more PT (physical therapy) to help c ambulation and mobility. [MEDICAL TREATMENT] M (Monday) - W (Wednesday) - F (Friday). The facility's recapitulation failed to document a complete recapitulation of Resident #16's stay which included nursing care with a wound, physical therapy services and occupational therapy services. During an interview in the conference room on 10/26/11 at 9:15 AM, the Director of Nursing (DON) was asked what is expected to be documented on the recapitulation of the resident's stay in the facility. The DON stated, .Nursing is responsible for the recapitulation, it should be a summary of why they were here, what occurred and where going . Yes, the recapitulation is not complete .",2016-09-01
9901,"NHC HEALTHCARE, HILLVIEW",445030,2710 TROTWOOD AVE,COLUMBIA,TN,38401,2011-10-26,371,D,0,1,F5D011,"Based on policy review, observation and interview, it was determined 2 of 3 staff members (Certified Nursing Assistants (CNA) #1 and Recreation Coordinator) staff members failed to ensure food was stored, prepared, distributed and served under sanitary conditions as evidenced by failure to have their hair covered while in the dietary department during 1 of 2 (10/25/11 lunch) dining observations. The findings included: Review of the faciliy's Safety & (and) Sanitation Best Practice Guidelines, Personal Hygiene policy documented, .3. Hair Restraints: a .shall wear hair restraints to keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles . Observations in the kitchen during meal preparation and serving on 10/25/11 at 12:30 PM, revealed the Recreation Coordinator in the kitchen with her hair uncovered. The Recreation coordinator placed multiple uncovered plated food and drink on a tray then left the kitchen with the tray up on her shoulder near her uncovered hair. The Recreation Coordinator took the uncovered plated food and drink and served three residents in the dining room. Observations in the kitchen during meal preparation and serving on 10/25/11 at 12:35 PM, CNA #1 entered the kitchen, walked past the steam table, walked past a table on the right side of the wall and past a sink area at the end of the wall. CNA #1 did not have her hair covered. During an interview in the Dietary Manager's (DM) office on 10/26/11 at 10:45 AM, the DM stated, .Anyone that comes into the kitchen must wear a hair net .",2016-09-01
9902,"NHC HEALTHCARE, HILLVIEW",445030,2710 TROTWOOD AVE,COLUMBIA,TN,38401,2011-10-26,441,D,0,1,F5D011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation and interview, it was determined 2 of 18 Certified Nursing Assistants (CNA #2 and 4) failed to use sanitary hand hygiene during dining observations by touching food with bare hands or turned the faucet off with bare hands. The findings included: 1. Review of the facility's Safety & (and) Sanitation Best Practice Guidelines . GLOVE USE policy documented, .The purpose is to prevent food-borne illness that is caused by direct hand contact on food . a. Observations in the main dining room on 10/24/11 at 5:00 PM, while CNA #2 was preparing the resident's meal tray, CNA #2 touched the bread with her bare hands and applied a condiment. b. Observations in room [ROOM NUMBER] on 10/24/11 at 6:00 PM, while CNA #4 was preparing the resident's meal tray she touched the bread with her bare hands and applied a condiment. During an interview in the conference room on 10/26/11 at 12:35 PM, the Director of Nursing (DON) was asked if the staff can touch the food with their bare hands. The DON stated, .No . 2. Review of the facility's INFECTION CONTROL Manual and HANDWASHING policy documented, .Turn water off with paper towel used to dry hands . Observations in room [ROOM NUMBER]A on 10/24/11 at 5:20 PM, CNA #4 turned the faucet off with her bare hand. During an interview in the conference room on 10/26/11 at 1:00 PM, the DON was asked what is the technique to turn the faucet off during hand washing. The DON stated .staff are to turn the faucet off with a paper towel, not by the bare hand .",2016-09-01
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
3706,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2017-03-28,224,D,1,0,E6GQ11,"**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 misappropriation of resident property for 1 Resident (#7) and failed to prevent misappropriation of medication for 2 residents (#13, 14) of 15 residents reviewed. The findings included: Review of facility policy, Abuse, Neglect, and Misappropriation of Property, revealed .It is the facility's policy to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property .Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish .Misappropriation of resident property means deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or property without the resident's consent .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. Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #7 scored 15 on the Brief Interview for Mental Status (BIMS), indicating she was alert, oriented, and able to make her needs known. Continued review revealed Resident #7 required extensive assistance of 2 people for transfers; extensive assistance of 1 person for dressing and grooming; was dependent on 1 person for bathing; supervision for eating; and was often incontinent of bowel and bladder. Review of the facility investigation dated 10/17/16, revealed during a care plan meeting the family brought in a bank statement from the bank of Resident #7 with some money withdrawals from the account. The family stated Resident #7 gave her bank card to 2 staff members to buy things for her. Resident #7 was interviewed and reported she had given her card multiple times to Certified Nursing Assistant #3 (CNA) and CNA #4 to purchase items for her. She denied giving permission for any of the CNAs to withdraw money from the account, or loan any money. Review of the facility investigation revealed a written statement from the Social Worker (SW) dated 10/18/16 revealed Resident #7 gives her debit card and pin numbers to CNAs #3 and #4 to go to vending machines or grocery stores to get food Resident #7 stated the charges for the vending machine purchases should be around $3.00 and the charges for going to the grocery store would be cash withdrawals from the ATM in amounts of about $100.00. She reports CNA #3 brings her receipts from the ATM cash withdrawals so she knows how much is being taken out and she will bring back the change from the shopping trip if there is some. Does not want police involved because it would be too much trouble. Denies the card has ever been gone overnight and not returned. She denies she has ever loaned anyone money or given permission for any sum of money to be taken from the card. Resident #7 was given information SW or QOL (Quality of Life) staff were the only ones to purchase items for the resident. Review of an undated written statement from CNA #5 revealed she .worked with (Resident #7) who stated to her she (Resident #7) wanted me to go get her some cold drinks with her card. I stated to her we couldn't take money or cards from them. She stated to me that (CNA #3 and #4) and some more of the staff do it all the time. I reported it to the nurse and she said she would speak to them about it . Review of an undated written statement from CNA #3 revealed .About 2 1/2 weeks ago (Resident #7) asked me to take her debit card and go to the drink machine to get her and her roommate a drink. I took the card and went to the drink machine, the card reader denied her card so I took it back to her and gave her card back to her and told her it was denied so out of my personal money I bought (Resident #7) and her roommate 1 bottled drink . Review of a written statement dated 10/13/16 from CNA #5 revealed .I witness one day (CNA #4) going down to get (Resident #7) and roommate some things from outside and I stated to her personally Please if you are using the credit card for them you need to stop before it be trouble . Review of an undated written statement by the Interim Director of Nursing (IDON) from an interview with CNA #4, revealed CNA #4 had the debit card of Resident #7 on 2 occasions. CNA #4 stated Resident #7 asked her to make several withdrawals from her account. CNA #4 stated she went to the blue store down the road and made the first withdrawal then Resident #7 asked her to withdraw more money. CNA #4 stated she withdrew a total of $640.00 for the resident. Resident #7 told CNA #4 to keep the card and get everything she could from the card. Review of the facility investigation revealed the nurse who was notified of the 2 CNAs using the resident's card was terminated for failure to report allegations of abuse to the Administrator, Director of Nursing (DON), or ADON (Assistant DON). The nurse had knowledge 2 CNAs were taking a resident's debit card and using it inside and outside the facility. She failed to report the misappropriation immediately and failed to start the investigation timely. Review of the facility investigation revealed CNA #3 was terminated for failing to report an allegation of misappropriation of resident funds and admitted to using resident's debit card when she understood the policy not to. Continued review revealed CNA #4 was terminated for using a resident's debit card at various locations; admitted to leaving the facility during working hours to use the debit card; and the resident was missing funds from her account. Review of the facility investigation revealed the police were called but Resident #7 denied any money was missing from her account. She stated she had just been to the ATM and got $500.00 but was unable to state which staff member accompanied her to the ATM. Resident #7 stated she gave her card to CNA #3 but it was always declined and the bank stated it was because she was trying to take out too much money. Resident #7 stated CNA #4 had also used her card. The police said there was nothing he could do since Resident #7 denied money was missing. Interview with the IDON, ADON, and Administrator on 3/16/17 at 9:45 AM in the conference room, revealed Resident #7 had allowed CNA #3 and CNA #4 use her debit card for drinks and groceries. This was a violation of facility policy and the 2 CNAs were terminated. The Administrator stated the funds which were removed by the CNAs were reimbursed to Resident #7. The Administrator also stated it was a hard lesson for the CNAs to learn but he needed to set an example for the facility this type of behavior would not be tolerated. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual MDS dated [DATE] revealed Resident #13 was severely impaired cognitively. Continued review revealed Resident #13 was dependent on 2 people for transfers; was dependent on 1 person for dressing, eating, grooming, and bathing; and was always incontinent of bowel and bladder. Review of physicians orders dated 1/30/17 revealed Resident #13 was ordered [MEDICATION NAME] 7.5/325 mg (milligram) twice daily and it was scheduled for 8:00 AM and 8:00 PM. Review of the Narcotic Sign-Out Sheet and the MAR dated 2/23/17 revealed a dose was signed out at 6:00 PM but not documented on the Medication Administration Record (MAR). A dose was signed out at 9:00 PM and documented on the MAR so the resident had an extra dose signed out. Review of the Narcotic Sign-Out Sheet and MAR dated 2/18/17 revealed a dose was signed out at 2:00 PM but not documented on the MAR. A dose was signed out at 9:00 PM so the resident had an extra dose signed out. Resident #14 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] revealed Resident #14 scored 15 on the BIMS indicating she was alert, oriented, and able to make her needs known. Continued review revealed Resident #14 required extensive assistance with transfers, dressing, and grooming; was dependent on 2 people for bathing; and was always incontinent of bowel and bladder. Review of physicians orders dated 2/7/17 revealed Resident #14 was ordered [MEDICATION NAME] 10/325 mg twice daily to be administered at 6:00 AM and 6:00 PM. Review of the Narcotic Sign-Out Sheet and the MAR dated a dose was signed out on 2/23/17 at 2:00 PM but not documented on the MAR. Review of the Narcotic Sign Out Sheet and the MAR revealed a dose was signed out on 2/28/17 at 1:00 PM and 6:30 PM and neither dose was documented on the MAR. All these medications were signed out by the same nurse. Review of the facility investigation of a statement from the Unit Manager dated 3/2/17 revealed .Upon doing weekly reports and audits it was noted on a resident's Controlled Drug Record she was ordered medication [MEDICATION NAME] 7.5/325 mg twice daily but the medication had been signed out twice in one shift. This resulted in the amount of pills signed out was more than the medical staff ordered. After checking several sheets were found with this same situation. This information was given to Nursing Administration on 2/27/17 . Review of a statement from the IDON dated 3/2/17 revealed .On Monday 2/27/17, Unit Manager came to me with copies of narcotic sheets and MARS and asked me to review. Upon review there were some discrepancies noted regarding administration of medication times and the actual MAR. On 2/28/17 reviewed with ADON and she was in agreement. Mentioned possible drug diversion to Assistant Administrator . Review of a written statement by the Assistant Administrator dated 3/1/17 of a meeting with the IDON, ADON, and Corporate Nurse and the nurse who signed out narcotics but failed to document them on the MAR. When questioned the nurse admitted to administering two resident's medications by memory resulting in her giving a narcotic that was not scheduled to be given at the time she signed it out on the narcotic log. When questioned as to why she didn't document them being given on the MAR she stated she had intended to go back later after she finished her med pass and sign them out but she forgot. She admitted she realized later she had given a medication when it wasn't due and knew she had made a medication error, yet she did not tell anyone. When questioned why she did not report it to anyone she responded :I don't know. She was asked to write out her statement then was informed she was being placed on suspension pending further investigation. The IDON requested she count off her cart with the other nurse and leave the premises. When she got to the floor the IDON called her to say she needed to return to Human Resources (HR) for a drug screen. She arrived at the Assistant Administrator's office and stated she had to leave because she had received a call from the hospital saying her mother's condition was worse. She was informed HR was ready and the test would only take 5 minutes. She then stated she couldn't go to the bathroom and needed some water. She again said her mother was sick and she had to leave. The IDON informed her if she refused to take the drug test she could possibly lose her job. She then walked toward the front of the building and stated Y'all can fire me, I don't care. Review of a written statement from the accused nurse dated 3/1/17 revealed .On the dates mentioned there were only 2 nurses and at time 3 techs. I messed up by giving extra med by mistake. I know being busy is not an excuse but I did not look at the MAR and passed out one or two by memory . Review of interview dated 3/3/17 with Resident #14 revealed she did not remember getting an extra dose of pain medication on 2/23/17. Interview with the Administrator, IDON, and ADON on 3/16/17 at 11:30 AM in the conference room revealed the nurse in question signed out medications and was inconsistent in documentation. Residents received medications when they were not scheduled. IDON and ADON reviewed all MARs and sign-out sheets and found discrepancies on her unit. She said she took out the medications and thought it was the right time. She did not look at the MAR and gave the medications by memory resulting in significant medication errors for the residents.",2020-03-01
3707,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2017-03-28,225,D,1,0,E6GQ11,"**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 nurse failed to report to the Administrator and begin an investigation of an allegation of misappropriation of resident property for 1 Resident (#7) of 3 residents reviewed for abuse. The findings included: Review of facility policy, Abuse, Neglect, and Misappropriation of Property, revealed .It is the facility's policy to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property .Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish .Misappropriation of resident property means deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or property without the resident's consent .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. Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #7 scored 15 on the Brief Interview for Mental Status (BIMS), indicating she was alert, oriented, and able to make her needs known. Continued review revealed Resident #7 required extensive assistance of 2 people for transfers; extensive assistance of 1 person for dressing and grooming; was dependent on 1 person for bathing; supervision for eating; and was often incontinent of bowel and bladder. Review of the facility investigation dated 10/17/16, revealed during a care plan meeting the family brought in a bank statement from the bank of Resident #7 with some money withdrawals from the account. The family stated Resident #7 gave her bank card to 2 staff members to buy things for her. Resident #7 was interviewed and reported she had given her card multiple times to Certified Nursing Assistant #3 (CNA) and CNA #4 to purchase items for her. She denied giving permission for any of the CNAs to withdraw money from the account, or loan any money. Review of the facility investigation revealed a written statement from the Social Worker (SW) dated 10/18/16 revealed Resident #7 gives her debit card and pin numbers to CNAs #3 and #4 to go to vending machines or grocery stores to get food Resident #7 stated the charges for the vending machine purchases should be around $3.00 and the charges for going to the grocery store would be cash withdrawals from the ATM in amounts of about $100.00. She reports CNA #3 brings her receipts from the ATM cash withdrawals so she knows how much is being taken out and she will bring back the change from the shopping trip if there is some. Does not want police involved because it would be too much trouble. Denies the card has ever been gone overnight and not returned. She denies she has ever loaned anyone money or given permission for any sum of money to be taken from the card. Resident #7 was given information SW or QOL (Quality of Life) staff were the only ones to purchase items for the resident. Review of an undated written statement from CNA #5 revealed she .worked with (Resident #7) who stated to her she (Resident #7) wanted me to go get her some cold drinks with her card. I stated to her we couldn't take money or cards from them. She stated to me that (CNA #3 and #4) and some more of the staff do it all the time. I reported it to the nurse and she said she would speak to them about it . Review of an undated written statement from CNA #3 revealed .About 2 1/2 weeks ago (Resident #7) asked me to take her debit card and go to the drink machine to get her and her roommate a drink. I took the card and went to the drink machine, the card reader denied her card so I took it back to her and gave her card back to her and told her it was denied so out of my personal money I bought (Resident #7) and her roommate 1 bottled drink . Review of a written statement dated 10/13/16 from CNA #5 revealed .I witness one day (CNA #4) going down to get (Resident #7) and roommate some things from outside and I stated to her personally Please if you are using the credit card for them you need to stop before it be trouble . Review of an undated written statement by the Interim Director of Nursing (IDON) from an interview with CNA #4, revealed CNA #4 had the debit card of Resident #7 on 2 occasions. CNA #4 stated Resident #7 asked her to make several withdrawals from her account. CNA #4 stated she went to the blue store down the road and made the first withdrawal then Resident #7 asked her to withdraw more money. CNA #4 stated she withdrew a total of $640.00 for the resident. Resident #7 told CNA #4 to keep the card and get everything she could from the card. Review of the facility investigation revealed the nurse who was notified of the 2 CNAs using the resident's card was terminated for failure to report allegations of abuse to the Administrator, Director of Nursing (DON), or ADON (Assistant DON). The nurse had knowledge 2 CNAs were taking a resident's debit card and using it inside and outside the facility. She failed to report the misappropriation immediately and failed to start the investigation timely. Interview with the IDON, ADON, and Administrator on 3/16/17 at 9:45 AM in the conference room, revealed Resident #7 had allowed CNA #3 and CNA #4 to use her debit card for drinks and groceries. This was a violation of facility policy and the 2 CNAs were terminated as well as the Nurse who had failed to report the misappropriation to the Administrator once the Nurse was aware of resulting in the failure to investigate the allegation timely as required The Administrator stated the funds which were removed by the CNAs were reimbursed to Resident #7. The Administrator also stated it was a hard lesson for the CNAs to learn but he needed to set an example for the facility this type of behavior would not be tolerated.",2020-03-01
3708,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2017-03-28,333,D,1,0,E6GQ11,"**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 significant medication errors from occurring for 2 residents (#13, #14) of 15 residents reviewed. The findings included: Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #13 was severely impaired cognitively. Continued review revealed Resident #13 was dependent on 2 people for transfers; was dependent on 1 person for dressing, eating, grooming, and bathing; and was always incontinent of bowel and bladder. Review of physician's orders [REDACTED].#13 was ordered [MEDICATION NAME] 7.5/325 milligrams (mg) twice daily and was scheduled for 8:00 AM and 8:00 PM. Review of the Narcotic Sign-Out Sheet and the Medication Administration Record (MAR) dated 2/23/17 revealed a dose was signed out at 6:00 PM but not documented on the MAR. A dose was signed out at 9:00 PM and documented on the MAR indicating the resident had an extra dose signed out. Review of the Narcotic Sign-Out Sheet and MAR dated 2/18/17 revealed a dose was signed out at 2:00 PM but not documented on the MAR. A dose was signed out at 9:00 PM indicating the resident had an extra dose signed out. Resident #14 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] revealed Resident #14 scored 15 on the Brief Interview Mental Status (BIMS) indicating she was alert, oriented, and able to make her needs known. Continued review revealed Resident #14 required extensive assistance with transfers, dressing, and grooming; was dependent on 2 people for bathing; and was always incontinent of bowel and bladder. Review of the physician's orders [REDACTED].#14 was ordered [MEDICATION NAME] 10/325 mg twice daily to be administered at 6:00 AM and 6:00 PM. Review of the Narcotic Sign-Out Sheet and the MAR revealed a dose was signed out on 2/23/17 at 2:00 PM but not documented on the MAR. Review of the Narcotic Sign Out Sheet and the MAR revealed a dose was signed out on 2/28/17 at 1:00 PM and 6:30 PM and neither dose was documented on the MAR. All these medications were signed out by the same nurse. Review of the facility investigation of a statement from the Unit Manager dated 3/2/17 revealed .Upon doing weekly reports and audits it was noted on a resident's Controlled Drug Record she was ordered medication [MEDICATION NAME] 7.5/325 mg twice daily but the medication had been signed out twice in one shift. This resulted in the amount of pills signed out was more than the medical staff ordered. After checking several sheets were found with this same situation. This information was given to Nursing Administration on 2/27/17 . Review of a statement from the Interim Director of Nursing (IDON) dated 3/2/17 revealed .On Monday 2/27/17, the Unit Manager came to me with copies of narcotic sheets and MARS and asked me to review. Upon review there were some discrepancies noted regarding administration of medication times and the actual MAR. On 2/28/17 reviewed with the Assistant Director of Nursing (ADON) and she was in agreement. Mentioned possible drug diversion to Assistant Administrator . Review of a written statement by the Assistant Administrator dated 3/1/17 of a meeting with the IDON, ADON, and Corporate Nurse and the nurse who signed out narcotics but failed to document them on the MAR. When questioned the nurse admitted to administering two resident's medications by memory resulting in her giving a narcotic that was not scheduled to be given at the time she signed it out on the narcotic log. When questioned as to why she didn't document them being given on the MAR she stated she had intended to go back later after she finished her med pass and sign them out but she forgot. She admitted she realized later she had given a medication when it wasn't due and knew she had made a medication error, yet she did not tell anyone. When questioned why she did not report it to anyone she responded, I don't know. She was asked to write out her statement then was informed she was being placed on suspension pending further investigation. The IDON requested she count off her cart with the other nurse and leave the premises. When she got to the floor the IDON called her to say she needed to return to Human Resources for a drug screen. She arrived at the Assistant Administrator's office and stated she had to leave because she had received a call from the hospital saying her mother's condition was worse. She was informed HR was ready and the test would only take 5 minutes. She then stated she couldn't go to the bathroom and needed some water. She again said her mother was sick and she had to leave. The IDON informed her if she refused to take the drug test she could possibly lose her job. She then walked toward the front of the building and stated Y'all can fire me, I don't care. Review of a written statement from the accused nurse dated 3/1/17 revealed .On the dates mentioned there were only 2 nurses and at the time 3 techs. I messed up by giving extra med by mistake. I know being busy is not an excuse but I did not look at the MAR and passed out one or two by memory . Review of interview dated 3/3/17 with Resident #14 revealed she did not remember getting an extra dose of pain medication on 2/23/17. Interview with the Administrator, IDON, and ADON on 3/16/17 at 11:30 AM in the conference room revealed the nurse in question signed out medications and was inconsistent in documentation. Residents received medications when they were not scheduled. IDON and ADON reviewed all MARs and sign-out sheets and found discrepancies on her unit. She said she took out the medications and thought it was the right time. She did not look at the MAR and gave the medications by memory resulting in significant medication errors for Resident #13 and #14.",2020-03-01
4907,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2016-06-21,279,D,1,0,8IKJ11,"**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 a care plan addressing the elopement risk for 1 (Resident #9) of 3 residents reviewed for elopement risk. The findings included: Review of the facility policy entitled Interim Plan of Care, last reviewed on 6/1/15, revealed .Policy: An interim plan of care to meet the resident's immediate needs shall be developed for each resident within twenty-four (24) hours of admission .Guidelines: To assure that the resident's immediate care needs are met and maintained, an interim plan of care will be developed within twenty-four (24) hours of the resident's admission. The Interdisciplinary Team will review the .nursing evaluation .and implement a nursing care plan to meet the resident's immediate care needs. The interim plan of care will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary care plan . Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Nursing Admission Information form with the date of admission of 6/14/16, in the Elopement Risk Evaluation section, revealed the resident was automatically placed at risk for elopement due to demonstrating exit-seeking behavior. Medical record review of the Interim Admission Care Plan dated 6/14/16 revealed the section addressing .Resident at risk for elopement . was not completed. Observation on 6/20/16 at 2:38 PM revealed Resident #9 in the physical therapy department wearing an alarming device on the left ankle. Interview with the Director of Nursing on 6/20/16 at 4:00 PM, in the conference room, confirmed the facility failed to follow the policy to develop an interim plan of care for Resident #9 that was assessed upon admission as an elopement risk.",2019-06-01
5204,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2016-04-07,241,D,0,1,W2TQ11,"Based on policy review, observation and interview, the facility failed to promote dignity of residents when 3 of 29 staff members (Hospitality Aide (HA)#1, Licensed Practical Nurse (LPN) #8) and Certified Nursing Assistant (CNA) #3 referred to residents as a feeder. The findings included: 1. The facility's Quality of Life - Dignity policy documented, .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 . 2. Observation and interview on 4/6/16 at 4:55 PM, in the Ruberio 1 dining room revealed a resident was moved to another table. HA #1 was asked why resident was moved, and HA #1 stated, She is a feeder. 3. Observations on 4/6/16 at 5:14 PM, in the Ruberio 1 dining room revealed CNA #3 was standing outside of the Ruberio 1 dining room and yelled out to staff in the dining room, the feeders against the wall. 4. Observations on 4/6/16 at 6:10 PM, on the Ruberio 1 south hall, LPN #8 was heard to say, have so many feeders. 5. Interview with CNA #3 on 4/6/16 at 5:56 PM, on Ruberio 1 hall, CNA #3 was asked whose 5 trays were still on the meal cart. CNA #3 stated, All the feeders.",2019-04-01
5205,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2016-04-07,252,D,0,1,W2TQ11,"Based on observation and interview, the facility failed to ensure residents had a homelike dining experience when there was not sufficient staff present to ensure the meal trays were passed in a timely manner on 1 of 5 (Ruberio 1 hall) halls during two meal observations. The findings included: Observations on Ruberio 1 (R-1) on 4/4/15, revealed the meal cart arrived at 11:36 AM, and the last tray was served at 12:24 PM, with a total of 48 minutes to complete tray pass. Observations on R-1 on 4/6/16, revealed dining started at 4:55 PM, and the last tray was served at 6:15 PM, with a total of 1 hour and 20 minutes to complete tray pass. Interview with the Director of Nursing (DON) and the Clinical Nurse Consultant (CNC) on 4/7/16 at 6:45 PM, in the DON's office, the DON and CNC were asked if it was acceptable for a resident to receive their tray an hour and 20 minutes after tray service began. The CNC stated, It's difficult.",2019-04-01
5206,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2016-04-07,278,D,0,1,W2TQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to accurately assess a resident for prognosis for life expectancy of 6 months or less for 1 of 17 (Resident #222) residents reviewed of the 28 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #222 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #222 had no prognosis for a life expectancy of 6 months or less, and received hospice services while a resident at the facility. The comprehensive care plan dated 10/30/15 documented, .Resident is diagnosed with [REDACTED]. currently receiving Hospice services . The care plan was reviewed 1/27/16 and documented, .Cont (continue) P[NAME] (plan of care) . Resident is followed by Hospice . The current physician's orders [REDACTED]. 10/23/2015 . HOSPICE SERVICES . Interview with Licensed Practical Nurse (LPN) #1 on 4/6/16 at 3:00 PM, in the administrative hallway, LPN #1 was asked whether the quarterly MDS dated [DATE] was accurate related to the prognosis. LPN #1 stated, It was error.",2019-04-01
5207,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2016-04-07,279,D,0,1,W2TQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to develop a care plan for dental status for 1 of 17 (Resident #103) sampled residents reviewed of the 28 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented Resident #103 required extensive staff assistance for personal hygiene. The comprehensive care plan last reviewed on 2/27/16 did not address Resident #103's need for assistance with oral hygiene. Observations on the B4 hall, on 4/5/16 at 8:47 AM and 4/6/16 at 9:14 AM, revealed Resident #103 had several missing teeth. Interview with the Director of Nursing (DON) on 4/7/16 at 4:09 PM, in the conference room, the DON was asked whether Resident #103 had any missing or broken teeth. The DON stated, He has some (teeth) missing. The DON was asked whether Resident #103's dental status should be addressed on the care plan. The DON stated, Yes.",2019-04-01
5208,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2016-04-07,322,D,0,1,W2TQ11,"Based on policy review, observation and interview, the facility failed to ensure 1 of 6 (Licensed Practical Nurse (LPN #5) nurses checked placement of the percutaneous endoscopy gastrostomy (PEG) tube before administering medications to 1 of 3 (Resident #32) sampled residents receiving medication via a PEG tube. The findings included: Review of the facility's Medication Administration Enteral Tubes documented, .8. Verify tube placement . aspirate stomach contents with syringe . Observations on 4/7/16 at 12:20 PM, in Resident #32's room, revealed LPN #5 inserted a syringe into the PEG tube but did not aspirate stomach contents. LPN #5 flushed the PEG tube, administered medications, flushed the PEG tube again and then removed the syringe. LPN #5 failed to check placement of the PEG tube prior to administering medications to Resident #32. Interview with the Director of Nursing (DON) on 4/7/16 at 2:30 PM, in the DON's office, the DON was asked do you expect the nurses to actually pull back (aspirate) stomach contents when checking PEG placement. The DON stated, Yes.",2019-04-01
5209,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2016-04-07,333,D,0,1,W2TQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Geriatric Medication Handbook, medical record review, observation and interview, the facility failed to ensure a resident was free from a significant medication error when 1 of 6 nurses (Licensed Practical Nurse (LPN) #4) failed to administer insulin within the proper time frame related to meals for Resident #196, who received an insulin injection. The failure to provide a significant snack or substantial meal within appropriate time of insulin administration resulted in a significant medication error. The findings included: Review of the Geriatric Medication Handbook, eleventh edition, page 41 documented, DIABETES: INJECTABLE MEDICATIONS . Humalog . Rapid-Acting Insulin Analog . ONSET . 15 min (minutes) . TYPICAL ADMINISTRATION/COMMENTS 15 minutes prior to meals . Medical record review revealed Resident #196 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. inject 10 units Sub-Q (subcutaneously) three times daily with meals . Observations in Resident #196's room on 4/6/16 at 5:25 PM, revealed LPN #4 administered 10 units of Humalog subcutaneously. Resident #196 then went to the B2 activity room. Observations in the B2 activity room on 4/6/16 at 6:04 PM is when Resident #196 took the first bite of food. Interview with LPN #4 on 4/7/16 at 2:40 PM, in B hall, LPN #4 was asked, how long after administering Humalog insulin should a resident receive their meal. LPN #4 stated, Immediately. Interview with the Director of Nursing (DON) on 4/7/16 at 2:30 PM, in the DON's office, the DON was asked how long after a resident receives Humalog insulin should it be until the resident receives their meal or a significant snack. The DON stated, Within 30 minutes. Humalog is a fast acting insulin. Resident #32 should have received a significant snack or substantial meal within 15 minutes after receiving the Humalog insulin.",2019-04-01
5210,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2016-04-07,371,F,0,1,W2TQ11,"Based on policy review, observation, and interview, the facility failed to ensure food was stored and served under sanitary conditions as evidenced by open buckets with the presence of chemicals in the food preparation (prep) area, food items with no date when they were opened, liquid items stored past their expiration date, baking pans stacked wet nested (water between the pans), and staff touching food with their bare hands. This had the potential to affect 24 residents receiving thickened liquids, and 205 residents receiving meal trays from the kitchen of the total census of 234. The findings included: 1. The facility's Food Storage policy stated, .All containers must be legibly and accurately labeled . Chemicals must be clearly labeled, kept in original containers when possible, and kept in a locked area away from food . Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated . Rewrap packages of frozen food which have been opened . Observations in the kitchen on 4/4/16 beginning at 10:35 AM, revealed the following: a. 1 - red bucket and 1- green bucket with soapy water sitting under the food prep table. b. 1 - opened box of mixed vegetables, stored in the freezer. c. 1 - opened box of tater tots, stored in the freezer. d. 1 - meat item wrapped in plastic wrap with no open date. e. 2 - opened bags of meat no open date stored in the freezer. f. 6 - 46 ounce (oz) containers of thickened orange juice stored in the stock room past the expiration date of 3/18/15. g. 6 - 46 oz thickened sweetened tea with lemon flavor stored in the stock room past the expiration date of 10/6/15. h. 6 - 46 oz honey-like consistency sweetened tea with lemon flavor stored in the stock room past the expiration date of 11/12/15. i. 2 - 46 oz honey-like consistency sweetened tea with lemon flavor stored in the stock room past the expiration date of 2/17/16. j. 1 - 46 oz thickened orange juice stored in the dairy refrigerator past the expiration date of 3/18/16. k. 4 - 46 oz honey-like consistency sweetened tea with lemon flavor stored in the dairy refrigerator past the expiration date 11/12/15. l. 4 shallow baking pans stacked wet nested. Interview with the Dietary Manager (DM) on 4/4/16 at 10:40 AM, in the kitchen prep area, the DM was asked what was in the red and green buckets. The DM stated, Red bucket just soap and water, green bucket is sanitizer. Interview with the DM on 4/4/16 at 10:45 AM, in the freezer, the DM was asked what the meat wrapped in plastic was. The DM did not answer, but took the wrapped food and stated, I will throw that away. The DM was asked what the 2 bags of meat in the opened bags were, and if they should be closed and dated. The DM stated, Black bean burgers and took the bags out of the freezer. Interview with the DM on 4/4/16 at 10:53 AM, in the stockroom, the DM was asked if it was acceptable to have expired juices stored on the shelves. The DM stated, No. Interview with the DM on 4/4/16 at 10:58 AM, in the kitchen, the DM was asked if stacking wet pans was acceptable. The DM stated, Wet nesting, no. Interview with the Registered Dietician (RD) on 4/7/16 at 3:00 PM, next to the conference room, the RD was asked if it was acceptable to have food items opened and not dated. The RD stated, No, it's not. The RD was asked if it was acceptable to have expired juices stored in the stockroom and refrigerator. The RD stated, No. The RD was asked if it was acceptable to have pans stacked wet-nested. The RD stated, No. The RD was asked if it was acceptable to have chemicals around food. The RD stated, No. 2. Observations in Ruberio 2 dining room on 4/4/16 at 12:50 PM, revealed certified nursing assistant (CNA) #1 assisted Resident #53 with the lunch meal. CNA #1 picked up the roll with bare hands, cut the roll and placed butter in the roll, then placed the roll in Resident #53's mouth for a bite, then took the roll bare handed, and placed it back on the plate. CNA #1 continued to pick the roll up with bare hands during the entire meal. Interview with the Director of Nursing (DON), on 4/7/16 at 6:00 PM, in the DON's office, the DON was asked if it was acceptable for staff to use bare hands to feed residents. The DON stated, No, it is not acceptable.",2019-04-01
5211,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2016-04-07,412,D,0,1,W2TQ11,"**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 related to dental health for 1 of 4 (Resident #103) sampled residents with dental needs of the 28 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented Resident #103 had a Brief Interview for Mental Status (BIMS) score of 1, indicating severe cognitive impairment, and required extensive staff assistance for personal hygiene. The speech therapy (ST) note dated 2/4/16 documented, .Reason for Referral . mechanical soft texture presents some confusion to resident regarding origin of food items and is not able to identify them . Dentition . partially edentulous with missing upper front teeth and on lower intermittently . Observations on the B4 hall, on 4/5/16 at 8:47 AM and on 4/6/16 at 9:14 AM, revealed Resident #103 had several missing teeth. Interview with the Assistant Administrator on 4/6/16 at 4:36 PM, in the conference room, the Assistant Administrator was asked whether Resident #103 had received any dental consults while a resident at the facility. The Assistant Administrator stated, I don't have anything. Interview with MDS Coordinator #2 on 4/7/16 at 2:48 PM, in the conference room, MDS Coordinator #2 was asked how are dental assessments performed. MDS Coordinator #2 stated, Floor nurses do them. Interview with Licensed Practical Nurse (LPN) #3 on 4/7/16 at 3:15 PM, on the B4 hall, LPN #3 was asked whether the floor nurses perform dental assessments. LPN #3 stated, No, we don't do them. Interview with the Director of Nursing (DON) on 4/7/16 at 4:09 PM, in the conference room, the DON was asked whether Resident #103 had any missing or broken teeth. The DON stated, He has some (teeth) missing. The facility was unable to provide documentation that Resident #103 had been offered dental services.",2019-04-01
5212,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2016-04-07,431,D,0,1,W2TQ11,"Based on policy review, observations, and interview, the facility failed to ensure medications were stored securely in 2 of 25 (Birmingham 4th floor crash cart and Rubiero 1 south hall medication cart) medication storage areas. The findings included: 1. The facility's medication storage policy stated, .The medication supply shall only be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications . Medications are to remain in these containers and stored in a controlled environment . Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access . 2. Observations on Birmingham 4th floor hallway, on 4/7/16 at 2:15 PM, revealed the unit's crash cart was left unlocked. Interview with Licensed Practical Nurse (LPN) #6 on 4/7/16 at 2:16 PM, in the hallway beside the crash cart, LPN #6 was asked why the crash cart was unlocked. LPN #6 stated, I had to order some Dextrose to replace in it. 3. Observations on Rubiero 1 on 4/6/16 at 6:16 PM, revealed the south hall medication cart was left unlocked, unattended and out of the view of the nurse. A side drawer in the cart had a clear plastic cup with a brown substance with green streaks in it. the cart remained unlocked for 15 minutes before Licensed Practical Nurse (LPN) #8 walked up to the cart and stated, I left my cart unlocked. Interview with LPN #8 on 4/6/16 at 6:31 PM on Rubiero 1, LPN #8 was asked if it was acceptable to leave the medication cart unlocked, unattended and out of view of a nurse. LPN #8 stated, No. Interview with the Director of Nursing (DON) on 4/6/16 at 7:20 PM, on Rubiero 1 hall, the DON was asked if it was acceptable to leave a medication cart unlocked, unattended and out of view of the nurse. The DON stated, No it is not.",2019-04-01
5213,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2016-04-07,441,D,0,1,W2TQ11,"**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 transmission of disease and/or infection when 2 of 29 staff members (Respiratory Therapist (RT) #1 and Certified Nursing assistant (CNA) #2) failed to perform proper hand hygiene during tracheostomy care or failed to disinfect a bedside table during dining. The findings included: 1. The facility's Tracheostomy Care policy documented .5. Wash and dry hand thoroughly, put on sterile gloves. 2. Medical record review revealed Resident #352 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations revealed Respiratory Therapist (RT) #1 performing trach care on 4/7/16 at 5:10 PM, in Resident #352's room. RT #1 put on clean gloves, applied sterile gloves over the clean gloves, and performed the trach care. RT #1 did not change the clean gloves or wash hands during the procedure. RT #1 was not observed washing hands prior to trach care. Interview with RT #1 on 4/7/16 at 6:00 PM, RT #1 was asked when she washed her hands during the trach care. RT #1 stated After. RT #1 was asked if she washed her hands before the trach care. RT #1 stated, No. 3. Observations on Ruberio 100 hall on 4/6/16 at 6:00 PM, revealed CNA #2 served supper trays. CNA #2 moved a bedside table out of room [ROOM NUMBER] to room [ROOM NUMBER] and placed the meal tray for 106 on the bedside table without sanitizing the table surface. At 6:15 PM, CNA #2 moved the bedside table from room [ROOM NUMBER] to room [ROOM NUMBER], and placed the meal tray on the table without sanitizing the table surface. Interview with the Director of Nursing (DON) on 4/7/16 at 6:00, in the DON office, the DON was asked if it was acceptable to move bedside tables from room to room to serve meals without sanitizing the the surface. The DON stated, No, it is not acceptable.",2019-04-01
6311,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2015-03-26,241,D,0,1,N2VZ11,"Based on policy review and interview, the facility failed to ensure 1 of 26 staff members (Certified Nursing Assistant (CNA) #1) members treated residents with dignity and respect when residents who required assistance with meals were referred to as feeders. The findings included: Review of the facility's Use of Courtesy Titles policy documented, .It shall be the policy of Nashville Community Care and Rehabilitation at Bordeaux that residents and staff will be addressed in a courteous, respectful manner . Interview with CNA #1 on 3/9/15 at 12:25 PM in the B4 (Birmingham) dining room, CNA #1 was asked if there was another cart for the halls. CNA #1 stated, We have another cart that comes up for feeders. This statement was made in the presence of several residents, staff members and a family member. Interview with the Administrator on 3/13/15 at 1:55 PM, in the conference room, the Administrator was asked if it is ever appropriate to refer to residents as feeders. The Administrator stated, No.",2018-08-01
6312,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2015-03-26,244,E,0,1,N2VZ11,"Based on interview and review of resident council meeting minutes, the facility failed to follow up on the resident council's concerns for 2 of 3 (January and (MONTH) (YEAR)) months of resident council meeting minutes reviewed. The findings included: 1. Interview with alert and oriented Resident #103 on 3/11/15 at 3:00 PM in Resident #103's room Resident #103 stated, staff does not listen to the resident council's view and act upon any grievances the resident/group has filed. Resident #103 stated, I don't know if anyone follows up because (named the Recreational Therapist) put confidential on the minutes so we can't follow up at the next meeting. Resident #103 was asked if she gets a copy of the council meeting minutes. Resident #103 stated, No. Resident #103 was asked how concerns are brought to the council meetings. Resident #103 stated, I have them typed up and I give them to (named staff) a day before the meeting. 2. Review of the typed resident concerns prepared for the resident council meeting in (MONTH) (YEAR) revealed, .Who is taking the Minutes, and is there any way we can get them before the next meeting? We would like to refresh our memory on Old Business and make sure there is a place for New Business. Also in the Old Business we need to know that any concerns stated earlier have been handled, the action taken, and the date completed, and was the concerned person notified . There were also concerns noted with staff behavior and assistance needed by residents. Review of the resident council minutes for 1/29/15 revealed that there was no discussion of the concerns with the meeting minutes and discussion of old business. There was no evidence that all of the residents concerns were addressed. There was no section for old business in the meeting minutes. The section for the council president to sign the minutes was blank. There was no evidence that a grievance was filed for the resident complaints in (MONTH) (YEAR). 3. Review of the typed resident concerns prepared for the resident council meeting in (MONTH) (YEAR) revealed concerns noted with staff behavior and assistance needed by residents. Review of the resident council minutes for 2/27/15 revealed that there was no follow-up to concerns voiced during the resident council meeting on 1/29/15. There was no evidence that all of the residents concerns were addressed. There was no section for old business in the meeting minutes. The section for the council president to sign the minutes was blank. There was no evidence that a grievance was filed for the resident complaints in (MONTH) (YEAR). 4. Interview with the Recreational Therapist on 3/12/15 at 8:15 AM, in the Recreational Therapist's office, the Recreational Therapist was asked how the facility follows up on issues discussed during the resident council meetings. The Recreational Therapist stated, I listen during the meeting and put it down in the minutes and pass it along to the department heads. The Recreational Therapist confirmed that old business was not discussed in the meeting, not all of the concerns she received in writing was addressed in the minutes and that the resident council president was not given a copy of the meeting minutes. Interview with the Administrator and the Nurse Consultant on 3/19/15 at 1:49 PM in the Administrators office, the Administrator and the Nurse Consultant confirmed that concerns raised by the council should be followed up on, old business should be discussed in the meetings and that the meeting minutes should be available to the resident council president and the council members.",2018-08-01
6313,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2015-03-26,278,D,0,1,N2VZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to accurately code the Minimum Data Set (MDS) for incontinence for 1 of 36 (Residents #68) sampled residents of the 58 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 11 which indicated the resident was moderately impaired and was occasionally incontinent of bladder (less than 7 episodes during the 7 day look back period). The quarterly MDS dated [DATE], documented a BIMS score of 12 which indicated the resident was moderately impaired and was frequently incontinent of bladder (7 or more episodes during the 7 day look back period). Review of a care plan dated 11/24/14 documented Resident #68 had a problem with Activities of Daily Living) (ADL) self care deficit and was at risk for complications related to the deficit and .Resident (#68) is occasionally incontinent with bladder/bowel . Approaches include: Assist with toileting as needed, Change brief/ pad as needed . Review of the incontinent reports documented the following: a. Resident #68 had 7 episodes of incontinence during the 7 day look back period (11/13/14 through (-) 11/19/14) for the 11/19/14 admission MDS which indicated frequently incontinent. b. Resident #68 had 5 episodes of incontinence during the 7 day look back period (2/9/15 - 2/15/15) for the 2/15/15 MDS which indicated occasionally incontinent. Observations in Resident #68's room, on 3/12/15 at 9:18 AM, revealed Resident #68 lying in bed with a bedside commode beside the bed. Interview with Resident #68 on 3/13/15 at 2:45 PM in Resident #68's room, Resident #68 was asked if she used the bedside commode to urinate and have a bowel movement. Resident #68 stated, Yes ma'am, the doctor doesn't want me to walk by myself so I use that. I hold on to the sides. She was asked if she wears briefs or pull ups and she pointed to a bag of pull ups on the dresser and stated, I wear those. Resident #68 was asked if she ever urinates in the pull ups. Resident #68 stated, Well sometimes, but not very often. Interview with Licensed Practical Nurse (LPN) #7 on 3/13/15 at 3:19 PM at the R2 (Riberio) nurses station, LPN #7 was asked about Resident #68's episodes of incontinence. LPN #7 stated, She gets up by herself and she is continent. She can tell me when she has a BM (bowel movement) and when she doesn't want her [MEDICATION NAME]. She is never incontinent. Interview with certified nursing assistant (CNA) #5 on 3/13/15 at 3:22 PM, CNA #5 was asked about Resident #68's incontinence. CNA #5 stated, She changes her clothes, she has her own wipes and cleans herself up when she needs to. Telephone interview with LPN #8 on 3/13/15 at 3:48 PM, LPN #8 was asked if she completed the bowel and bladder section of the MDS. LPN #8 stated, I do. LPN #8 was asked where she gets the information to put into the MDS. LPN #8 stated, I get it from what the techs (technicians) put into (named kiosk program) . Let me look at the documentation. I will print them out. For the first MDS 1 bowel and 7 of incontinence, but I think the 2nd one. I may have that backwards in that coding. She went from 7 episodes to 5 episodes. Interview with LPN #8 on 3/13/15 at 3:57 PM at R2 nurses station, while reviewing the incontinence reports, LPN #8 stated, I marked them. I evidently miss counted. That's what I would chalk that up to. I don't like making mistakes.",2018-08-01
6314,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2015-03-26,280,D,0,1,N2VZ11,"**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 to include the interventions put in place for pressure ulcers for 1 of 36 (Resident #14) sampled residents reviewed of the 58 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Braden scale dated 2/10/15 revealed a score of 11 indicating Resident #14 was a high risk for pressure ulcers. Review of the admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 2/17/15 revealed, Resident #14 had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact and at risk for pressure ulcers. Review of the pressure ulcer report dated 2/24/15 documented, .Date of Origin 2/24/15 . Site Location: Buttocks . (checked) Facility acquired . (checked) Unstageable . MEASUREMENTS Length (cm) (centimeters) 12.5 x (by) Width (cm) 5.0 Depth (cm) 0.1 . The care plan dated 2/24/15 documented, .Resident is with pressure ulcer (s) Classified as . (checked) Unstageable Location: Rt (right) Buttocks . Interventions . 1. Assess & (and) monitor for s/s (signs and symptoms) of Infection . 2. Provide low AF (air loss surface) . Tx (treatment) Skin prep & [MEDICATION NAME] . Review of pressure ulcer reports documented the following: a. 3/2/15 - STAGE . (checked) Unstageable . MEASUREMENTS Length (cm): 12.5 x Width (cm): 5.5 Depth (cm) 0.1 . Pt (patient) sets up in bed on coccyx during the day to play on computer instructed pt that he needs to turn get off buttocks to heal . b. 3/9/15 - STAGE . (checked) Unstageable . MEASUREMENTS Length (cm) 13.0 x Width (cm) 7 x Depth (cm) 2 . Pt sets straight up in bed every day all day that causes pressure Instructed pt not to do it all day. Pt. stated I have to do something . Observations in Resident #14's room on 3/13/15 at 2:31 PM, revealed Resident #14 sitting up in bed playing a car garage game on his computer tablet. Interview with the Director of Nursing (DON) on 3/18/15 at 3:51 PM, in the conference room, the DON was asked if the resident teaching in the progress notes of the the pressure ulcer record on 3/2/15 and 3/9/15 was appropriate for the care plan. The DON stated, Yes, I don't see anything about that on there (care plan). I don't see it.",2018-08-01
6315,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2015-03-26,309,D,0,1,N2VZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, the facility failed to assess skin conditions for non pressure ulcers for 1 of 36 (Resident #232) sampled residents of the 58 residents included in the stage 2 review. The findings included: 1. The facility's Skin Management and Prevention At - A - Glance policy documented, .weekly skin . will be utilized to determine if any new skin alterations have developed . 2. Medical record review revealed Resident #232 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The facility was unable to provide weekly skin integrity reviews completed between 2/3/15 through 3/8/15. Interview with the Assistant Director of Nursing (ADON) / Registered Nurse (RN) #2 on 3/12/15 at 10:12 AM, at the B2 (Birmingham) nurses station confirmed the weekly skin integrity reviews between 2/3/15 and 3/8/15 had not been completed.",2018-08-01
6316,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2015-03-26,312,D,0,1,N2VZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide assistance with daily oral hygiene for 1 of 5 (Resident #196) sampled residents reviewed for activities of daily living (ADL) of the 58 residents included in the stage 2 review. The findings included: 1. Medical record review revealed Resident #196 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/13/15 documented, the Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact and required extensive to total assistance for all activities of daily living (ADL). Review of the care plan dated 1/6/15 documented, .Problem . Resident has ADL Self Care Deficit & (and) is at risk for complication related to [MEDICAL CONDITION] and stated bed bound status . Resident requiring various levels of staff assistance for the completion of his daily ADL's . Approaches . Provide oral care daily and as needed . Call light w/in (within) reach . arrive promptly when in use . Interview with Resident #196 on 3/10/15 at 1:27 PM, in Resident #196's room, Resident #196 was asked how often are your teeth / dentures / mouth cleaned. Resident #196 stated, Every 2 to 3 days. Interview with Certified Nursing Assistant (CNA) #2 on 3/12/15 at 4:00 PM, outside Resident #196's room, CNA #2 was asked if she had provided oral care for Resident #196. CNA #2 stated, Yes, this morning. CNA #2 was asked if there was any charting in the kiosk specific to oral care. CNA #2 stated, No, it falls under personal hygiene. Interview with Resident #196 on 3/12/15 at 4:02 PM, in Resident #196's room, Resident #196 was asked if his teeth had been brushed today. Resident #196 stated, No. Resident #196 was asked if he had his teeth brushed yesterday. He stated, No. Resident #196 was asked if his teeth had been brushed the day before yesterday. He stated, No, it's been a long time. Interview with the Assistant Director of Nursing (ADON) / Registered Nurse (RN) #2 on 3/12/15 at 4:15 PM, at the B4 nurses station, the ADON was asked if she believed her staff was completing oral care on the residents. The ADON stated, I have been in rooms where I could tell oral care wasn't done.",2018-08-01
6317,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2015-03-26,314,H,0,1,N2VZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the National Pressure Ulcer Advisory Panel (NPUAP) Pressure Ulcer Prevention quick reference guide, policy review, medical record review, review of the facility's weekly pressure ulcer tracking forms, observation and interview, the facility failed to ensure nurses completed weekly skin assessments and identify pressure ulcers timely, identify the correct anatomical location of a pressure ulcer, obtain a physician's orders [REDACTED].#14, 115, 196, 277, 65, 96, 163 and 248) sampled residents reviewed of the 17 residents with pressure ulcers. The failure of the facility staff to complete weekly skin assessments on residents who were at risk for developing pressure ulcers and identify pressure ulcers before residents developed an unstageable pressure ulcer resulted in actual harm for Residents #14, 115, 196 and 277. This resulted in substandard quality of care. An extended survey was completed on 3/26/15. The findings included: 1. Review of the NPUAP Pressure Ulcer Prevention quick reference guide revealed, .Ongoing assessment of the skin is necessary to detect early signs of pressure damage . Skin inspection should include assessment for localized heat, [MEDICAL CONDITION], or induration (hardness) . Accurate documentation is essential for monitoring the progress of the individual and to aiding communication between professionals . 2. Review of the facility's Skin Management and Prevention policy revealed, .weekly skin . will be utilized to determine if any new skin alterations have developed . Any new skin condition(s) found during the weekly skin rounds will be documented . 3. Medical record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Braden scale dated 2/10/15 revealed a score of 11 indicating Resident #14 was a high risk for pressure ulcers. Review of the nursing admission information revealed, .2/11/15 11:00 . Pt. (patient) assessed head to toe by wound care. No skin breakdown or alteration in skin integrity at this time . Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/17/15 revealed Resident #14 did not have any pressure ulcers. Review of the interim care plan (developed on admission) dated 2/10/15 documented, .Skin assessment weekly . The facility was unable to provide documentation of weekly skin integrity reviews were completed from the date of admission (2/10/15) until 2/24/15. The weekly skin integrity review dated 2/24/15 documented, (checked) Rash . (checked) Redness . Open Area . (checked) Old . 2/24/15 . (checked) Open Area (black) area . (checked) Old . 12.5x (by) 5.0 . black eschar . soft . Review of a physician's orders [REDACTED]. Assess and monitor Daily . Review of the pressure ulcer report dated 2/24/15 documented, .Date of Origin 2/24/15 . Site Location: Buttocks . (checked) Facility acquired . (checked) Unstageable . MEASUREMENTS Length (cm) (centimeters) 12.5 x Width (cm). 5.0 Depth (cm) 0.1 . Observations in Resident #14's room on 3/13/15 at 2:43 PM, revealed Licensed Practical Nurse (LPN) #1 (wound care nurse) performed wound care as ordered by the physician for of Resident #14. Resident #14's coccyx wound was the size of a small toy football with brown loose slough covering the wound bed. Interview with the Medical Director on 3/17/15 at 3:50 PM at the B2 (Birmingham) nurses station, the Medical Director was asked about Resident #14's unstageable pressure ulcer. The Medical Director stated, The wound could have come on suddenly but with the size and the black eschar you would think someone would have noticed it when they were cleaning him up. Black eschar takes some time to develop. Interview with the Director of Nursing (DON) on 3/17/15 at 4:35 PM in the conference room, the DON was asked if she expected the staff to identify a wound before it was noted to be unstageable. The DON stated, Yes. Failure of the facility to complete weekly skin assessments and to identify a pressure ulcer before it was unstageable resulted in actual harm to Resident #14. 4. Medical record review revealed Resident #115 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Braden scale dated 12/22/14 for Resident #115 was 16 indicating the resident was a mild risk of developing a pressure ulcer. The significant change MDS assessment with an ARD of 1/4/15 documented, a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact and required extensive assistance for activities of daily living (ADL) with functional limitation in range of motion (ROM) in upper and lower and extremities on both sides. The comprehensive care plan dated 1/12/15 documented, .Problem . Increased potential for impaired skin integrity R/T (related to) Dx (diagnosis) [MEDICAL CONDITION] and related weakness with presence of incontinence and impaired ROM/Mobility . Goal . Skin will remain intact . Approach . assess for prompt intervention s/s (signs and symptoms) of further impaired skin integrity and report prn (as needed) to MD (medical doctor) as per facility practice and consult with wound care nsg (nursing) prn (as needed) . A care plan dated 3/9/15 documented, .Resident is with pressure ulcer(s) Classified as: Unstageable Location: Lt (left) posterior L.E. (lower extremity) below base of buttocks . Goals . Will address all needed treatment to specific ulcer(s) / wound(s) to facilitate healing thru (through) next review date . Interventions . assess and monitor daily . Use clean technique for wound care . Tx (treatment) 3/9/15 calcium alginate [MEDICATION NAME] . A physician's orders [REDACTED].Wound care to Lt posterior L.E. below base of buttocks as follows. Clean c (with) wound cleanser gauze, apply Calcium alginate, [MEDICATION NAME] 4 x wk assess and monitor daily . Review of the weekly skin integrity review sheets dated 12/1/14 through 3/9/15 revealed skin assessments were not done on 12/8/14, 12/15/14, 12/22/14, 12/19/14, 2/9/15, 2/16/15, 2/23/15, and 3/2/15. The weekly skin integrity review form dated 3/9/15 documented, .skin intact . completed by Licensed Practical Nurse (LPN) #3. The pressure ulcer record dated 3/9/15 documented, .Lt Posterior L.E. @ (at) base of buttocks . Facility acquired . Unstageable . Length (cm) . 2 x Width (cm) . 2.5 . Depth (cm) . 0.5 . Wound Bed . Slough . 80% (percent) . Eschar . 20% . Consult received noted new wound treatment orders . Review of the nurse's notes dated 3/9/15 documented, .Observed open area on Lt posterior L.E. Under base of buttocks new orders to treat wound. Instructed pt (patient) importance to reposition to help c (with) healing and off load pressure. Pt verbalizes understanding . LPN #1 and LPN #2 (wound nurses) entered Resident #15's room, on 3/14/15 at 10:45 AM to allow the surveyor to observe Resident #115's pressure ulcer. While observing the pressure ulcer LPN #2 stated to LPN #1, This left buttock wound actually looks like a stage III. I think you (LPN #1) miss-staged this. Interview with the Assistant Director of Nursing (ADON) / Registered Nurse (RN) #1 on 3/13/15 at 9:55 AM, at R2 (Riberio 2nd floor) nurses station, ADON/RN #1 was asked to explain the difference between the weekly skin integrity review and the pressure ulcer record. The ADON/RN #1 stated, I really can't. ADON/RN #1 was asked what she expected from her nursing staff when performing skin assessments. The ADON/RN #1 stated, I expect them to do the weekly skin assessments and notify the MD (medical doctor), treatment nurse and family if something is discovered. The ADON/RN #1 was asked whose responsibility was it to make sure the skin assessments were being done weekly. The ADON/RN #1 stated, Mine. The ADON/RN #1 was shown the weekly skin integrity review sheets for the months 12/1/14 through 3/9/15 and was asked if weekly skin assessments had been completed. The ADON/RN #1 stated, No. Interview with LPN #3 on 3/13/15 at 10:08 AM, at R2 nurses station, LPN #3 was shown the weekly skin integrity review form dated 3/9/15 and was asked if she completed the skin assessment on 3/9/15 for Resident #115. LPN #3 stated, Yes. LPN #3 was shown the pressure ulcer record dated 3/9/15 and asked if her assessment was accurate. LPN #3 stated, Other than I didn't see it (the pressure ulcer). I just didn't see it, that's all I can say. Failure of the facility to complete weekly skin assessments and to identify a pressure ulcer before it was unstageable resulted in actual harm to Resident #115. 5. Medical record review revealed Resident #196 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Braden scale dated 1/6/15 documented a score of 14 indicating the resident was a moderate risk for developing a pressure ulcer. The admission MDS assessment with an ARD of 1/13/15 documented, a BIMS score of 15, indicating the resident was cognitively intact, required extensive to total assistance for all ADL's, had no functional limitations in ROM, had an indwelling catheter and an ostomy. The pressure ulcer record dated 2/4/15 documented, .Lt. Buttocks . Facility acquired . Unstageable . 3.0cm x 7.5cm x 0.1cm . Exudate . Serous . Scant . 100% slough . A wound care note dated 2/5/15 documented, .Unstageable wound on L (left) (circled) buttox (buttock) . Drainage . Large amount . Foul . A physician's orders [REDACTED].Lt buttocks unstageable pressure ulcer: cleanse c (with) wound cleanser Apply Dakin's moistened gauze. cover c dry drsg. (dressing) 4x/wk . The facility was unable to provide weekly skin integrity review sheets from 2/23/15 to 3/12/15. Observations in Resident #196's room on 3/12/15 at 8:50 AM revealed a large unstageable left buttock wound. There was 20% eschar and 80% slough with slight bright red bleeding from around the edges. Interview with LPN #2 (wound nurse) on 3/12/15 at 1:59 PM, in the conference room, LPN #2 was asked who discovered the unstageable buttocks wound. LPN #2 stated, When you are doing treatments in the area (of the body where the wound is) sometimes we will start treating (a second wound). LPN #2 was asked how often do you treat Resident #196. LPN #2 stated, Four times a week. I'm pretty sure it (left buttock wound) started out red. He (Resident #196) wouldn't stay off his left side. The nursing staff probably wouldn't notice anything wrong as it was probably covered with a dressing. It could have been I just missed it or forgot to start documentation. Yep, I think I missed that. Interview with RN #2/ADON on 3/12/15 at 4:00 PM, at the B4 nurses desk, RN #2/ADON was asked what she expected from her nursing staff regarding skin assessments. RN #2/ADON stated, I expect my staff to complete skin assessments per policy which is weekly or normally in the shower since the residents are in their birthday suits. Interview with the Medical Director on 3/24/15 at 4:00 PM, in the conference room, the Medical Director was asked about Resident #196's pressure ulcer. The Medical Director stated, Based on what the wound nurse told me, she (wound nurse) was treating the new area that was close to the surgical coccyx wound, but she did not document on the new area until it was open. She (wound nurse) knows it was started as a DTI (deep tissue injury) and used skin prep until it opened, but I have no supporting documentation. I did not sign it (determination that development of pressure sore is unavoidable form) because I had no verification of documentation. She (wound nurse) said right in front of me that she forgot to document it. Failure of the facility to identify a pressure ulcer before it was unstageable resulted in actual harm to Resident #196. 6. Medical record review revealed Resident #277 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission nurses note dated 2/27/15 documented, .Multiple bruises noted on abdomen and BUE (bilateral upper extremities) . Skin warm and dry no [MEDICAL CONDITION] or rash noted . The admission nurses note dated 3/1/15 at 9:00 AM documented, Wound care full skin assessment done at admission . pressure ulcer on buttocks/coccyx noted wound care orders wrote for treatment . There is no evidence in the medical record that Resident #277 was admitted to the facility with a pressure ulcer on 2/27/15. Review of the pressure ulcer record dated 3/1/15 revealed, .Date of Origin 3/1/15 . Site Location: Coccyx . (checked) admitted with . Date 3/1/15 . STAGE . (checked) Unstageable . Length (cm) 9 x Width (cm) 7.5 Depth (cm) 0.5 . (checked) Slough . 80% . (checked) Eschar . 20% . SPECIALTY INTERVENTIONS . (checked) Mattress . PROGRESS NOTES . Upon assessment on admission noted pt has unstageable coccyx wound new orders . gave over phone . A physician's orders [REDACTED]. A nutritional progress note dated 3/2/15 at 2:58 documented, .skin intact . Observations in the Resident #277's room on 3/24/15 8:36 AM with LPN #2 (wound nurse) present revealed Resident #277's coccyx pressure ulcer was irregular shaped the size of a small plum, with yellow slough in the wound bed. LPN #2 stated, It (the pressure ulcer) is unstageable due to slough, you can't see the wound bed. Interview with the DON on 3/23/15 at 4:45 PM in the DON's office, the DON was asked what she expected of her nurses regarding skin assessments on admission. The DON stated, To fill out the skin assessment sheet within 24 hours. The DON was asked what she expected of her wound nurses as far as completing a skin assessment. The DON stated, The policy says 24 (hours) but sometimes they don't get around to it until 48 hours. The DON was asked why the coccyx wound was documented as being present when admitted when it was not discovered until 3/1/15 and the resident was admitted [DATE]. The DON stated, I can't answer that question. Interview with the Medical Director on 3/24/15 at 4:05 PM in the conference room, the Medical Director was asked about Resident #277's unstageable pressure ulcer. The Medical Director stated, If it (the pressure ulcer) was from (named hospital) they would have written wound orders. (Nurses) Have to open up the folds during the assessment. The failure of the facility to identify a pressure ulcer before it became unstageable resulted in actual harm to Resident #277. 7. Medical record review revealed Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual MDS with an ARD of 11/15/14 documented Resident #65 had a BIMS score of 2 indicating the resident was severely cognitive impaired and there were no pressure ulcers present. The weekly skin integrity review form dated 12/25/14 documented, Skin Condition . (checked) Redness . (checked) Other . There were no identifying marks on the body figures on the feet or toes. The facility was unable to provide evidence that the weekly skin integrity review forms were completed after 12/25/14 until 2/21/15. The physician's orders [REDACTED].Wound care to evaluate SDTI (suspected deep tissue injury) on L (left) 2nd toe . Skin Prep 2nd Left Toe Q (every) shift & (and) avoid placing strap over L 2nd toe . The facility was unable to provide evidence that wound care evaluated the SDTI on Resident #65's left 2nd toe as ordered by the physician. Review of the Medication Administration Record [REDACTED]. Review of the MAR for 1/1/15 - 1/31/15 revealed Skin Prep Treatment to the 2nd left toe was not applied as ordered by the physician on the 7AM - 7PM shift for 1/1, 1/2, 1/3, 1/10, 1/11, 1/12, 1/13, 1/16, 1/17, 1/18, 1/21, 1/23, 1/25, 1/26, 1/30 and 1/31/15 or on the 7PM-7AM shift for 1/5, 1/6/ 1/10, 1/11, 1/13, 1/14, 1/15, 1/16, 1/17, 1/18, 1/19, 1/20, 1/21, 1/22, 1/23, 1/25, 1/26, 1/27, 1/28, 1/29, 1/30 and 1/31/15. Review of the MAR for 2/1/15 - 2/28/15 revealed Skin Prep Treatment to the 2nd left toe was not applied as ordered by the physician on the 7AM - 7PM shift for 2/1, 2/3, 2/4, 2/6, 2/8, 2/9, 2/10, 2/11, 2/13, 2/14, 2/15, 2/16, 2/18, 2/19, 2/20, 2/21, 2/22, 2/23, 2/24, 2/27, 2/28 or on the 7PM-7AM shift for 2/1, 2/2, 2/4, 2/5, 2/6, 2/9, 2/10, 2/11, 2/17, 2/19, 2/20, 2/22, 2/23, 2/24, 2/25, 2/27 and 2/28/15. Review of the MAR for 3/1/15 - 3/16/15 revealed Skin Prep Treatment to the 2nd left toe was not applied as ordered by the physician on the 7AM-7PM shift for 3/1, 3/4, 3/6, 3/7, 3/9, 3/10, 3/11, 3/12, 3/13, 3/14 and 3/15/15 or on the 7PM-7AM shift for 3/1, 3/2, 3/3, 3/4, 3/9, 3/11, 3/12 and 3/16/15. Observations of Resident #65's lower extremities on 3/18/15 at 9:04 AM revealed an immobilizer on her left lower extremity and a heel protector on her right foot. Observations of Resident #65's left foot on 3/18/15 at 9:20 AM with RN #2/ADON revealed an open area on the knuckle of her left 2nd toe. Interview with LPN #2 (wound nurse) on 3/18/15 at 9:04 AM in Resident #65's room, LPN #2 was asked if wound care was provided for Resident #65's left 2nd toe. LPN #2 stated, We don't do anything on her feet. Interview with the Corporate Nurse Consultant on 3/18/15 at 11:24 AM, in the conference room, the Corporate Nurse Consultant confirmed that the wound consult by the wound care nurses to evaluate the SDTI on the left 2nd toe ordered by the physician on 12/26/14 had not been done. Interview with the DON on 3/18/15 at 6:26 PM in the conference room, the DON confirmed that the Skin Prep treatment ordered on [DATE] - 3/16/15 to Resident #65's left 2nd toe had not been applied as ordered by the physician. 8. Medical record review revealed Resident #96 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change MDS dated [DATE] documented Resident #96 was unable to complete a BIMS assessment because she was rarely/never understood. Resident #96 was admitted to Hospice care and documented an unstageable pressure ulcer with slough and or eschar and one unstageable suspected deep tissue injury in evolution. A pressure ulcer record dated 1/19/15 documented site location: Rt. Ischium / admitted pressure ulcer. This record identified an admitted wound on the right ischium. A physician's orders [REDACTED]. (every) shift and cover c dry drsg. Notify wound care if worsens. Keep pressure off area Q shift . This order identified the wound was on the left ischium. A physician's orders [REDACTED]. Assess & monitor daily . This order identified the wound was on the left ischium. A physician's orders [REDACTED]. This order identified the wound on the ischium not specifying left or right. A physician's orders [REDACTED]. This order identified the wound on the right ischium. A pressure ulcer record dated 2/5/15 for Resident #96 documented site location: Rt. Ischium / admitted with. The body diagram has the left ischium marked. This record identified the wound as admitted and was on the right ischium. Review of the facility's weekly pressure wound tracking forms dated 1/19/15 through 3/9/15 documented the Lt. Ischium was facility acquired. These weekly pressure ulcer tracking forms identified the wound as facility acquired on the left ischium. The weekly skin integrity sheets documented an open area on the right ischium on 1/23/15, 2/3/15, 2/7/15, (no date), 2/13/15, 2/20/15, 2/24/15, (no date), 3/3/15, 3/6/15, 3/9/15 and 3/10/15. These records identified the wound as an admitted pressure ulcer and was on the right ischium. The Bedside Care Guide (CNA care guide) documented: off left side, turn no left side. Observations in Resident #96's room on 3/19/15 10:40 AM, revealed Resident #96 had a wound on the coccyx not on the ischial. Structures were visible in the wound bed. There was undermining in the wound. Brown, tan and yellowish slough was noted in the wound bed and in the undermined areas. The loose skin was moved by the wound nurse. There was a round white structure in the wound bed. Interview with LPN #2 (wound nurse) on 3/11/15 at 6:05 PM in the DON's office, LPN #2 was asked to verify if this wound was facility acquired or admitted with, and where this wound was on Resident #96's body. LPN #2 verified this was a facility acquired wound, and the wound was on the resident's right ischium. She also verified the weekly pressure wound tracking form incorrectly documented the wound was on the left ischium. Interview with the DON on 3/18/15 at 3:36 PM, in the conference room, the DON was asked if a wound on the right side should have the intervention of turn no left side and off left side. The DON stated, I see what you are talking about, keep pressure off area the right side, but this (bedside care guide) says off the left side. I see where she (LPN #1/wound nurse) taught the CNA that day, another teaching moment for (named LPN #1). Interview with the Nurse Practitioner (NP) (during the observation of Resident #96's pressure ulcer) on 3/19/15 10:40 AM, in Resident #96's room with wound nurses (LPN #1 and LPN #2) at the bedside. There was a round white structure noted in the pressure ulcer. The surveyor asked what the round white structure was in the wound bed. The NP stated, Let me touch it. As she touched the structure, she gently moved the white substance. The NP stated, It moves, it is not bone, It may be slough Interview with the NP on 3/19/15 at 11:00 AM at the R2 nurses desk, the NP was asked if the pressure ulcer was on the coccyx or on the ischium. The NP stated, It does encompass the coccyx, the ischium is further down (on the body). It is stageable now, to me it is a stage 4. Interview with the DON on 3/19/15 at 11:20 AM in the long hall, the DON confirmed the wound was on the coccyx. 9. Medical record review revealed Resident #163 was admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. A care plan dated 1/9/15 documented, .PROBLEMS . Stage 2 Coccyx . INTREVENTION(S) . Prevent infection c treatment care . Tx: [MEDICATION NAME] Cream Foam Drsg . A physician's orders [REDACTED].Coccyx Stage 2 Pressure Ulcer: Cleanse with wound cleanser, apply [MEDICATION NAME] Cream, Cover with foam drsg. 4xweek. assess and monitor daily. A pressure ulcer record dated 2/2/15 documented, .Coccyx . (X) STAGE II . Change to unst (unstageable) . MEASUREMENTS . Length (cm) 7.0 x Width (cm) 4.5 . WOUND BED (marked with a slash mark) Slough - moist yellow or gray necrotic tissue 100% . PROGRESS NOTES . (Delta sign) (change) to unstageable. Treatment (Delta sign) (change) to Iodosorb . A care plan updated on 2/9/15 documented, .PROBLEMS . Unstageable . Coccyx . INTREVENTION . Iodosor . A pressure ulcer record dated 2/9/15 documented, .Coccyx .(X) Unstageable . MEASUREMENTS . Length (cm) 7.5 x Width (cm) 4.0 .WOUND BED (marked with a slash mark) Slough - moist yellow or gray necrotic tissue 100% . PROGRESS NOTES . Iodosorb Tx . Review of the physician's orders [REDACTED]. Resident #163's MAR indicated [REDACTED].APPLY [MEDICATION NAME] CREAM . 4X/WK . Review of this MAR indicated [REDACTED]. The MAR indicated [REDACTED].APPLY IODOSORB . 4X/WK . Review of this MAR indicated [REDACTED]. Review of the physician's recertified orders for March, (YEAR) and dated 2/27/15 revealed the physician signed the recertification orders that documented, .APPLY IODOSORB COVER WITH DRY DRSG . Iodosorb was used as a treatment in the coccyx wound from 2/2/15 through 2/27/15 without a physician's orders [REDACTED].>Interview with the DON and LPN #2 (wound nurse) on 3/25/15 beginning at 1:02 PM in the conference room, the DON and LPN #2 were asked about Resident #163's wound treatment change from [MEDICATION NAME] cream to Iodosorb. LPN #2 stated, It was a stage 2, now it is unstageable. On 2/2/15 the order changed to Iodosorb. I don't see an order written [REDACTED]. I don't see it. LPN #2 was asked if there was an order for [REDACTED].#2 stated, No. Interview in the DON's office on 3/18/15 at 6:37 PM, the DON was asked, do you expect your nurses to provide and document treatments as ordered. The DON stated, Yes Ma'am. 10. Medical record review revealed Resident #248 was admitted to the facility on [DATE] and re-admitted on [DATE], 1/14/15 and 2/11/15 with [DIAGNOSES REDACTED]. Review of admission MDS with an ARD of 12/22/14 revealed Resident #248 was admitted to the facility with 5 unstageable wounds with the largest being 8.0cm x 3.5cm x 1.0cm and 2cm unstageable - deep tissue injuries. Most severe tissue type present in any pressure ulcer bed was coded as .Slough - yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous . Review of weekly skin integrity review sheets revealed there were no weekly skin assessments performed during the weeks of 1/19/15 and 2/16/15. Interview with RN #5/ADON on 3/12/15 at 4:10 PM at the B2 nurses station, RN #5/ADON was asked about the gap in the skin assessment dates. RN #5/ADON stated, That is my fault. I made changes in the assignments and it just happened. Interview with the DON on 3/13/15 at 10:00 AM in the DON's office the DON was asked about the weekly skin assessment. The DON stated, The weekly skin assessments for the weeks of 1/19/15 and 2/16/15 are not documented.",2018-08-01
6318,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2015-03-26,323,D,0,1,N2VZ11,"**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 chair alarm intervention was always implemented as ordered for 1 of 5 (Resident #200) sampled residents with falls of the 58 residents included in the stage 2 review. The findings included: Review of the facility's Resident Alarms policy documented, .Test alarm for . functioning. Clip must be snug . Check battery for strength or need of changing . Monitor alarm periodically to ensure that it is still attached to resident and alarm is still working . Medical record review revealed Resident #200 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED].chair alarm when up in wheelchair . Observations and interview in Resident #200's room on 3/11/15 at 4:10 PM, revealed Resident #200 lying in bed with bruising and swelling noted below both of the resident's eyes. Resident #200 stated, I fell out of my wheelchair a week ago Sunday trying to go to the bathroom. I won't get up now without calling for help. Observations on 3/12/15 at 2:30 PM, revealed Resident #200 sitting up in her wheelchair, at a table in the B2 (Birmingham) activity room. A chair alarm was attached to resident's wheelchair, however, the cable was unplugged from the alarm and the clip was not attached to the resident and alarm was not going off. Observations of Resident #200 on 3/12/15 at 2:45 PM in the B2 activity room revealed the chair alarm was not attached to the resident nor was the device plugged in. The chair alarm was not alarming. Interview with Registered Nurse (RN) #5 / Assistant Director of Nursing (ADON) on 3/12/15 at 3:00 PM in the B2 activity room RN #5 confirmed the chair alarm was not in working condition. Interview with RN #5/ADON on 3/13/15 at 9:00 AM at the B (Birmingham) 2 nurse's station the ADON stated, We have no log or method of making sure chair alarm batteries are functioning.",2018-08-01
6319,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2015-03-26,362,D,0,1,N2VZ11,"Based on observation and interview, the facility failed to ensure the there was sufficient staff present to ensure meal trays were passed in a timely manner for 2 of 46 (Residents #64 and 202) residents served a lunch meal on Ribeiro 2 (R2). The findings included: 1. Observations on R2 on 3/9/15 at 11:58 AM, revealed cart #1 was delivered to the floor and serving was started at 11:59 AM. At 12:08 PM, 5 trays remained on cart #1 including the lunch trays for Resident #64 and #202. Observations on R2 on 3/9/15 at 12:20 PM revealed cart #2 was delivered to the floor. Residents on the R2 hall were not served until 12:43 PM. There were 4 trays left on cart #2 when it was returned to the dining room. The five trays from cart #1 were then placed on cart #2, including the trays for Residents #64 and #202. Observations on R2 on 3/9/15 at 1:10 PM revealed the last 2 trays were served to Resident #64 and #202. That was 1 hour and 12 minutes after the trays were delivered to R2. 2. Interview with Certified Nursing Assistant (CNA) #3 on 3/10/15 at 5:18 PM in the R2 dining room CNA #3 was asked when residents should be served their meal tray. CNA #3 stated, As soon as possible. CNA #3 was asked to explain about meal service on R2. CNA #3 stated, It depends on how many techs (technicians) and what you have to do for each resident. If we do not have enough staff it takes longer. It also depends on what is served and how much you have to open up for each resident. It takes about 2 hours for everything from passing the trays to feeding everyone. CNA #3 was asked if it was acceptable to have a tray come up on the first cart and not be served until after the last cart was sent to the floor. CNA #3 stated, It is not acceptable. Interview with Registered Nurse (RN) #1 / Assistant Director of Nursing (ADON) on 3/10/15 at 5:30 PM, in the ADON's office, the ADON was asked to explain the meal service on R2. The ADON stated, Trays should be passed in 30 minutes to an hour. Trays for residents in the dining room should be passed immediately then trays are passed on the halls. RN #1/ADON was asked if it was acceptable for trays to come up on the first cart and not be served until the last cart was delivered. RN #1/ADON stated, No. Interview with the Director of Nursing (DON) on 3/13/15 at 3:25 PM in the DON's office, the DON was asked when meal trays should be passed. The DON stated, Trays should be passed immediately up to and not more than 45 minutes.",2018-08-01
6320,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2015-03-26,369,D,0,1,N2VZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to provide a sippy cup assistive device for dining as ordered by the physician for 1 of 36 (Resident #78) sampled residents of the 58 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #78 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].DIET ORDER: RESIDENT TO USE SIPPY CUP, NO STRAWS EACH SHIFT . The orange meal tray card documented, .Instructions: no straws . The orange meal tray card did not include the physician's orders [REDACTED]. Observations in Resident #78's room on 3/17/15 at 8:52 AM, revealed Resident #78 sitting up in bed eating breakfast. Certified Nursing Assistant (CNA) #5 was seated in a chair by Resident #78's bed. Resident #78 had 3 cups of thin liquids in regular cups on the breakfast tray with no sippy cup present. Interview with the Chef on 3/17/15 at 10:10 AM in the conference room, the Chef was asked how information on the orange tray card was communicated to the kitchen. The Chef stated, We receive instructions from Dietitian and we type it. Interview with the Registered Dietitian (RD) on 3/17/15 at 10:34 AM in the conference room, the RD was asked why the physician's orders [REDACTED]. The RD stated, I don't know why. Interview with the Director of Nursing (DON) on 3/17/15 at 12:09 PM, in the conference room, the DON was asked if she expected physician orders [REDACTED].",2018-08-01
6321,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2015-03-26,431,D,0,1,N2VZ11,"**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 as evidenced by medications and biologicals found in 1 of 34 (Resident #215's room) resident rooms on Riberio (R) 2; in 2 of 35 (Room B305 and B308) resident rooms on Birmingham 3 (B); and in 2 of 35 (Room B404 and B433) residents rooms on B4. The findings included: 1. The facility's Medication Storage policy documented, .The medication supply is accessible only to licensed nursing personnel . The facility's Bedside Medication Storage policy documented, .Bedside medication storage is permitted for residents who are able to self-administer medication . upon the written order of the prescriber and when it is deemed appropriate in the judgement of the nursing care center's interdisciplinary resident assessment team. Procedures . 2 a written order for the bedside storage of medication is present in the resident's medical record . 2. Observations in Resident #215's room on 3/11/15 at 9:07 AM revealed a box of 50 extra strength headache powders (Acetaminophen / Aspirin / Caffeine) lying on the bedside table. Interview with Resident #215 on 3/11/15 at 9:08 AM, in Resident #215's room, Resident #215 was asked if he takes the headache powders. Resident #215 stated, Yes, I do for bad headaches. Interview with Licensed Practical Nurse (LPN) #3 on 3/11/15 at 9:09 AM, in Resident #215's room LPN #3 revealed Resident #215 was not supposed to have the headache powders at his bedside and he does not self administer medications. 3. Observations in room B305 on 3/10/15 at 3:31 PM, revealed a 4 ounce bottle of Hydrogen Peroxide 3 percent (%) on the overbed table. 4. Observations in room B308 on 3/9/15 at 4:30 PM, revealed a 4 ounce bottle of Hydrogen Peroxide 3% on the bedside table and on the window sill. Observations in room B308 on 3/10/15 at 7:55 AM and at 2:09 PM, on 3/11/15 at 7:52 AM, and on 3/12/15 at 8:23 AM revealed a 4 ounce bottle of Hydrogen Peroxide 3% on the bedside table. 5. Observations in room B404 on 3/9/15 at 3:36 PM, revealed a bottle of 91% Isopropyl Alcohol on the bedside table. Interview with Registered Nurse (RN) #2 / Assistant Director of Nursing (ADON) on 3/12/15 at 3:31 PM in room B404, the ADON asked if it was appropriate to have alcohol out on bedside table. RN #2/ADON stated, No. and removed the bottle from the resident's room. 6. Observations in room B433 on 3/10/15 at 3:31 PM, revealed a bottle of Chlorhexidine Gluconate on the window sill. 7. Interview with the Director of Nursing (DON) on 3/13/15 at 3:30 PM, in the conference room, the DON confirmed that medications and biologicals should not be left at the bedside unless there is a physician's orders [REDACTED].",2018-08-01
6322,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2015-03-26,441,D,0,1,N2VZ11,"**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 when 1 of 2 nurses (Licensed Practical Nurse (LPN) #5) failed to disinfect the glucometer after use and failed to change wall suction canisters timely for 1 of 36 (Resident #80) sampled residents of the 58 residents included in the the stage 2 review. The findings included: 1. The facility's Cleaning and Disinfecting Non-Critical Resident-Care Items policy documented, .3. d. Reusable items are cleaned and disinfected between residents . Observations in Resident #244's room on 3/10/15 beginning at 5:12 PM, revealed LPN #5 performed an accucheck on Resident #244. LPN #5 did not disinfect the glucometer before or after performing the accucheck on Resident #244. LPN #5 placed the glucometer in a drawer in the medication cart without disinfecting it. Interview with LPN #5 on 3/10/15 at 5:23 PM in the B2 (Birmingham) hall, LPN #5 was asked when the glucometer should be cleaned. LPN #5 stated, I normally clean the machine afterwards. LPN #5 was then asked when she was going to clean the glucometer. LPN #5 stated, I don't have anymore accuchecks so was gonna clean it later. 2. Medical record review revealed Resident #80 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #80's room on 3/25/15 at 5:21 PM and on 3/26/15 at 8:17 AM, revealed a sign on the wall WALL SUCTION CANISTER AND TUBING ARE TO BE CHANGED EVERY 3 - DAYS CANISTER MUST BE LABELED WITH DATE CHANGED. Observations in Resident #80's room on 3/25/15 at 5:22 PM and on 3/26/15 at 8:18 AM, revealed a [MEDICATION NAME] (helps clear secretions from the mouth) attached to suction tubing laying on the bed and the other end was attached to a wall suction canister containing a tan colored substance. The wall suction canister was labeled, 3/15/15 . Interview with Registered Nurse (RN) #2 / Assistant Director of Nursing (ADON) on 3/26/15 at 8:30 AM, in the conference room, the ADON confirmed the nurses are responsible for changing the suction canister. The ADON stated, The canisters should be changed when they are full or become stinky. Not more than several days. The ADON was asked to go to Resident #80's room and check the canister. When the ADON saw the sign on the wall and the date on the canister she stated, We will get that (canister) changed. Interview with the Director of Nursing (DON) on 3/26/15 at 9:15 AM, in the conference room, the DON was asked how often she expected the wall suction canisters to be changed. The DON stated, Daily and prn (as needed).",2018-08-01
6323,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2015-03-26,456,D,0,1,N2VZ11,"**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 chair alarm was in an operating condition for 1 of 5 (Resident #200) sampled residents with falls of the 58 residents included in the stage 2 review. The findings included: Review of the facility's Resident Alarms policy documented, .Test alarm for . functioning. Clip must be snug . Check battery for strength or need of changing . Monitor alarm periodically to ensure that it is still attached to resident and alarm is still working . Medical record review revealed Resident #200 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED].chair alarm when up in wheelchair . Observations on 3/12/15 at 2:30 PM, revealed Resident #200 sitting up in her wheelchair, at a table in the B2 (Birmingham) activity room. A chair alarm was attached to resident's wheelchair, however, the cable was unplugged from the alarm and the clip was not attached to the resident and alarm was not going off. Observations of Resident #200 on 3/12/15 at 2:45 PM in the B2 activity room revealed the chair alarm was not attached to the resident nor was the device plugged in. The chair alarm was not alarming. Interview with Registered Nurse (RN) #5 / Assistant Director of Nursing (ADON) on 3/12/15 at 3:00 PM in the B2 activity room RN #5 confirmed the chair alarm was not in working condition. Interview with RN #5/ADON on 3/13/15 at 9:00 AM at the B (Birmingham) 2 nurse's station the ADON stated, We have no log or method of making sure chair alarm batteries are functioning.",2018-08-01
6324,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2015-03-26,514,H,0,1,N2VZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, review of facility weekly pressure ulcer tracking forms, observation and interview, the facility failed to ensure documentation was correct and/or complete for weekly skin assessments, correctly identifying the origin of a pressure ulcer and correctly identifying the anatomical location of a pressure ulcer for 7 of 58 (Residents #14, 115, 196, 277, 96, 232 and 248) sampled residents included in the stage 2 review. The failure of the facility staff to complete weekly skin assessments on residents who were at risk for developing pressure ulcers and identify pressure ulcers before residents developed an unstageable pressure ulcer resulted in actual harm for 4 of 9 (Residents #4, 115, 196 and 277) sampled residents with pressure ulcers. The findings included: 1. Review of the facility's Skin Management and Prevention policy revealed, .weekly skin . will be utilized to determine if any new skin alterations have developed . Any new skin condition(s) found during the weekly skin rounds will be documented . 2. Medical record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Braden scale dated 2/10/15 revealed a score of 11 indicating Resident #14 was at a high risk for pressure ulcer. Review of the interim plan of care (developed on admission) dated 2/10/15 documented, .Skin assessment weekly . Review of the nursing admission information documented, .2/11/15 11:00 . Pt. (patient) assessed head to toe by wound care. No skin breakdown or alteration in skin integrity at this time . Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/17/15 revealed Resident #14 did not have any unhealed pressure ulcers. Review of the weekly skin integrity form dated 2/24/15 documented, (checked) Rash . (checked) Redness . Open Area . (checked) Old . 2/24/15 . (checked) Open Area (black) area . (checked) Old . 12.5x (by) 5.0 . black eschar . soft . Review of a physician's orders [REDACTED]. Assess and monitor Daily . Review of the pressure ulcer report dated 2/24/15 documented, .Date of Origin 2/24/15 . Site Location: Buttocks . (checked) Facility acquired . (checked) Unstageable . MEASUREMENTS Length (cm) (centimeters) 12.5 x Width (cm). 5.0 Depth (cm) 0.1 . The facility was unable to provide documentation of the weekly skin integrity reviews were completed from the date of admission (2/10/15) until 2/24/15. Observations in Resident #14's room on 3/13/15 at 2:43 PM, revealed Resident #14 coccyx pressure ulcer was the size of a small toy football with brown loose slough covering the wound bed. Interview with the Medical Director on 3/17/15 at 3:50 PM at the B2 (Birmingham) nurses station, the Medical Director was asked about the unstageable pressure ulcer on Resident #14. The Medical Director stated, he wound could have come on suddenly but with the size and the black eschar you would think someone would have noticed it when they were cleaning him up. Black eschar takes some time to develop. Failure of the facility to complete weekly skin assessments and to identify a pressure ulcer before it was unstageable resulted in actual harm to Resident #14. 3. Medical record review revealed Resident #115 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The comprehensive care plan dated 1/12/15 documented, .Problem . Increased potential for impaired skin integrity R/T (related to) Dx (diagnosis) [MEDICAL CONDITION] and related weakness with presence of incontinence and impaired ROM/Mobility . Goal . Skin will remain intact . Approach . assess for prompt intervention s/s (signs and symptoms) of further impaired skin integrity and report prn (as needed) to MD (medical doctor) as per facility practice and consult with wound care nsg (nursing) prn . A care plan dated 3/9/15 documented, .Resident is with pressure ulcer(s) Classified as: Unstageable Location: Lt (left) posterior L.E. (lower extremity) below base of buttocks . Goals . Will address all needed treatment to specific ulcer(s) / wound(s) to facilitate healing thru (through) next review date . Interventions . assess and monitor daily . Use clean technique for wound care . Tx (treatment) 3/9/15 calcium alginate [MEDICATION NAME] . A physician's orders [REDACTED].Wound care to Lt posterior L.E. below base of buttocks as follows. Clean c (with) wound cleanser gauze, apply Calcium alginate, [MEDICATION NAME] 4 x wk assess and monitor daily . Review of the weekly skin integrity review sheet dated 12/1/14 through 3/9/15 revealed skin assessments were not done on 12/8/14, 12/15/14, 12/22/14, 12/19/14, 2/9/15, 2/16/15, 2/23/15, and 3/2/15. The weekly skin integrity review form dated 3/9/15 documented, .skin intact . completed by Licensed Practical Nurse (LPN) #3. The pressure ulcer record dated 3/9/15 documented, .Lt Posterior L.E. @ (at) base of buttocks . Facility acquired . Unstageable . Length (cm) . 2 x Width (cm) . 2.5 . Depth (cm) . 0.5 . Wound Bed . Slough . 80% (percent) . Eschar . 20% . Consult received noted new wound treatment orders . Review of the nurse's notes dated 3/9/15 documented, .Observed open area on Lt posterior L.E. Under base of buttocks new orders to treat wound . LPN #1 and LPN #2 (wound nurses) entered Resident #15's room, on 3/14/15 at 10:45 AM to allow the surveyor to observe Resident #115's pressure ulcer. While observing the pressure ulcer LPN #2 stated to LPN #1, This left buttock wound actually looks like a stage III. I think you (LPN #1) miss-staged this. Interview with the Assistant Director of Nursing (ADON) / Registered Nurse (RN) #1 on 3/13/15 at 9:55 AM, at R2 (Riberio 2nd floor) nurses station, the ADON was asked what she expected from her nursing staff when performing skin assessments. The ADON stated, I expect them to do the weekly skin assessments and notify the MD (medical doctor), treatment nurse and family if something is discovered. The ADON/RN #1 was asked whose responsibility was it to make sure the skin assessments were being done weekly. The ADON/RN #1 stated, Mine. The ADON/RN #1 was shown the weekly skin integrity review sheets for the months 12/1/14 through 3/9/15 and was asked if weekly skin assessments had been completed. The ADON/RN #1 stated, No. Interview with LPN #3 on 3/13/15 at 10:08 AM, at R2 nurses station, LPN #3 was shown the weekly skin integrity review form dated 3/9/15 and was asked if she completed the skin assessment on 3/9/15 for Resident #115. LPN #3 stated, Yes. LPN #3 was shown the pressure ulcer record dated 3/9/15 and asked if her assessment was accurate. LPN #3 stated, Other than I didn't see it (the pressure ulcer). I just didn't see it, that's all I can say. Failure of the facility to complete weekly skin assessments and to identify a pressure ulcer before it was unstageable resulted in actual harm to Resident #115. 4. Medical record review revealed Resident #196 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Braden scale dated 1/6/15 documented a score of 14 indicating the resident was a moderate risk for developing a pressure ulcer. The pressure ulcer record dated 2/4/15 documented, .Lt. Buttocks . Facility acquired . Unstageable . 3.0cm x 7.5cm x 0.1cm . Exudate . Serous . Scant . 100% slough . A wound care note dated 2/5/15 documented, .Unstageable wound on L (circled) buttox (buttock) . Drainage . Large amount . Foul . A physician's orders [REDACTED].Lt buttocks unstageable pressure ulcer: cleanse c (with) wound cleanser Apply Dakin's moistened gauze. cover c dry drsg. (dressing) 4x/wk . The facility was unable to provide weekly skin integrity review sheets from 2/23/15 to 3/12/15. Observations in Resident #196's room on 3/12/15 at 8:50 AM revealed a large unstageable left buttock wound. There was 20% eschar and 80% slough with slight bright red bleeding from around the edges. Interview with LPN #2 (wound nurse) on 3/12/15 at 1:59 PM, in the conference room, LPN #2 was asked who discovered the unstageable buttocks wound. LPN #2 stated, When you are doing treatments in the area (of the body where the wound is) sometimes we will start treating (a second wound). LPN #2 was asked how often do you treat Resident #196. LPN #2 stated, Four times a week. I'm pretty sure it (left buttock wound) started out red. He (Resident #196) wouldn't stay off his left side. The nursing staff probably wouldn't notice anything wrong as it was probably covered with a dressing. It could have been I just missed it or forgot to start documentation. Yep, I think I missed that. Interview with RN #2/ADON on 3/12/15 at 4:00 PM, at the B4 nurses desk, RN #2/ADON was asked what she expected from her nursing staff regarding skin assessments. RN #2/ADON stated, I expect my staff to complete skin assessments per policy which is weekly or normally in the shower since the residents are in their birthday suits. Interview with the Medical Director on 3/24/15 at 4:00 PM, in the conference room, the Medical Director was asked about Resident #196's pressure ulcer. The Medical Director stated, Based on what the wound nurse told me, she (wound nurse) was treating the new area that was close to the surgical coccyx wound, but she did not document on the new area until it was open. She (wound nurse) knows it was started as a DTI (deep tissue injury) and used skin prep until it opened, but I have no supporting documentation. I did not sign it (determination that development of pressure sore is unavoidable form) because I had no verification of documentation. She (wound nurse) said right in front of me that she forgot to document it. Failure of the facility to identify a pressure ulcer before it was unstageable resulted in actual harm to Resident #196. 5. Medical record review revealed Resident #277 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission nurses' notes documented the following: a. 2/27/15 - .Multiple bruises noted on abdomen and BUE (bilateral upper extremities) . Skin warm and dry no [MEDICAL CONDITION] or rash noted . b. 3/1/15 at 9:00 AM - Wound care full skin assessment done at admission . pressure ulcer on buttocks/coccyx noted wound care orders wrote for treatment . There is no evidence in the medical record that Resident #277 was admitted to the facility with a pressure ulcer on 2/27/15. Review of the pressure ulcer record dated 3/1/15 revealed, .Date of Origin 3/1/15 . Site Location: Coccyx . (checked) admitted with . Date 3/1/15 . STAGE . (checked) Unstageable . Length (cm) 9 x Width (cm) 7.5 Depth (cm) 0.5 . (checked) Slough . 80% . (checked) Eschar . 20% . SPECIALTY INTERVENTIONS . (checked) Mattress . PROGRESS NOTES . Upon assessment on admission noted pt has unstageable coccyx wound new orders . gave over phone . A physician's orders [REDACTED]. A Nutritional Progress Note dated 3/2/15 at 2:58 documented, .skin intact . Interview with the Director of Nursing (DON) on 3/23/15 at 4:45 PM in the DON's office, the DON was asked what she expected of her nurses regarding skin assessments on admission. The DON stated, To fill out the skin assessment sheet within 24 hours. The DON was asked what she expected of her wound nurses as far as completed a skin assessments. The DON stated, The policy says 24 (hours) but sometimes they don't get around to it until 48 hours. The DON was asked why the coccyx wound was documented as being admitted with when it was discovered on 3/1/15 and the resident was admitted [DATE]. The DON stated, I can't answer that question. Interview with the Medical Director on 3/24/15 at 4:05 PM in the conference room, the Medical Director was asked about the unstageable pressure ulcer on Resident #277. The Medical Director stated, If it (the pressure ulcer) was from (named hospital) they would have written wound orders. Have to open up the folds during the assessment. The failure of the facility to identify a pressure wound before it became unstageable resulted in actual harm to Resident #277. 6. Medical record review revealed Resident #96 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A pressure ulcer record dated 1/19/15 documented Resident #96 was admitted with a pressure ulcer on the right ischium. A physician's orders [REDACTED]. (every) shift and cover c (symbol for with) dry drsg. Notify wound care if worsens. Keep pressure off area Q shift . This order identified the wound was on the left ischium. A physician's orders [REDACTED]. Assess & monitor daily . This order identified the wound was on the left ischium. A physician's orders [REDACTED]. This order identified the wound on the right ischium. A pressure ulcer record dated 2/5/15 documented Resident #96 was admitted with a pressure ulcer on the right ischium, yet the body diagram had the left ischium marked. Review of the facility's weekly pressure wound tracking forms dated 1/19/15 to 3/9/15 documented a left ischium pressure ulcer, facility acquired and date of occurrence 1/19/15. These weekly pressure ulcer tracking forms identified the wound as facility acquired on the left ischium. The weekly skin integrity sheets documented an open area on the right ischium on 1/23/15, 2/3/15, 2/7/15, (no date), 2/13/15, 2/20/15, 2/24/15, (no date), 3/3/15, 3/6/15, 3/9/15 and 3/10/15. These records identified the wound as an admitted pressure ulcer and was on the right ischium. The bedside care guide (certified nursing assistant care guide) documented keep off left side, turn no left side, this inaccurate for a pressure ulcer on the right ischium. Observation in Resident #96's room on 3/19/15 10:40 AM, revealed Resident #96's pressure ulcer was on the coccyx. Interview with the DON on 3/18/15 at 3:36 PM, in the conference room, the DON was asked if a wound on the right side should have the intervention of turn no left side and off left side. The DON stated, I see what you are talking about. Keep pressure off area the right side, but this (bedside care guide) says off the left side. I see where she (LPN #1) taught the CNA that day, another teaching moment for (named LPN #1). Interview with LPN #2/wound nurse on 3/11/15 at 6:05 PM, in the DON's office, LPN #2/wound nurse was asked to verify if this wound was facility acquired or admitted with, and where this wound was on Resident #96's body. LPN #2/wound nurse verified this was a facility acquired wound, and the wound was on the resident's right ischium. LPN #2/wound nurse verified the weekly pressure wound tracking form incorrectly documented the wound was on the left ischium. Interview with the Nurse Practitioner (NP) on 3/19/15 at 11:00 AM at the R2 (Riberio) nurses desk, the NP was asked if the pressure ulcer was a coccyx wound or an ischial wound. The NP stated, It does encompass the coccyx, the ischium is further down (on the body) . Interview with the DON on 3/19/15 at 11:20 AM, on the long hall, the DON confirmed Resident 96's pressure ulcer was on the coccyx. 7. Medical record review revealed Resident #232 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The facility was unable to provide weekly skin integrity reviews completed between 2/3/15 through 3/8/15. Interview with the Assistant Director of Nursing (ADON) / Registered Nurse (RN) #2 on 3/12/15 at 10:12 AM, at the B2 (Birmingham) nurses station confirmed the weekly skin integrity reviews between 2/3/15 and 3/8/15 had not been completed. 8. Medical record review revealed Resident #248 was admitted to the facility on [DATE] and re-admitted on [DATE], 1/14/15 and 2/11/15 with [DIAGNOSES REDACTED]. Review of admission MDS with an Assessment Reference Date (ARD) of 12/22/14 revealed Resident #248 was admitted to the facility with 5 unstageable wounds with the largest being 8.0cm x 3.5cm x 1.0cm and 2 Unstageable - Deep tissue injuries. Most severe tissue type present in any pressure ulcer bed was coded as .Slough - yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous . Review of weekly skin integrity review sheets revealed there were no weekly skin assessments performed during the weeks of 1/19/15 and 2/16/15. Interview with Registered Nurse (RN) #5/ADON on 3/12/15 at 4:10 PM at the B2 nurse's station revealed, RN #5/ADON was asked about the gap in the skin assessment dates. The ADON stated, That is my fault. I made changes in the assignments and it just happened. Interview with the DON on 3/13/15 at 10:00 AM in the DON's office the DON stated, The weekly skin assessments for the weeks of 1/19/15 and 2/16/15 are not documented.",2018-08-01
6325,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2015-03-26,520,H,0,1,N2VZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the National Pressure Ulcer Advisory Panel (NPUAP) Pressure Ulcer Prevention quick reference guide, policy review, medical record review, review of the facility's weekly pressure ulcer tracking forms, observation and interview, the facility's quality assessment and assurance committee failed to identify and address quality assurance issues to identify and implement plans of actions to correct concerns when nurses failed to complete weekly skin assessments and identify pressure ulcers timely, identify the correct anatomical location of a pressure ulcer, obtain a physician's orders [REDACTED].#14, 115, 196, 277, 65, 96, 163 and 248) sampled residents reviewed of the 17 residents with pressure ulcers. The failure of the facility staff to complete weekly skin assessments on residents who were at risk for developing pressure ulcers and identify pressure ulcers before residents developed an unstageable pressure ulcer resulted in actual harm for Residents #14, 115, 196 and 277. The findings included: The failure of the Quality Assessment and Assurance (QAA) committee to identify and address concerns when nurses failed to complete weekly skin assessments and identify pressure ulcers timely, identify the correct anatomical location of a pressure ulcer, obtain a physician's orders [REDACTED].#14, 115, 196, 277, 65, 96, 163 and 248) sampled residents reviewed of the 17 residents with pressure ulcers. The failure of the facility staff to complete weekly skin assessments on residents who were at risk for developing pressure ulcers and identify pressure ulcers before residents developed an unstageable pressure ulcer resulted in actual harm for Residents #14, 115, 196 and 277. Refer to F314. Interview with the Quality Assurance (QA) Coordinator on 3/26/15 at 4:28 PM in the QA Coordinator's office, the QA Coordinator was asked what where the concerns discussed in the January, (YEAR) QA meeting, what did you do, and was it effective. The QA Coordinator stated, We did the in-service for the handwashing from the (MONTH) (2014) meeting and that was effective, and we had no other issues. The QA Coordinator was asked what issues were identified in the February, (YEAR) QA meeting, what did you do and was it effective, the QA Coordinator stated, .(Named Staff), the PAE (Preadmission Screening Evaluation) nurse went back to school to get her RN (Registered Nurse) and we have been losing leads and money, so we have hired someone in her place. We did an event manager update and did nurse training, now all the falls go in event manager and they do not give me any paper. (Named CNA computer program) was out of compliance so we educated staff and put announcements in place. Interview with the Director of Nursing (DON) on 3/26/15 at 3/26/15 at 5:48 PM in the conference room, the DON was asked if QA committee had identified a trend in pressure ulcers. The DON stated, No.",2018-08-01
8205,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2013-12-18,159,D,0,1,3V4V11,"Based on interview, it was determined the facility failed to ensure residents had access to petty cash when requested on an ongoing basis for 2 of 3 (Residents #60 and Resident #141) sampled residents interviewed with a personal funds account of the 47 residents included in the stage 2 review. The findings included: 1. During an interview in Resident's #60's room on 12/16/13 at 4:21 PM, Resident #60 was asked, Can you get your money when you need it, including on weekend? Resident #60 stated, No, closed on weekend . 2. During an interview in Resident #141's room on 12/16/13 at 3:46 PM, Resident #141 was asked, Can you get your money when you need it, including on weekend? Resident #141 stated, No one here on weekend to give out money . 3. During an interview in the mini conference room on 12/18/13 at 2:05 PM, the Patient Account Specialist was asked what the hours of operation were and the days of week the office was open for residents to request money from their account. The Patient Account Specialist stated, 7:30 AM til (until) 4:00 PM, Monday through Friday . Most of the residents know our hours so they come and get their money for the weekend on Friday .",2017-07-01
8206,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2013-12-18,241,D,0,1,3V4V11,"Based on observation and interview, it was determined the facility failed to enhance the residents dignity by serving milk in milk cartons during 2 of 2 (lunch 12/16/13 and dinner 12/17/13) dining observations and by standing while feeding Resident #9. The findings included: 1. Observations during dining on Birmingham (B) 3 on 12/16/13 11:55 AM, revealed 8 of 26 residents observed being served meal trays, were served milk in milk cartons. Observations during dining on Birmingham 2 on 12/17/13 at 5:55 PM, revealed 3 of 4 residents observed being served meal trays, were served milk in milk cartons During an interview on Birmingham 2 in the Patient Care Manager's office on 12/18/13 at 2:41 PM, Nurse #2 was asked how should milk be served. Nurse #2 stated, .Milk should be served in a glass . During an interview on Birmingham 3 in the Patient Care Manager's office on 12/18/13 at 2:51 PM, Nurse #3 was asked how milk should be served. Nurse #3 stated, Expect them (staff) to serve milk in a glass . 2. Observations during dining on Birmingham 3 west hall on 12/16/13 at 12:31 PM, revealed certified nursing assistant (CNA) #1 stood over Resident #9 while feeding him. During an interview on Birmingham 2 in the Patient Care Manager's office on 12/18/13 at 2:41 PM, Nurse #2 was asked how staff should assist residents to eat. Nurse #2 stated, .(staff) Should be at eye level. Most of them would be sitting . During an interview on Birmingham 3 in the Patient Care Manager's office on 12/18/13 at 2:51 PM, Nurse #3 was asked how staff should assist residents to eat. Nurse #3 stated, .(staff) would be sitting facing the resident (when assisting to eat) .",2017-07-01
8207,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2013-12-18,280,D,0,1,3V4V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, it was determined the facility failed to update and revise the care plans related to falls and/or urinary catheters for 3 of 47 (Residents #180, 242 and 268) sampled residents included in the stage 2 review. The findings included: 1. Review of the facility's care plan policy documented, .Care Plans are to be updated as needed . to include new .interventions . 2. Medical record review for Resident #180 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the fall event assessment dated [DATE] at 11:15 AM documented, .housekeeping staff found lying on floor beside bed . New Intervention . Encourage resident to call for assistance . The care plan dated 11/4/13 was not updated to include the new intervention implemented for the fall on 11/25/13. During an interview in the Director of Nursing's (DON) office on 12/18/13 at 10:35 AM, the DON was asked would it be expected to add new fall interventions to the care plan. The DON stated, .I would expect it to be put on the care plan . 2. Medical record review for Resident #242 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan for Resident #242 dated 9/11/13 documented, .INCONTINENCE . Resident occasionally incontinent with bladder/bowel . Review of the quarterly Minimum Data Set ((MDS) dated [DATE] documented Resident #242 was always incontinent of bladder and bowel. the care plan was not updated to reflect that Resident #242 is always incontinent. During an interview at Birmingham 2 nurses' station on 12/18/13 at 9:45 AM, Nurse #2 was asked should there be a care plan for always incontinent. Nurse #2 stated, Yes. 3. Medical record review for Resident #268 with an admitted [DATE] with [DIAGNOSES REDACTED]., Hiatal hernia, Anxiety, Throbocytosis, [MEDICAL CONDITION], history of coccyx fracture, Urinary devices, Vascular catheter and acute respiratory infections. The entry MDS dated [DATE] had no documentation for bladder incontinence. The admission physician's orders [REDACTED]. The New admission orders [REDACTED]. Review of the interdisciplinary progress notes documented the following: a. 12/9/13 - .foley patent draining yellow urine . b. 12/11/13 - .foley draining scant amount of yellow urine to bedside bag . Review of the care plan dated 12/10/13 had no documentation for urinary continence or the use of the Foley catheter. Review of the physician's orders [REDACTED]. D/C (discontinue) Foley . Observations in Resident #268's room on 12/16/13 at 5:42 PM, revealed Resident #268 lying in bed with the Foley catheter in privacy bag. Observations in Resident #268's room on 12/17/13 at 8:09 AM, revealed Resident #268 did not have a Foley catheter. During an interview at the Birmingham 2 nurses' station on 12/18/13 at 2:20 PM, Nurse #2 was asked about the documentation for a Foley on the new admission orders [REDACTED].that is an oversight, in this box should have checked keep Foley in or D/C Foley on admission .",2017-07-01
8208,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2013-12-18,315,D,0,1,3V4V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, it was determined the facility failed to obtain an appropriate [DIAGNOSES REDACTED].#54 and 242) sampled residents included in the stage 2 review. The findings included: 1. Medical record review for Resident #54 with an admitted [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].Indwelling Foley Catheter Size # (16 f (french) /10ml (milliliter)) change (Q (every) 30 Days & (and) PRN (as needed)) (DX (diagnosis): SACRAL EXCORIATION .) Review of the admission minimum data set ((MDS) dated [DATE] documented, Resident #54 had an indwelling catheter and urinary continence was not rated. Review of the care plan dated 11/25/13 documented, .INCONTINENCE / INDWELLING CATHETER: She has a 16F/10ml indwelling catheter intact / patent to BSD (bedside drainage) d/t (due to) sacral escoriation . Observations in Resident #54's room on 12/18/13 at 11:10 AM, revealed Resident #54 with a Foley catheter in privacy bag. During an interview at the Birmingham 2 nurses' station on 12/18/13 at 2:10 PM, Nurse #2 was asked if sacral excoriation is a proper [DIAGNOSES REDACTED].#2 stated, No. 2. Medical record review for Resident #242 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the interdisciplinary progress notes dated 8/28/13 at 4:30 PM documented, .cont. (continent) of B&B (bowel and bladder). Urinal provided 350 cc (cubic centimeters) clear yellow urine noted . Review of section H of Resident #242's MDS dated [DATE] documented Resident #242 was occasionally incontinent. Review of the care plan dated 9/11/13 documented, .INCONTINENCE . Resident occasionally incontinent with bladder/bowel . with no intervention for any type of toileting program to maintain or restore continence. Review of section H of the quarterly MDS dated [DATE] documented Resident #242 was always incontinent of bladder and bowel. During an interview at the Birmingham 2 nurses station on 12/18/13 at 9:45 AM, Nurse #2 was asked should a bowel and bladder program have been started for Resident #242. Nurse #2 stated, Yes.",2017-07-01
8209,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2013-12-18,332,D,0,1,3V4V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Geriatric Medication Handbook, policy review, medical record review, observation and interview, it was determined the facility failed to ensure 3 of 7 (Nurses #6, 7 and 8) medication nurses administered medications with a medication error rate of less than five percent (%). There were 3 medication errors made out of 25 opportunities for error, which resulted in a medication error rate of 12%. The findings included: 1. Review of the facility's medication administration policy documented, .[MEDICATION NAME]: Snack or meal within 5- (to) 10 minutes of administering the insulin . Medical record review for Resident #306 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].ACCU CHECKS BID (twice daily) WITH [MEDICATION NAME] INSULIN SSI (sliding scale insulin) .IF BS (BLOOD SUGAR) is > (greater than) 180 SLIDING SCALE INSULIN AS INDICATED . Observations in Resident #306's room on 12/18/13 at 4:09 PM, revealed Nurse #6 administered 2 units of [MEDICATION NAME]to Resident #306. Resident #306's meal tray had not been delivered as of 5:35 PM, 1 hour and 26 minutes after administration of the insulin. Resulted in medication error #1. During an interview on the south hall, second floor Birmingham on 12/18/13 at 5:10 PM, Nurse #6 was asked about the administration of [MEDICATION NAME]in relation to meal time. Nurse #6 stated, .([MEDICATION NAME] insulin) should be given 30 minutes before meals . During an interview on the north hall, fourth floor Birmingham on 12/18/13 at 5:30 PM, Nurse #9 was asked about the administration of [MEDICATION NAME]in relation to meal time. Nurse #9 stated, .Normally [MEDICATION NAME] is given with meals . 2. Review of the Geriatric Medication Handbook, tenth edition, page 57, documented, .If another puff of the same or different medication is required, wait 1-2 minutes . then repeat procedure . a. Medical record review for Resident #16 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].[MEDICATION NAME] INHALER 2 PUFFS . Observations in Resident #16's room on 12/18/13 at 7:41 AM, Nurse #7 administered 2 puffs of a [MEDICATION NAME] Inhaler to Resident #16. Nurse #7 waited 25 seconds between puffs. The failure to wait at least 1 minute between puffs resulted in medication error #2. b. Medical record review for Resident #177 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].[MEDICATION NAME] INHALER 0.09 . 2 PUFFS . Observations in Resident #177's room on 12/18/13 at 10:10 AM, revealed Nurse #8 administered two puffs of an [MEDICATION NAME] inhaler to Resident #177. Nurse #8 waited 20 seconds between puffs. The failure to wait at least 1 minute between puffs resulted in medication error #3.",2017-07-01
8210,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2013-12-18,333,D,0,1,3V4V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, it was determined the facility failed to ensure 1 of 7 (Nurse #6) medication nurses administered medications free of significant medication errors. Nurse #6 failed to administer insulin within the proper time frame related to meals for Resident #306. The finding included: Review of the facility's medication administration policy documented, .[MEDICATION NAME]: Snack or meal within 5- (to) 10 minutes of administering the insulin . Medical record review for Resident #306 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].ACCU CHECKS BID (twice daily) WITH [MEDICATION NAME] INSULIN SSI (sliding scale insulin) .IF BS (BLOOD SUGAR) is > (greater than) 180 SLIDING SCALE INSULIN AS INDICATED . Observations in Resident #306's room on 12/18/13 at 4:09 PM, revealed Nurse #6 administered 2 units of [MEDICATION NAME]to Resident #306. Resident #306's meal tray had not been delivered as of 5:35 PM, 1 hour and 26 minutes after administration of the insulin. this resulted in a significant medication error. During an interview on the south hall, second floor Birmingham on 12/18/13 at 5:10 PM, Nurse #6 was asked about the administration of [MEDICATION NAME]in relation to meal time. Nurse #6 stated, .([MEDICATION NAME] insulin) should be given 30 minutes before meals . During an interview on the north hall, fourth floor Birmingham on 12/18/13 at 5:30 PM, Nurse #9 was asked about the administration of [MEDICATION NAME]in relation to meal time. Nurse #9 stated, .Normally [MEDICATION NAME] is given with meals .",2017-07-01
8211,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2013-12-18,371,D,0,1,3V4V11,"Based on policy review, observation and interview, it was determined the facility failed to ensure food was not stored past the expiration date and failed to ensure food was dated when opened on 1 of 3 (12/16/2013) days of the survey. The findings included: Review of the facility's food storage policy documented, .It is our policy to prepare and store food that is stored in accordance with federal, state, and local sanitary codes . Procedure . 2. Refrigerator . d. Raw meats, poultry, and fish will be wrapped labeled, and dated . f. Milk will be rotated with each delivery . Milk with the earliest expiration date will be used first . 4 . a. All leftovers will be properly sealed . labeled, and dated . Observations in the kitchen on 12/16/13 at 11:15 AM revealed the following: a. Dairy cooler had two eight ounce cartons of fat free milk and a gallon of buttermilk stored past the expiration date of 12/13/13. b. Dairy cooler had a quart of heavy whipping cream with a manufacturer's use-by date of 12/15/13 with a hand-written label stating, Use by 11/23/13. c. Meat cooler had an opened container of chicken bacon with no date when it was opened. d. Produce cooler had an opened, undated container of pimento and cheese spread that was not dated when it was opened. During an interview in the kitchen on 12/16/13 at 11:15 AM, the Registered Dietician (RD) was asked about the opened and undated container of chicken bacon. The RD stated, I'll throw that away. During an interview in the kitchen on 12/17/13 at 9:45 AM, the Dietary Manager (DM) was asked about the expired milk products. The DM stated, We use a crate specifically for outdated milk in the dairy cooler, so it can be returned to the vendor for credit. These items were not in the expired crate. The DM was asked if these items got missed. The DM stated, Yes.",2017-07-01
8212,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2013-12-18,431,D,0,1,3V4V11,"Based on policy review, observation and interview, it was determined the facility failed to ensure medications were stored properly as evidenced by a Heparin syringe laying on top of a medication cart, internal medications stored with external medications and disinfectant wipes and medications not dated when opened in 3 of 26 (Birmingham 2 south hall medication cart, Birmingham 3 north hall medication cart and Birmingham 2 north medication cart) medication storage areas. The findings included: 1. Review on the facility's medication storage policy documented, .C. Orally administered medications are kept separate from externally used medications, such as suppositories, liquids, and lotions . F. Except for those requiring refrigeration, medications intended for internal use are stored in medication cart . H. Potentially harmful substances (such as . disinfectants) . stored in a locked area separately from medications . 2. Observations on Birmingham 2 south hall on 12/17/13 at 11:39 AM, revealed a 1 milliliter syringe of Heparin laying on top of the Birmingham 2 medication cart unattended and out of the nurses' view. During an interview on Birmingham 2 south hall on 12/17/13 at 11:39 AM, Nurse #1 was asked what was in the syringe and what should have been done concerning the syringe of Heparin laying on the medication cart. Nurse #1 stated, .Heparin . should have drawn it up when ready to take the rest of the medicines in (to the resident) . During an interview in the Birmingham 2 nurse manager's office on 12/17/13 at 12:08 PM, Nurse #2 was asked what should the nurse have done with the syringe left laying on the medication cart unattended. Nurse #2 stated, .Would have expected (Nurse #1) to put it back in the cart and lock it up . During an interview in the Director of Nursing's (DON) office on 12/18/13 at 5:20 PM, the DON was asked where would she expect Heparin injection to be stored. The DON stated, .in the med (medication) cart . 3. Observations on Birmingham 3 north hall on 12/17/13 at 2:20 PM, revealed the Birmingham 3 north hall medication cart had packaged Ibuprofen tablets stored in a box with antibiotic ointment packets, an unlabeled suppository stored with Acetaminophen tablets, 4 containers of Sani-Hands wipes stored in a drawer with liquid medications. During an interview on the Birmingham 3 north hall on 12/17/13 at 2:35 PM, Nurse #4 stated in regards to the Sani-Hands wipes .they're not open . During an interview in the Director of Nursing's (DON) office on 12/18/13 at 5:20 PM, the DON was asked where would she expect Heparin injection to be stored. The DON stated, .in the med (medication) cart . 4. Observations on the Birmingham 2 north hall on 12/17/13 at 2:45 PM, revealed the Birmingham 3 north hall medication cart contained Pyrazinamide and Vasolex ointments that were not dated when opened. During an interview on Birmingham 2 north hall on 12/17/13 at 2:55 PM, Nurse #5 was asked if the medication should be dated when opened. Nurse #5 stated, .I would assume so, everything that has been opened would need a date . During an interview in the DON's office on 12/18/13 at 5:20 PM, the DON was asked if multiple dose medications should be dated when opened. The DON stated, .would expect it to be dated .",2017-07-01
8213,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2013-12-18,441,D,0,1,3V4V11,"Based on policy review and observation, it was determined the facility failed to ensure 1 of 7 (Nurse #10) medication nurses failed to change gloves between administering eye drops into Resident #247's eyes to prevent the potential spread of infection or cross contamination. The findings included: Review of the facility's Med Pass Technique documented, .change gloves in between each eye drop administration . Observations in Resident #247's room on 12/17/13 at 2:32 PM, Nurse #10 administered eye drops in one of Resident #247's eyes. Nurse #10 did not wash hands or change gloves before administering eye drops into Resident #247's other eye.",2017-07-01
10503,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2012-08-16,252,D,0,1,TT0611,"Based on observation and interview, it was determined the facility failed to provide a homelike environment by not removing the plates off of trays when serving the residents during 2 of 2 (8/13/12 and 8/14/12) dining observations. The findings included; 1. Observations in the R200 hall dining room on 8/13/12 beginning at 11:28 AM, revealed plates were not taken off the meal tray 2. Observations in the R400 hall dining room on 8/14/12 beginning at 4:30 PM, revealed resident plates were not taken off their meal trays. Observations in the B400 hall dining room on 8/14/12 beginning at 5:00 PM, revealed all meals were served to the 13 residents in the dining room on their meal trays. 3. During an interview in the Director of Nursing's (DON) office on 8/16/12 at 1:45 PM, the DON confirmed that plates are not taken off trays except for on R1 occasionally.",2016-06-01
10504,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2012-08-16,278,D,0,1,TT0611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to accurately assess hospice services for 1 of 29 (Resident #33) sampled residents with assessments of the 31 included in the stage 2 review. The findings included: Medical record review for Resident #33 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] documented a significant change in section O special treatments, procedures and programs. Hospice was not checked. Review of a physician's orders [REDACTED].admit to (name of Hospice) program with dx (diagnosis) of AFT (Adult Failure to Thrive) . During an interview in the unit assessment coordinator's office on 8/15/12 at 8:20 AM, Nurse #8 was asked about hospice not being checked on the significant change MDS. Nurse #8 stated, .MDS was for hospice but was overlooked .",2016-06-01
10505,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2012-08-16,279,D,0,1,TT0611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, it was determined the facility failed to develop a comprehensive care plan for the new [DIAGNOSES REDACTED].#61) sampled residents with care plans of the 31 included in the stage 2 review. The findings included: Review of the facility's Care Plan policy documented, .Care Plans are to be updated as needed by the interdisciplinary team to resolve problems which no longer exist and to include new problems, goals and interventions. Copies of the Physician order [REDACTED]. Medical record review for Resident #61 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Physician orders [REDACTED].Start [MEDICATION NAME] 50 mg (milligrams) sq (subcutaneous) q (every) 12 hr (hours) ([MEDICAL CONDITIONS] right upper extremity) . Review of the care plan updated 6/6/12 did not document the new [DIAGNOSES REDACTED]. During an interview in the conference room on 8/16/12 at 11:00 AM, Nurse #7 verified there was no care plan for [MEDICAL CONDITION] or [MEDICATION NAME].",2016-06-01
10506,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2012-08-16,280,D,0,1,TT0611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to revise the care plan to reflect new interventions for falls for 1 of 29 (Resident #119) sampled residents of the 31 included in the stage 2 review. The findings included: Medical record review for Resident #119 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] documented under Section J the resident had 1 fall since admission but no injury. Review of the quarterly MDS dated [DATE] documented in section J that the resident had 2 falls since the last assessment but no injury. Review of the care plan dated 2/6/12 until present documented falls on 2/6/12, 3/2/12, 4/4/12, 5/23/12, 6/11/12, 6/22/12, 7/31/12. with no injuries. There were no new interventions put in place for falls after the fall on 3/2/12. During an interview in the resident assessment office on the birmingham 2nd floor on 8/15/12 at 11:11 AM, Nurse #2 stated, .They (staff) may not put new interventions in place . They keep the ones already in place. During an interview in the hallway outside room B228 on 8/15/12 at 2:15 PM, Nurse #3 stated, .After each fall they (staff) put in a new intervention. They try to monitor him more frequently . Nurse #3 was asked about any new interventions put in place for the falls that had occurred after 3/2/12. Nurse #3 stated .may have exhausted all the interventions. During an interview in the unit assessment coordinator's office on 8/15/12 at 4:55 PM, Nurse #4 stated, (Resident #119) has every intervention available .",2016-06-01
10507,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2012-08-16,322,D,0,1,TT0611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, it was determined 1 of 10 nurses (Nurse #5) observed administering medications failed to ensure proper placement of a percutaneous endoscopy gastrostomy (PEG) tube before administering medications to 1 of 2 (Resident #25) sampled residents observed receiving medications via PEG tube. The findings included: Medical record review documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].[MEDICATION NAME] 20 mg (milligrams) per PEG BID (twice daily) . [MEDICATION NAME] 1000 mg per peg BID . [MEDICATION NAME] 0.5 mg per peg BID . PEG Tube [MEDICATION NAME] 1 cal (calorie) liq (liquid) enteral tube each shift @ (at) 76 ml (milliliters) / (per) hr (hour) x (times) 19 hrs (hours) . Flush tube with 95 ml/hr of H2O (water) from 2P- (to) 4P and 10P-12A . Review of the care plan dated 5/25/12 documented, .Feeding tube long term . TF (tube feeding) dependence d/t (due to) dysphagia following [MEDICAL CONDITION]. Check placement gastric residuals per protocol . Observations in Resident #25's room on 8/14/12 at 4:40 PM, revealed Nurse #5 aspirated the PEG tube with no visible gastric contents returned. Nurse #5 then injected a full 60 ml of air into the PEG tube without using a stethoscope to auscultate for placement as the air was injected. Nurse #5 did not bring a stethoscope into the room. Nurse #5 then gave Resident #25's medications per PEG tube. Nurse #5 failed to properly check the placement of the PEG tube prior to administering medications. During an interview in the patient care manager's office on the birmingham 4th floor, Nurse #6 stated, .PEG placement should be verified by aspiration and by using a stethoscope to listen as you inject a small amount of air into the PEG tube . not a full 60 ml syringe .",2016-06-01
10508,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2012-08-16,323,D,0,1,TT0611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, it was determined the facility failed to implement new interventions to prevent falls for 1 of 6(Resident #119) sampled residents of the 6 residents reviewed with falls included in the stage 2 review. The findings included: Review of the facility's Falls and Restraints policy documented ACTIONS NECESSARY AFTER FALLS After a resident falls, a licensed nurse in charge of care must immediately put in place measurable interventions to prevent future accidents .' Medical record review for Resident #119 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] documented under section J the resident had 1 fall since admission with no injury. Review of the quarterly MDS dated [DATE] documented in section J that the resident had 2 falls since the last assessment with no injury. Review of the care plan dated 2/6/12 until present documented falls on 2/6/12, 3/2/12, 4/4/12, 5/23/12, 6/11/12, 6/22/12, and 7/31/12 with no injuries. There were no new interventions put in place for falls after the fall on 3/2/12 During interview in the resident assessment office on 8/15/12 at 11:11 AM, Nurse #2 stated, .They (staff) may not put new interventions in place. They keep the ones already in place . During an interview in the hallway outside room B228 on 8/15/12 at 2:15 PM, Nurse #3 stated, .After each fall they (staff) put in a new intervention. They try to monitor him more frequently . Nurse #3 was asked about any new interventions put in place for the falls that had occurred after 3/2/12. Nurse #3 stated .may have exhausted all the interventions. During interview in the unit assessment coordinator's office on 8/15/12 at 4:55 PM, Nurse #4 stated Resident #119 .has every intervention available . Feels like they have tried all the interventions .",2016-06-01
10509,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2012-08-16,371,E,0,1,TT0611,"Based on policy review, observation and interview, it was determined the facility failed to ensure practices to prevent the potential spread of infection were maintained when 11 of 33 certified nursing technicians (CNT #6, 10, 11, 13, 14, 15, 19, 20, 21, 23 and 24) failed to practice sanitary hand hygiene by touching the residents' environment and then prepared meal trays and fed residents, handled residents' food and straws with bare hands or placed contaminated trays back on the cart with unserved meal trays during dining observations. The findings included: 1. Review of the facility's Tray Setup policy documented, Procedure . 6. Prior to beginning the meal tray pass, staff should clean their hands with soap and water. Staff should NOT wear gloves during meal tray service. Instead, between tray passes, staff should sanitize their hands using the Sani Wipes or Alcohol Foam. Staff members who have touched a resident during a tray pass must clean their hands with soap and water before the next tray pass. 7. Staff are to clean their hands with soap and water between touching a resident and opening food or liquid containers on tray . 10. If a straw is needed, it should be unwrapped and placed in a beverage being careful not to touch the end of the straw that the resident will put in their mouth . 2. Observations in the R400 hall dining room on 8/13/12 beginning at 12:20 PM, CNT #6 touched the resident's silverware with bare hands and touched the tip of the fork and spoon. 3. Observations in R400 dining room on 8/13/12 beginning at 12:20 PM, CNT#10 handled the straw with her bare hands when placing it in the resident's drink. 4. Observations in the R400 hall dining room on 8/13/12 beginning at 12:20 PM, CNT #11 moved her hair away from her face and continued to prepare the residents' tray. 5. Observations in the B400 hall dining room on 8/14/12 beginning at 5:00 PM, CNT #13 fed graham crackers and a sandwich to Resident #420 with her bare hands. 6. Observations in room 406B on 8/14/12 beginning at 5:00 PM, CNT #14 delivered a meal tray to room 406B, adjusted the bed manually, pulled the resident's shoulders over to reposition him in bed, applied a clothing protector on the resident after wearing it over her shoulder throughout setup of the tray. CNT #14 then set up the tray, including silverware and straw, handling all items with her bare unwashed hands. CNT #14 proceeded to room B422, opened the straw and handled it with her bare hands after tray setup. 7. Observations in room B429 on 8/14/12 beginning at 5:00 PM, CNT #15 delivered a tray, set up the tray, peeled the boiled egg with her bare hands, placed the egg into the serving bowl with her bare hands, opened the straw and handled it without washing her hands. 8. Observations on B300 hall on 8/13/12 beginning at 11:15 AM, CNT #19 carried a meal tray into room 330 and placed the tray on the resident's overbed table. The resident refused the tray. CNT #19 picked up the tray and returned it to the tray cart which contained meal trays that had not been served. 9. Observations in the R100 hall dining room on 8/13/12 beginning at 11:30 AM, CNT #20 handled the straw with bare hands when placing it in the resident's drink. 10. Observations in the R100 hall dining room on 8/13/12 beginning at 11:30 AM, CNT #21 handled a baked potato while applying butter. 11. Observations in the R100 hall dining room on 8/13/12 beginning at 11:30 AM, CNT #23 handled the straw with bare hands when placing it in the resident's drinks. 12. Observations in the R100 hall dining room on 8/13/12 beginning at 11:30 AM, CNT #24 handled the straw with bare hands when placing it in the resident's drinks. 13. During an interview in the Director of Nursing's (DON) office on 8/16/12 at 1:45 PM, the DON was asked about expectations of staff when serving meal trays. The DON stated, Depend on what they've touched. If resident contact, at least use wipe and after three times must wash hands. Should not come in contact with food. Hold bread/food inside bag and butter it. They are not to touch food or silverware other than handle.",2016-06-01
10510,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2012-08-16,431,D,0,1,TT0611,"Based on policy review, observation and interview, it was determined the facility failed to ensure medications were not stored past their expiration date in 4 of 25 (Ribeiro Building 4th floor North hall medication cart, Ribeiro Building 4th floor South hall medication cart, Ribeiro Building 1st floor East hall medication cart and Ribeiro Building 1st floor North hall medication cart) medication storage areas. The findings included: 1. Review of the facility's Medication Storage in the Facility policy documented, .Expired . medications . are immediately removed from medication carts and medication rooms, disposed of according to procedures for medication destruction, and reordered from the pharmacy . 2. Observations and interview in Ribeiro Building 4th floor North hall medication cart on 8/15/12 at 8:30 AM revealed Clonidine 0.1 milligram (mg) tablets stored past the expiration date of 7/6/12. The dates on the expired medication was confirmed with the nurse responsible for this medication cart. 3. Observations and interview in Ribeiro Building 4th floor South hall medication cart on 8/15/12 at 8:30 AM, revealed Vistaril 25 mg capsules stored past the expiration date of 7/6/12 and a bottle of Nitroglycerin 0.4 mg sublingual tablets stored past the expiration date of 7/6/12. The dates on the expired medications was confirmed with the nurse responsible for this medication cart. 4. Observations and interview on Ribeiro Building 1st floor East hall medication cart on 8/15/12 at 3:00 PM, Premarin vaginal cream stored past the expiration date of 7/22/12 and Lorazepam 0.5 mg tablets stored past the expiration date of 7/18/12. The dates on the expired medications was confirmed with the nurse responsible for this medication cart. 5. Observations in Ribeiro Building 1st floor North hall medication cart on 8/15/12 at 3:10 PM, revealed Clonidine 0.1 mg tablets stored past the expiration date of 7/6/12 and Promethazine 25 mg tablets stored past the expiration date of 7/5/12. The dates on the expired medications was confirmed with the nurse responsible for this medication cart.",2016-06-01
10511,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2012-08-16,514,D,0,1,TT0611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to ensure medical records were accurate for 1 of 19 (Resident #282) sampled residents of the 31 residents included in the stage 2 review. The findings included: Medical record review for Resident #282 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the recertification physician's orders [REDACTED].Order Date . 2/19/12 . MED (medication) - [MEDICATION NAME] 25-100 25 MG (milligram) -100 MG TAB (tablet) adm. (administer) 2 tabs bid (twice a day) ([MEDICATION NAME] / [MEDICATION NAME]) Oral Twice daily . Review of a physician's orders [REDACTED].Change [MEDICATION NAME] 25/100 mg (2) tabs po tid (three times a day) . Review of the recertification Physician orders [REDACTED].Order Date . 04/18/12 . MED - [MEDICATION NAME] 25-100 25 MG-100 MG TAB adm. 2 tabs bid ([MEDICATION NAME]/[MEDICATION NAME]) Oral Three times daily . Review of a physician's progress note dated 4/18/12 documented, .Trial of increasing [MEDICATION NAME] to 25/100 mg two tablets t.i.d. (three times a day) If there is no improvement whatsoever, he may be better not on any [MEDICATION NAME] at all . Review of the medication administration records (MAR) dated from 3/1/12 through (-) 8/15/12 documented Resident #282 received [MEDICATION NAME] 25-100 mg tabs BID until 4/18/12. From 4/18/12 to present, Resident #282 received [MEDICATION NAME] 25-100 mg tabs TID. During an interview in the Director of Nursing's (DON) office on 8/15/12 at 3:55 PM, the DON was asked about the two different frequencies of the [MEDICATION NAME] on the recertification orders. The DON confirmed the recertification orders were inaccurate and stated, .must have been an error, should just say tid here, that is how he is getting it on the MARs .",2016-06-01
12746,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2011-05-18,318,D,0,1,7GRH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, it was determined the facility failed to ensure the care plan intervention and physician's orders for a therapy carrot were followed for 1 of 8 (Resident #14) sampled residents with range of motion (ROM) limitations. The findings included: Medical record review for Resident #14 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a care plan dated 2/18/10 documented, ""INCONTINENCE / PRESSURE ULCER... INTERVENTIONS... Carrot to left hand as tolerated."" Review of a physician's order dated 4/29/11 documented, ""...Therapy carrot to left hand as tolerated..."" Observations in Resident #14's room on 5/16/11 at 12:23 PM and 5:52 PM and on 5/17/11 at 7:36 AM and 10:30 AM, revealed Resident #14 lying in bed without a carrot in his left hand. Observations in Resident #14's room on 5/18/11 at 8:10 AM, revealed Resident #14 seated in a geri-chair without a carrot in his left hand. During an interview at B 4 nurses' station on 5/18/11 at 8:40 AM, Nurse #9 stated, ""...It (therapy carrot) should be in the right hand..."" Nurse #9 confirmed no therapy carrot was in place in either hand.",2015-07-01
12747,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2011-05-18,322,D,0,1,7GRH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, it was determined the facility failed to monitor and ensure 1 of 4 (Resident #14) sampled residents fed by continuous Percutaneous Endoscopy Tube (PEG) received the appropriate formula and rate to maintain the resident's required nutritional needs. The findings included: Review of the facility's ""...TF (Tube Feeding) Guidelines and Documentation..."" policy documented, ""...Tube fed residents will be routinely monitored to assure that nutritional goals are achieved. Dietician's routine review of residents on tube feeding should include: Visitation with the resident to note that the pump (if applicable) is infusing according to the tube feeding order..."" Medical record review for Resident #14 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Observations in Resident #14's room on 5/16/11 at 5:52 PM, revealed Resident #14 was receiving a PEG tube formula of Two Calorie High Nutrition (HN) at the rate of 50 ml/hr. During an interview in the Resident #14's room on 5/16/11 at 6:00 PM, Nurse #10 stated, ""Order supposed to be [MEDICATION NAME] at 74 ml per hour.""",2015-07-01
12748,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2011-05-18,323,D,0,1,7GRH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, it was determined the facility failed to ensure that a resident at risk for falls had appropriate interventions implemented after a fall for 1 of 9 (Resident #26) sampled residents at risk for falls. The findings included: Review of the facility's ""Falls and Restraints"" policy documented, ""...After a resident falls, a licensed nurse in charge of care must immediately put in place measurable interventions to prevent further accidents..."" Medical record review for Resident #26 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum (MDS) data set [DATE] documented ""...resident is rarely/never understood... Memory problem..."" Review of the care plan dated 8/3/10 and updated 5/14/11 documented ""...PROBLEMS / STRENGTHS... Resident at risk of injury from falls R/T (related to): Weakness. occ. (occasional) confusion, Refuses assist often... 5/14/11 Slid from W/C (wheelchair) while on toilet removing shoes... INTERVENTIONS... 5/14/11 Educate elder related to safety et (and) allowing staff to assist..."" This was not an appropriate intervention for this resident's cognitive status. During an interview at R2 nurses' station on 5/18/11 at 1:08 PM, Nurse #11 was asked if she felt that educating Resident #26 was an appropriate intervention given her cognitive status. Nurse #11 stated, ""... she likes to do things her way...""",2015-07-01
12749,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2011-05-18,325,D,0,1,7GRH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to implement new interventions to prevent additional weight loss for 1 of 8 (Resident #8) sampled residents with weight loss. The findings included: Medical record review for Resident #8 documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #8's monthly weights documented the following: 12/17/11 - 97.2 pounds (lb) and 1/11/11 - 92.2 lb. Review of the progress notes dated 1/20/11 documented Resident #8 was removed from the nutritional at risk program and weekly weights were discontinued. During an interview at the B4 nurses' station on 5/18/11 at 1:00 PM, Nurse #9 confirmed there were no new interventions implemented after the recorded weight loss on 1/11/11. During an interview at the B4 nurses' station on 5/18/11 at 3:48 PM, Dietician #1 stated, ""I didn't do an intervention because her wounds were improving, and she had a [DIAGNOSES REDACTED].",2015-07-01
12750,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2011-05-18,328,D,0,1,7GRH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, it was determined the facility failed to ensure that oxygen (O2) was administered at the rate prescribed by the physician; O2 saturation levels were checked; the Minimum Data Set (MDS) was accurately completed; the care plan was revised and/or a physician's order was obtained for O2 for 3 of 10 (Residents #10, 20 and 22) sampled residents receiving oxygen. The findings included: 1. Medical record review for Resident #10 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's order dated 4/29/11 documented, ""...02 per NC (nasal cannula) @ (at) 2L/min (liters per minute)..."" Observations in Resident #10's room on 5/16/11 at 10:35 AM and 3:55 PM, on 5/17/11 at 7:33 AM and 12:45 PM and on 5/18/11 at 8:30 AM, revealed Resident #10's 02 rate was set at 1.5 L/min. 2. Medical record review for Resident #20 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's order dated 3/25/11 documented, ""...O2 @ 2 L/M to keep sats (saturations) above 92% (percent) as needed..."" The facility was unable to provide documentation of Resident #20's O2 saturations. The MDS dated [DATE] was not coded for the use of O2. Review of the care plan dated 11/17/10 and updated 2/11 revealed no interventions for use of O2. Observations in Resident #20's room on 5/18/11 at 9:10 AM and 2:10 PM, revealed Resident #20 was receiving O2 per nasal cannula at 2 L/min. During an interview in the conference room on 5/18/11 at 2:15 PM, Resident Assessment Manager and Nurse # 12 confirmed that the O2 sats had not been checked, the MDS was not accurately completed and the care plan was not revised. 3. Medical record review for Resident #22 documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders dated 4/28/11 did not include no order for oxygen. Observations in Resident #22's room on 5/16/11 at 12:00 PM and on 5/18/11 at 2:00 PM, revealed Resident #22 receiving O2 at 2L/min per NC. During an interview at the B4 nurses' station on 5/18/11 at 2:00 PM, Nurse #9 confirmed there was no physician's order for O2 for Resident #22.",2015-07-01
12751,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2011-05-18,332,D,0,1,7GRH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the ""Medication Guide for the Long-Term Care Nurse"", policy review, medical record review, observation and interview, it was determined the facility failed to ensure 4 of 18 (Nurses #1, 2, 3 and 4) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 4 errors were observed out of 43 opportunities for error, resulting in a medication error rate of 9.01%. The findings included: 1. Review of the facility's ""ADMINISTERING MEDICATIONS VIA GASTROSTOMY TUBE"" policy documented, ""...5. Verify the medications with the eMAR (electronic Medication Administration Record). 6. Crush pill and/or empty capsules if appropriate. 7. Liquid medications- use dosing cup or syringe to measure... 12. Mix medications with water and administer through tube..."" a. Medical Record review for Resident #8 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Observations in Resident #8's room on 5/17/11 at 7:37 AM, revealed Nurse #3 poured [MEDICATION NAME] suspension into a plastic medication cup and administered the [MEDICATION NAME] suspension to Resident #8. Nurse #3 did not use a syringe to measure the dosage. Failure to use a syringe to measure the accurate dosage resulted in medication error #1. During an interview at the B4 nurses' station on 5/17/11 at 12:40 PM, Nurse 33 was asked about Resident #8's dosage of [MEDICATION NAME]. Nurse #3 stated, ""I poured it at eye level just a little bit above the ten."" During an interview in the conference room on 5/18/11 at 10:00 AM, the Director of Nursing (DON) stated, ""If dosage not on cup they need to use a syringe to measure the dose."" b. Medical record review for Random Resident (RR) #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Observations in RR #1's room on 5/16/11 at 11:45 AM, Nurse #1 administered [MEDICATION NAME] 800 mg to RR #1 per Percutaneous Endoscopy Gastrostomy tube. Nurse #1 left a large amount of the crushed medication in the medication cup. Failure to administer the complete dosage of the medication resulted in medication error #2. During an interview at B3 nurses' station on 5/17/11 at 4:10 PM, Nurse #1 stated, ""I need to make sure I get all the medication."" During an interview in the conference room on 5/18/11 at 10:00 AM, the DON stated, ""They need to make sure the cup is empty, give all the med (medication)..."" 2. Review of the facility's ""Expected snack or meal delivery in conjunction with routine insulin or SSI (Sliding Scale Insulin) delivery"" policy documented, ""[MEDICATION NAME]: Snack or meal within 10- (to) 20 minutes of delivery..."" Medical record review for RR #3 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].> (greater than) 180 SLIDING SCALE [MEDICATION NAME] INSULIN AS INDICATED & (and) DOCUMENT. 180-250... 2U (units) OF [MEDICATION NAME] INSULIN..."" Observations in RR #3's room on 5/16/11 at 4:23 PM, revealed Nurse #2 administered [MEDICATION NAME]2U to RR #3. RR #3 did not receive her meal tray until after 6:00 PM. The administration of the [MEDICATION NAME]more than an hour and thirty-seven minutes before supper was served resulted in medication error #3. During an interview in the conference room on 5/18/11 at 10:00 AM, the DON was asked about insulin administration and and mealtimes. The DON stated, ""With [MEDICATION NAME] should have a snack or meal within 10 to 20 minutes..."" 3. Review of the ""Medication Guide for the Long-Term Care Nurse"", page 75, documented, ""...Wait one minute between ""puffs"" for multiple inhalations of the same drug..."" Medical record review for RR #2 documented an admitted 5/9/11 with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Observations in RR #2's room on 5/18/11 at 9:07 AM, Nurse #4 administered two puffs of an [MEDICATION NAME] inhaler to RR #2 without pausing between puffs. Nurse #4 did not pause at least one minute between the puffs. Failure to wait at least one minute between puffs resulted in medication error #4. During an interview in the conference room on 5/18/11 at 10:20 AM, the DON stated, ""Need to wait at least 30 seconds between puffs if it's the same medication.""",2015-07-01
12752,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2011-05-18,333,D,0,1,7GRH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, it was determined the facility failed to ensure 1 of 18 nurses (Nurse #2) administered medications without a significant error. Nurse #2 failed to administer insulin within the proper time frame related to meals for Random Resident (RR) #3. The findings included: Review of the facility's ""Expected snack or meal delivery in conjunction with routine insulin or SSI (Sliding Scale Insulin) delivery"" policy documented, ""[MEDICATION NAME]: Snack or meal within 10- (to) 20 minutes of delivery..."" Medical record review for RR #3 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].> (greater than) 180 SLIDING SCALE [MEDICATION NAME] INSULIN AS INDICATED & (and) DOCUMENT. 180-250... 2U (units) OF [MEDICATION NAME] INSULIN..."" Observations in RR #3's room on 5/16/11 at 4:23 PM, Nurse #2 administered [MEDICATION NAME]2U to RR #3. RR #3 did not receive her meal tray until after 6:00 PM. The administration of the [MEDICATION NAME]more than an hour and thirty-seven minutes before supper was served resulted in a significant medication error.",2015-07-01
12753,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2012-03-06,315,D,1,0,OXES11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Intakes: TN 332 Based on policy review, medical record review, observation and interview, it was determined the facility failed to ensure a urinary drainage bag did not touch the floor for 1 of 5 (Resident #1) sampled residents with urinary catheters. The findings included: Review of the facility's ""Indwelling and Condom Catheter"" policy documented, ""...Keep tubing coiled on bed by resident's side. Do not allow tubing to hang off the bed in hoops. Keep the bedside drainage bag off of the floor..."" Medical record review for Resident #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. Observations in Resident #1's room on 3/6/12 at 11:25 AM, revealed Resident #1's Foley catheter bag was in a privacy bag and the tubing was laying on the floor under Resident #1's bed. Observations in Resident #1's room on 3/6/12 at 11:55 AM, revealed Resident #1's Foley catheter bag in a privacy bag laying on the floor under Resident #1's bed. During an interview in Resident #1's room on 3/6/12 at 11:30 AM, Nurse #1 was asked if it was permissible for the catheter bag to be on the floor. Nurse #1 stated, ""No..."" During an interview in Resident#1's room on 3/6/12 at 11:55 AM, Certified Nurse Technician (CNT) #1 was asked where the catheter bag should be located. CNT #1 stated ""...on the bed and not on the floor...""",2015-07-01
12901,NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2012-02-06,309,D,1,0,MVDN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Intakes: TN 338 Based on medical record review and interview, it was determined the facility failed to follow physician's orders for scheduling a computerized tomography (CT) scan for 1 of 10 (Resident #2) sampled residents. The findings included: Closed medical record review for Resident #2 documented an admission date of [DATE] [DIAGNOSES REDACTED]. Review of physician's orders dated 3/17/11 at 12:30 AM documented, ""Please schedule for a X-Ray of the right knee in A.M."" Review of the X-Ray report of the right knee dated 3/17/11 documented, ""IMPRESSION: 1. Severe [MEDICAL CONDITION]. 2. Findings consistent with a joint effusion..."" Review of physician's orders dated 3/17/11 at 9:30 AM documented, ""...Schedule CT scan of R (right) knee (Dx (diagnosis): Joint Pain)..."" Review of physician's orders dated 3/23/11 at 3:40 PM documented, ""Transfer to (name of hospital) ER (emergency room ) for evaluation."" The facility was unable to provide documentation that the CT scan of the right knee that was ordered on [DATE] was scheduled or performed. During an interview conducted via phone on 2/3/12 at 10:05 AM, registered nurse (RN) #1 was asked if the facility was able to find the results for the CT scan of the right knee ordered on [DATE]. RN #1 stated the CT scan had not been completed before the resident was transferred to the hospital.",2015-06-01
14257,BORDEAUX LONG TERM CARE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2010-03-30,157,D,,,DJ8011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #TN 194 Based on policy review, medical record review and interview, it was determined the facility failed to ensure the physician was notified of a low blood sugar (BS) for 1 of 30 (Resident #30) sampled residents. The findings included: Review of the facility's ""Protocol: [DIAGNOSES REDACTED]"" documented, ""...Risk for Injury related to insufficient glucose to meet metabolic needs. Blood glucose less than or = (equal) 60 mg/dl (milligrams per deciliter) and are symptomatic. Notify MD (Medical Doctor)... 2. treatment of [REDACTED].=60 mg/dl (complete a - (through) f below ASAP (as soon as possible) a. Check glucostick b. If less than or equal to 60 mg/dl then treat resident based on level of consciousness and notify medical staff for further instructions. c. If after hours contact house supervisor who will in turn notify medical staff. 1. If responsive, give juice, milk, ensure or Insta Glucose and recheck blood glucose within 15 min. (minutes). If blood glucose continues to be = or < (less than) 60 mg/dl then give the [MEDICATION NAME] IM (intramuscular) and recheck blood glucose in 15 min. If blood glucose continues to be = or <60 mg/dl repeat IM [MEDICATION NAME], recheck blood glucose in 15 minutes. If resident continues not to respond to treatment then start process to send resident out for evaluation and treatment..."" Medical record review for Resident #30 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #30's diabetic monitoring flow sheet documented ""BS for 1/22/09 - 1600 (4:00 PM) BS= (result) 40 food/juice given."" Review of a progress note dated ""1/22/10-1600- Res (resident) c/o (complained of) not feeling well, asked for feet to be put on bed, BS (checked) earlier was 40. Food and drink given, family present. 1700 (5:00 PM) Res c/o (not) feeling well still... 1740 (5:40 PM) Res called for assistance. Wanted her legs off bed. Still appears tired... Will continue to monitor. 1815 (6:15 PM) Found Res in w/c (wheelchair) in room, unresponsive, attempted to revive c (with) out success. Called for assistance to put in bed. 1822 (6:22 PM) Code Blue called D/T (due to) unresponsiveness..."" There was no documentation Resident #30's BS was being checked every 15 minutes after the initial blood sugar of 40. The next documented BS on the diabetic monitoring flow sheet was at 6:30 PM with a BS of 161. There was no documentation the MD was notified of the low BS. During an interview in the conference room on 3/30/10 at 8:20 AM, the Director of Nursing (DON) stated, ""Less than 60 MD or medical staff should be notified. Give juice, milk, food or Instant glucose. Recheck BS in 15 minutes, still not up give IM [MEDICATION NAME] recheck in 15 minutes, still not up repeat IM [MEDICATION NAME]. If not responding need to go out."" The DON was asked what should have been done for this resident. The DON stated, ""Should have been checked (referring to BS) again in 15 minutes and the doctor should have been notified.""",2014-02-01
14258,BORDEAUX LONG TERM CARE,445033,1414 COUNTY HOSPITAL RD,NASHVILLE,TN,37218,2010-03-30,309,D,,,DJ8011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Amended 2567 on 4/27/10 Based on policy review, medical record review, observation and interview, it was determined the facility failed to follow physician's orders [REDACTED].#1, 15 and 30) sampled residents. The findings included: 1. Medical record review for Resident #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]."" Observations in the recreation room on 3/29/10 at 11:21 AM, revealed Resident #1 sitting in a wheelchair (w/c) with her feet dangling. Observations in Resident #1's room on 3/29/10 at 11:45 AM, revealed Resident #1 sitting in the w/c eating lunch with her feet dangling. During an interview in the Patient Care Manager's office, on 3/29/10 at 11:34 AM, the Patient Care Manager stated, ""(Resident #1's) feet should be elevated."" 2. Medical record review for Resident #15 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]."" Observations in Resident #15's room on 3/29/10 at 12:05 PM and on 3/30/10 at 9:00 AM, revealed Resident #15 lying in bed with no heel protectors in use as ordered. During an interview in Resident #15's room on 3/30/10 at 9:00 AM, Nurse #5 stated, ""Oh you (Resident #15) don't have your heel protectors on."" 3. Review of the facility's ""Protocol: [DIAGNOSES REDACTED]"" documented, ""...Risk for Injury related to insufficient glucose to meet metabolic needs. Blood glucose less than or = (equal) 60 mg/dl (milligrams per deciliter) and are symptomatic. Notify MD... 2. treatment of [REDACTED].=60 mg/dl (complete a - (through) f below ASAP (as soon as possible) a. Check glucostick b. If less than or equal to 60 mg/dl then treat resident based on level of consciousness and notify medical staff for further instructions. c. If after hours contact house supervisor who will in turn notify medical staff. 1. If responsive, give juice, milk, ensure or Insta Glucose and recheck blood glucose within 15 min. (minutes). If blood glucose continues to be = or < (less than) 60 mg/dl then give the [MEDICATION NAME] IM (intramuscular) and recheck blood glucose in 15 min. If blood glucose continues to be = or <60 mg/dl repeat IM [MEDICATION NAME], recheck blood glucose in 15 minutes. If resident continues not to respond to treatment then start process to send resident out for evaluation and treatment..."" Medical record review for Resident #30 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #30's diabetic monitoring flow sheet documented ""BS for 1/22/09 - 1600 (4:00 PM) BS= (result) 40 food/juice given."" Review of a progress note dated ""1/22/10-1600- Res (resident) c/o (complained of) not feeling well, asked for feet to be put on bed, BS (checked) earlier was 40. Food and drink given, family present. 1700 (5:00 PM) Res c/o (not) feeling well still... 1740 (5:40 PM) Res called for assistance. Wanted her legs off bed. Still appears tired... Will continue to monitor. 1815 (6:15 PM) Found Res in w/c (wheelchair) in room, unresponsive, attempted to revive c (with) out success. Called for assistance to put in bed. 1822 (6:22 PM) Code Blue called D/T (due to) unresponsiveness..."" There was no documentation Resident #30's BS was being checked every 15 minutes after the initial BS of 40. The next documented BS on the diabetic monitoring flow sheet was at 6:30 PM with a BS of 161. There was no documentation the MD was notified of the low BS. During an interview in the conference room on 3/30/10 at 8:20 AM, the Director of Nursing (DON) stated, ""Less than 60 MD or medical staff should be notified. Give juice, milk, food or Instant glucose. Recheck BS in 15 minutes, still not up give IM [MEDICATION NAME] recheck in 15 minutes, still not up repeat IM [MEDICATION NAME]. If not responding need to go out."" The DON was asked what should have been done for this resident. The DON stated, ""Should have been checked (referring to BS) again in 15 minutes and the doctor should have been notified.""",2014-02-01
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
4613,"NHC HEALTHCARE, MILAN",445069,8017 DOGWOOD LANE P O BOX A,MILAN,TN,38358,2016-11-09,356,F,0,1,2WIR11,"Based on observation and interview, the facility failed to ensure nurse staffing information was posted in a prominent place easily visible to the public on 3 of 3 (11/7/16, 11/8/16, and 11/9/16) days of the survey. The findings included: Observations in the facility throughout the days of 11/7/16 and 11/8/16 revealed no visible postings of the nurse staffing information. Observations in the Assistant Director of Nursing (ADON) office on 11/9/16 at 12:30 PM, revealed the staff posting for 11/9/16 was pinned on a bulletin board. Interview with the Director of Nursing (DON) on 11/9/16 at 12:45 PM, the DON was asked where the staff posting was located. The DON stated, .It is on the door of the ADON's office .I don't know why it is on the bulletin board . The DON was asked if the staff posting was visible to the public. The DON stated, Not really.",2019-08-01
4614,"NHC HEALTHCARE, MILAN",445069,8017 DOGWOOD LANE P O BOX A,MILAN,TN,38358,2016-11-09,441,D,0,1,2WIR11,"Based on policy review, review of employee files, and interview, the facility failed to provide documentation that employees were free from communicable disease for 2 of 9 (Dietary Manager (DM) and Activities Director (AD) employee health records reviewed. The findings included: 1. The facility's Partner Health policy documented, .An annual health screen is completed, reviewed, and filed annually in the partner health record . 2. Review of the employee file for the DM revealed no documentation that the DM had a physical in (YEAR), or that a physician had reviewed the health record or found the DM to be free from communicable disease and infection. Review of the employee file for the AD revealed no documentation that the AD had a physical in (YEAR), nor that a physician had reviewed the health record or found the AD to be free from communicable disease and infection. Interview with the Director of Nursing (DON) on 11/9/16 at 12:24 PM, in the Day Room, the DON was asked if there was a recent physical or a physican's statement that the DM and the AD were free from communicable disease. The DON stated, .No, there is no signature on the health form that states the employees are free of communicable disease .",2019-08-01
7371,"NHC HEALTHCARE, MILAN",445069,8017 DOGWOOD LANE P O BOX A,MILAN,TN,38358,2014-08-13,371,E,0,1,SRFH11,"Based on policy review, observation and interview, it was determined the facility failed to ensure food was protected from physical contaminates and other sources of contamination as evidence by kitchen doors observed propped open and 18 of 18 unauthorized persons (Administrator, Director of Nursing (DON), Business Office Manager (BOM), Certified Nursing Assistant (CNA #1, 2, 3, 4, 5, 6, 7, 8 and 9, Maintenance Director, Physical Therapy Assistant #1, Housekeeper #1, 2 and 3 and family member #1) entered the kitchen without a hair net. The facility had a resident census of 92 with 5 residents currently under isolation precautions. One (1) of 15 staff members (CNA #3) failed to ensure practices were performed to prevent the potential spread of infection when CNA #3 adjusted Resident #65's underpad, removed a pillow between the resident's legs, set up the meal tray and assisted Resident #65 to eat without performing hand hygiene. The findings included: 1. Review of facility's Safety & (and) Sanitation Best Practice Guidelines policy documented, .3. Hair Restraints . (a) Dietary partners shall wear hair restraints such as hats, hair coverings, or nets . that covers body hair, that are designed and worn to effectively keep their hair from contacting expose food; clean equipment, utensils, and linens . 5. Persons unnecessary to the food establishment operation are not allowed in the food preparation, food storage, or warewashing areas . 2. Observations on 8/11/14 beginning at 7:25 AM through 8:15 AM revealed the following: Three (3) doors allowed entrance into the kitchen from the main dining room. The door on the far left entered the dietary office/kitchen hallway. This hallway contained the dietary office, the walk in refrigerator and freezer, dietary storage cabinet, the dish drying rack, an opening into the dish room, the dietary bathroom, and an entrance directly into the kitchen adjacent to the dish machine. The door to this hallway was observed propped open. The following staff members were observed to enter the kitchen during the breakfast meal on 8/11/14. None of these staff members wore hair coverings. a. 7:28 AM - the administrator entered the kitchen. b. 7:43 AM - the BOM entered the kitchen. c. 7:45 AM - the DON entered the kitchen. d. 7:58 AM - the administrator re-entered the kitchen. Observations on 8/11/14 from 7:25 AM through 8:15 AM revealed, the door on the far right of the main dining room entered directly into the kitchen. Just inside there was a drink/ice bar to the right. The tray line/steam table was in front of and ran to the left of this entrance. There was a walk space across the front of the tray line/steam table that ended in front of and to the right of the middle door that entered the kitchen from the main dining room. At both corners of the tray line/steam table were signs that documented Dietary partners only beyond this point. The door entering the kitchen on the far right side was observed propped open. Both doors were observed to be open throughout the breakfast service. The following staff members were observed to enter the kitchen through the far right door at the drink bar/tray line during the breakfast meal on 8/11/14. None of these staff members wore hair coverings. a. 7:25 AM - CNA #1 got a plate of food. b. 7:30 AM - CNA #2 got a plate of food. CNA #2's hair was long dreadlocks and was uncovered. c. 7:35 AM - CNA #3 got a bowl of cereal. CNA #3's hair was long dreadlocks and was uncovered. d. 7:38 AM - CNA #1 re-entered the kitchen to get coffee. e. 7:38 AM - CNA #2 re-entered the kitchen to ask a dietary staff member a question and left. f. 7:40 AM - BOM and CNA #1 entered the kitchen and fixed coffee. The Maintenance Director entered the kitchen and spoke with a dietary staff member and left. g. 7:44 AM - CNA #3 entered kitchen and fixed coffee at the drink bar. h. 7:45 AM - CNA #4 entered kitchen and left. i. 7:50 AM - CNA #5 entered kitchen and got coffee. j. 7:52 AM - PTA #1 entered the kitchen and got bowl of cereal. k. 7:58 AM - CNA #4 entered the kitchen. l. 8:00 AM - Housekeeper #1 entered the kitchen and got a cup of coffee and CNA #6 entered the kitchen and spoke with a dietary staff member. m. 8:10 AM - CNA #4 entered the kitchen and got a glass of ice. n. 8:12 AM - CNA #2, CNA #3, and CNA #7 all re-entered the kitchen. 3. Observations on 8/12/14 at 8:00 AM through 8:40 AM revealed the far left door entering the dietary office / kitchen hallway was propped open. Observations on 8/12/14 from 8:00 AM through 8:15 AM revealed the far right door entering the kitchen was propped open while dietary staff were serving the breakfast meal. The following staff were observed to enter the kitchen during the breakfast meal. None of these staff members wore hair coverings. a. 8:00 AM - CNA #8 entered the kitchen. b. 8:15 AM - CNA #9 entered kitchen and got a bowl of cereal. A dietary staff member was observed to close the far right kitchen door at 8:15 AM. Observations on 8/12/14 the following staff members entered the kitchen through the center door that was closed. None of these staff members wore a hair covering. a. 8:20 AM - CNA #3 entered the kitchen. b. 8:23 AM - Housekeeper #2 entered the kitchen and got a glass of tea. c. 8:25 AM - Housekeeper #3 and CNA #1 entered the kitchen. Observations on 8/12/14 at 12:50 PM, revealed the far left and far right kitchen doors were propped open, while dietary staff were serving the noon meal. Observations on 8/12/14 from 4:25 PM through 5:20 PM, revealed the far left and far right kitchen doors were propped open, while dietary staff were serving the supper meal. Observations on 8/12/14 from 4:25 PM through 5:20 PM, revealed an unauthorized person (family member #1) entered the kitchen through the open far right door multiple times talking to staff and moving the filled meal carts to the hall area outside the main dining room. Family member #1 did not wear any hair covering while in the kitchen during the supper meal service. 4. Observations on 8/13/14 at 7:30 AM through 7:45 AM, revealed the far left and far right kitchen doors were propped open while dietary staff were serving the breakfast meals. The BOM was entered the kitchen to get a cup of coffee through the far right kitchen door. The BOM did not wear a hair covering during this breakfast meal service. Observations on 8/13/14 at 11:15 AM and at 12:30 PM, revealed the far left and the far right kitchen doors were propped open while dietary staff were serving the noon meal. 5. During an interview at the south nurses' station on 8/11/14 at 10:55 AM, CNA #2 was asked about the resident meal service. CNA #2 stated, No one eats in the dining rooms at breakfast. We sanitize our hands, get the tray, knock on the door, and set the tray up. If there is something missing or the resident requests something different we go to the kitchen to get it. If it is coffee we go to the drink bar and fix it for the resident. If it is a food or juice we ask the dietary staff and they will hand it to us. During an interview at the south nurses' station on 8/11/14 at 2:00 PM, CNA #7 was asked the about the meal service process. CNA #7 stated, We sanitize hands, get tray, knock on door, take tray to the room and set tray up for the residents. If they (residents) ask for alternates or something else we go to the kitchen and get it. CNA #7 was asked about the process for getting things from the kitchen. CNA #7 stated, If the resident wants a drink like coffee we go in and fix that ourselves from the drink line. If it is a juice or food we ask the dietary staff and they will give it to us. CNA #7 was asked what the process was for staff entering the kitchen. CNA #7 stated, We sanitize our hands and go in. During an interview in the conference room on 8/13/14 at 8:40 AM, the head cook was asked to explain the signs posted at the corners of tray line. The head cook stated, That is to let staff and visitors know they are not go past those signs. Past those signs they have to wear hair nets but only dietary staff are past those signs. The head cook was asked about entering the kitchen. The head cook stated, Staff and visitors can come into the front area. They do not have to wear hairnets, they can get drinks. The doors are open to allow staff and visitors to come in to fix their drinks. During an interview in the conference room on 8/13/14 at 9:00 AM, the DON was asked about staff in the kitchen. The DON stated, Staff and visitors can go into the front area of the kitchen. They cannot go past the tray line. They can go in and get drinks. We don't have to wear hairnets in the area we can go in. The DON confirmed a resident census of 92 with 5 residents currently under isolation precautions. During an interview in the conference room on 8/13/14 at 12:45 PM, the Registered Dietician (RD) was asked what her expectations were regarding the kitchen doors. The RD stated, The doors leading into the kitchen food serving area are suppose to be closed. The door leading into the dietary office hallway is sometimes closed and sometimes open. The RD was asked what her expectation were regarding hairnet use in the kitchen. The RD stated, Anyone going beyond the tray line has to have either a hairnet on or a cap. The RD was asked what her expectations were regarding non dietary staff entering the kitchen. The RD stated, Staff can go into the kitchen up to the tray line. There are signs at the ends of the tray line for dietary staff only past that point. The RD was asked if staff in these areas are required to have hairnets on. The RD stated, No, as long as they don't go past the tray line. The RD was asked what her expectations were regarding family going into the kitchen. The RD stated, It is the same, they cannot go past the tray line area. They do not have to have on hairnets in the front part of the kitchen at the tray line. The facility failed to ensure that food was protected from sources of physical contamination such as hair and from other sources of contamination. 6. Review of the facility's Safety & Sanitation Best Practice Guidelines HANDWASHING policy documented, .OUTCOME: All partners handling food products or contacting equipment in food preparation should wash their hands . The basic practice of hand washing is the single most important action that can be taken to prevent the spread of disease . GUIDELINES: 1. Hands should be washed . after touching hair, face, or body . touching clothing . or after touching anything that might contaminate hands . Observations in Resident #65's room on 8/11/14 at 7:42 AM, revealed CNA #3 repositioned Resident #65, adjusted the resident's underpad and removed a pillow between her legs, touching the resident's legs. CNA #3 continued to set up the meal tray, then started to assist Resident #65 to eat, without performing hand hygiene. During an interview in front of the conference room on 8/13/14 12:40 PM, the DON was asked what should staff do while passing meal trays or assisting a resident to eat after touching a resident or inanimate objects. The DON stated, They (staff) should wash their hands.",2018-01-01
9246,"NHC HEALTHCARE, MILAN",445069,8017 DOGWOOD LANE P O BOX A,MILAN,TN,38358,2013-05-23,157,D,0,1,H1TY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, it was determined the facility failed to notify the physician of a severe weight loss for 1 of 3 (Resident #167) sampled residents reviewed of the 15 residents with nutritional concerns. The findings included: Review of the facility's DOCUMENTATION GUIDELINES policy documented, .Weights . Any unusual variation in weights . report to licensed nurse who reports to physician and dietitian . Medical record review for Resident #167 documented an admission date of [DATE] and discharge date of [DATE] with [DIAGNOSES REDACTED]. Review of a dietary note dated 12/18/12 documented, .Weight records indicate 7# (pounds) (5.9% (percent)) weight loss since admission . Mini Nutrition Assessment (MNA) completed with a score indicating malnutrition . Recommend: med pass supplement with each med (medication) pass for additional calories and protein . A dietary note dated 1/8/13 documented, .Weight records indicate pt (patient) has lost 12# (9.7%) since admission . Mini Nutrition Assessment score indicates malnutrition . pt (patient) reports that she had not tried the med pass supplement yet . Review of Resident #167's weight records documented, 12/11/12 - 119#, 12/18/12 - 112#, 12/26/12 -109.6#, 1/2/13 - 106.8# and 1/8/13 - 107.4#. There was no documentation in the medical record that the physician had been notified of Resident #167's 10% weight loss. During an interview in the conference room on 5/22/13 at 11:55 AM, the Registered Dietician (RD) stated, .nurses notify MD (Medical Doctor) of weight loss . they go by weights they document on the flow sheet . During an interview in the conference room on 5/22/13 at 11:58 AM, the Director of Nursing (DON) was asked if the nurses are required to notify the physician when there is a significant or severe weight loss. The DON stated, Yes . Nurses are required to notify the doctor of weight loss . The doctor is notified by fax by the nurses . I couldn't locate a fax for (named Resident #167's weight loss) . They (nurses) didn't document it .",2017-01-01
9247,"NHC HEALTHCARE, MILAN",445069,8017 DOGWOOD LANE P O BOX A,MILAN,TN,38358,2013-05-23,278,D,0,1,H1TY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, it was determined the facility failed to the Minimum Data Set (MDS) was complete and accurate for nutritional status for 1 of 3 (Resident #167) sampled residents reviewed of the 15 residents with nutritional concerns. The findings included: Review of facility's Long-Term Care Facility Resident Assessment Instrument User's Manual Version 3.0 October, 2012 policy documented, .Definitions PHYSICIAN - PRESCRIBED WEIGHT LOSS REGIMEN A weight reduction plan ordered by the resident's physician with the care plan goal of weight reduction. May employ a calorie-restricted diet or other weight loss diets and exercise. Also includes planned diuresis. It is important that weight loss is intentional . Coding Instructions Code 1, yes on physician-prescribed weight-loss regimen: if the resident has experienced a weight loss of 5% (percent) or more in the past 30 days or 10% or more in the last 180 days, and the weight loss was planned and pursuant to a physician's orders [REDACTED]. Medical record review for Resident #167 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the vital sign flow sheet documented the following weights: 12/11/12 - 119 pounds (#) admission weight, 12/18/12 - 112#, 12/26/12 - 109.6# (7.5% weight loss in 15 days), 1/2/13 - 106.8#, 1/8/13 - 107.4#, 1/17/13 - 105.6# (10% weight loss in a month), 1/22/13 - 104.4#, 2/1/13 - 104#, 2/3/13 - 104.4#, 2/12/13 - 106.4# and 3/8/13 102.6#. The Physician's admission orders [REDACTED]. The admission MDS dated [DATE], and the 14 day MDS dated [DATE] documented, K0300. Weight Loss Loss of 5% or more in the last month or loss of 10% or more in last 6 months 1. Yes, on physician - prescribed weight-loss regimen . During an interview in the conference room on 5/22/13 at 11:55 AM, the Registered Dietician stated, Admission note documented [MEDICAL CONDITION] on admission. Nurse document the weights. I usually look at the weights over a 30/90/60/days . She (Resident #167) was on [MEDICATION NAME], so she had a physician's orders [REDACTED].*No order found for [MEDICATION NAME].* She didn't have a order then . In February she got med pass supplement and in March she had a 2 pound weight gain. She was admitted [DATE] with [MEDICAL CONDITION] probably came from nursing admission assessment. Yes, on 12/12/12 the nurse documented 2T (plus) [MEDICAL CONDITION] to right lower extremity. Med pass supplements are documented in my notes . If a resident is on [MEDICATION NAME] for [MEDICAL CONDITION] I mark yes on a planned weight loss program, this is MDS instruction on the help screen. During an interview in the conference room on 5/22/13 at 11:55 AM the Director of Nursing (DON) stated, We don't document med pass, doesn't require an order, we only document prescribed supplements. Nurses are required to notify the MD of weight loss. The MD is notified by fax by the nurses. There is a purple sheet on the MARS, this alerts nurses to give with med pass, they are suppose to give with med pass documentation is not on the MARS, we don't document RD (Registered Dietitian) recommendations we only document MD prescribed supplements . the MDS is based on entire medical record, Section K of MDS (named RD) does that part. The MDS dated [DATE] and 12/25/12 inaccurately documented the resident was on a physician's prescribed weight loss regimen order.",2017-01-01
9248,"NHC HEALTHCARE, MILAN",445069,8017 DOGWOOD LANE P O BOX A,MILAN,TN,38358,2013-05-23,315,D,0,1,H1TY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, it was determined the facility failed to ensure strict intake and output was documented for 1 of 2 (Resident #13) sampled residents of the 2 residents include in the stage 2 review with foley catheters. The findings included: Review of the facility's DOCUMENTATION GUIDELINES policy documented, .Intake and Output Records are used when requested by a physician . records include . Total fluid intake in ml's (milliliters) . total fluid output in ml's . Correct addition of total fluids for 24 hours . Medical record review for Resident #13 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].Insert #16/5 F/C (foley catheter) to BSD (bedside drain) R/T (related to) need for strict I&O (intake and output) X (times) 30 days & (and) reassess - F/C care q (every) shift & prn (as needed) - (symbol for change) F/C prn and q 30 days. The facility was unable to provide documentation of intake on the I&O record for 5/14/13 through 5/21/13. During an interview in the conference room on 5/22/13 at 2:25 PM, the Director of Nursing (DON) was asked why Resident #13 had a foley catheter. The DON stated, .Strict I and O . monitoring intake and output to record what she is taking in and putting out . The DON was asked where the intake and output was documented. The DON stated, The intake and output sheet . The DON confirmed that Resident #13's intake was not documented as ordered by the physician.",2017-01-01
9249,"NHC HEALTHCARE, MILAN",445069,8017 DOGWOOD LANE P O BOX A,MILAN,TN,38358,2013-05-23,325,D,0,1,H1TY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, it was determined the facility failed to ensure each resident received nutritional interventions to maintain acceptable nutritional status to maintain and prevent weight loss for 1 of 3 (Resident #167) sampled residents reviewed of the 15 residents with nutritional concerns. The findings included: Review of the facility's Clinical Resource/Best Practice Guidelines for Dietary Services policy documented, .A high calorie, high protein commercial supplement will be given during medication pass . Review of the facility's MED PASS SUPPLEMENT PROCEDURE FOR PLACING PATIENT policy documented, .PURPOSE: To assure patients receive Med Pass Supplement when nutritional status warrants . MED NURSE . Give med pass supplement . Review of the facility's UNPLANNED WEIGHT LOSS policy documented, .Implement interventions and evaluate outcomes . Revise goals and approaches as needed . Medical record review for Resident #167 documented an admission date of [DATE] and discharge date of [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive care plan with an admission date of [DATE] and updated 3/12/13 documented, .BMI (Body Mass Index) During an interview in the conference room on 5/22/13 at 11:55 AM, the Registered Dietician (RD) stated, I document in my notes if a resident gets supplements . nurses notify the doctor of weight loss . I go over the 30, 60 and 90 days weights . she (Resident #167) got med pass supplement . Med pass supplements are documented in my notes . The nurses document in the MAR (Medication Administration Record) if they have a med pass supplement . During an interview in the conference room on 5/22/13 at 11:58 AM, the Director of Nursing (DON) was asked for documentation of the med pass supplement provided for Resident #167. The DON stated, .We don't document med pass . doesn't require an order . we only document prescribed supplements . There is a purple sheet on the MARs . this alerts nurses to give with med pass . they are suppose to give with med pass . documentation is not on the MARs . we don't document RD recommendations we only document MD prescribed supplements . During an interview in the conference room on 5/23/13 at 8:40 AM, the DON was asked to provide the House Med. Pass, Meal %, BM (bowel movement) Tracking Sheet for December 2012 that documented the Med Pass supplement was administered to Resident #167. The DON stated, We destroy them after 6 months . don't have December (2012) . The DON was asked if there is a policy or procedure for weight loss. The DON stated, There isn't a written policy . There is a procedure . The Restorative Team weighs the resident . If a discrepancy is found the team notifies the nurse . nurse verifies discrepancy . discrepancy referred to Dietician . Dietician works from that form .",2017-01-01
11721,"NHC HEALTHCARE, MILAN",445069,8017 DOGWOOD LANE P O BOX A,MILAN,TN,38358,2012-02-28,156,D,0,1,V9VF11,"Based on review of Advanced Beneficiary Notices (ABN) and interview, it was determined the facility failed to ensure advanced notice of the estimated cost per day to continue services when Medicare benefits were expected to end for 3 of 3 (Resident #17 and Random Residents (RR) #4 and 5) residents reviewed for ABN. The findings included: Review of the ABN for Resident #17, RR #4 and RR #5 revealed Medicare coverage would end 2/23/12. Review of the signature page revealed no signatures of the patient or the authorized representative. During an interview in the conference room on 2/28/12 at 1:10 PM, the Social Worker (SW) was asked when the ABN notices were mailed. The SW stated, .mailed them 2/23/12. The SW was asked for any ABN letters prior to the 2/23/12 letters. The SW stated, .can't find any of last years. this is all I have.",2015-11-01
11722,"NHC HEALTHCARE, MILAN",445069,8017 DOGWOOD LANE P O BOX A,MILAN,TN,38358,2012-02-28,164,D,0,1,V9VF11,"**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 privacy of medical records was maintained when 1 of 8 (Nurse #1) nurses left the Medication Administration Record [REDACTED]. The findings included: Review of the facility's PREPARATION AND GENERAL GUIDELINES policy documented, .privacy is maintained at all times for all resident information (e.g. (such as) MAR) by closing the MAR indicated [REDACTED] Observations on the family 1 hall on 2/26/12 at 11:30 AM, Nurse #1 walked away from room [ROOM NUMBER]A with the MAR indicated [REDACTED]. Observations on the family 1 hall on 2/26/12 at 11:45 AM, Nurse #1 walked away from the medication cart with the MAR indicated [REDACTED] During an interview in the Director of Nursing's (DON) office on 2/27/12 at 11:50 AM, the DON confirmed the MAR indicated [REDACTED]",2015-11-01
11723,"NHC HEALTHCARE, MILAN",445069,8017 DOGWOOD LANE P O BOX A,MILAN,TN,38358,2012-02-28,246,E,0,1,V9VF11,"Based on policy review, observation and interview, it was determined the facility failed to ensure the call light was within residents' reach for 5 of 19 sampled residents observed (Residents #2, 6, 9, 16 and 18) and random residents (RR) #1, 2, 3 and 4. The findings included: 1. Review of the facility's CALL LIGHTS policy documented, .8. Be sure the call light is always within easy reach of the patient. 2. Observation in Resident #2's room on 2/27/12 at 11:00 AM, revealed the call light was tied to the top of the left siderail out of Resident #2's reach. During an interview in Resident #2's room on 2/27/12 at 4:10 PM, Resident #2 was asked if she could reach the call light. Resident #2 stated, No, I just ask (named her roommate) to push her button for me. 3. Observations in Resident #6's room on 2/27/12 at 11:00 AM and 12:15 PM, revealed Resident #6 seated in a wheelchair. The call light was clipped to her pants with the push button hanging near the floor out of Resident #6's reach. During an interview in Resident #6's room on 2/27/12 at 12:15 PM, Nurse #3 was asked if Resident #6 could reach her call light. Nurse #3 stated, No. 4. Observations in Resident #9's room on 2/27/12 at 8:10 AM, revealed Resident #9 seated in bed with the breakfast tray on the overbed table. The call light was tied to the top of the left siderail out of Resident #9's reach. During an interview in Resident #9's room on 2/27/12 at 8:10 AM, Resident #9 was asked where the call light was. Resident #9 stated, I don't know. Resident #9 was asked how she could get help if needed. Resident #9 shrugged her shoulders and did not verbalize a reply. 5. Observations in Resident #16's room on 2/27/12 at 2:30 PM and 4:30 PM, revealed Resident #16 lying in bed with the call light lying at the foot of the bed out of Resident #16's reach. Observations in Resident #16's room on 2/28/12 at 7:35 AM, revealed Resident #16 lying in bed with the call light out of reach. The call light was draped over the bedrail at the foot of the bed with only a short section of the cord visualized. There was no push button observed. 6. Observations in Resident #18's room on 2/28/12 at 7:45 AM, revealed Resident #18 lying in bed. The call light was on the floor behind the bed out of Resident #18's reach. During an interview in Resident #18's room on 2/28/12 at 7:45 AM, Certified Nursing Assistant (CNA) #8 confirmed Resident #18 could not reach her call light. 7. Observations in RR #1's room on 2/26/12 at 8:22 AM, revealed RR #1 seated in a wheelchair. The call light was at the end of the bed out of RR #1's reach. 8. Observations in RR #2's room on 2/26/12 at 8:48 AM, revealed RR #2 seated in a wheelchair. The call light was on RR #3's bed out of RR #2's reach. During an interview in RR #2's room on 2/26/12 at 8:48 AM, RR #2 was asked where her call light was. RR #2 stated, I don't know. I usually just call, nurse, nurse. Observations in RR #2's room on 2/27/12 at 7:00 AM, revealed RR #2 seated in a wheelchair. The call light was on the end of the bed covered by the privacy curtain out of RR #2's reach. 9. Observations in RR #3's room on 2/26/12 at 8:48 AM, revealed RR #3 seated in a wheelchair. The call light was on RR #3's bed out of RR #3's reach. Observations in RR #3's room on 2/27/12 at 7:00 AM, revealed RR #3 seated in a wheelchair calling out help me. The call light was on RR # 3's bed out of RR #3's reach. Observations in RR #3's room on 2/27/12 at 4:35 PM, revealed RR #3 seated in a wheelchair calling out, Help, Help. The call light was on RR #3's bed out of RR #3's reach. During an interview in RR #3's room on 2/27/12 at 4:35 PM, RR #3 was asked if she could reach her call light. RR #3 stated, .No, I don't think I can. During an interview in RR #3's room on 2/27/12 at 7:00 AM, CNA #7 was asked if RR #3 could reach her call light. CNA #7 stated, No. 10. Observations in RR #4's room on 2/26/12 at 8:58 AM, revealed RR #4 seated in a wheelchair. The call light was on the floor out of RR #4's reach.",2015-11-01
11724,"NHC HEALTHCARE, MILAN",445069,8017 DOGWOOD LANE P O BOX A,MILAN,TN,38358,2012-02-28,278,D,0,1,V9VF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, it was determined the facility failed to ensure the accuracy of the Minimum Data Set (MDS) related to height and oxygen therapy for 2 of 22 (Residents #6 and 10) sampled residents. The findings included: 1. Medical record review for Resident #6 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS dated [DATE] documented, .K0200. Height. 66 inches. Review of the quarterly MDS dated [DATE] documented, .K0200. Height. 65 inches. During an interview at family 3 and 4 nurses' station, on 2/28/12 at 8:05 PM, Nurse #7 confirmed the height on the quarterly MDS dated [DATE] was incorrect. 2. Medical record review for Resident #10 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].12/08/11: O2 (oxygen) @ (at) 2- (to) 3 LPM (liters per minute) BNC (binasal cannula) PRN (as needed) SOB (shortness of breath). Review of the quarterly MDS dated [DATE] did not document oxygen therapy. Observations in Resident #10's room on 2/26/12 at 8:50 AM, 2:25 PM and 3:25 PM, revealed Resident #10 with oxygen in use. During an interview in the MDS office on 2/28/12 at 9:00 AM, Nurse #7 confirmed the oxygen therapy on the quarterly MDS dated [DATE] was incorrect.",2015-11-01
11725,"NHC HEALTHCARE, MILAN",445069,8017 DOGWOOD LANE P O BOX A,MILAN,TN,38358,2012-02-28,315,D,0,1,V9VF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Long-Term Care Pocket Guide for Infection Control, policy review, medical record review, observation and interview, it was determined the facility failed to follow the physician's orders [REDACTED].#8 and 11) sampled residents with a foley catheter. The findings included: 1. Review of the facility's USE OF FOLEY CATHETER policy documented, .Follow the Physician order [REDACTED].>2. Review of the Long-Term Care Pocket Guide for Infection Control documented, .Remove gloves after contact with a resident/ the surrounding environment (including medical equipment) using proper technique to prevent hand contamination. Medical record review for Resident #8 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED].# (number) 16/(catheter size)/10 (bulb size) F/C (Foley catheter) to BSD (bedside drain bag) D/T (due to) [MEDICAL CONDITION] FOLEY CATH (catheter) care every shift. Observations in Resident #8's room on 2/27/12 at 10:00 AM, revealed a Foley catheter size 16 catheter with 30 cubic centimeter (cc) bulb to bedside bag. During an interview in the conference room on 2/28/12 at 3:00 PM, the Director of Nursing (DON) confirmed that a 30 cc bulb was not the size ordered. Observations in Resident #8's room on 2/27/12 at 3:07 PM, revealed Certified Nursing Assistant (CNA #6) performed the catheter care. CNA #6 washed her hands, donned her gloves, adjusted the height of the bed, moved the Foley bag, lowered the rail, removed the diaper, removed the pillow between the legs and performed the catheter care without her changing gloves. CNA #6 finished the catheter care and reclosed the diaper, placed a pillow between Resident #8's legs, raised the side rail, bagged the dirty laundry, raised the head of the bed, emptied the wash basin, dried thoroughly and put it in the bedside table. CNA #6 removed and discarded her gloves at this time. 3. Medical record review for Resident #11 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].#18/5 F/C to BSB (bedside bag) R/T (related to) [MEDICAL CONDITION] Observations in Resident #11 room on 2/27/12 at 3:25 PM, revealed Resident #11 catheter size was 16 with a 5 cc bulb. During an interview at the family 1 nurses' station on 2/27/12 at 3:25 PM, Nurse #8 confirmed there was no order for a size 16/5 cc bulb Foley.",2015-11-01
11726,"NHC HEALTHCARE, MILAN",445069,8017 DOGWOOD LANE P O BOX A,MILAN,TN,38358,2012-02-28,431,D,0,1,V9VF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined the facility failed to ensure medications were not stored past their expiration date in 1 of 8 (South Medication Room) medication storage areas. The findings included: Observation in the South Medication Room on [DATE] at 9:47 AM, revealed the medication refrigerator contained one vial of Procrit 5,000 units/1 milliliter vial with an expiration date of ,[DATE] and two vials of Procrit 5,000 units/1 milliliter with an expiration date of ,[DATE]. During an interview in the South Medication Room on [DATE] at 9:47 AM, Nurse #6 confirmed the 3 vials of Procrit 5,,[DATE] milliliter were expired.",2015-11-01
11727,"NHC HEALTHCARE, MILAN",445069,8017 DOGWOOD LANE P O BOX A,MILAN,TN,38358,2012-02-28,441,E,0,1,V9VF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the American Society of Consultant Pharmacists Geriatric Medication Handbook, policy review, observation and interview, it was determined the facility failed to ensure 4 of 6 medication nurses (Nurses #1, 2, 3 and 5), 1 of 1 (Nurse #4) nurse performing a dressing change and 5 of 9 Certified Nursing Assistants (CNAs #1, 2, 3, 4 and 9) maintained infection control practices to prevent the possibility of cross contamination by improper hand hygiene or improper cleaning of shared medical equipment. The findings included: 1. Review of the facility's HANDWASHING policy documented, .Wash hands before and after contact with each patient. and before and after removal of gloves. Review of the facility's PREPARATION AND GENERAL GUIDELINES policy documented, .Hands are washed before and after examination gloves are worn for administration of topical, ophthalmic, infections, enteral, rectal, and vaginal medications. 2. Observations outside room [ROOM NUMBER]A on 2/26/12 at 11:30 AM, revealed Nurse #1 pushed resident into the room per wheelchair, returned to the medication cart, donned gloves with no handwashing after touching the environment prior to donning gloves. Upon entering room [ROOM NUMBER]A, Nurse #1 placed the glucometer on the resident's wheelchair and trouser leg with no barrier. After performing the fingerstick, Nurse #1 returned to the medication cart, placed the glucometer on top of the medication cart with no barrier before cleaning, removed the soiled gloves, and donned new gloves without handwashing. Observations in room [ROOM NUMBER]A on 2/26/12 at 11:40 AM, revealed Nurse #1 placed the glucometer on the overbed table with no barrier, performed the procedure, then returned the glucometer to the top of the medication cart with no barrier prior to cleaning. Nurse #1 cleaned the glucometer wearing gloves, removed gloves, then proceeded to the next task with no handwashing after glove removal. Observations in room [ROOM NUMBER]B on 2/26/12 at 11:42 AM, revealed Nurse #1 donned gloves without handwashing after previous glove removal. Nurse #1 placed the glucometer on the bed linen with no barrier. The resident in room [ROOM NUMBER]B was in contact isolation for Methicillin Resistant Staphylococcus Aureus (MRSA) wound infection. After performing the procedure, Nurse #1 returned the glucometer to the top of the medication cart with no barrier, cleaned the glucometer, then removed gloves with no handwashing after glove removal. Observations in room [ROOM NUMBER]A on 2/26/12 at 11:45 AM, revealed Nurse #1 donned gloves without handwashing after previous glove removal, Nurse #1 placed the glucometer on the overbed table with no barrier, performed the procedure, then returned the glucometer to the top of the medication cart with no barrier prior to cleaning. Observations in room [ROOM NUMBER] on 2/26/12 at 11:50 AM, revealed Nurse #1 donned gloves without handwashing after previous glove removal. Nurse #1 placed the glucometer on the bed linen with no barrier, performed the procedure, then returned the glucometer to the top of the medication cart with no barrier prior to cleaning. Nurse #1 cleaned the glucometer, removed gloves, did not wash hands, proceeded to the medication cart, and drew up Insulin into a syringe. Nurse #1 returned to room [ROOM NUMBER], placed the Insulin syringe on the bed, donned gloves without washing hands, retrieved the Insulin syringe from the bed and placed the capped end of the syringe into her mouth, pulling the cap off with her teeth prior to administering the injection to the resident. During an interview in the conference room on 2/28/12 at 8:30 AM, the Director of Nursing (DON) was asked if it was an acceptable practice for a nurse to remove a syringe cap with her mouth prior to administering a subcutaneous injection. The DON replied, .No, it is not okay to remove a cap with your teeth. 3. Observations in room [ROOM NUMBER] on 2/26/12 at 4:40 PM, revealed Nurse #2 placed the glucometer on the overbed table with no barrier. Nurse #2 performed fingerstick wearing gloves, removed gloves, and without washing hands donned new gloves. Nurse #2 returned the glucometer to the top of the medication cart with no barrier, cleaned the glucometer and removed gloves, with no handwashing after glove removal. Observations in room [ROOM NUMBER]B on 2/26/12 at 4:50 PM, revealed Nurse #2 gathered the supplies needed for fingerstick procedure without washing hands after previous glove removal. Nurse #2 donned gloves, placed the glucometer on the overbed table with no barrier, performed the procedure, then returned the glucometer to the top of the medication cart with no barrier prior to cleaning, then removed gloves with no handwashing after glove removal. 4. During an interview in the DON's office on 2/27/12 at 11:50 AM, the DON was asked what her expectations were for handwashing after glove removal. The DON replied, .wash hands after glove removal. The DON was asked what her expectations were for cleaning of glucometers. The DON replied, .expect glucometer to be cleaned prior to and after use. was not aware barrier needed. 5. Review of American Society of Consultant Pharmacists Geriatric Medication Handbook, 10th Edition, documented, .Eyedrop Administration. If administering medication to BOTH eyes. change gloves between eyes. Observations in room [ROOM NUMBER] on 2/27/12 at 8:37 AM, revealed Nurse #3 administered one eye drop to the resident's left eye, then used the same gloved hands to administer one eye drop to the resident's right eye, with no glove change or handwashing between eyes. Observations in room [ROOM NUMBER] on 2/27/12 at 8:42 AM, revealed Nurse #3 administered one eye drop to the resident's left eye, then used the same gloved hands to administer one eye drop to the resident's left eye, with no glove change or handwashing between eyes. 6. Observations on the family 4 hall on 2/26/12 at 4:30 PM, revealed Nurse #5 placed glucometer supplies in a tray. Nurse #5 took the tray into the resident's room, placed it on the bedside table, performed the procedure, and returned the tray to the medication cart. Nurse #5 was not observed to clean the tray. 7. Review of the facility's Cleaning of Shared Medical Equipment policy documented, .1. Apply gloves 2. Clean shared medical equipment with sodium hypochlorite solution 1: (to) 10. Observations during a dressing change in Resident #13's room on 2/27/12 at 8:50 AM, Nurse #4 used her scissors to cut [MEDICATION NAME] then placed the scissors on the overbed table. Nurse #4 completed the dressing change, removed her gloves and washed her hands. Nurse #4 carried the scissors out of the room on a towel, placed the towel in a bin in the soiled utility room then placed the scissors in her pocket without cleaning the scissors. Nurse #4 washed her hands, removed the scissors from her pocket, cleaned the scissors with alcohol and placed the scissors in the drawer of the treatment cart. Nurse #4 did not use sodium hypochlorite solution or wear gloves to clean the scissors as per policy. During an interview on the family 1 hall on 2/27/12 at 9:30 AM, Nurse #4 confirmed she had placed the scissors on the table without a barrier, then placed the scissors in her pocket without cleaning them. Nurse #4 confirmed when she did clean the scissors, she used alcohol. During an interview at the family 1 and 2 nurses' station on 2/28/12 at 10:45 AM, the DON was asked what reusable equipment such as scissors should be cleaned with. The DON stated, .sani cloth. 8. Observations in the dependent dining room on 2/26/12 at 11:22 AM, revealed CNA #1 moved a chair to the dining table then fed the resident without using hand sanitizer or washing her hands. 9. Observations in the dependent dining room on 2/26/12 at 11:25 AM, revealed CNA #2 moved a chair to the dining table then fed the resident without using hand sanitizer or washing her hands. 10. Observations in the dependent dining room on 2/26/12 at 11:27 AM, revealed CNA #3 moved a chair to the dining table then fed the resident without using hand sanitizer or washing her hands. 11. Observations in the dependent dining room on 2/26/12 at 11:35 AM, revealed CNA #4 moved a chair to the dining table then fed the resident without using hand sanitizer or washing her hands. 12. Observations in room [ROOM NUMBER]A on 2/27/12 at 11:30 AM, revealed CNA #9 moved the resident's chair, moved the overbed table in front of the resident, placed the napkin on the resident's lap, placed the fork on the plate, put the salad dressing on the resident's salad, handled the straw and placed it in the milk, added artificial sweetener to the iced tea, and fed the resident a bite of the pie without washing her hands between tasks.",2015-11-01
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
5331,CLAIBORNE HEALTH AND REHABILITATION CENTER,445071,1850 OLD KNOXVILLE ROAD,TAZEWELL,TN,37879,2016-02-03,241,D,0,1,7BBB11,"**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 respect resident privacy for 1 resident (#26) of 32 residents reviewed. The findings included: Review of facility policy Resident's Rights Under Federal Law, revised 1/14, revealed .has the right to personal privacy and confidentiality of his or her personal and clinical records . Resident #26 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #26 was severely cognitively impaired. Observation of Resident #26 on 2/3/16 at 10:46 AM, in the resident's room, revealed Licensed Practical Nurse (LPN) #1 and Certified Nursing Assistant (CNA) #1 completing a dressing change for a pressure ulcer. Continued observation revealed CNA #2 pushed open the resident's door without knocking and began talking in a loud voice .(CNA #1) are you in here? CNA #2 continued to walk forward to the end of the resident's bed and spoke with CNA #1 about another resident while the treatment was in process for Resident #26. Interview with CNA #2 on 2/3/16 at 11:03 AM in the 100 Hall (First Floor) hallway, confirmed .I didn't wait for a response. I just walked in while the treatment was going on . and began discussing another resident in the presence of Resident #26 while a treatment was taking place. Interview with the Administrator on 2/3/16 at 1:30 PM, in the Administrator's office, confirmed .expect the staff to knock on the resident's door and wait for a response to enter .",2019-03-01
5332,CLAIBORNE HEALTH AND REHABILITATION CENTER,445071,1850 OLD KNOXVILLE ROAD,TAZEWELL,TN,37879,2016-02-03,441,D,0,1,7BBB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, review of a Journal of Wound, Ostomy and Continence Nursing, medical record review, observation, and interview, the facility failed to ensure infection control standards were maintained during a pressure ulcer dressing change for 1 resident (#26) of 3 residents reviewed for pressure ulcers of 32 sampled residents. The findings included: Review of facility policy Nursing Home Skin Care Policy, undated, revealed .to use clean technique in performing dressing changes .Universal precautions are utilized . Review of Journal of Wound, Ostomy and Continence Nursing (March/April 2012), Clean vs. (versus) Sterile Dressing Techniques for Management of Chronic Wounds: A Fact Sheet revealed .clean technique .involves strategies used in patient care to reduce the number of microorganisms .involves meticulous handwashing, maintaining a clean environment by preparing a clean field, using clean gloves .preventing direct contamination of materials and supplies . Resident #26 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #26 .1 unstageable - deep tissue: suspected deep tissue injury in evolution . Medical record review of a physician telephone order dated 12/15/15 revealed .pack wound .Dakins Solution (a dilute solution containing sodium hypochlorite and boric acid, used as an antiseptic in the treatment of [REDACTED]. 1/2 strength wet to dry. Cover /c (with) dry gauze wrap /c Kerlix/Conform. Secure /c tape .change BID (twice a day) . Medical record review of Nurse's Treatment Notes dated 1/29/16 revealed .DTI (deep tissue injury) to left heel measures 6.5 cm (centimeters) L (Length) x 6.0 cm W (Width) x 0 cm d (Depth) .75% black soft eschar (a scab or dry crust that results from trauma, such as a thermal or chemical burn, infection, or excoriating skin disease) /c 25% soft yellow slough .(no) odor noted moderate serous discharge . Observation on 2/3/16 at 10:46 AM, in the resident's room, revealed the Wound Care Nurse obtained gauze, packs of 4x4's, Dakins Solution poured on to a 4x4, a drape, and tape, and walked into the resident room and placed the items on the bedside table. Continued observation at 10:49 AM, revealed the Wound Care Nurse dropped the old removed wet to dry dressing on the clean work field, then picked the dressing up and threw it away in a garbage bag at the end of Resident #26's bed. Further observation revealed the Wound Care Nurse turned to the bedside table, opened two clean 4x4 packages, and pulled one 4x4 out with the dirty gloves used to remove the old dressing. Continued observation revealed the Wound Care Nurse sprayed Resident #26's left foot with saline which ran onto a drape under the foot. Certified Nursing Assistant (CNA) #1 dropped Resident #26's foot into the contaminated saline water on the drape under Resident #26's foot. Further observation revealed the Wound Care Nurse opened additional clean 4x4 packages, pat dried Resident #26's foot, took the gloves off, and walked to the treatment cart outside Resident #26's room, without washing the hands, to collect more clean 4x4's. Continued observation revealed the Wound Care Nurse placed the clean 4x4's on the bedside table work field, placed new clean gloves on without washing the hands, squeezed out excess Dakins Solution from a 4x4, placed it on the resident's left heel, and began wrapping Resident #26's foot with Kerlix. Further observation revealed, while wrapping Resident #26's foot, the Wound Care Nurse dropped the Kerlix into the contaminated saline water on the drape under Resident #26's foot, picked the Kerlix up, continued wrapping resident's foot with the contaminated Kerlix, and secured it with tape. Interview with the Wound Care Nurse on 2/3/16 at 10:57 AM, in the hallway outside Resident #26's room, confirmed she failed to ensure infection control standards were followed during the dressing change.",2019-03-01
6879,CLAIBORNE HEALTH AND REHABILITATION CENTER,445071,1850 OLD KNOXVILLE ROAD,TAZEWELL,TN,37879,2015-01-07,176,D,0,1,B3BC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, facility policy review, and interview, the facility failed to assess two (#86, #3) of five residents reviewed for self-administration of medications. The findings included: Resident #86 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation during a medication administration pass on January 5, 2015, at 9:30 a.m., revealed Licensed Practical Nurse (LPN) #1 was administering medications to resident #86. Continued observation revealed the LPN handed a Flo Vent Diskus Aerosol inhaler to the resident to self-administer. Further observation revealed the resident self-administered the medication by inhaling one puff. Medical record review of a physician's order dated January 1, 2015, revealed, [MEDICATION NAME] Diskus Aerosol 250 mg (milligram) 1 puff inhale orally two times a day. Continued review revealed no physician's order to self-administer medications. Further medical record review revealed no assessment for self-administration of medications had been completed. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation during a medication administration pass on January 5, 2015, at 9:40 a.m., revealed LPN #2 was administering medications to the resident. Continued observation revealed LPN #2 handed the resident the nose spray [MEDICATION NAME] to self-administer. Further observation revealed the resident attempted three sprays to one nostril. Continued observation revealed the nurse at that time took the medication and administered one puff to the other nostril. Medical record review of a physician's order dated December 15, 2014, revealed, [MEDICATION NAME] 1 spray in both nostrils one time a day. Continued review revealed no physician's order to self-administer medications. Further medical record review revealed no assessment for self-administration of medications had been completed. Review of the facility's policy Self Administration of Drugs revealed, Upon order of the attending physician and resident's request for self- administration of medication .the interdisciplinary team will start the evaluation process .If the evaluation indicates the resident is able to self-administer, such will be entered into the resident's care plan .The physician's order sheet will state when and which medications will be self-administered by the resident. Interview with the Director of Nursing on January 6, 2015, at 3:30 p.m., in the conference room, confirmed residents' #86 and #3 had not been assessed to self-administer medications and physician's orders had not been obtained for self-administration of medications.",2018-04-01
6880,CLAIBORNE HEALTH AND REHABILITATION CENTER,445071,1850 OLD KNOXVILLE ROAD,TAZEWELL,TN,37879,2015-01-07,282,D,0,1,B3BC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, observation, and interview, the facility failed to follow the care plan for one resident (#115) of thirty residents reviewed. The findings included: Resident #115 was admitted to the facility on [DATE], for [DIAGNOSES REDACTED]. Medical record review of a physician's recapitulation order dated December 2014, revealed, .fallen star program RSD (resident) to wear red non skid socks when not wearing regular shoes . Medical record review of a fall risk assessment dated [DATE], revealed Resident #115 scored a 12, indicating the resident was at high risk for falls. Medical record review of the resident's care plan, last revised December 15, 2014, revealed, .fallen star program .red non skid socks when not wearing regular shoes . Review of facility policy Falling Star Program, last revised on May, 2008, revealed, .residents who have a history of frequent falls or have high risk factors for falling will be identified .plan of care shall be updated with the plan that is being used to prevent falls .when resident is out of room non-skid red socks will be on resident for high visibility to enhance staff awareness .will alert all staff of the potential for falls . Observation on January 7, 2015, at 9:17 a.m., revealed Resident #115 was sitting in a chair in the second floor day room. Continued observation revealed the resident was wearing blue and pink striped fuzzy socks and no shoes. Interview with Licensed Practical Nurse (LPN) #3 on January 7, 2015, at 9:24 a.m., at the second floor nurses station, revealed, .fallen star program means .wear red socks with tread on them when they aren't wearing shoes .that way we know they are a falls risk . Observation and interview with LPN #3 on January 7, 2015, at 9:30 a.m., in the second floor day room, confirmed the resident was not wearing red non-skid socks and she should be.",2018-04-01
6881,CLAIBORNE HEALTH AND REHABILITATION CENTER,445071,1850 OLD KNOXVILLE ROAD,TAZEWELL,TN,37879,2015-01-07,329,D,0,1,B3BC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, review of the Psychiatric Consultation, and interview, the facility failed to attempt a gradual dose reduction of an antipsychotic medication for one resident (#46) of five residents reviewed for unnecessary medications. The findings included: Resident #46 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation on January 5, 2015, at 3:00 p.m., revealed resident #46 sleeping in bed with a tube feeding infusing via a feeding pump at 50 milliliters per hour. Medical record review of the Psychiatric Progress Note dated September 18, 2014, revealed, .staff report patient is cooperative with care .no aggression .advanced [MEDICAL CONDITION] .no problems with sleep .no new or worsening anxious or agitated behaviors .Recommendations: 1.Consider discontinue [MEDICATION NAME] .Mood and Behaviors are stable . Medical record review of a Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had severe cognitive impairment and was totally dependent for all Activities of Daily Living (ADLs). Medical record review of the Order Summary Report for January 2015 revealed the resident received [MEDICATION NAME] 25 (an antipsychotic medication) one tablet via the PE[DEVICE] (percutaneous [MEDICAL CONDITION] gastric feeding tube) at bedtime each day. Interview with the Director of Nurses (DON) on January 7, 2015, at 8:40 a.m., outside of the DON's office, revealed the MDS Coordinator received a list each month of residents on psychoactive drugs and was responsible to coordinate gradual dose reductions. Interview with the MDS Coordinator on January 7, 2015, at 9:43 a.m., in the nursing station, confirmed the resident had continued on the same dose of [MEDICATION NAME] for twelve months; the nursing staff had not recorded any behaviors during the previous five months; the MDS Coordinator had no knowledge of behaviors related to the resident's [DIAGNOSES REDACTED].",2018-04-01
9117,CLAIBORNE COUNTY NURSING HOME,445071,1850 OLD KNOXVILLE ROAD,TAZEWELL,TN,37879,2013-11-19,161,C,0,1,U5R111,"Based on review of the facility's Long Term Care Facility Resident Fund Bond and review of the facility Aging Report balance, the facility failed to ensure the Surety Bond was greater than or equal to the amount of the combined resident funds. The findings included: Review of the facility Surety Bond revealed the bond was for a maximum amount of ten thousand dollars ($10,000.00). Review of the facility Aging Report (report with the combined resident trust total) revealed the combined total ending balance of the residents' trust accounts was $12,259.24. Interview with the Business Office Manager on November 18, 2013, at 12:51 p.m., in the Business Office, confirmed the facility failed to ensure the Surety Bond was greater than or equal to the amount of the resident funds.",2017-02-01
9118,CLAIBORNE COUNTY NURSING HOME,445071,1850 OLD KNOXVILLE ROAD,TAZEWELL,TN,37879,2013-11-19,323,D,0,1,U5R111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility falls investigations, and interview, the facility failed to ensure falls safety devices were in place and functioning for one resident (#39) of four residents reviewed for falls. The findings included: Resident #39 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the resident's Care Plan dated March 7, 2012, revealed, Potential for falls and injury due to: Hx (history) of falls .Mobile alarm. Bed alarm . Medical record review of an update to the Care Plan dated November 19, 2012, revealed, Resident had fall from bed on 11/17/12 at 1700 (5:00 p.m.) c (with) 0 (no) injury noted .Mobile alarm did not sound, bed alarm did sound . Medical record review of an update to the Care Plan dated December 10, 2012, revealed, Resident had a fall on 12/9/12 from low bed @ (at) 1720 (5:20 p.m.). Mobile & (and) bed alarm in use but did not sound. Staff to ensure alarms are working. 0 injury . Medical record review of the resident's Care Plan dated February 6, 2013, revealed, Potential for falls and injury due to .Hx of falls .Mobile Alarm. Bed alarm . Medical record review of an update to the Care Plan dated February 26, 2013, revealed, Resident had fall on 2/26/13 at 2030 (8:30 p.m.) from low bed c 5th toenail on Lt (left) foot torn off. Mobile was not attached possibly removed by resident. Also has bed alarm. Neither alarm sounded . Medical record review of the facility falls investigation dated February 26, 2013, revealed, .R (resident) on mat lying in floor .alarm not sounding .self-removal of mobile alarm . Medical record review of the Rehabilitation Screen dated February 28, 2013, revealed, Patient screened this date due to falls on 02-26-13 .mobile alarm was not attached .and bed alarm was not turned to the on position .Recommend education of staff in proper management of alarms and close supervision of patient . Medical record review of an update to the Care Plan dated April 10, 2013, revealed, Resident had fall on 4/10/13 at 0010 (12:10 a.m.) from low bed c no injuries. Bed alarm did not sound and mobile was not attached to resident. CNAs (Certified Nursing Assistants) instructed to make sure alarms are in place and working properly . Medical record review of a Rehabilitation Screen dated April 11, 2013, revealed, Pt (patient) seen this date 2 (secondary) to fall from bed on 4-10-13 .Pt has bed & mobile alarms in place however mobile alarm had come detached from pt & bed alarm was malfunctioning staff to check on this & recommed nursing to check mobile alarm often . Interview with the Minimum Data Set (MDS) nurse on November 18, 2013, at 9:47 a.m., in the MDS office, revealed the resident had one alarm placed under the resident in the bed (pressure alarm) and the resident was not capable of turning the alarm off. Further interview confirmed the bed alarm had malfunctioned and been replaced. Interviews with the Director of Nursing (DON) and the Maintenance Director on November 19, 2013, at 10:35 a.m., in the conference room, confirmed, .(resident #39) couldn't possibly turn on or off the bed alarm . Further interviews with the DON confirmed the facility failed to ensure the safety alarms were always attached to the resident, and turned on and functioning to prevent falls.",2017-02-01
9119,CLAIBORNE COUNTY NURSING HOME,445071,1850 OLD KNOXVILLE ROAD,TAZEWELL,TN,37879,2013-11-19,371,F,0,1,U5R111,"Based on observation, review of facility policy, and interview, the facility failed to store refrigerated and frozen foods to avoid contamination and failed to remove dented cans from dry storage in the Dietary Department. The findings included: Observation on November 17, 2013, at 9:20 a.m., in the dietary department revealed: 1. In the reach-in freezer, one package of eighteen breakfast burritos opened, undated, and available for use. 2. In the walk-in refrigerator, one five pound bag of shredded carrots with a hole in the side of the bag opened to air, undated, and available for use. 3. In the walk-in freezer, one five pound bag of chicken tenders open to air, undated, and available for use; one five pound bag of chicken filets open to air, undated, and available for use; a plastic bag containing six chicken breast filets open to air, undated, and available for use; and one ten pound bag of mixed vegetables opened to air, undated, and available for use. 4. In the stand-up freezer, twelve individual sized, angel food cakes stored unlabeled, undated, and available for use; one two pound bag of cod nuggets opened, unlabeled, undated, and available for use; and one two pound bag of battered cauliflower open unlabeled, undated, and available for use. 5. In the dry storage area, one seven pound can of vanilla pudding dented and stored available for resident use; and one seven pound can of green beans dented, and stored available for resident use. Review of the facility policy Sanitation and Storage, effective January 1994, revised January 2010, revealed, .any frozen foods that are frozen for left overs are to be covered and dated .no dented cans are to be opened and used . Interview with the Dietary Manager on November 17, 2013, at 10:30 a.m., in the Dietary Manager's office, confirmed refrigerated and frozen foods were to be labeled and dated, dented cans were to be removed from stock, and the foods were improperly stored.",2017-02-01
9120,CLAIBORNE COUNTY NURSING HOME,445071,1850 OLD KNOXVILLE ROAD,TAZEWELL,TN,37879,2013-11-19,412,D,0,1,U5R111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility policy, and interview, the facility failed to provide yearly dental services for one resident (#52) of twenty-two residents reviewed. The findings included: Resident #52 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the care plan, last updated on October 1, 2013, revealed, .dental services yearly and PRN (as needed) . Medical record review revealed the resident did not receive a dental evaluation until November 15, 2013, a time span of seventeen months. Review of the facility policy, Dental Services, effective April 1994, revised October 2012, revealed, .An assessment will be performed by a qualified dentist or by the resident's attending physician on an annual basis . Interview with the Director of Nursing (DON) on November 18, 2013, at 2:50 p.m., in the DON's office, confirmed no dental evaluation had been performed for seventeen months and the facility failed to provide dental services.",2017-02-01
11172,CLAIBORNE COUNTY NURSING HOME,445071,1850 OLD KNOXVILLE ROAD,TAZEWELL,TN,37879,2012-10-10,278,D,0,1,614411,"**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 accurately document the number of falls on the Quarterly Minimum Data Set for one resident (#8) of eighteen residents reviewed. The findings included: Resident #8 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of facility investigations revealed the resident had falls on June 12, 2012; June 15, 2012; July 4, 2012; July 18, 2012; July 20, 2012; July 29, 2012; August 14, 2012 and August 31, 2012, for a total of eight (8) falls between June 12, 2012 and August 31, 2012. Review of a Quarterly Minimum Data Set (MDS) dated [DATE], revealed documentation the resident had one fall with injury since prior MDS Initial assessment dated [DATE]. Interview on October 9, 2012, at 3:00 p.m., in the Dining Room, with the MDS Coordinator, confirmed the Quarterly MDS did not accurately document the number of falls the resident had experienced since the prior MDS.",2016-02-01
11173,CLAIBORNE COUNTY NURSING HOME,445071,1850 OLD KNOXVILLE ROAD,TAZEWELL,TN,37879,2012-10-10,322,D,0,1,614411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to label and date tube feeding solution for one resident (#5) of eighteen residents reviewed. The findings included: Resident #5 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation of the resident on October 8, 2012, at 1:00 p.m., 2:00 p.m., 3:45 p.m., and 4:30 p.m., revealed the resident receiving continuous tube feeding solution at 66 ml (milliliters) per hour via pump and gastrostomy tube (a tube surgically placed into the stomach through the abdominal wall). Continued observation revealed the solution was contained in a 1200 ml opaque plastic container with the manufacturer's label affixed and no date or time of administration was noted on the container or the line from the container to the resident. Interview with LPN #2 on October 8, 2012, at 4:35 p.m. at the 200 hall nursing station, revealed the administration of the solution began on October 7, 2012, at 10:00 p.m., and confirmed the facility had failed to ensure the time and date of administration was on the label.",2016-02-01
11174,CLAIBORNE COUNTY NURSING HOME,445071,1850 OLD KNOXVILLE ROAD,TAZEWELL,TN,37879,2012-10-10,323,D,0,1,614411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, review of facility investigation, and interview, the facility failed to ensure proper use of safety devices for two residents (#8, #13), failed to properly ensure the safety of one resident (#8) during transfer using a Hoyer lift, failed to document and ensure implementation of new interventions to prevent future falls for one resident (#8), and failed to transfer one resident (#12) per care plan, of eighteen residents reviewed. The findings included: Resident #8 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had severely impaired cognition and required extensive assistance with activities of daily living (ADLs). Observation of the resident's room on October 8, 2012, at 2:15 p.m., revealed alarms and motion sensors to each side of the resident's bed and fall mats to both sides of the resident's bed. Observation of the resident on October 8, 2012, at 2:30 p.m., outside the second floor nurse's station, revealed the resident sitting in a rocking wheelchair with sensor alarms to each side of the wheelchair and a wanderguard bracelet attached to the resident's right ankle. Review of facility investigations dated October 1, 2011, October 29, 2011, Novmber 2, 2011, November 14, 2011, December 29, 2011, and March 3, 2011, revealed the resident had falls without injury. Continued review revealed interventions of .continue low bed, alarm .respond to alarms quickly .Make sure bed alarm pad laying horizontal .continue low bed and alarms .continue low bed with fall mats bilaterally .continue to keep fall mats at bedside and respond to alarms, continue low bed Review of a facility investigation dated April 5, 2012, revealed the resident while seated in a wheelchair in front of the second floor nurse's station, flipped the wheelchair over without injury. Continued review of the facility investigation revealed alarm on wheelchair .was not turned on . Review of facility investigations dated June 2, 2012, June 12, 2012, June15, 2012, July 4, 2012, July 18, 2012, and July 20, 2012, revealed the resident had falls without injury. Review of the facility investigations revealed interventions of .alarm on resident at all times, instructed daughter .Place bolsters on sides of bed .monitor frequently, maintain alarms, PT (physical therapy) screen .continue use of low beds and alarms .monitor resident frequently when restless behavior .continue low bed and respond to alarms as quick as possible . Continued review revealed no new interventions implemented to prevent further falls on on July 4, 2012, or July 20, 2012. Review of a facility investigation dated July 29, 2012, revealed the resident had a fall on in the resident's room resulting in no injury to the resident. Continued review of the facility investigation revealed safety alarms were not sounding, mobile alarms did not detach from the resident, and .motion sensor turned off .AC adaptor not plugged into alarm . Review of facility investigations dated August 14, 2012 and August 31, 2012, revealed the resident had falls without injury. Continued review revealed no new interventions were implemented to prevent further falls after the August 14, 2012, fall. Continued review revealed interventions of .monitor frequently when up in w/c (wheelchair) and reposition resident back in w/c when needed, OT (occupational therapy) to screen . Review of a facility investigation dated September 19, 2012, revealed the resident was dropped without injury during a transfer to bed by one staff person using a Hoyer lift (device used to transfer residents who cannot safely transfer themselves). Further review of the facility investigation revealed, .should have x2 (times two) staff with transfers with lift . Medical record review of the Care Plan updated on September 20, 2012, revealed, .Only 1 CNA (Certified Nurse Assistant) was present at time of fall. 2 CNA (s) are supposed to be present during TF (transfer) with lift . Interview on October 9, 2012, at 2:45 p.m., with the Director of Nursing (DON), in the DON's office, confirmed the safety devices in place at the time of the resident's falls on April 5, 2012, and July 29, 2012, were not functioning properly. Continued interview with the DON confirmed two staff members were required to be present while transferring the resident with a Hoyer lift and the resident's care plan was not followed resulting in a fall on September 19, 2012. Further interview with the DON confirmed no new interventions were implemented after falls on November 14, 2011, December, 29, 2011, and March 31, 2012. Continued interview confirmed were not aware of other interventions to be attempted on additional falls which occurred on July 4, 2012, July 20, 2012, and August 14, 2012. Resident #13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation of the resident in the resident's room, on October 10, 2012, at 9:45 a.m., revealed the resident lying in bed with a full padded side rail up on the right side of the bed. Continued observation revealed an alarm hanging from the side rail of the bed. Review of a facility investigation dated April 17, 2012, revealed .found R (resident) on BR (bedroom) SOB (side of bed) .alarm attached to R and bed still . Further review revealed, .make sure mobile alarm is attached to bedrail where will not slide with resident . Interview on October 10, 2012, at 10:20 a.m., with the DON, in the DON's office, confirmed the facility had failed to ensure the safety alarms were applied correctly to alert staff of unassisted transfers. Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Care Plan revealed the resident fell on [DATE], with no injury, and the Care Plan had been updated to include interventions to prevent falls including .assist of two for transfers . Continued medical record review of the Care Plan revealed the resident fell again on June 11, 2012, and was updated to include .Resident was lowered to floor during transfer with assist x1. Resident needs assist x2 for safe transfers . Review of a facility investigation dated June 11, 2012, revealed .transfer with assist of one with fall .care plan called for assist of two .educate CNA (Certified Nursing Assistant) on following care plan for assist of two on transfers .PT (Physical Therapy) to evaluate . Interview with the Assistant Director of Nursing (ADON), in the DON's office, on October 10, 2012, at 10:20 a.m., confirmed the resident's fall on June 11, 2012, was the result of the CNA not following the care plan.",2016-02-01
11175,CLAIBORNE COUNTY NURSING HOME,445071,1850 OLD KNOXVILLE ROAD,TAZEWELL,TN,37879,2012-10-10,441,D,0,1,614411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility policy, and interview, the facility failed to provide a sanitary, labeled, nebulizer facemask for one resident (#3), of eighteen residents reviewed. The findings included: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation of the resident during the initial tour on October 8, 2012, at 10:50 a.m., revealed the respiratory nebulizer face mask in a clear plastic bag was undated, without the resident's name, and had a buildup of a yellow substance inside the mask. Review of facility policy, Oxygen Therapy, revised October 2008, revealed .Change handheld nebulizer setups weekly. Keep setup in plastic bag when not in use, labeled with residents name and date . Interview with Licensed Practical Nurse (LPN) #1 in the residents' room on October 8, 2012, at 10:53 a.m., confirmed the nebulizer mask had a buildup of a yellow colored substance and did not have a date or name written on it. Continued interview confirmed LPN #1 could not provide documentation of when the nebulizer mask had been changed.",2016-02-01
11176,CLAIBORNE COUNTY NURSING HOME,445071,1850 OLD KNOXVILLE ROAD,TAZEWELL,TN,37879,2012-10-10,514,D,0,1,614411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to maintain a current and readily accessible clinical record for one resident (#13) of eighteen residents reviewed. The findings included: Resident #13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of Physician Recapitulation Orders revealed the Physician Recapitulation Orders were last signed and dated by the Physician on July 27, 2012, and .No order may stand for more than 60 days . Continued medical record review revealed no additional Physician Recapitulation orders in the medical record after July 27, 2012. Interview on October 10, 2012, at 9:10 a.m., with the Director of Nursing (DON) in the DON's office, confirmed Physician Recapitulation Orders were not current and not in the resident's chart.",2016-02-01
13238,CLAIBORNE COUNTY NURSING HOME,445071,1850 OLD KNOXVILLE ROAD,TAZEWELL,TN,37879,2011-11-08,441,D,1,0,ZQ2E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of Centers for Disease Control and Prevention (CDC) literature, medical record review, observation, and interview, the facility failed to provide a sanitary environment to prevent infestation with and/or transmission of scabies for two residents (#5, #3) of five sampled residents and failed to maintain hygienic infection control measures for one resident (#3) on one floor (second) of two floors. The findings included: Review of CDC literature revealed, ""Prevention and Control...When a person is infested with scabies mites the first time, symptoms may not appear for up to two months after being infested. However, an infested person can transmit scabies, even if they do not have symptoms...usually passed by direct, prolonged skin-to-skin contact with an infested person. However, a person with crusted (Norwegian) scabies can spread the infestation by brief skin-to-skin contact or by exposure to bedding, clothing, or even furniture that he/she has used...All...other potentially exposed persons should be treated at the same time as the infested person to prevent possible reexposure and reinfestation. Bedding and clothing worn or used next to the skin anytime during the 3 days before treatment should be machine washed and dried using the hot water and hot dryer cycles or be dry-[MEDICATION NAME] cream 5% )([MEDICATION NAME])...kills the scabies mites and eggs...drug of choice for the treatment of [REDACTED]. Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's progress note dated July 6, 2011, revealed, ""...rash/allergic dermatitis..."" Medical record review of a physician's progress note dated August 3, 2011, revealed, ""...current rash for mos. (months)...rash noted to be spread all over (resident's) body...[DIAGNOSES REDACTED]tous (red)...with some papules (small solid usually inflammatory elevation of the skin that does not contain pus) crusted over...consult dermatology for rash...atopic dermatitis."" Medical record review of a Dermatology Visit Note dated August 4, 2011, revealed, ""...Chief Complaint rash...abd (abdomen), back, chest, arms...since April...itching, Prior Tx (treatment) [MEDICATION NAME], Ivermectin, hdrocortisone, aqualacten, [MEDICATION NAME] each tx the rash will improve but always reappears...micro positive for scabies...Scabies Tx Ivermectin 18 mg/po (milligrams by mouth) repeat one week, [MEDICATION NAME] head to toe repeat one week and [MEDICATION NAME] 0.1 % cream BID (two times daily)...Instructed nursing home to clean pts (patient's) environment very carefully...Referring Physician (M.D. #1)."" Telephone interview with M.D. #1 (the facility's medical director) on October 31, 2011, at 2:35 p.m., revealed he had treated a resident at the facility for scabies (approximately two months ago), he was unable to identify the resident and he stated, ""...very resistant scabies, Norwegian scabies a couple of months ago...not aware of another case since then. If facility thinks a resident has scabies can initiate treatment without notifying me."" Interview with the DON on October 31, 2011, at 10:45 a.m., in the DON's office confirmed the facility failed to appropriately identify/diagnose/and effectively treat scabies for Resident #5. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident was severely impaired with decision-making skills and required limited assistance with eating. Medical record review of a care plan note dated September 28, 2011, revealed, ""CPM (care plan meeting) with dtr (daughter)...conc. (concerned) with rash...If rash doesn't clear will try (urinary catheter)..."" Medical record review of a nurse's note dated October 2, 9, 22, 23, and 24, 2011, revealed the resident had areas of rash on multiple areas of the body. Medical record review of a physician's orders [REDACTED]. Observation on October 31, 2011, from 1:05 p.m. through 1:22 p.m., in the second floor dining area, revealed the resident scratched the lower back, placed both hands into the front of the incontinence brief three times, picked up food in the left hand and placed the food in the resident's mouth. Continued observation revealed the resident placed both hands into the incontinence brief, raised the sweatshirt, scratched the lower back, and two reddened, dime-size circular skin areas on the upper portion of the resident's right upper buttock/lower back. Continued observation revealed the resident touched the beverage container, two food containers, and the eating utensils with contaminated hands. Interview with LPN #2 on October 31, 2011, at 1:22 p.m., at the second floor nurse's station, revealed the certified nursing assistant assigned to the resident was assisting another resident and the resident would not let staff feed (Resident #3). Interview with the Director of Nursing (DON) on October 31, 2011, at 10:45 a.m., in the DON's office, revealed the facility failed to complete laboratory testing to rule out/confirm the [DIAGNOSES REDACTED]. Telephone interview with the DON on November 8, 2011, at 1:55 p.m., revealed the facility did not have a policy regarding the identification, treatment, prevention and/or control of scabies. Continued interview confirmed the facility had failed to provide a sanitary environment to prevent the development of infection and/or prevent infestation with scabies for Resident #3. C/O: #",2015-03-01
13388,CLAIBORNE COUNTY NURSING HOME,445071,1850 OLD KNOXVILLE ROAD,TAZEWELL,TN,37879,2011-04-20,252,D,0,1,VVMW11,"Based on observation and interview the facility failed to provide an environment free of objectionable odors for one resident (#4) of twenty-four sampled residents. The findings included: Observation of resident #4's room during initial tour on April 18, 2011, at 10:20 a.m., revealed no resident in the room at that time and a strong urine odor was noted. Observation on April 19, 2011, at 9:00 a.m., revealed resident #4 lying in bed and the room continued to have a strong urine odor. Observation on April 19, 2011, at 10:45 a.m., revealed the resident was no longer in the room but a foul odor remained. Interview with the RN (Registered Nurse) Supervisor on April 19, 2011, at 10:50 a.m., confirmed the foul odor and immediately contacted housekeeping. Interview with the Housekeeper on April 19, 2011, at 11:00 a.m., confirmed the odor was coming from the resident's mattress and proceeded to wash the mattress. Observation on April 19, 2011, at 3:00 p.m., revealed the room no longer had an objectionable odor after the mattress was cleaned.",2015-01-01
13389,CLAIBORNE COUNTY NURSING HOME,445071,1850 OLD KNOXVILLE ROAD,TAZEWELL,TN,37879,2011-04-20,441,D,0,1,VVMW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to maintain sanitary conditions for a suction catheter for one resident (#2) of twenty-four residents reviewed. The findings included: Resident #2 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident was dependent for all activities of daily living and received nutrition through a percutaneous endoscopic endoscopic gastrostomy (PEG) tube. Observation during the initial during on April 18, 2011, in the resident's room revealed the resident had a suction machine with clear liquid in the container, sitting on a bedside night stand. Continued observation revealed the suction tubing had the suction catheter attached to the tubing placed under the suction machine without any type protection of the suction catheter. Observation on April 19, 2011, at 8:30 a.m., 12:40 p.m., and 1:20 p.m., in the resident's room revealed the suction container continued to have the clear liquid in the container and the suction catheter was placed under the suction machine without any type of protection of the suction catheter. Interview on April 19, 2011, at 1:20 p.m., with RN #1 (registered nurse), in the resident's room, confirmed the suction catheter was to be in a plastic bag for protection and confirmed the suction container had not been emptied. Interview with the Assistant Director of Nursing on April 20, 2011, at 9:55 a.m., in the hallway, confirmed the suction catheter was to be in a closed bag for protection.",2015-01-01
13390,CLAIBORNE COUNTY NURSING HOME,445071,1850 OLD KNOXVILLE ROAD,TAZEWELL,TN,37879,2011-04-20,176,D,0,1,VVMW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to assure one resident (#12) was assessed prior to self administration of a medication of twenty-four residents reviewed. The findings included: Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Observation of resident #12 in the resident's room on April 19, 2011, at 9:25 a.m., revealed a nebulizer mask placed around the resident's mouth in the on position and no facility staff in the room. Interview with Registered Nurse (RN) #1 at the first floor nurse's desk on April 19, 2011, at 9:40 a.m., revealed RN #1 placed the nebulizer mask, turned the nebulizer machine to the on position, placed the [MEDICATION NAME] inside the plastic cylinder, and attached the nebulizer mask and left the room. Interview with the facility Minimum Data Set (MDS) coordinator at the first floor nurse's desk, on April 19, 2011, at 9:45 a.m., confirmed the resident had not been assessed for self administration of medications prior to self administration.",2015-01-01
13391,CLAIBORNE COUNTY NURSING HOME,445071,1850 OLD KNOXVILLE ROAD,TAZEWELL,TN,37879,2011-04-20,315,D,0,1,VVMW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to complete a bowel and bladder assessment and develop an individualized toileting plan for one resident (#13) of twenty-four residents reviewed. The findings included: Resident #13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Continued medical record review of the Minimum Data Set (MDS) dated [DATE], revealed no limitations on making self understood, no limitations on understanding others and was occasionally incontinent of bowel and urine. Interview and medical record review with the facility MDS Coordinator, in the facility dining room, on April 19, 2011, at 2:01 p.m., confirmed the resident had not been assessed for a bowel and bladder program, and an individualized toileting program had not been developed.",2015-01-01
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
4908,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2016-06-23,278,D,1,0,E5Y811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to accurately identify the medication classification for 1 (Resident #2) of 14 residents reviewed. The findings included: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed the resident was discharged from the facility on 5/31/16. Medical record review revealed the physician telephone order dated 9/28/15 and continued to the 5/31/16 discharge for .[MEDICATION NAME] (anti-anxiety) 1 milligram (mg)/[MEDICATION NAME] (anti-psychotic) 2 mg per milliliter (ml). Apply 1 ml [MEDICATION NAME]/[MEDICATION NAME] Gel topically to inner wrist two times daily . Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 had received administration of anti-anxiety and anti-hypnotic medication for the past 4 days. A Quarterly MDS dated [DATE] revealed Resident #2 had received administration of an anti-anxiety medication for the past 7 days. Interview with the MDS Nurse #1 on 6/8/16 at 8:50 AM in the conference room confirmed the facility failed to accurately identify the [MEDICATION NAME] as an anti-psychotic medication on the 2/15/16 and 5/7/16 MDS.",2019-06-01
4909,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2016-06-23,281,D,1,0,E5Y811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, interview and observation the facility failed to follow the physician order [REDACTED]. The findings included: Medical record review revealed Resident #9 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician telephone order dated 5/13/16 revealed .1. D/C (discontinue) [MEDICATION NAME] 2.5 mg (milligrams). 2. [MEDICATION NAME] 3.0 mg PO QD (by mouth every day) . Medical record review of the physician telephone order dated 5/16/16 revealed .1. [MEDICATION NAME] 3 mg QHS (every bedtime) . Medical record review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Interview with the Director of Nursing, on 6/22/16 at 1:15 PM in the conference room, confirmed the facility failed to follow the physician order [REDACTED]. Medical record review revealed Resident #1 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physicians Order dated 1/20/15 revealed .[MEDICAL CONDITION](Continuous Positive Airway Pressure) 8 cm (centimeters) H2O (water), Bleed in O2 (oxygen) at 2 LPM (liters per minute) while sleeping . Medical record review of the (MONTH) (YEAR) and ongoing 6/22/16 MAR indicated [REDACTED]. Medical Record Review of the Care Plan dated 1/21/15 revealed Resident #1 had [MEDICAL CONDITION] Condition/[DIAGNOSES REDACTED]. Intervention dated 1/21/15 for nursing revealed [MEDICAL CONDITION] as ordered. Interview with LPN (Licensed Practical Nurse) #3 on 6/22/16 at 9:25 AM at the East nurses station stated LPN #3 wasn't sure if the resident had O2 on his [MEDICAL CONDITION]. Telephone interview with the daughter of the resident on 6/22/16 at 9:47 AM stated the [MEDICAL CONDITION] machine was Resident #1's personal machine and he had never received oxygen through his [MEDICAL CONDITION] machine. Telephone interview with LPN #1 on 6/22/16 at 10:45 AM stated Resident #1 never received oxygen with the [MEDICAL CONDITION] since she started to work here in 5/2016. Telephone interview with LPN #4 on 6/22/16 at 11:30 AM stated the resident never received oxygen with the [MEDICAL CONDITION] machine. Telephone interview with the facility physician on 6/22/16 at 1:00 PM stated the resident had not received oxygen through his [MEDICAL CONDITION] machine. The physician confirmed that he reviewed the orders and should have canceled the order for the oxygen because his oxygen levels were within normal perimeters. Telephone interview with Registered Nurse (RN) #1 on 6/22/16 at 2:20 PM stated the resident never had oxygen with the [MEDICAL CONDITION] machine. Observation in Resident #1's room on 6/22/16 at 7:12 AM revealed the [MEDICAL CONDITION] mask in place and attached to the [MEDICAL CONDITION] machine. Further observation revealed no oxygen attached to the machine and the [MEDICAL CONDITION] setting at 8cm H2O. Interview with Director of Nursing on 6/23/16 at 9:00 AM in the conference room confirmed the order to bleed in 2 LPM of oxygen with the [MEDICAL CONDITION] was not administered. Medical record review of the Physicians Order for Resident #1 dated 11/13/15 revealed original order for [MEDICATION NAME] 125 mg (milligram) /5 ml (milliliter) suspension, give 4 ml (100 mg) per tube every 8 hours. Physician order [REDACTED].administer 175 mg from 12/18/15 through 1/1/16; then administer 50 mg 1/2/16 through 1/16/16 then discontinue. Medical record review of the Physician order [REDACTED]. Medical record review of the (MONTH) (YEAR) MAR indicated [REDACTED]. (In addition to the 100 mg give 75 mg in afternoon for two weeks to equal total daily dose of 175 mg) to be administered. Medical record review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Interview with Director of Nursing on 6/23/16 at 8:35 AM in the conference room confirmed the [MEDICATION NAME] was not administered as ordered by the physician.",2019-06-01
4910,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2016-06-23,514,D,1,0,E5Y811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, interview, and facility policy review, the facility failed to accurately identify the wound site on the care plan and the treatment section on the Medication Administration Record for 1 (Resident #5); failed to accurately document the monitor for bleeding for 1 (Resident #9); failed to accurately document the insulin units administered for 2 (Resident #13, 14); and inaccurately documented the administration of oxygen while on a [MEDICAL CONDITION] (Continuous Positive Airway Pressure) for 1 (Resident #1) of 14 residents reviewed. The findings included: Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Weekly Skin form dated 6/2/16 revealed Resident #5 had ulcers identified as Suspected Deep Tissue Injury (SDTI) with one on the right heel and the second on the inner right heel. The third site was identified on the right ankle as an open area. All areas were present upon admission. Medical record review of the Initial Weekly Wound form dated 6/3/16 revealed the following: 1.) Wound Location: Right Heel, Wound Type: SDTI, Wound Measurements (in cm): 1.5 x 1.5 x 0.0. 2.) Wound Location: Right (inner) Heel, Wound Type: SDTI, Wound Measurements (in cm): 1.0 x 1.0 x 0.0. 3.) Wound Location Right Ankle, Wound Type: Pressure Ulcer, Wound Measurements (in cm): 2.0 x 0.03 x 0.01. Medical record review of the care plan dated 6/2/16 revealed the resident .has pressure ulcers on the lt (left) inner ankle stage 2, lt back heel SDTI, lt side heel SDTI . Medical record review of the 6/2016 Medication Administration Record (MAR) revealed the following: 1.) .Clean wound Lt (left) inner ankle . was treated 6/4/16 through 6/7/16. 2.) .Clean wound to back of heel (no foot identified) . was treated on 6/4/16 through 6/7/16. 3.) .Clean wound Lt back of heel . had no documentation of treatment. Observation on 6/8/16 at 8:25 AM in Resident #5's room revealed Wound Nurse #1 providing treatment to 3 sites on the right foot/ankle area to Resident #5. Interview with the Director of Nursing on 6/8/16 at 1:15 PM in the conference room, confirmed the facility failed to maintain an accurate medical record, for the care plan, for the MAR treatment, and for the wound identified on the right heel and ankle. Further interview revealed Wound Nurse #1 had completed the Weekly Skin form, the Initial Weekly Wound form, and the care plan. Interview with Wound Nurse #1 on 6/8/16 at 1:35 PM in the conference room confirmed she had filled out the Weekly Skin form, the Initial Weekly Wound form, and the care plan. Further interview confirmed she had inaccurately identified the wound location on the treatment section of the MAR and the care plan. Medical record review revealed Resident #9 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician order dated 4/25/16, and was on-going to the present day, revealed .Monitor of abnormal bleeding: Monitor for bleeding every shift . Medical record review of the (MONTH) (YEAR) Medication Administration Record of the 7:00 AM-7:00 PM shift for monitoring for bleeding every shift failed to document the monitoring 19 out of 31 opportunities on 5/4, 9, 10, 11, 13, 15, 15, 18, 19, 20, 21, 24, 25, 26, 27, 28, 29, 30, and 31/2016. Interview with the Director of Nursing, on 6/22/16 at 1:15 PM in the conference room, confirmed the facility failed to accurately document the monitoring for bleeding on the 7:00 AM - 7:00 PM shift in (MONTH) (YEAR). Review of the facility policy entitled Physician Orders, last reviewed on 6/1/15, revealed .Physician/Medical Practitioner order given (via telephone; directly written in chart; verbal; faxed) .Nurse receiving order is responsible for complete order documentation .Nurse receiving order determines if order is formulary compliant and clarifies variance with Medical Practitioner .Medications placed in EZMAR (computerized Mediation Administration Record) for specific resident by designated Nurse including dosage, medication, route and frequency of administration .Designated Nurse reviews all charts daily to insure no orders were missing . Review of the undated facility policy entitled Medication Administration revealed .Documentation: The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication given .The resident's MAR .is initialed by the person administering the medication, in the spaces provided under the date, and on the line for the specific dose administered and time . Medical record review revealed Resident #13 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician orders revealed the following: 1. On 7/22/15 and ongoing to the present, an order for [REDACTED]. 2. On 7/22/15 and ongoing to the present, an order for [REDACTED]. 3. On 5/27/15 and ongoing to the present, an order for [REDACTED].[MEDICATION NAME] .Insulin inject sub-q (subcutaneous) according to scale before meals and at bedtime on Mon (Mondays), Thurs (Thursdays), and Sat (Saturdays) . with specific units to be administered pending the result of the accucheck. Medical record review of the MARs for the sliding scale insulin administration and the accucheck results revealed the facility failed to consistently document the units of insulin administered per the out of range accucheck results as followed: 1. There were a total of 12 opportunities (first week of each month for a total of 3 days) documented for sliding scale insulin administration in (MONTH) and (MONTH) (YEAR), April, (MONTH) and (MONTH) (YEAR). After the first 3 days of the month there was no documentation of the sliding scale insulin administration. 2. On (MONTH) (YEAR) of the 52 opportunities with 21 refusals for the accucheck - of the 31 opportunities remaining -11 entries required insulin administration for out of range accucheck, and 5 entries lacked documentation of the accucheck and/or required insulin if needed. 3. On (MONTH) (YEAR) of the 52 opportunities with 20 refusals for the accucheck - of the 32 opportunities remaining - 8 entries required insulin administration for out of range accucheck, and 4 entries lacked documentation of the accucheck and/or required insulin if needed. 4. On (MONTH) (YEAR) of the 52 opportunities with 12 refusals for the accucheck - of the 40 opportunities remaining - 8 entries required insulin administration for out of range accucheck, and 4 entries lacked documentation of the accucheck and/or required insulin if needed. 5. On (MONTH) (YEAR) of the 52 opportunities - 28 entries required insulin administration for out of range accucheck, and 5 entries lacked documentation of the accucheck and/or required insulin if needed. 6. On (MONTH) 1-23, (YEAR) up to 8:00 AM of the 37 opportunities - 25 entries required insulin administration for out of range accucheck. Medical record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician orders revealed the following: 1. On 2/15/16 and ongoing to the present for .Accuchek (Accucheck) SQ (subcutaneous) ACHS (before meals and bedtime) . 2. On 2/15/16 and ongoing to the present for .Accuchek SQ as needed . 3. on 2/15/16 and ongoing to the present for sliding scale insulin of .Humolog .Insulin inject sub-q four times daily before meals & (and) at bedtime . with specific units to be administered pending the result of the accucheck. Medical record review of the MARs revealed the facility failed to consistently document the units of insulin administered per the out of range accucheck results as followed: 1. On (MONTH) (YEAR) of the 117 opportunities - 48 entries lacked insulin units administered for out of range accucheck, and 3 entries lacked documentation. 2. On (MONTH) (YEAR) of the 124 opportunities - 47 entries lacked insulin units administered for out of range accucheck, 1 entry lacked documentation, and 1 entry was a REFUSED. 3. On (MONTH) 1-23, (YEAR) up to 8:00 AM of the 89 opportunities - 23 entries lacked insulin units administered for out of range accucheck. Interview with the Director of Nursing and the Corporate Clinical Consultant,on 6/23/16 beginning at 1:20 PM in the conference room, confirmed the facility failed to follow the facility policy to correctly data enter the physician order into the EZMAR and failed to consistently document in the EZMAR the units of insulin administered pending the result of the accucheck for Residents #13 and 14. Medical record review revealed Resident #1 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physicians Order dated 1/20/15 revealed an order for [REDACTED]. Medical record review of the MAR dated 9/1/2015 revealed an order for [REDACTED]. The MAR was initialed as administered daily with O2. Interview with LPN (Licensed Practical Nurse) #3 on 6/22/16 at 9:25 AM at the East nurses station stated that he wasn't sure if the resident had oxygen on his [MEDICAL CONDITION]. Telephone interview with the daughter on 6/22/16 at 9:47 AM stated Resident #1 never received oxygen through the [MEDICAL CONDITION] machine. Telephone interview with LPN #1 on 6/22/16 at 10:45 AM stated the resident never received O2 with the [MEDICAL CONDITION] since she started to work here in 5/2016. Telephone interview with LPN #4 on 6/22/16 at 11:30 AM stated the resident never received O2 with the [MEDICAL CONDITION] machine. Telephone interview with the facility physician 6/22/16 at 1:00 PM stated the resident never received oxygen through his [MEDICAL CONDITION] machine. The physician confirmed that he reviewed the orders and should have canceled the order for the oxygen. Telephone interview with Registered Nurse (RN) #1 on 6/22/16 at 2:20 PM stated the resident never had oxygen with the [MEDICAL CONDITION] machine. Observation in Resident #1's room on 6/22/16 at 7:12 AM revealed the [MEDICAL CONDITION] mask in place and attached to the [MEDICAL CONDITION] machine. Further observation revealed no oxygen attached to the machine and the [MEDICAL CONDITION] setting at 8cm H2O. Interview with Director of Nursing on 6/23/16 at 9:00 AM in the conference room confirmed the facility failed to maintain accurate medical records.",2019-06-01
5333,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2016-03-17,309,D,1,0,RDMH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the Lippincott Manual of Nursing Practice, 10th edition for [MEDICATION NAME] (TB) testing (Purified Protein Derivative-PPD) standard of practice, medical record review and interview, the facility failed to prevent the administration of the PPD to a resident that had a prior allergic reaction and failed to obtain chest x-rays following 2 positive PPD tests for 1 (Resident #1) of 5 residents reviewed. The findings included: Review of the Lippincott Manual of Nursing Practice, 10th edition, for TB testing (PPD) protocol revealed .Nursing Action .Do not give PPD to person who has had a positive test or TB in the past .Rationale .Any positive response should raise the index of suspicion for TB and merits investigation regardless of the test results .Chest x-ray as indicated for screening and symptom review Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #1 was transferred from another nursing facility. Review of the transferring facility discharge physician orders [REDACTED]. Further review of the transferring facility TB Screening and Immunization Record dated 12/23/14 revealed a TB test (PPD) was conducted with a negative result. Further review revealed a chest x-ray dated 12/28/14 completed due to history of productive cough, with the .Impression .No acute cardiopulmonary abnormality . Medical record review of the admitting facility Admission Minimum (MDS) data set [DATE] revealed Resident #1 was severely cognitively impaired, had adequate hearing, clear speech, was sometimes able to make self understood, usually could understand others, no [MEDICAL CONDITION], no change in mental status, no [MEDICAL CONDITION], no behaviors, required extensive to total assistance with staff, physical support of all activities of daily living, received scheduled pain medication, and was not in pain. Medical record review of the facility TB Screening and Immunization Record form, with the allergy section, including [MEDICATION NAME] and PCN ([MEDICATION NAME]), dated 6/13/15 revealed a TB test to the .R (right) forearm .Result of Test .+ (positive) .chest x-ray - (negative) .See EMAR (computerized Medication Administration Record) . Further review revealed the form included no documentation under the section addressing .Chest X-Ray .Results . Medical record review of the Nurse's Note dated 6/16/15 at 5:30 PM revealed .Daughter informed nurse today that her mother was allergic to [MEDICATION NAME] that she got red areas on her arm. Nurse noted raised areas to TB site. Daughter .stated I forgot to tell you, you all will have to cover that up to prevent mother from scratching. Area covered with bandage to prevent scratching. Allergy noted on E-ZMAR (computerized MAR/EMAR) per DON (Director of Nursing) instructions .Daughter stated her mother had a chest x-ray @ (at) (named transferring facility) and it was negative . Further review of the 6/2015 Nurse's Notes revealed no further documentation addressing the TB reactive site. Medical record review of the physician telephone orders dated 6/17/15 revealed .Rt (right) forearm cleanse area (with) wound cleanser pat dry apply drsg (dressing) q (every) day et (and) prn (as needed) until healed . Further review revealed a telephone physician order [REDACTED].DC (discontinue) TX (treatment) to R forearm . Medical record review of the 6/2015 EMAR revealed the following: 1. There was no documentation the TB test was administered. 2. There was no documentation of the TB test reading and result. 3. The listed allergies [REDACTED]. Medical record review revealed no information related to a chest x-ray in 6/2015. Medical record review of the monthly physician's orders [REDACTED].Drug allergies [REDACTED]. Medical record review of the TB Screening and Immunization Record form, revealed a TB test was administered to Resident #1 on 9/24/15, even though the resident had a known allergy to [MEDICATION NAME], to the .R forearm .Result of test .+ . chest x-ray - .See EMAR . Further review revealed .Chest X-ray .Date 9/27/15 .Results .No TB identified . Medical record review of the 9/2015 Nurse's Notes revealed no documentation of the TB administration or of any TB positive reaction. Medical record review of the 9/2015 EMAR revealed no documentation of the administration of the TB test or of any result. Medical record review of the telephone physician order [REDACTED].Right forearm rash clean area pat dry apply dry dressing q d (day) et prn until resolved .Indication/Dx (Diagnoses) allergic reaction . Medical record review of an Event form dated 10/2/15 at 5:00 PM revealed .What was the event? Observed blister .how this occurred? blistery rash R/T (related to) an allergic reaction .Body Injuries Right Forearm .Injury description blistery rash . Medical record review of the Nurse's Notes dated 10/3/15 at 7:30 AM revealed .showed no further issues other than a rash on her R forearm from the allergic reaction to a PPD ([MEDICATION NAME] test) . Medical record review of the Nurse's Notes dated 10/3/15 at 6:00 PM revealed .TX to area Rt forearm per orders, area unchanged . Medical record review of the 10/2015 EMAR revealed the TB test was administered on 10/1/15 and the result dated 10/4/15 measured 15 mm (millimeters) although the Event form dated 10/2/15 at 5:00 PM documented a blistery rash resulting from an allergic reaction, the telephone physician order [REDACTED]. Medical record review revealed no information related to chest x-rays in (MONTH) or (MONTH) (YEAR). Medical record review of the monthly physician's orders [REDACTED].Drug allergies [REDACTED]. Medical record review revealed on 3/14/16 a chest x-ray with the .Results .The lung fields are without mass or infiltrate . Interview with the Director of Nursing (DON) on 3/15/16 at 8:55 AM in the conference room confirmed the facility failed to obtain chest x-rays after 2 separate positive TB test reactions. Further interview confirmed it was a standard of practice to get an x-ray after a positive result from a TB test. When asked why the second TB test was administered if the resident had a known allergy to [MEDICATION NAME], the DON stated .allergy not updated after the first (TB administration) . although it was listed in every monthly physician's orders [REDACTED]. Interview with the Assistant Director of Nursing (ADON), on 3/15/16 at 10:35 AM and 11:25 AM in the conference room confirmed she had administered the 10/1/15 TB test. Further interview with the ADON revealed .I already gave the 10/15 TB test when I realized there was no result on the 6/15 (test) .When I went to record mine (TB test administered 10/1/15) there was no result documented on 6/13/15 (TB Screening and Immunization Record) .I filled in the data for 6/13/15 .and I added [MEDICATION NAME] to the allergy section on the TB Screening and Immunization Record form . When the ADON was asked where she obtained the negative chest x-ray information the ADON stated she may have looked at and recorded the information from another resident x-ray in error . When the ADON was asked why she documented the TB test was administered on 9/24/15 the ADON stated she .must have transcribed it wrong .",2019-03-01
5334,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2016-03-17,514,D,1,0,RDMH11,"**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 accurate medical records for addressing allergies [REDACTED].#1 and #9) of 5 records reviewed for allergies [REDACTED].>The findings included: Review of the facility policy, reviewed 6/1/15, entitled allergies [REDACTED].Guidelines for Obtaining Information at Time of Admission: Obtain allergy information from the resident regarding past history of allergies [REDACTED].Record stated allergy information .On front of medical record cover . Medical record review revealed Resident #1 was admitted to the facility, from another nursing facility, on 6/12/15 with [DIAGNOSES REDACTED]. Continued record review of the transferring facility discharge physician orders revealed the resident was allergic to [MEDICATION NAME] and [MEDICATION NAME]. Medical record review of the Admitting Physician's Order Sheet dated 6/12/15 revealed .Drug allergies [REDACTED]. although the discharging facility physician orders documented the allergies [REDACTED]. Medical record review of the TB Screening and Immunization Record form, with the allergy section including .[MEDICATION NAME] and PCN ([MEDICATION NAME]) ., dated 6/13/15 revealed a TB test to the .R (right) forearm .Result of Test .+ (positive) .chest x-ray - (negative) .See EMAR (computerized Medication Administration Record) . Further review revealed the form included no documentation under the section addressing .Chest X-Ray .Results . Medical record review of the Nurse's Note dated 6/16/15 at 5:30 PM revealed .Daughter informed nurse today that her mother was allergic to [MEDICATION NAME] that she got red areas on her arm. Nurse noted raised areas to TB site. Daughter .stated I forgot to tell you, you all will have to cover that up to prevent mother from scratching. Area covered with bandage to prevent scratching. Allergy noted on E-ZMAR (computerized MAR/EMAR) per DON (Director of Nursing) instructions .Daughter stated her mother had a chest x-ray @ (at) (named transferring facility) and it was negative . Further review of the 6/2015 Nurse's Notes revealed no further documentation addressing the TB reactive site. Medical record review of the 6/2015 EMAR revealed the following: 1. There was no documentation the TB test was administered. 2. There was no documentation of the TB test reading and result. 3. The listed allergies [REDACTED]. Medical record review revealed no information related to a chest x-ray in 6/2015. Medical record review of the monthly Physician's Order Sheet dated 7/2015, 8/2015 and 9/2015 revealed .Drug allergies [REDACTED]. although the discharging facility physician orders documented the allergies [REDACTED]. Medical record review of the TB Screening and Immunization Record form revealed a TB test was administered on 9/24/15, although the resident had a documented allergy to [MEDICATION NAME], to the .R forearm .Result of test .+ . chest x-ray (negative) .See EMAR . Further review revealed .Chest X-ray .Date 9/27/15 .Results .No TB identified . Medical record review of the 9/2015 Nurse's Notes revealed no documentation of the TB administration or of any TB positive reaction. Medical record review of the 9/2015 EMAR revealed no documentation of the administration of the TB test or of any result. Medical record review of the telephone physician order dated 10/2/15 revealed .Right forearm rash clean area pat dry apply dry dressing q d (day) et prn until resolved .Indication/Dx (Diagnoses) allergic reaction . Medical record review of an Event form dated 10/2/15 at 5:00 PM revealed .What was the event? Observed blister .how this occurred? blistery rash R/T (related to) an allergic reaction .Body Injuries Right Forearm .Injury description blistery rash . Medical record review of the Nurse's Notes dated 10/3/15 at 7:30 AM revealed .showed no further issues other than a rash on her R forearm from the allergic reaction to a PPD ([MEDICATION NAME] test) . Medical record review of the 10/2015 EMAR revealed the TB test was administered on 10/1/15 and the result dated 10/4/15 measured 15 mm (millimeters) although the Event form dated 10/2/15 at 5:00 PM documented a blistery rash resulting from an allergic reaction, the telephone physician order dated 10/2/15 for treatment for [REDACTED]. Medical record review revealed no information related to chest x-rays in (MONTH) or (MONTH) (YEAR). Medical record review of the monthly Physician's Order Sheet dated 10/2015, 11/2015, 12/2015, 1/2016, 2/2016 and 3/2016 revealed .Drug allergies [REDACTED].Other allergies [REDACTED]. Medical record review revealed the inside of the chart cover included a sticker with allergies [REDACTED]. Further review revealed [MEDICATION NAME] was not included on the allergy sticker. Interview with the Director of Nursing (DON) on 3/15/16 at 8:55 AM in the conference room confirmed the facility failed to obtain chest x-rays after 2 separate positive TB test reactions. When asked why the second TB test was administered if the resident had a known allergy to [MEDICATION NAME] prior to administration of the test, the DON stated .allergy not updated after the first (TB test administration) . although it was listed in every monthly Physician's Order Sheet from 7/2015 to 3/2016. Interview with the Assistant Director of Nursing (ADON), on 3/15/16 at 10:35 AM and 11:25 AM in the conference room confirmed she had administered the 10/1/15 TB test. Further interview with the ADON stated .I already gave the 10/15 TB test when I realized there was no result on 6/13/15 .When I went to record mine (TB test administered 10/1/15) there was no result documented on 6/13/15 (TB Screening and Immunization Record) .I filled in the data for 6/13/15 .and I added [MEDICATION NAME] to the allergy section on the TB Screening and Immunization Record form . When the ADON was asked where she obtained the negative chest x-ray information the ADON stated she may have looked at and recorded the information from another resident x-ray in error . When the ADON was asked why she documented the TB test was administered on 9/24/15 the ADON stated she .must have transcribed it wrong . Interview with the DON on 3/15/16 1:08 PM in the conference room confirmed the medical chart inside cover allergy sticker was to alert staff to the resident's allergy. Further interview confirmed the allergy sticker failed to include the [MEDICATION NAME] allergy since 6/2015. The facility failed to maintain an accurate medical record for Resident #1 by failing to include the allergies [REDACTED]. TB result when no chest x-rays were obtained; failing to accurately document the date of the TB test administered on 10/1/15 on the TB Screening and Immunization Record form; and failing to update the allergies [REDACTED]. Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Disease, and Joint Contracture. Medical record review of the monthly Physician's Order Sheets dated 11/15, 12/15, 1/16, 2/16 and 3/16 revealed .Drug allergies [REDACTED]. Medical record review of the inside cover of the resident's medical record revealed an allergy sticker with PPD Serum, [MEDICATION NAME]. Further record revealed Opioid allergy was not included on the allergy sticker in the resident's medical record. Interview with the DON and corporate representative on 3/15/16 at 1:08 PM in the conference room confirmed the facility failed to maintain an accurate medical record for Resident's #1 and #9.",2019-03-01
5464,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2015-10-21,280,D,0,1,384I11,"**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 the care plan to monitor the [MEDICAL CONDITION] medication for 1 (Resident #64) of 5 residents reviewed with [MEDICAL CONDITION] medications. The findings included: Review of the facility policy, Monitoring [MEDICAL CONDITION] Medication Usage, with the effective date of 12/2010, revealed .Immediate Care Planning for Behavior Symptoms is completed .of any [MEDICAL CONDITION] medication .The Behavior Monitoring Form [MEDICAL CONDITION] Medications is initiated . Medical record review revealed Resident #64 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician or nurse practitioner's orders revealed in 3/2015 the anti-anxiety medication, [MEDICATION NAME], was ordered and continued through 10/2015. Medical record review of the care plan updated 10/2015 revealed a problem .At risk for sign/symptoms (s/s) of [MEDICAL CONDITION] medication. Receives .anti anxiety medication . Further review revealed the approaches included .Administer medication .and monitor for effectiveness . Medical record review of the Behavior/Intervention Monthly Flow Record revealed the facility failed to monitor the behaviors and medication effectiveness, per the care plan, after 4/2015. Interview with the Director of Nursing (DON), Assistant Director of Nursing, and Minimum Data Set Coordinator on 10/21/15 at 4:50 PM in the DON's office, confirmed the facility failed to complete the Behavior/Intervention form since 4/2015 and therefore failed to follow the care plan to monitor the effectiveness of the medication.",2019-02-01
5465,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2015-10-21,329,D,0,1,384I11,"**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 the [MEDICAL CONDITION] medication for 1 (Resident #64) of 5 residents reviewed with [MEDICAL CONDITION] medications. The findings included: Review of the facility policy, Monitoring [MEDICAL CONDITION] Medication Usage, with the effective date of 12/2010, revealed .The Behavior Monitoring Form [MEDICAL CONDITION] Medications is initiated .Nursing staff will document behavior/interventions/side effect information on the flow record daily . Medical record review revealed Resident #64 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician or nurse practitioner's orders for the anti-anxiety medication, [MEDICATION NAME], revealed the following: 1. In 3/2015 the orders included [MEDICATION NAME] 0.5 milligrams (mg) three times per day (tid) and every (q) 6 hours as needed (6 hr prn). 2. On 3/31/15 [MEDICATION NAME] decreased to 0.25 mg two times daily (bid) and continued 0.5 mg Q (every)bed time (HS). 3. On 7/9/15 to .discontinue (DC) the 2PM dose [MEDICATION NAME] 0.25 mg and continue [MEDICATION NAME] 0.25 mg Q AM and 0.5 mg q HS . 4. On 7/23/15 .DC [MEDICATION NAME] 0.25 mg q AM .continue 0.5 mg q HS . 5. The 10/2015 recapitulation orders included [MEDICATION NAME] 0.5 mg q HS. Medical record review of the Behavior/Intervention Monthly Flow Record revealed the facility failed to monitor the behaviors and medication effectiveness after 4/2015. Medical record review, including nurses notes, weekly and monthly summaries, revealed the facility failed to document any behavior monitoring and failed to document the [MEDICAL CONDITION] medication effectiveness. Interview with the Assistant Director of Nursing (ADON) on 10/21/15 at 2:35 PM in the medical record office confirmed the facility failed to have behavior monitoring forms since 4/2015. Interview with the Director of Nursing (DON), and the ADON on 10/21/15 at 4:50 PM in the DON's office, confirmed the facility failed to complete the Behavior/Intervention form after 4/2015, per facility policy, to monitor the effectiveness of the anti-anxiety medication.",2019-02-01
5466,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2015-10-21,371,F,0,1,384I11,"Based on observation and interview, the facility dietary department failed to store store chemicals and food separately, failed to prevent the possible cross contamination of dishes, and failed to properly process dishes during the dish machine cycle to ensure they were sanitized in 8 observed operations of the dish machine. The findings included: Observation on 10/19/15 at 12:08 PM, by a storage closet in the utility hall, with the Chef present, revealed 2 five-gallon containers of dish machine rinse agent were stored next to canned food in cases, and some cases were opened. Interview with the Chef and corporate staff member #1, on 10/19/15 at 12:08 PM, at the storage closet in the utility hall, confirmed chemicals were not to be stored with food. Observation on 10/20/15 beginning at 9:30 AM, in the dish room area of the dietary department, with the Chef present, revealed the dish machine was in operation. Further observation revealed the dietary staff member on the dirty side of the dish machine opened the dish machine door, pushed a rack of dirty dishes into the dish rack containing cleaned dishes inside the dish machine to eject the cleaned dishes in 2 of 8 observations of the dish machine operation. Further observation revealed 1 coffee cup, 1 quart size pitcher, and 1 coffee carafe came out of the dish machine filled with water, were inverted to drain the water and stored by the dietary staff member on the clean side of the dish machine in 3 of 8 operations of the dish machine. Interview with the Chef, on 10/20/15 beginning at 9:30 AM, by the dish machine, confirmed the 2 dish racks containing dirty dishes were pushed into the cleaned dishes and possibly contaminated the cleaned dishes. Further interview confirmed the dietary staff failed to ensure the dishes were properly sanitized when they failed to re-wash the coffee cup, pitcher, and coffee carafe that had been filled with water when they came out of the dish machine.",2019-02-01
5467,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2015-10-21,428,D,0,1,384I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to act upon pharmacy recommendations in a timely manner for 1 (Resident #23) of 33 residents reviewed. The findings included: Medical record review revealed Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Physician Recapitulation Orders dated 10/1 - 10/31/15 revealed medications to include Atorvastatin (Lipitor, a cholesterol lowering medication) 20 mg (milligram) PO (by mouth) QD (every day), with a start date of 4/7/15. Medical record review of a Pharmacy Review dated 3/28/15 revealed .please consider adding Atorvastatin 20 or 40 mg PO daily . Continued review revealed a note written .original response dated 3/14/15 fasting lipid panel .Atorvastatin 20 mg po qd . and the agree box was checked, acknowledging the recommendation, and the form was signed and dated by the Nurse Practitioner (NP) on 4/7/15. After requesting all Pharmacy Reviews from 12/14 through 3/15, the facility provided a batch printed list, dated 2/21/15, of Resident #23's pharmacy recommendations and all were dated 1/20/15. Continued review revealed recommendations .please consider adding Atorvastatin 20 or 40 mg PO daily .please consider ordering a serum B-12 level annually to monitor therapy . Continued review revealed (handwritten notes on the right side of the paper) .Atorvastatin 20 mg po QD .B-12 level now, then q year . Continued review revealed the NP signed and dated the reviews on 2/25/15. Medical record review of the 3/15 and 4/15 Physician Recapitulation Orders failed to include orders for Atorvastatin 20 mg po QD and a Vitamin B-12 level. Further record review revealed the (MONTH) (YEAR) pharmacy recommendations were not acted upon until 4/7/15, when a Physician's Telephone Order .B-12 level in a.m. then every year .Atorvastatin 20 mg po qd . was obtained by the facility. Interview with the Director of Nursing (DON) on 10/21/15 at 3:30 PM in the Administrator's office, when asked why the pharmacy recommendations were not acted upon until 4/7/15 revealed the pharmacy recommendations had been misplaced and could not be located. Continued interview with the DON confirmed the facility failed to follow pharmacy recommendations in a timely manner.",2019-02-01
8601,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2014-05-31,157,J,1,0,3X0Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, medical record review, observation, and interview, the facility failed to immediately notify the physician of the incorrect placement of a pressure prevention device that resulted in a Deep Tissue Injury (DTI), failed to immediately notify the Physician of a change in resident condition, failed to notify the Physician of a delay in the placement of a peripherally inserted central catheter line (to administer intravenous medications), failed to immediately notify the Physician of oral and intravenous antibiotics not administered as ordered for one resident (#13) of nineteen residents reviewed. The facility's failure resulted in resident (#13) with a [DIAGNOSES REDACTED].#13 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) and Corporate Chief Nursing Officer (CCNO) were informed of the Immediate Jeopardy in the Conference Room on May 29, 2014, at 9:00 p.m. The findings included: Review of facility policy, Change in Condition, revised 2010 revealed, Policy: It is the policy of this facility to provide for communication of appropriate information relative to a resident's change of condition to the resident's attending physician .Procedure: .4. Situations in which the physician .should be notified immediately of a change in a resident's condition include, but are not limited to: Onset of any acute condition .Any accident/incident with suspected or actual injury .Significant and unexpected change/decline in a resident's physical .status .When there is a need to immediately commence, discontinue or significantly alter form of treatment . Review of facility policy, Change in Condition, revised 2010 revealed, Policy: It is the policy of this facility to provide for communication of appropriate information relative to a resident's change of condition to the resident's attending physician .Procedure: .4. Situations in which the physician .should be notified immediately of a change in a resident's condition include, but are not limited to: Onset of any acute condition .Any accident/incident with suspected or actual injury .Significant and unexpected change/decline in a resident's physical .status .When there is a need to immediately commence, discontinue or significantly alter form of treatment . Review of facility policy, Skin Management Standard, revised October 2013 revealed, . The resident's Physician and Responsible Party shall be notified of a change in the resident's skin condition .Skin Ulceration Management: .3. The Physician will be contacted and orders obtained for treatment . Resident #13 was admitted to the facility initially on April 16, 2009, with [DIAGNOSES REDACTED]. Medical record review of an Annual Minimum Data Set (MDS) dated [DATE], revealed the resident's cognition was moderately impaired with a Brief Interview for Mental Status score of 8 (with zero being the lowest indicating severely impaired cognition and fifteen being the highest indicating intact cognition). Continued review revealed the resident did not reject care. The resident was totally dependent for bed mobility and transfers; and was non-ambulatory. The resident's range of motion in the upper and lower extremities was functionally impaired on both sides. Further review revealed the resident had no pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), but was at risk of developing pressure ulcers. Medical record review of the Pressure Ulcer Risk Assessments (screening tool that is designed to help identify residents who might develop a pressure ulcer) dated December 31, 2013, January 17, 2014, January 24, 2014, February 12, 2014, March 21, 2014, April 3, 2014, April 10, 2014, April 17, 2014, and April 24, 2014, revealed the resident was at high risk for the development of pressure ulcers. Medical record review of a Skin/Wound Note dated December 31, 2013, at 2:07 p.m., and electronically signed by the Treatment Nurse, revealed an offloading heel elevator (pressure prevention device used to prevent or promote healing, which is designed to suspend the heels off the end of the device to ensure heels are free of the surface of the bed) was placed under the resident (lower extremities) to allow pressure relief of the bilateral (both) heels. Medical record review of the Care Plan dated December 31, 2013, revealed, .The resident need (needs) (Offloading Heel Elevator) at all times excpet (except) during ADL (Activities of Daily Living) care to protect the skin while in bed .Date Initiated: December 31, 2013 . Medical record review of a Skin/Wound Note dated February 13, 2014, at 4:28 p.m., and electronically signed by the Treatment Nurse revealed Stage I (one) (an observable, pressure-related alteration of intact skin, when compared to an adjacent or opposite area on the body may include changes in skin temperature, tissue consistency, sensation and/or a defined area of persistent redness) area noted to the outer lateral portion of the left calf. Area is red in color with no blanching (reddened areas of tissue that do not turn white or pale when pressed firmly with a finger or device). (Offloading Heel Elevator) in place .Area will be observed daily. Continued review revealed no documentation the Treatment Nurse measured the Stage I Pressure Ulcer area or notified the Physician or Responsible Party of the newly identified Stage I Pressure Ulcer. Medical record review of a Skin/Wound Note dated March 17, 2014, at 12:44 p.m., and electronically signed by the Treatment Nurse revealed the offloading heel elevator was incorrectly placed under the resident, and stated, .Stage I (Pressure Ulcer) was noted to the left lower lateral leg .area will be treated with [MEDICATION NAME] to assist in decreasing possibility of shearing trauma .(Offloading Heel Elevator) is in place and was repositioned to below the knees to allow better pressure relief to this area as well as pressure free to the heels .Spoke to (daughter) and gave update . Continued review revealed no documentation the Physician was notified of the incorrect placement of the (Offloading Heel Elevator). Medical record review of a Weekly Wound Progress Note dated March 17, 2014, at 12:53 p.m., and electronically signed by the Treatment Nurse revealed, Date identified .March 17, 2014 .Left lower lateral leg .Stage I .Acquired (wound developed in the facility) Peri-Wound (around the pressure ulcer) .Length: 8.0 centimeters (cm) .Width: 1.0 cm .Depth: 0.0 cm .Area: [DIAGNOSES REDACTED] (redness) .induration (abnormal hardness) .Exuderm [MEDICATION NAME] .order date March 17, 2014 .Spoke to (daughter) . Medical record review of the March 2014 physician's orders [REDACTED]. Medical record review of a Weekly Wound Progress Note dated March 21, 2014, at 11:58 a.m., and electronically signed by the Treatment Nurse revealed the Stage III on the left lower lateral leg measured 7.4 cm x 1.3 cm, with 0.0 cm in depth (The Skin/Wound Note dated March 21, 2014, at 12:22 p.m., revealed a depth of 0.3 cm). Continued review revealed the Pressure Ulcer had five percent slough, had a moderate amount of serosanguineous exudate (Any fluid that has been forced out of the tissues or its capillaries because of inflammation or injury. It may contain serum, cellular debris, bacteria and leukocytes) with a foul odor. The peri-wound area had [DIAGNOSES REDACTED] and induration. Continued review revealed, .Other: Area was Stage I and advanced to Stage III in between dressing changes from Wed (Wednesday) to Friday. Education of staff is being performed for proper use of the (Offloading Heel Elevator) . Medical record review of a Skin/Wound Note for Resident #13 dated March 21, 2014, at 12:22 p.m., and electronically signed by the Treatment Nurse revealed the offloading heel elevator was incorrectly placed under the resident, and stated, During treatments this shift, area to left lower lateral leg was noted to advance in stage from a I to a III (three) (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed). Slough (necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, and stringy, at times) .area was noted to have a moderate amount of serosanguineous (bloody, thin, and watery) drainage present .area went from measurement of stage I of 8.0 x (by) 1.0 to open with muscle exposure total size of 7.4 (cm) x 1.3 (cm) x 0.3 (cm) (depth). There are a total of 3 (three) open areas to the middle of the area that is red and nonblanching (non-blanching) .(Offloading Heel Elevator) was repositioned to proper alignment to ensure pressure redistribution . Medical record review of a typed Physician's Progress Note dated March 24, 2014, dictated at 10:21 a.m., revealed, .Over the past several days (resident) has generally not felt well and during the past 24 (twenty-four) hours, has complained of abdominal pain and also has developed a fever. Today, I am seeing (resident) in regards to that problem .Temperature is 100 (one-hundred) . Continued review revealed no documentation the Physician was aware of the resident's Stage III Pressure Ulcer. Medical record review of a Nurse Practitioner's Telephone Order dated March 24, 2014, at 12:35 p.m., revealed orders for an X-Ray of the Left Lower Leg to rule-out [DIAGNOSES REDACTED] (infection of the bone and bone marrow) and [MEDICATION NAME] (antibiotic) 300 milligrams (mg) by mouth (PO) every six hours for Left Leg [MEDICAL CONDITION] (bacterial infection just below the skin surface) for 10 days. Medical record review of an X-Ray obtained on March 24, 2014, revealed, Results: .No evidence of [DIAGNOSES REDACTED] .Conclusion: .Small pocket of gas adjacent to the fibula (the lateral and smaller of the two bones of the lower leg) which could be soft tissue wound versus gas-forming infection (typically, Gangrene). Medical record review of a Weekly Wound Progress Note dated March 24, 2014, at 4:57 p.m., and electronically signed by the Treatment Nurse revealed, .Right lateral lower leg (left lateral lower leg) . Continued review revealed the Stage III Pressure ulcer measured 8.0 cm x 1.0 cm x 0.4 cm, with less than 100% (percent) slough, a copious (extensive in quantity) amount of exudate that was purulent (consisting of or containing pus) with a foul odor. The peri-wound area had [DIAGNOSES REDACTED], swelling/[MEDICAL CONDITION], and induration. Medical record review of a typed Nurse Practitioner's Progress Note dated March 25, 2014, dictated at 11:36 a.m., revealed the Nurse Practitioner conducted a follow-up visit related to the abrupt onset off the Stage III Pressure Ulcer, and stated, .X-Ray is free of [DIAGNOSES REDACTED] .[MEDICATION NAME] pocket adjacent to the fibula .[MEDICATION NAME] is making (resident) nauseous .has not vomited to date .frail elderly (resident) .uncomfortable with dressing change .left leg with stage III ulceration and two small satellite areas (two small ulcerations near the large ulcer), confluent (flow together) [DIAGNOSES REDACTED]. Wound bed is covered with pink granulation (pink-red moist tissue that fills an open wound, when starts to heal) tissue and yellow slough. There is a copious amount of serosanguineous purulent drainage. It is malodorous (bad, foul odor) .Acute [MEDICAL CONDITION] left leg .Stage III ulceration to left calf .nausea .pain associated with left leg ulceration .Today, I am going to continue the [MEDICATION NAME] therapy. I will in fact change it to IV (intravenous) secondary to the patient's nausea. To cover the nausea, I have provided [MEDICATION NAME] to be taken either IM (intramuscular) (by injection) or p.o. (by mouth). I have additionally scheduled .[MEDICATION NAME] (pain narcotic) 5/325 mg q. (every) 8h (eight hours) for the duration of five days (previously ordered and administered at the same dosage every four hours, as needed (PRN) .reevaluate at that time . Medical record review of a Physician's Telephone Order dated March 25, 2014, with an electronic order entry time of 2:23 p.m., revealed the [MEDICATION NAME] 300 mg PO (by mouth) every six hours had been discontinued; and [MEDICATION NAME] 300 mg IV every six hours for 10 days was ordered. Medical record review of a Physician's Telephone Order dated March 25, 2014, with an electronic order entry time of 2:35 p.m., revealed May place PICC (peripherally inserted central catheter) line (to administer [MEDICATION NAME] IV). Medical record review of a Nurse's Note dated May 25, 2014, at 3:00 p.m., revealed the PICC line placement provider was notified to .start PICC line for IV [MEDICATION NAME] to be administered . Medical record review of a Nurse's Note dated March 26, 2014, at 12:00 a.m., revealed, (PICC line placement provider) called (by the facility) .pertaining to f/u (follow-up) on order for PICC line. At this time no call back pertaining to arrival time to place PICC line . Continued review revealed no documentation the facility contacted the PICC line placement provider regarding the delay in placing the PICC line between March 26 at 3:00 p.m., and 12:00 a.m. Continued review of a Nurse's Notes dated March 26, 2014, at 12:11 a.m., revealed nursing spoke with the PICC line placement provider, who informed the nurse it would be early morning before (PICC line placement provider) could send someone to place the PICC line. Will pass on in report . Medical record review revealed no documentation of the date or time the PICC line was placed. Medical record review of a Physician's Telephone Order dated March 26, 2014, with an electronic entry time of 12:11 p.m., revealed, .Continue [MEDICATION NAME] PO until IV medication ([MEDICATION NAME]) is started . Medical record review of a Skin Sweep (tool used to document skin assessments) dated March 26, 2014, and electronically signed by the Treatment Nurse revealed, .Lt (left) Lat (lateral) Leg .Pressure .8.0 cm x 1.0 cm x1.0 cm .Stage IV (full thickness tissue loss with exposed bone, tendon, or muscle) . Medical record review of the March 2014 Medication Administration Records revealed the following: March 24; [MEDICATION NAME] 300 mg PO every six hours at 12:00 a.m., 6:00 a.m., 12:00 p.m., and 6:00 p.m., and the first dose was to start at 6:00 p.m. (order was received on March 24, 2014, at 12:35 p.m.). Continued review revealed the 6:00 p.m., dose was not administered. March 25; [MEDICATION NAME] PO was discontinued on March 25, (at 2:23 p.m.) and [MEDICATION NAME] 300 mg IV every six hours was ordered at the same administration times, and the first IV dose was to start at 6:00 p.m. Continued review revealed the resident was administered [MEDICATION NAME] PO at 6:00 p.m., after the PO had been discontinued, and did not receive the IV [MEDICATION NAME] at 6:00 p.m, as ordered. March 26; [MEDICATION NAME] PO was administered at 12:00 a.m., after the PO had been discontinued, and did not receive the IV [MEDICATION NAME] at 12:00 a.m., as ordered. Continued review revealed no [MEDICATION NAME] (PO or IV) was administered at 6:00 a.m. Continued review revealed an order (at 12:11 p.m.) for [MEDICATION NAME] PO until the [MEDICATION NAME] IV was started. Further review revealed no [MEDICATION NAME] (PO or IV) was administered at 12:00 p.m. Medical record review revealed no documentation the Physician was notified the resident did not receive any [MEDICATION NAME] on March 24 at 6:00 p.m.; on March 25 at 12:00 a.m.; and on March 26 at 6:00 a.m., and 12:00 p.m. Continued review revealed the Physician was not notified the resident received the [MEDICATION NAME] PO on March 25 at 6:00 p.m., and on March 26 at 12:00 a.m., instead of the [MEDICATION NAME] IV, as ordered. Medical record review of a Physician's Telephone Order dated March 26, 2014, (no time), revealed an order to send the resident for Direct Admit to the hospital for Stage IV wound to the left calf. Medical record review of a hospital Discharge Summary, dated March 31, 2014, revealed, .Discharge Diagnoses: [REDACTED]. 2. [DIAGNOSES REDACTED] .(Resident) was admitted .Cultures were obtained .placed on empiric (treatment prior to determination of a firm diagnosis) antibiotics .wound care provided .That leg ulcer was not felt typical of decubitus, but likely some injury with deep tissue loss .did have some infection around the wound with proteus and alpha strep .was maintained on antibiotics as appropriate . Continued review revealed the resident was discharged on [DATE], back to (facility) and continued to require antibiotics, with orders for [MEDICATION NAME] 500 mg twice a day for seven days. Observation of the resident on May 7, 2014, at 8:58 p.m., during a dressing change completed by the Assistant Director of Nursing (ADON) and Registered Nurse (RN) #1, confirmed a Stage IV Pressure Ulcer was present on the left lateral calf area of the leg. The resident was lying on the bed with the left lateral leg rotated outward toward the resident's left and the left calf area was in contact with the (Offloading Heel Elevator's) surface. Continued observation of the Stage IV Pressure Ulcer confirmed a moderate amount of dark pink serosanguineous drainage and a moderate amount of slough hanging from the ulcer and attached to the dressing as the dressing was removed. Deep tissue, muscle, and tendon were exposed within the ulcer; and bone was exposed at the 3:00 position (facing the wound and viewing it as a clock) of the ulcer. The Stage IV Pressure Ulcer measured 11.5 cm in length x 2.0 cm in width x 1.2 cm in depth. Interview with the Treatment Nurse, on May 2, 2014, beginning at 5:05 p.m., in the Conference Room, confirmed the (Offloading Heel Elevator) was implemented for use on resident #13 on December 31, 2013. Upon the surveyor questioning what stage resident #13's Pressure Ulcer (on the left lateral calf of the leg) was upon identification and the cause, the Treatment Nurse stated, It was a Stage I .I'll just tell you .On multiple occasions I have found the (Offloading Heel Elevator) was placed either incorrectly or not in place at all on the resident .this happened on five-to-ten occasions that I observed when I would go in to assess the resident and do treatments .The wound was a Stage I on February 13 .wound progressed fast .it scared me .on March 21, 2014, the wound progressed from a Stage I to a Stage III measuring 7.4 cm x 1.3 cm x 0.5 cm .the resident was complaining of pain .On March 24 it increased in size to 8.0 cm x 1.0 cm x 0.4 cm and slough was building with a large amount of purulent drainage and a foul odor. The Nurse Practitioner was notified, an x-ray obtained, antibiotics were started, and the treatment was changed. On March 26 the leg bone was visible. The resident was admitted to the hospital on March 26, 2014, received IV antibiotics, and returned here on March 31. Continued interview with the Treatment Nurse confirmed the Physician was not notified from February 13, 2014 to March 24, 2014. The Treatment Nurse stated, I followed our wound protocols and wrote orders for the treatments (Exuderm [MEDICATION NAME]) until it progressed .then I notified the Nurse Practitioner on March 24 . and further confirmed after the surveyor reviewed the Skin Management Standards with the Treatment Nurse, the Physician is to be notified of all Pressure Ulcers to obtain orders for treatment. A second interview with the Treatment Nurse on May 5, 2014, in the presence of the Interim Director of Nursing (DON), beginning at 1:30 p.m., in the Conference Room, confirmed, .I first identified the (Offloading Heel Elevator) incorrectly placed two-to-five times between December 31, 2013 and March 17, 2014 .and the Physician was not notified . Continued interview with the Treatment Nurse and review of the medical record confirmed the initial onset of the Pressure Ulcer on the Left lateral calf of the leg was identified on as a Stage I on February 13, 2014. Continued interview and review of the medical record with the Treatment Nurse confirmed no assessments or follow-up of the Pressure Ulcer were completed after February 13 until March 17, when the Treatment Nurse identified the Pressure Ulcer as a Stage I and stated, .I can't recall the condition of the left leg (from February 13 until March 17) .nothing stands out in my memory .I didn't assess it .I missed a DTI (Deep Tissue Injury) (Purple or maroon area of discolored intact skin due to damage of underlying soft tissue) . Continued interview confirmed, I observed the device placed incorrectly approximately three-to-five more times between March 17 and March 26 .I observed the (Offloading Heel Elevator) placed incorrectly, above the bend of the knees and ending striking the mid-calf .or in the floor .I told a former Interim Director of Nursing (DON) sometime during the week of March 17 and the in-services were started on March 21 .the Physician was not notified . Continued interview with the Treatment Nurse confirmed the failure to notify the Physician resulted in the resident developing an avoidable DTI, which progressed to a Stage IV Pressure Ulcer, and required direct-admission to the hospital for IV antibiotics and wound care. Interview with Registered Nurse (RN) #3 on May 7, 2014, at 6:09 p.m., in the Conference Room, confirmed to have observed the (Offloading Heel Elevator) placed under the resident incorrectly during the months of February and March 2014, and stated, I can't recall the exact number of times .at least a couple for sure .one time, it was under the thighs and knees with the edge striking the middle of the calves of the legs .another time it was the same way, just a little farther than half-way down the calves . Continued interview confirmed RN #3 failed to notify the Physician of the incorrectly placed (Offloading Heel Elevator). Interview with the Interim Director of Nursing (DON) on May 23, 2014, at 12:00 p.m., in the Conference Room, confirmed the facility failed to notify the Physician of an (Offloading Heel Elevator) placed incorrectly on several occasions under resident #13. Continued interview confirmed the resident developed a Pressure Ulcer on February 13, 2014, and the facility failed to notify the Physician. The DON confirmed the order for the PICC line was received on March 25, 2014, at 2:35 p.m., and the PICC line placement provider was notified of the order on March 25, 2014, at 3:00 p.m. Continued interview confirmed the PICC line was not placed until March 26, 2014, at 6:30 a.m., fifteen and one-half hours later. Further interview confirmed the facility failed to notify the Physician of the delay in placing the PICC line and the missed doses of PO and IV [MEDICATION NAME]. Interview with the resident's Physician and Nurse Practitioner on May 23, 2014, at 1:30 p.m., together in the Conference Room, confirmed the Physician stated, I was not made aware of the incorrect placement of the (Offloading Heel Elevator) until after the State began investigating the resident's wound .sometime during the week of May 12, 2014 . The Nurse Practitioner stated, I was never made aware the (Offloading Heel Elevator) was placed incorrectly . Continued interview with both the Physician and Nurse Practitioner confirmed neither was notified of the onset of the resident's Stage I Pressure Ulcer, identified by the Treatment Nurse on February 13, 2014. The Nurse Practitioner confirmed it wasn't until March 24, 2014, notification was received the Pressure Ulcer was a Stage III. Continued interview with the Nurse Practitioner confirmed orders were given initially for PO [MEDICATION NAME], then later IV [MEDICATION NAME]. The Physician and Nurse Practitioner confirmed they were not notified the resident did not receive all PO [MEDICATION NAME]; and were not notified the resident did not receive any of the IV [MEDICATION NAME]. The Nurse Practitioner stated, The facility was unable to obtain IV access and a PICC line was ordered. I was not notified of the delay in placing the PICC line .I would have expected to be notified if the PICC line couldn't be placed within three-to-four hours, so the resident could have been sent out for an alternate plan of care. Continued interview with the Physician and Nurse Practitioner confirmed the incorrect placement of the (Offloading Heel Elevator) restricted blood flow to an already compromised extremity, which resulted in a Stage IV Pressure Ulcer. The Physician confirmed, If I had been informed of the incorrect placement of the (Offloading Heel Elevator) I would have ensured nursing was aware of just how dangerous the incorrect placement (of the Offloading Heel Elevator) was .which impeded blood flow with the potential for loss of the extremity and/or life. In summary, the facility failed to ensure the Physician was notified of the incorrect placement of the (Offloading Heel Elevator). The Treatment Nurse observed the (Offloading Heel Elevator) placed incorrectly under resident #13 on multiple occasions between December 31, 2013, and March 26, 2014. RN #3, failed to notify the Physician of observations of the (Offloading Heel Elevator) placed incorrectly. On February 13, 2014, the Treatment Nurse identified a new Stage I Pressure Ulcer on resident #13's lateral calf area of the left leg. The Physician was not notified of the new pressure ulcer, which was not assessed or monitored further until March 17, 2014, and was identified as a Stage I; but on March 21, 2014, the ulcer had progressed from a Stage I to a Stage III Pressure Ulcer. It wasn't until March 24, 2014, the facility notified the Nurse Practitioner, which was approximately one and one-half months after the wound was initially identified on February 13, 2014; and had progressed to a Stage III Pressure Ulcer. Orders were initially received to administer oral antibiotics for the resident's infected wound, but the resident became nauseous and the oral antibiotics were changed to IV antibiotics. On March 25, 2014, at 3:00 p.m., the PICC line placement provider was notified to place the PICC line. The PICC line wasn't placed until March 26, 2014, at 6:30 a.m. The facility failed to administer both the PO and IV [MEDICATION NAME], as ordered; and failed to notify the Physician of the delay in placing the PICC line and the missed doses of [MEDICATION NAME]. On March 26, 2014, the Pressure Ulcer was a Stage IV, and the Nurse Practitioner ordered the resident be sent to the hospital where IV antibiotics and wound care was provided. The Immediate Jeopardy was effective from December 31, 2013, through May 29, 2014. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated by the surveyor through review of documents, staff interviews, and observations conducted onsite on May 31, 2014. The surveyor verified the allegation of compliance by: 1. Reviewing the facility's in-service records to ensure nursing staff were educated or re-educated regarding changes to and implementation of the facility's following policies: a. Use of Offloading Heel Elevators and Pressure Redistribution Surfaces b. Skin Management Standard, including Risk Assessments, Pressure Ulcer Risk Assessments, Prevention/Body Audits (daily by CNA's; weekly by Licensed Nurses; and quarterly Skin Sweeps by Licensed Nurses), Routine Preventative Care, Staging, Documentation, Wound Care Protocol, and Negative Pressure Wound Therapy (re-educated) c. Weekly At-Risk Meetings d. Daily Clinical Wound Reviews e. Weekly Wound Team Rounds f. Change in (Resident) Condition (re-educated) g. Physician Notification of Delay in Treatment and Services (re-educated) h. Administrative Team Resident Rounds 2. Conducted interviews with administration and nursing staff, to include the Administrator, eight Registered Nurses (which included the DON and ADON), eight Licensed Practical Nurses, and fourteen Certified Nursing Assistants for a total of thirty nursing staff of fifty-four licensed and certified nurses on staff; and one Administrator to determine the level of comprehension gained through in-service education conducted regarding changes to and implementation of the facility's policies, Use of Offloading Heel Elevators and Pressure Redistribution Surfaces; Skin Management Standards; Weekly At-Risk Meetings; Daily Clinical Wound Reviews; Weekly Wound Team Rounds; Change in Resident Condition; and Physician Notification of Delay in Treatment and Services to ensure staff recognize and respond to the following: a. The rationale for an At-Risk assessment, preventative daily and weekly skin assessments, and monitoring of the resident's skin along with skin impairment that warrants Physician notification and intervention. Including but not limited to: all Stages of Pressure Ulcers (I, II, III, IV, and Suspected Deep Tissue Injuries) and changes in the Stage of a Pressure Ulcer. The interviews included a verbal explanation of each Pressure Ulcer Stage; when and by who are the At-Risk and preventative skin assessments are completed and documented; what encompasses a Pressure Ulcer assessment; and when and by whom are Pressure Ulcers assessed and documented. b. The facility's educational and procedural requirement for the implementation and monitoring of the (Offloading Heel Elevator) and all future purchases of resident assistive devices, in which staff must be educated prior to the use of any new equipment and upon hire, before working with the resident and the assistive devices. The interviews included the process for education prior to implementing the newly purchased device, implementation, and monitoring. Additional validation included a skills competency demonstration of placing the (Offloading Heel Elevator) to ensure comprehension in the correct placement of the device. c. The facility's Daily Clinical Wound reviews included a verbal explanation of their purpose, when are the reviews held, and who is responsible for the documentation and who oversees the reviews. d. The facility's Weekly Wound Rounds included a verbal explanation of the purpose, when the rounds are conducted, who is required to participate in the rounds, what observation would constitute follow-up, and who oversees the rounds and ensures the follow-up. e. What constitutes a change in a resident's condition and what is required when a change in a resident's condition occurs. Interviews included a verbal explanation of prompts notifications, who is notified and by whom, how soon, and required documentation. f. The facility's policy and procedural requirement for medication administration and time-sensitive treatment, services, and Physician orders. Interviews included a verbal explanation on ensuring adequate and timely communication with outside providers and Physician notification if the services cannot be provided timely to ensure an alternate plan of care (PICC line insertion must be inserted within a four-hour window; if not inserted within four-hours, the Physician must be notified for an alternate plan of care). Further, a review of the Medication Administration Records and a verbal explanation of the standards of practice and facility policy related to Medication Administration. g. The facility's policy for Administrative C",2017-05-01
8602,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2014-05-31,282,J,1,0,3X0Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of manufacturer's directions, review of facility records, observation, and interview, the facility failed to ensure all nursing staff were trained and competent in the correct use of a pressure preventative device in accordance with the resident's care plan for one resident (#13) of nineteen residents reviewed. The facility's failure resulted in resident (#13's) (Offloading Heel Elevator) being placed incorrectly under the resident and the development of a Stage IV (four) (full thickness tissue loss with exposed bone, tendon, or muscle) Pressure Ulcer and placed resident #13 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) and Corporate Chief Nursing Officer (CCNO) were informed of the Immediate Jeopardy in the Conference Room on May 29, 2014, at 9:00 p.m. The findings included: Review of the Manufacturer's Directions for Use, (Offloading Heel Elevator), (no date), revealed, .Place (Offloading Heel Elevator) under the lower legs, so that the users heels are fully suspended. The highest portion is at the heel area, with the taper extending beneath the knees (as noted on the cover) (a picture of the Offloading Heel Elevator under the lower part of the legs, between the knees and ankles, with the device fully supporting the entire calves of the legs) . Resident #13 was admitted to the facility initially on April 16, 2009, with [DIAGNOSES REDACTED]. Medical record review of an Annual Minimum Data Set (MDS) dated [DATE], revealed the resident's cognition was moderately impaired with a Brief Interview for Mental Status score of 8 (with zero being the lowest indicating severely impaired cognition and fifteen being the highest indicating intact cognition). Continued review revealed the resident did not reject care. The resident was totally dependent for bed mobility and transfers; and was non-ambulatory. The resident's range of motion in the upper and lower extremities was functionally impaired on both sides. Further review revealed the resident had no pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), but was at risk of developing pressure ulcers. Medical record review of the Pressure Ulcer Risk Assessments (screening tool that is designed to help identify residents who might develop a pressure ulcer) dated December 31, 2013, January 17, 2014, January 24, 2014, February 12, 2014, March 21, 2014, April 3, 2014, April 10, 2014, April 17, 2014, and April 24, 2014, revealed the resident was at high risk for the development of pressure ulcers. Medical record review of a Skin/Wound Note dated December 31, 2013, at 2:07 p.m., and electronically signed by the Treatment Nurse, revealed an offloading heel elevator (pressure relieving device) used to prevent or promote healing, which is designed to suspend the heels off the end of the device to ensure heels are free of the surface of the bed) was placed under the resident (lower extremities) to allow pressure relief of the bilateral (both) heels. Medical record review of resident #13's Care Plan dated December 31, 2013, revealed, .The resident need (needs) (Offloading Heel Elevator) at all times excpet (except) during ADL (Activities of Daily Living) care to protect the skin while in bed .Date Initiated: December 31, 2013 . Medical record review of a Skin/Wound Note dated March 17, 2014, at 12:44 p.m., and electronically signed by the Treatment Nurse revealed the offloading heel elevator was incorrectly placed under the resident, and stated, .Stage I (Pressure Ulcer) was noted to the left lower lateral leg .(Offloading Heel Elevator) is in place and was repositioned to below the knees to allow better pressure relief to this area as well as pressure free to the heels . Medical record review of a Weekly Wound Progress Note dated March 17, 2014, at 12:53 p.m., and electronically signed by the Treatment Nurse revealed, Date identified .March 17, 2014 .Left lower lateral leg .Stage I .Acquired (wound developed in facility) Peri-wound (around the pressure uler) .Length: 8.0 centermeters (cm) .Width: 1.0 cm .Depth: 0.0 cm .Area: [DIAGNOSES REDACTED] (redness) .induration (abnormal Hardness) . Medical record review of a Weekly Wound Progress Note and Skin/Wound Note, both dated March 21, 2014, and electronically signed by the Treatment Nurse revealed the offloading heel elevator was incorrectly placed under the resident, and stated, During treatments this shift, area to left lower lateral leg was noted to advance in stage from a I to a III (three) (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed). Slough (necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, and stringy, at times) .area was noted to have a moderate amount of serosanguineous (bloody, thin, and watery) drainage present .area went from measurement of stage I of 8.0 x (by) 1.0 to open with muscle exposure total size of 7.4 (cm) x 1.3 (cm) x 0.3 (cm) (depth). There are a total of 3 (three) open areas to the middle of the area that is red and nonblanching (non-blanching) .(Offloading Heel Elevator) was repositioned to proper alignment to ensure pressure redistribution . Medical record review of a Physician's Telephone Order for resident #13, dated March 24, 2014, 12:35 p.m., revealed orders for an X-Ray of the Left Lower Leg to rule-out [DIAGNOSES REDACTED] and [MEDICATION NAME] (antibiotic) 300 milligrams (mg) by mouth (PO) every six hours for Left Leg [MEDICAL CONDITION] for 10 days. Medical record review of a typed Nurse Practitioner's Progress Note dated March 25, 2014, dictated at 11:36 a.m., revealed the Nurse Practitioner conducted a follow-up visit related to the abrupt onset of Stage III Pressure Ulcer. Medical record review of resident #13's Skin Sweep dated March 26, 2014, and electronically signed by the Treatment Nurse revealed, .Lt (left) Lat (lateral) Leg .Pressure .8.0 cm x 1.0 cm x1.0 cm .Stage IV (full thickness tissue loss with exposed bone, tendon, or muscle) . Medical record review of a Physician's Telephone Order dated March 26, 2014, (no time), revealed an order to send the resident for Direct Admit to the hospital for Stage IV wound to the left calf. Medical record review of the hospital History and Physical (H&P), dated March 26, 2014, revealed, .does state that .leg is painful .report that the wound on .leg has progressed .Extremities: Left lateral calf with large wound tracking to the bone with surrounding [DIAGNOSES REDACTED] .Diagnosis, Assessment & (and) Plan: .Wound tracks to the bone so will need to treat as osteo[DIAGNOSES REDACTED] for now. CT (Computed Tomography) done and not consistent with [DIAGNOSES REDACTED] (flesh-eating bacteria syndrome). Will consult with ID (Infectious Diseases) and wound care. Will start empirically on vanc ([MEDICATION NAME]) (antibiotic) and meropenem (ultra-broad-spectrum antibiotic) .Problem List: 1. Left lateral leg ulcer; 2. [DIAGNOSES REDACTED] . Medical record review of a hospital Consultation Report dated March 26, 2014, revealed, .was sent to the hospital .because of (resident's) left leg ulceration or wound. It is unclear how all this started .Skin: .The left lateral leg area has a long wound, which is deep in some area with underlying exposed tendon. There is surrounding [DIAGNOSES REDACTED] and tenderness currently .has very thin, fragile skin on (resident's) legs and feet. There is [MEDICAL CONDITION] of the legs in addition to the feet .Tests: .CT of the leg .shows a lateral posterior soft tissue defect with surrounding soft tissue [MEDICAL CONDITION] .no soft tissue gas .Assessment and Recommendations: .Elderly demented patient .now has a deep wound on the posteriolateral left leg, exact cause is unclear, but I suspect (resident) must have had some kind of injury .may have had a deep injury, which subsequently resulted in necrosis (dead tissue) of the overlying tissue and now has an open wound . Medical record review of resident #13's hospital Discharge Summary, dated March 31, 2014, revealed, .Discharge Diagnoses: [REDACTED]. 2. [DIAGNOSES REDACTED] .(Resident) . Continued review revealed the resident was discharged on [DATE], back to (facility) and continued to require antibiotics, with orders for [MEDICATION NAME] 500 mg twice a day for seven days. Observation of resident #13 on May 7, 2014, at 8:58 p.m., during a dressing change completed by the Assistant Director of Nursing (ADON) and Registered Nurse (RN) #1, confirmed a Stage IV Pressure Ulcer was present on the left lateral calf area of the leg. Continued observation of the Stage IV Pressure Ulcer confirmed a moderate amount of dark pink serosanguineous drainage and a moderate amount of slough hanging from the ulcer and attached to the dressing as the dressing was removed. Deep tissue, muscle, and tendon were exposed within the ulcer; and bone was exposed at the 3:00 position (facing the wound and viewing it as a clock) of the ulcer. The Stage IV Pressure Ulcer measured 11.5 cm in length x 2.0 cm in width x 1.2 cm in depth. Interview with the Treatment Nurse, (a Registered Nurse) on May 2, 2014, beginning at 5:05 p.m., in the Conference Room, confirmed the (Offloading Heel Elevator) was implemented for use on resident #13; and the Treatment Nurse revised the care plan on December 31, 2013, to implement the (Offloading Heel Manager). Upon the surveyor questioning what stage resident #13's Pressure Ulcer (on the left lateral calf of the leg) was upon identification and the cause, the Treatment Nurse stated, It was a Stage I .I'll just tell you .On multiple occasions I have found the (Offloading Heel Elevator) was placed either incorrectly or not in place at all on the resident .this happened on five-to-ten occasions that I observed when I would go in to assess the resident and do treatments . A second interview with the Treatment Nurse on May 5, 2014, in the presence of the Interim Director of Nursing (DON), beginning at 1:30 p.m., in the Conference Room, confirmed, .I first identified the (Offloading Heel Elevator) incorrectly placed two-to-five times between December 31, 2013 and March 17, 2014 .I observed the device placed incorrectly approximately three-to-five more times between March 17 and March 26 .I observed the (Offloading Heel Elevator) placed incorrectly, above the bend of the knees and ending striking the mid-calf .or in the floor . Continued interview confirmed the facility failed to ensure all nursing staff were qualified to use the (Offloading Heel Elevator) as care planned. Review of a facility in-service, Heel Protect In-Service Training, dated March 21, 2014, with attached illustrations and literature specific to the (Offloading Heel Elevator), revealed, Summary of Topic Covered: The heel positioner (offloading heel elevator) is to be placed from below the bend of the knees down, not across the back of the (arrow indicating upper) legs. The heel positioner is not to be placed in the floor. Continued review revealed only six Certified Nursing Assistants (CNA's), two Licensed Practical Nurses (LPN's), and two Registered Nurses (RN's), for a total of ten nursing staff, attended the training. Further review revealed no documentation of competency being validated. Review of a facility Current Employee Listing (as of April 29, 2014) revealed 59 nursing staff were employed by the facility; and of the 59 nursing staff working as of April 29, 2014, only 9 had been in-serviced on the use of the (Offloading Heel Elevator). Interviews on May 7, 2014, with Certified Nursing Assistant (CNA) #1 (1:30 p.m.), #2 (1:47 p.m.), #3 (2:15 p.m.), #4 (3:14 p.m.), #5 (3:35 p.m.), #6 (4:10 p.m.), and #7 (5:05 p.m.), in the Conference Room, confirmed to have received no training on the use and/or placement of the (Offloading Heel Elevator) prior to May 6 and 7, 2014. Continued interviews confirmed CNA's #2, #3, #4, #6, and #7 provided care and assistance to resident #13. Continued interview with CNA #3 on May 7, 2014, beginning at 2:15 p.m., in the Conference Room, confirmed upon CNA #3 arrival to work and entering the resident's room, had observed the (Offloading Heel Elevator) placed under the resident incorrectly two-to-three times. Continued interview confirmed CNA #3 found it (Offloading Heel Elevator) in a chair or in the closet in the resident's room three-to-four times. CNA #3 stated, I found it under (resident's) thighs and ending in (resident's) mid-calf area two-to-three times .I just removed it and did (resident's) morning care, then put it back under (resident) correctly .between the bend of (resident's) knees and ankles. Continued interview confirmed the resident was unable to independently place the (Offloading Heel Elevator) incorrectly under the resident's own legs. Interviews on May 7, 2014, with Registered Nurse (RN) #2 (1:00 p.m.) and #3 (6:09 p.m.), in the Conference Room, confirmed to have received no training on the use and/or placement of the (Offloading Heel Elevator) prior to May 6 and 7, 2014. Continued interviews confirmed RN #2 and #3 provided care and assistance to resident #13. Continued interview with RN #3 on May 7, 2014, beginning at 6:09 p.m., in the Conference Room, confirmed to have observed the (Offloading Heel Elevator) placed under the resident incorrectly during the months of February and March 2014, and stated, I can't recall the exact number of times .at least a couple for sure .one time, it was under the thighs and knees with the edge striking the middle of the calves of the legs .another time it was the same way, just a little farther than half-way down the calves . Interviews on May 7, 2014, with Licensed Practical Nurse (LPN) #1 (3:00 p.m.) and #2 (8:22 p.m.), in the Conference Room, confirmed to have received no training on the use and/or placement of the (Offloading Heel Elevator) prior to May 6 and 7, 2014. Continued interviews confirmed LPN #2 and #3 provided care and assistance to resident #13. Interview with the current Interim DON on May 23, 2014, at 12:00 p.m., in the Conference Room, confirmed the DON started as Interim DON on March 19, 2014, and was unaware of the (Offloading Heel Elevator's) placed incorrectly or not at all on occasions for #13. Continued interview with the DON confirmed the facility failed to ensure all nursing staff were qualified to implement and use the (Offloading Heel Elevator) as care planned. Interview with the Administrator on May 29, 2014, at 2:55 p.m., in the Conference Room, confirmed the facility failed to ensure the nursing staff were qualified to implement and use the (Offloading Heel Elevator) as care planned. In summary, the facility failed to ensure all nursing staff were qualified to use an (Offloading Heel Elevator) care planned and implemented for resident #13 on December 31, 2013. The Treatment Nurse confirmed to be unqualified with no previous training on the use of an (Offloading Heel Elevator), yet implemented and care planned the device for the resident. Further, of 11 (eleven) of 11 nursing staff interview confirmed to be unqualified, nine of which provided care and assistance to resident #13. The Treatment Nurse, RN #3, and CNA #3, confirmed observations of the device being placed either incorrectly under the resident, or not at all. The Treatment Nurse alone confirmed to have five-to-ten observations of incorrect placement under the resident from December 31, 2013 through March 26, 2014. Registered Nurse #3 observed the (Offloading Heel Elevator) placed incorrectly on more than one occasion and confirmed to not know whether it was placed correctly under the resident or not and sent a CNA to check the device. The resident developed a Pressure Ulcer, documented as a Stage I on February 13, 2014, which progressed to a Stage III on March 24, 2014, then to a Stage IV on March 26, 2014. The resident's Pressure Ulcer progressed to a Stage III on March 24, 2014, and a Stage IV on March 26, 2014. On March 26, 2014, the Nurse Practitioner ordered the resident be sent to the hospital where IV antibiotics and wound care was provided. The Immediate Jeopardy was effective from December 31, 2013, through May 29, 2014, and was removed on May 30, 2014. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated by the surveyor through review of documents, staff interviews, and observations conducted onsite on May 31, 2014. The surveyor verified the allegation of compliance by: 1. Reviewing the facility's in-service records to ensure nursing staff were educated or re-educated regarding changes to and implementation of the facility's following policies: a. Use of Offloading Heel Elevators and Pressure Redistribution Surfaces b. Skin Management Standard, including Risk Assessments, Pressure Ulcer Risk Assessments, Prevention/Body Audits (daily by CNA's; weekly by Licensed Nurses; and quarterly Skin Sweeps by Licensed Nurses), Routine Preventative Care, Staging, Documentation, Wound Care Protocol, and Negative Pressure Wound Therapy (re-educated) c. Weekly At-Risk Meetings d. Daily Clinical Wound Reviews e. Weekly Wound Team Rounds f. Change in (Resident) Condition (re-educated) g. Administrative Team Resident Rounds 2. Conducted interviews with administration and nursing staff, to include the Administrator, eight Registered Nurses (which included the DON and ADON), eight Licensed Practical Nurses, and fourteen Certified Nursing Assistants for a total of thirty nursing staff of fifty-four licensed and certified nurses on staff; and one Administrator to determine the level of comprehension gained through in-service education conducted regarding changes to and implementation of the facility's policies, Use of Offloading Heel Elevators and Pressure Redistribution Surfaces; Skin Management Standards; Weekly At-Risk Meetings; Daily Clinical Wound Reviews; Weekly Wound Team Rounds; and Change in Resident Condition to ensure staff recognize and respond to the following: a. The rationale for an At-Risk assessment, preventative daily and weekly skin assessments, and monitoring of the resident's skin along with skin impairment that warrants Physician notification and intervention. Including but not limited to: all Stages of Pressure Ulcers (I, II, III, IV, and Suspected Deep Tissue Injuries) and changes in the Stage of a Pressure Ulcer. The interviews included a verbal explanation of each Pressure Ulcer Stage; when and by who are the At-Risk and preventative skin assessments are completed and documented; what encompasses a Pressure Ulcer assessment; and when and by whom are Pressure Ulcers assessed and documented. b. The facility's educational and procedural requirement for the implementation and monitoring of the (Offloading Heel Elevator) and all future purchases of resident assistive devices, in which staff must be educated prior to the use of any new equipment and upon hire, before working with the resident and the assistive devices. The interviews included the process for education prior to implementing the newly purchased device, implementation, and monitoring. Additional validation included a skills competency demonstration of placing the (Offloading Heel Elevator) to ensure comprehension in the correct placement of the device. c. The facility's Daily Clinical Wound reviews included a verbal explanation of their purpose, when are the reviews held, and who is responsible for the documentation and who oversees the reviews. d. The facility's Weekly Wound Rounds included a verbal explanation of the purpose, when the rounds are conducted, who is required to participate in the rounds, what observation would constitute follow-up, and who oversees the rounds and ensures the follow-up. e. What constitutes a change in a resident's condition and what is required when a change in a resident's condition occurs. Interviews included a verbal explanation of prompts notifications, who is notified and by whom, how soon, and required documentation. f. The facility's policy for Administrative Clinical Rounds included a verbal explanation of the purpose, when the rounds are conducted, who conducts the rounds, what observation would constitute follow-up, and who oversees the rounds and ensures the follow-up. 3. Review of Weekly Wound Progress Notes, the facility's Weekly Wound Report, and observation of respective Pressure Ulcers of four residents to validate accuracy in assessment and documentation. 4. Observation of a dressing change and application of a Negative Pressure Wound Therapy System to validate accuracy in assessment, treatment, and application of the Negative Pressure Wound Therapy System. 5. Observation of four residents requiring offloading of the heels to confirm correct positioning using a regular pillow; the (Offloading Heel Elevators) were discontinued effective May 22, 2014, and none were in use for review. 6. Review of At-Risk Assessments of 13 residents for timeliness and correct implementation of preventative interventions based upon the assessments. 7. Observation of a Medication Pass to validate administration and accuracy of medications administered, as ordered by the Physician. 8. Observation of the facility's Clinical Board for wound-related information, used as a tool to ensure focused and effective communication and follow-up during Daily Clinical Wound Reviews (Monday through Friday, during normal work days). 9. Review of the minutes from an emergency Quality Assurance/Performance Improvement Committee Meeting held on May 7, 2014, with the Administrator, Medical Director, Director of Nursing, Corporate Quality Improvement Consultant, Minimum Data Set Coordinator, Certified Dietary Manager, Therapy Director, and Social Services. Based upon the complaint survey initiated on April 29, 2014, the Committee discussed the Skin Management Standard (assessments, accuracy of assessments, frequency of assessments, documentation) and corrective actions as identified in the Allegation of Compliance. Non-compliance continues at a D level 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-157 (J)",2017-05-01
8603,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2014-05-31,309,J,1,0,3X0Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to place a peripherally inserted central catheter line (to administer intravenous medications) timely and failed to administer oral and intravenous (IV) antibiotics as ordered for one resident (#13) of nineteen residents reviewed. The facility's failure resulted in resident (#13) with a [DIAGNOSES REDACTED].#13 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) and Corporate Chief Nursing Officer (CCNO) were informed of the Immediate Jeopardy in the Conference Room on May 29, 2014, at 9:00 p.m. F309 resulted in Substandard Quality of Care. The findings included: Resident #13 was admitted to the facility initially on April 16, 2009, with [DIAGNOSES REDACTED]. Medical record review of an Annual Minimum Data Set (MDS) dated [DATE], revealed the resident's cognition was moderately impaired with a Brief Interview for Mental Status score of 8 (with zero being the lowest indicating severely impaired cognition and fifteen being the highest indicating intact cognition). Continued review revealed the resident did not reject care. Further review revealed the resident had no pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), but was at risk of developing pressure ulcers. Medical record review of resident #13's Pressure Ulcer Risk Assessments (screening tool that is designed to help identify residents who might develop a pressure ulcer) dated December 31, 2013, January 17, 2014, January 24, 2014, February 12, 2014, and March 21, 2014, revealed the resident was at high risk for the development of pressure ulcers. Medical record review of a Skin/Wound Note for Resident #13 dated February 13, 2014, at 4:28 p.m., and electronically signed by the Treatment Nurse revealed Stage I (one) (an observable, pressure-related alteration of intact skin, when compared to an adjacent or opposite area on the body may include changes in skin temperature, tissue consistency, sensation and/or a defined area of persistent redness) area noted to the outer lateral portion of the left calf . Medical record review of a Skin/Wound Note for Resident #13 dated March 17, 2014, at 12:44 p.m., and electronically signed by the Treatment Nurse revealed the offloading heel elevator was incorrectly placed under the resident, and stated, .Stage I (Pressure Ulcer) was noted to the left lower lateral leg .(Offloading Heel Elevator) is in place and was repositioned to below the knees to allow better pressure relief to this area as well as pressure free to the heels . Medical record review of a Weekly Wound Progress Note dated March 17, 2014, at 12:53 p.m., and electronically signed by the Treatment Nurse revealed, Date identified .March 17, 2014 .Left lower lateral leg .Stage I .Acquired (wound developed in the facility) Peri-Wound (around the pressure ulcer) .Length: 8.0 centimeters (cm) .Width: 1.0 cm .Depth: 0.0 cm .Area: [DIAGNOSES REDACTED] (redness) .induration (abnormal hardness) . Medical record review of a Skin/Wound Note for Resident #13 dated March 21, 2014, at 12:22 p.m., and electronically signed by the Treatment Nurse revealed the offloading heel elevator was incorrectly placed under the resident, and stated, During treatments this shift, area to left lower lateral leg was noted to advance in stage from a I to a III (three) (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed). Slough (necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, and stringy, at times) .area was noted to have a moderate amount of serosanguineous (bloody, thin, and watery) drainage present .area went from measurement of stage I of 8.0 x (by) 1.0 to open with muscle exposure total size of 7.4 (cm) x 1.3 (cm) x 0.3 (cm) (depth). There are a total of 3 (three) open areas to the middle of the area that is red and nonblanching (non-blanching) .(Offloading Heel Elevator) was repositioned to proper alignment to ensure pressure redistribution . Medical record review of a typed Physician's Progress Note dated March 24, 2014, dictated at 10:21 a.m., revealed the resident had not generally felt well over the past several days and had developed a temperature of 100 degrees (Fahrenheit). Medical record review of a Physician's Telephone Order dated March 24, 2014, 12:35 p.m., revealed orders for [MEDICATION NAME] (antibiotic) 300 milligrams (mg) by mouth (PO) every six hours for Left Leg [MEDICAL CONDITION] for 10 days. Medical record review of a Weekly Wound Progress Note dated March 24, 2014, at 4:57 p.m., and electronically signed by the Treatment Nurse revealed the resident's Stage III Pressure Ulcer measured 8.0 cm x 1.0 cm x 0.4 cm had slough and a large amount of purulent (contained pus) drainage, with a foul odor. Medical record review of a typed Nurse Practitioner's Progress Note for Resident #13 dated March 25, 2014, dictated at 11:36 a.m., revealed the Nurse Practitioner conducted a follow-up visit related to the abrupt onset of Stage III Pressure Ulcer, and stated, .[MEDICATION NAME] is making (resident) nauseous .left leg with stage III ulceration and two small satellite areas (two small ulcerations near the large ulcer), confluent (flow together) [DIAGNOSES REDACTED]. Wound bed is covered with pink granulation (pink-red moist tissue that fills an open wound, when starts to heal) tissue and yellow slough .copious (extensive) amount of serosanguineous purulent drainage .malodorous (bad, foul odor) .Acute [MEDICAL CONDITION] left leg .Stage III ulceration to left calf .nausea .continue the [MEDICATION NAME] therapy .change it to IV (intravenous) secondary to the patient's nausea . Medical record review of a Physician's Telephone Order dated March 25, 2014, with an electronic order entry time of 2:23 p.m., revealed the [MEDICATION NAME] 300 mg PO (by mouth) every six hours had been discontinued; and ordered [MEDICATION NAME] 300 mg IV every six hours for 10 days. Medical record review of a Physician's Telephone Order dated March 25, 2014, with an electronic order entry time of 2:35 p.m., to place a PICC (peripherally inserted central catheter) line (to administer [MEDICATION NAME] IV). Medical record review of a Nurse's Note dated March 26, 2014, at 12:00 a.m., revealed, (PICC line placement provider) called .pertaining to f/u (follow-up) on order for PICC line. At this time no call back pertaining to arrival time to place PICC line . Continued review of a Nurse's Notes dated March 26, 2014, at 12:11 a.m., revealed nursing spoke with the PICC line placement provider, who informed the nurse it would be early morning before the provider could send someone to place the PICC line. Medical record review revealed no documentation of the date or time of the PICC line placement. Medical record review of a Physician's Telephone Order dated March 26, 2014, with an electronic entry time of 12:11 p.m., revealed, .Continue [MEDICATION NAME] PO until IV medication ([MEDICATION NAME]) is started . Medical record review of the March 2014 Medication Administration Records revealed the following: March 24; [MEDICATION NAME] 300 mg PO every six hours at 12:00 a.m., 6:00 a.m., 12:00 p.m., and 6:00 p.m., and the first dose was to start at 6:00 p.m. (order was received on March 24, 2014, at 12:35 p.m.). Continued review revealed the 6:00 p.m., dose was not administered, as ordered. March 25; [MEDICATION NAME] PO was discontinued on March 25, (at 2:23 p.m.) and [MEDICATION NAME] 300 mg IV every six hours was ordered at the same administration times, and the first IV dose was to start at 6:00 p.m. Continued review revealed the resident was administered [MEDICATION NAME] PO at 6:00 p.m., after the PO had been discontinued, and did not receive the IV [MEDICATION NAME] at 6:00 p.m, as ordered. March 26; [MEDICATION NAME] PO was administered at 12:00 a.m., after the PO had been discontinued, and did not receive the IV [MEDICATION NAME] at 12:00 a.m., as ordered. Continued review revealed no [MEDICATION NAME] (PO or IV) was administered at 6:00 a.m. Continued review revealed an order (at 12:11 p.m.) for [MEDICATION NAME] PO until the [MEDICATION NAME] IV was started. Further review revealed no [MEDICATION NAME] (PO or IV) was administered at 12:00 p.m., as ordered. Medical record review of a Skin Sweep for resident #13 dated March 26, 2014, and electronically signed by the Treatment Nurse revealed, .Lt (left) Lat (lateral) Leg .Pressure .8.0 cm x 1.0 cm x1.0 cm .Stage IV (full thickness tissue loss with exposed bone, tendon, or muscle) . Medical record review of a Physician's Telephone Order dated March 26, 2014, (no time), revealed an order to send the resident for Direct Admit to the hospital for Stage IV wound to the left calf. Medical record review of the hospital History and Physical (H&P), dated March 26, 2014, revealed, .report that the wound on .leg has progressed over the past 2-3 (two-to-three) days .Extremities: Left lateral calf with large wound tracking to the bone with surrounding [DIAGNOSES REDACTED] .Diagnosis, Assessment & (and) Plan: .admitted for further evaluation of left lateral leg ulcer. Wound tracks to the bone so will need to treat as osteo[DIAGNOSES REDACTED] for now. Will start empirically on vanc ([MEDICATION NAME]) (antibiotic) and meropenem (ultra-broad-spectrum antibiotic) .Problem List: 1. Left lateral leg ulcer; 2. [DIAGNOSES REDACTED] . Medical record review of a hospital Discharge Summary for Resident #13 dated March 31, 2014, revealed, .Discharge Diagnoses: [REDACTED]. 2. [DIAGNOSES REDACTED] .(Resident) was admitted .placed on empiric (treatment prior to determination of a firm diagnosis) antibiotics .wound care provided .did have .infection around the wound with proteus and alpha strep .was maintained on antibiotics . Continued review revealed the resident was discharged [DATE], back to (facility) and continued to require antibiotics, with orders for [MEDICATION NAME] 500 mg twice a day for seven days. Observation of the resident on May 7, 2014, at 8:58 p.m., during a dressing change completed by the Assistant Director of Nursing (ADON) and Registered Nurse (RN) #1, confirmed a Stage IV Pressure Ulcer was present on the left lateral calf area of the leg and measured 11.5 cm in length x 2.0 cm in width x 1.2 cm in depth. The Stage IV Pressure Ulcer had a moderate amount of dark pink serosanguineous drainage and a moderate amount of slough hanging from the ulcer and attached to the dressing as the dressing was removed. Deep tissue, muscle, tendon, and bone were exposed within the ulcer. Interview with the Interim Director of Nursing (DON) on May 23, 2014, at 12:00 p.m., in the Conference Room, confirmed the facility had a delay of more than fifteen and one-half hours from the time the PICC line was ordered until it was placed. Further, the DON confirmed the facility failed to administer resident #13's PO and IV [MEDICATION NAME], as ordered. Interview with the resident's Physician and Nurse Practitioner on May 23, 2014, at approximately 1:30 p.m., together in the Conference Room, and the Physician and Nurse Practitioner confirmed they were not notified the resident did not receive all PO [MEDICATION NAME]; and were not notified the resident did not receive any of the IV [MEDICATION NAME]. The Nurse Practitioner stated, The facility was unable to obtain IV access and a PICC line was ordered. I was not notified of the delay in placing the PICC line .I would have expected to be notified if the PICC line couldn't be placed within three-to-four hours, so the resident could have been sent out for an alternate plan of care. Interview with the Administrator on May 29, 2014, at approximately 2:55 p.m., in the Conference Room, confirmed the facility failed to ensure the PICC line was placed timely and failed to administer oral and intravenous antibiotics, as ordered for one resident (#13). In summary, the facility failed to ensure the PICC line was placed timely and failed to administer the PO and IV antibiotics, as ordered by the Physician. The facility's failure to place the PICC line timely and administer the antibiotics as ordered, resulted in resident #13 being admitted to the hospital for IV antibiotics and wound care. The Immediate Jeopardy was effective from December 31, 2013, through May 29, 2014. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated by the surveyor through review of documents, staff interviews, and observations conducted onsite on May 31, 2014. The surveyor verified the allegation of compliance by: 1. Reviewing the facility's in-service records to ensure nursing staff were educated or re-educated regarding changes to and implementation of the facility's following policies: a. Use of Offloading Heel Elevators and Pressure Redistribution Surfaces b. Skin Management Standard, including Risk Assessments, Pressure Ulcer Risk Assessments, Prevention/Body Audits (daily by CNA's; weekly by Licensed Nurses; and quarterly Skin Sweeps by Licensed Nurses), Routine Preventative Care, Staging, Documentation, Wound Care Protocol, and Negative Pressure Wound Therapy (re-educated) c. Weekly At-Risk Meetings d. Daily Clinical Wound Reviews e. Weekly Wound Team Rounds f. Change in (Resident) Condition (re-educated) g. Physician Notification of Delay in Treatment and Services (re-educated) h. Administrative Team Resident Rounds 2. Conducted interviews with administration and nursing staff, to include the Administrator, eight Registered Nurses (which included the DON and ADON), eight Licensed Practical Nurses, and fourteen Certified Nursing Assistants for a total of thirty nursing staff of fifty-four licensed and certified nurses on staff; and one Administrator to determine the level of comprehension gained through in-service education conducted regarding changes to and implementation of the facility's policies, Use of Offloading Heel Elevators and Pressure Redistribution Surfaces; Skin Management Standards; Weekly At-Risk Meetings; Daily Clinical Wound Reviews; Weekly Wound Team Rounds; Change in Resident Condition; and Physician Notification of Delay in Treatment and Services to ensure staff recognize and respond to the following: a. The rationale for an At-Risk assessment, preventative daily and weekly skin assessments, and monitoring of the resident's skin along with skin impairment that warrants Physician notification and intervention. Including but not limited to: all Stages of Pressure Ulcers (I, II, III, IV, and Suspected Deep Tissue Injuries) and changes in the Stage of a Pressure Ulcer. The interviews included a verbal explanation of each Pressure Ulcer Stage; when and by who are the At-Risk and preventative skin assessments are completed and documented; what encompasses a Pressure Ulcer assessment; and when and by whom are Pressure Ulcers assessed and documented. b. The facility's educational and procedural requirement for the implementation and monitoring of the (Offloading Heel Elevator) and all future purchases of resident assistive devices, in which staff must be educated prior to the use of any new equipment and upon hire, before working with the resident and the assistive devices. The interviews included the process for education prior to implementing the newly purchased device, implementation, and monitoring. Additional validation included a skills competency demonstration of placing the (Offloading Heel Elevator) to ensure comprehension in the correct placement of the device. c. The facility's Daily Clinical Wound reviews included a verbal explanation of their purpose, when are the reviews held, and who is responsible for the documentation and who oversees the reviews. d. The facility's Weekly Wound Rounds included a verbal explanation of the purpose, when the rounds are conducted, who is required to participate in the rounds, what observation would constitute follow-up, and who oversees the rounds and ensures the follow-up. e. What constitutes a change in a resident's condition and what is required when a change in a resident's condition occurs. Interviews included a verbal explanation of prompts notifications, who is notified and by whom, how soon, and required documentation. f. The facility's policy and procedural requirement for medication administration and time-sensitive treatment, services, and Physician orders. Interviews included a verbal explanation on ensuring adequate and timely communication with outside providers and Physician notification if the services cannot be provided timely to ensure an alternate plan of care (PICC line insertion must be inserted within a four-hour window; if not inserted within four-hours, the Physician must be notified for an alternate plan of care). Further, a review of the Medication Administration Records and a verbal explanation of the standards of practice and facility policy related to Medication Administration. g. The facility's policy for Administrative Clinical Rounds included a verbal explanation of the purpose, when the rounds are conducted, who conducts the rounds, what observation would constitute follow-up, and who oversees the rounds and ensures the follow-up. 3. Review of Weekly Wound Progress Notes, the facility's Weekly Wound Report, and observation of respective Pressure Ulcers of four residents to validate accuracy in assessment and documentation. 4. Observation of a dressing change and application of a Negative Pressure Wound Therapy System to validate accuracy in assessment, treatment, and application of the Negative Pressure Wound Therapy System. 5. Observation of four residents requiring offloading of the heels to confirm correct positioning using a regular pillow; the (Offloading Heel Elevators) were discontinued effective May 22, 2014, and none were in use for review. 6. Review of At-Risk Assessments of 13 residents for timeliness and correct implementation of preventative interventions based upon the assessments. 7. Observation of a Medication Pass to validate administration and accuracy of medications administered, as ordered by the Physician. 8. Observation of the facility's Clinical Board for wound-related information, used as a tool to ensure focused and effective communication and follow-up during Daily Clinical Wound Reviews (Monday through Friday, during normal work days). 9. Review of the minutes from an emergency Quality Assurance/Performance Improvement Committee Meeting held on May 7, 2014, with the Administrator, Medical Director, Director of Nursing, Corporate Quality Improvement Consultant, Minimum Data Set Coordinator, Certified Dietary Manager, Therapy Director, and Social Services. Based upon the complaint survey initiated on April 29, 2014, the Committee discussed the areas of concern and corrective actions as identified in the Allegation of Compliance. Non-compliance continues at a D level 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-157 (J); F-282 (J)",2017-05-01
8604,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2014-05-31,314,J,1,0,3X0Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility policies, review of manufacturer's information, review of facility training records, review of facility records, review of employee personnel files, observation, and interview, the facility failed to ensure training and competency of nursing staff in the correct placement of a pressure prevention device, failed to assess and monitor the new development of a Stage I Pressure Ulcer, failed to place a peripherally inserted central catheter (PICC) line (to administer intravenous medications) timely, failed to administer oral and intravenous (IV) antibiotics as ordered for one resident (#13), and failed to ensure accurate assessments and Pressure Ulcer Staging (classifications of Pressure Ulcers based on severity) for one resident (#14) of six residents reviewed. The facility's failure resulted in resident (#13) with a [DIAGNOSES REDACTED].#13 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) and Corporate Chief Nursing Officer (CCNO) were informed of the Immediate Jeopardy in the Conference Room on May 29, 2014, at 9:00 p.m. F314 resulted in Substandard Quality of Care. The findings included: Resident #13 was admitted to the facility initially on April 16, 2009, with [DIAGNOSES REDACTED]. Medical record review of an Annual Minimum Data Set (MDS) dated [DATE], revealed the resident's cognition was moderately impaired with a Brief Interview for Mental Status score of 8 (with zero being the lowest indicating severely impaired cognition and fifteen being the highest indicating intact cognition). Continued review revealed the resident did not reject care. The resident was totally dependent for bed mobility and transfers; and was non-ambulatory. The resident's range of motion in the upper and lower extremities was functionally impaired on both sides. Further review revealed the resident had no pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), but was at risk of developing pressure ulcers. Medical record review of the Pressure Ulcer Risk Assessments (screening tool that is designed to help identify residents who might develop a pressure ulcer) dated December 31, 2013, January 17, 2014, January 24, 2014, February 12, 2014, and March 21, 2014, revealed the resident was at high risk for the development of pressure ulcers. Medical record review of a Skin/Wound Note for Resident #13 dated December 31, 2013, at 2:07 p.m., and electronically signed by the Treatment Nurse, revealed an offloading heel elevator (device used to prevent or promote healing, which is designed to suspend the heels off the end of the device to ensure heels are free of the surface of the bed) was placed under the resident (lower extremities) to allow pressure relief of the bilateral (both) heels. Medical record review of the Care Plan dated December 31, 2013, revealed the resident required an (Offloading Heel Elevator) at all times except during ADL (Activities of Daily Living) care to protect the skin (to offload the pressure to the heels) while in bed. Medical record review of a Skin/Wound Note for Resident #13 dated February 13, 2014, at 4:28 p.m., and electronically signed by the Treatment Nurse revealed Stage I (one) (an observable, pressure-related alteration of intact skin, when compared to an adjacent or opposite area on the body may include changes in skin temperature, tissue consistency, sensation and/or a defined area of persistent redness) area noted to the outer lateral portion of the left calf. Area is red in color with no blanching (reddened areas of tissue that do not turn white or pale when pressed firmly with a finger or device). (Offloading Heel Elevator) in place .Area will be observed daily. Continued review revealed no documentation the Treatment Nurse measured the Stage I Pressure Ulcer. Medical record review of a Weekly Wound Progress Note dated February 17, 2014, at 3:17 p.m., and electronically signed by the Treatment Nurse revealed no assessment or documentation of the Stage I Pressure Ulcer on the outer lateral portion of the left calf. Medical record review of a Skin Sweep (tool used to document skin assessments) record dated February 18, 2014, and electronically signed by the Treatment Nurse revealed, Left lower leg (rear) .blanching red area . Continued review revealed no further assessments or documentation of the Stage I Pressure Ulcer on the left lateral calf until March 17, 2014. Medical record review of a Skin/Wound Note for Resident #13 dated March 17, 2014, at 12:44 p.m., and electronically signed by the Treatment Nurse revealed the offloading heel elevator was incorrectly placed under the resident, and stated, .Stage I (Pressure Ulcer) was noted to the left lower lateral leg .(Offloading Heel Elevator) is in place and was repositioned to below the knees to allow better pressure relief to this area as well as pressure free to the heels . Medical record review of a Weekly Wound Progress Note dated March 17, 2014, at 12:53 p.m., and electronically signed by the Treatment Nurse revealed, Date identified .March 17, 2014 .Left lower lateral leg .Stage I .Acquired (wound developed in the facility) Peri-Wound (around the pressure ulcer) .Length: 8.0 centimeters (cm) .Width: 1.0 cm .Depth: 0.0 cm .Area: [DIAGNOSES REDACTED] (redness) .induration (abnormal hardness) . Medical record review of the March 2014 Treatment Administration Records, from the facility's Electronic Charting System (ECS), with an order date of March 17, 2014, revealed to clean the area to left lateral lower leg with wound cleanser, pat dry and apply Exuderm [MEDICATION NAME] (wound dressing designed to create a moist environment to encourage wound healing, while absorbing minimal-to-moderate wound exudate) to area and change every Monday and Friday. Medical record review of the physician's orders [REDACTED]. Medical record review of a Weekly Wound Progress Note dated March 21, 2014, at 11:58 a.m., and electronically signed by the Treatment Nurse revealed the Stage III on the left lower lateral leg measured 7.4 cm x 1.3 cm, with 0.0 cm in depth (The Skin/Wound Note dated March 21, 2014, at 12:22 p.m., revealed a depth of 0.3 cm). Continued review revealed the Pressure Ulcer had slough (necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, and stringy, at times) and a moderate amount of serosanguineous exudate (Any fluid that has been forced out of the tissues or its capillaries because of inflammation or injury. It may contain serum, cellular debris, bacteria and leukocytes) with a foul odor. The peri-wound area had [DIAGNOSES REDACTED] and induration. Continued review revealed, .Area was Stage I and advanced to Stage III in between dressing changes from Wed (Wednesday, March 19, 2014) to Friday (March 21, 2014). Medical record review of a Skin/Wound Note for Resident #13 dated March 21, 2014, at 12:22 p.m., and electronically signed by the Treatment Nurse revealed the offloading heel elevator was incorrectly placed under the resident, and stated, During treatments this shift, area to left lower lateral leg was noted to advance in stage from a I to a III (three) (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed). Slough .moderate amount of serosanguineous (bloody, thin, and watery) drainage present .area went from measurement of stage I of 8.0 x (by) 1.0 to open with muscle exposure total size of 7.4 (cm) x 1.3 (cm) x 0.3 (cm) (depth). There are a total of 3 (three) open areas to the middle of the area that is red and nonblanching (non-blanching) .(Offloading Heel Elevator) was repositioned to 'proper alignment' to ensure pressure redistribution . Medical record review of a typed Physician's Progress Note dated March 24, 2014, dictated at 10:21 a.m., revealed, .Over the past several days (resident) has generally not felt well and during the past 24 (twenty-four) hours, has complained of abdominal pain and also has developed a fever. Today, I am seeing (resident) in regards to that problem .Temperature is 100 (one-hundred) . Continued review revealed the Physician was not aware of the Pressure Ulcer. Medical record review of a Physician's Telephone Order for Resident #13 dated March 24, 2014, 12:35 p.m., revealed orders for an X-Ray of the Left Lower Leg to rule-out [DIAGNOSES REDACTED] and [MEDICATION NAME] (antibiotic) 300 milligrams (mg) by mouth (PO) every six hours for Left Leg [MEDICAL CONDITION] for 10 days. Medical record review of an X-Ray obtained on March 24, 2014, revealed, Results: .No evidence of [DIAGNOSES REDACTED] .Conclusion: .Small pocket of gas adjacent to the fibula (the lateral and smaller of the two bones of the lower leg) which could be soft tissue wound versus gas-forming infection (typically, Gangrene). Medical record review of a Weekly Wound Progress Note dated March 24, 2014, at 4:57 p.m., and electronically signed by the Treatment Nurse revealed, .Right lateral lower leg (left lateral lower leg) . Continued review revealed the Stage III Pressure ulcer measured 8.0 cm x 1.0 cm x 0.4 cm, with slough, copious (extensive in quantity) amount of purulent (containing pus) exudate with a foul odor. The peri-wound area had [DIAGNOSES REDACTED], swelling/[MEDICAL CONDITION], and induration. Medical record review of a typed Nurse Practitioner's Progress Note for Resident #13 dated March 25, 2014, dictated at 11:36 a.m., revealed the Nurse Practitioner conducted a follow-up visit from March 24, 2014, related to the abrupt onset of Stage III Pressure Ulcer, and stated, .X-Ray is free of [DIAGNOSES REDACTED] .[MEDICATION NAME] pocket adjacent to the fibula .[MEDICATION NAME] is making (resident) nauseous .has not vomited to date .frail elderly (resident) .uncomfortable with dressing change .left leg with stage III ulceration and two small satellite areas (two small ulcerations near the large ulcer), confluent (flow together) [DIAGNOSES REDACTED] .There is a copious amount of serosanguineous purulent drainage. It is malodorous (bad, foul odor) .Acute [MEDICAL CONDITION] left leg .Stage III ulceration to left calf .nausea .pain associated with left leg ulceration .Today, I am going to continue the [MEDICATION NAME] therapy will .change it to IV (intravenous) secondary to .nausea. To cover the nausea, I have provided [MEDICATION NAME] .either IM (intramuscular) (by injection) or p.o. (by mouth). I have additionally scheduled .[MEDICATION NAME] (pain narcotic) 5/325 mg q. (every) 8h (eight hours) for the duration of five days (previously ordered and administered at the same dosage every four hours, as needed (PRN) .reevaluate at that time . Medical record review of a Physician's Telephone Order dated March 25, 2014, with an electronic order entry time of 2:23 p.m., revealed the [MEDICATION NAME] 300 mg PO (by mouth) every six hours had been discontinued; and ordered [MEDICATION NAME] 300 mg IV every six hours for 10 days. Medical record review of a Physician's Telephone Order for Resident #13 dated March 25, 2014, with an electronic order entry time of 2:35 p.m., revealed May place PICC (peripherally inserted central catheter) line (to administer [MEDICATION NAME] IV). Medical record review of a Nurse's Note dated May 25, 2014, at 3:00 p.m., revealed the PICC line placement provider was notified to .start PICC line for IV [MEDICATION NAME] to be administered . Medical record review of a Nurse's Note dated March 26, 2014, at 12:00 a.m., revealed the PICC line placement provider was called by the nurse, the call was not answered, and a message was left with the provider pertaining to f/u (follow-up) on order for PICC line. Continued review revealed the provider called back minutes later, at 12:11 a.m., and informed the nurse it would be early morning before (PICC line placement provider) could send someone to place the PICC line and the nurse stated, Will pass on in report . Continued review revealed no documentation of the date or time of the PICC line placement. Medical record review of a Physician's Telephone Order dated March 26, 2014, with an electronic entry time of 12:11 p.m., revealed, .Continue [MEDICATION NAME] PO until IV medication ([MEDICATION NAME]) is started . Medical record review of the 2014 Medication Administration Records (MAR's) revealed, .[MEDICATION NAME] 300 mg .by mouth . until IV medication is started. Medical record review of a Physician's Telephone order dated March 25, 2014, (no time), revealed the Exuderm [MEDICATION NAME] was discontinued and an order was received to clean the wound to left lateral leg with wound cleanser, pat dry and pack wound with Opticel AG (medicated wound dressing for moderate-to-heavy drainage); cover with Optilock (non-adhesive dressing) and secure with Bordered Gauze (pad with an adhesive border) every Monday, Wednesday, and Friday. Medical record review of a Skin Sweep for resident #13 dated March 26, 2014, and electronically signed by the Treatment Nurse revealed the Pressure Ulcer on the left lateral leg had progressed to a Stage IV (full thickness tissue loss with exposed bone, tendon, or muscle) Pressure Ulcer and measured 8.0 cm x 1.0 cm x1.0 cm. Medical record review of the March 2014 Medication Administration Records revealed the following: March 24; [MEDICATION NAME] 300 mg PO every six hours at 12:00 a.m., 6:00 a.m., 12:00 p.m., and 6:00 p.m., and the first dose was to start at 6:00 p.m. (order was received on March 24, 2014, at 12:35 p.m.). Continued review revealed the 6:00 p.m., dose was not administered. March 25; [MEDICATION NAME] PO was discontinued on March 25, (at 2:23 p.m.) and [MEDICATION NAME] 300 mg IV every six hours was ordered at the same administration times, and the first IV dose was to start at 6:00 p.m. Continued review revealed the resident was administered [MEDICATION NAME] PO at 6:00 p.m., after the PO had been discontinued, and did not receive the IV [MEDICATION NAME] at 6:00 p.m, as ordered. March 26; [MEDICATION NAME] PO was administered at 12:00 a.m., after the PO had been discontinued, and did not receive the IV [MEDICATION NAME] at 12:00 a.m., as ordered. Continued review revealed no [MEDICATION NAME] (PO or IV) was administered at 6:00 a.m. Continued review revealed an order (at 12:11 p.m.) for [MEDICATION NAME] PO until the [MEDICATION NAME] IV was started. Further review revealed no [MEDICATION NAME] (PO or IV) was administered at 12:00 p.m. Medical record review of a Physician's Telephone Order dated March 26, 2014, (no time), revealed an order to send the resident for Direct Admit to the hospital for Stage IV wound to the left calf. Medical record review of a Nurse's Note dated March 26, 2014, at 2:48 p.m., and electronically signed by the Treatment Nurse revealed the order had been received and a complete history and skin condition had been reported to the receiving Nurse. Continued review revealed, .Receiving facility is aware of wound and evaluation for possible surgical intervention . Continued review of the Nurse's Notes dated March 26, 2014, at 3:29 p.m., revealed Emergency Medical Services (EMS) arrived at the facility and transported the resident to the hospital. Medical record review of the hospital History and Physical (H&P), dated March 26, 2014, revealed, .92yo ([AGE] year-old) with dementia .demented and unable to provide much history .does state .leg is painful .received report that the wound on .leg has progressed over the past 2-3 (two-to-three) days .Extremities: Left lateral calf with large wound tracking to the bone with surrounding [DIAGNOSES REDACTED] .Diagnosis, Assessment & (and) Plan: .admitted for further evaluation of left lateral leg ulcer. Wound tracks to the bone so will need to treat as osteo[DIAGNOSES REDACTED] for now. CT (Computed Tomography) done and not consistent with [DIAGNOSES REDACTED] (flesh-eating bacteria syndrome). Will consult with ID (Infectious Diseases) and wound care. Will start empirically on vanc ([MEDICATION NAME]) (antibiotic) and meropenem (ultra-broad-spectrum antibiotic) .Problem List: 1. Left lateral leg ulcer; 2. [DIAGNOSES REDACTED] . Medical record review of a hospital Consultation Report dated March 26, 2014, revealed, .dementia .was sent to the hospital for admission today because of (resident's) left leg ulceration or wound. 'It is unclear how all this started,' but it is supposedly progressed over the last 2 (two) or 3 (three) days .Skin: .The left lateral leg area has a long wound, which is deep in some area with underlying exposed tendon. There is surrounding [DIAGNOSES REDACTED] and tenderness currently .has very thin, fragile skin on .legs and feet. There is [MEDICAL CONDITION] of the legs in addition to the feet .Tests: .CT of the leg .shows a lateral posterior soft tissue defect with surrounding soft tissue [MEDICAL CONDITION] .no soft tissue gas .Assessment and Recommendations: .Elderly demented patient, nursing home resident who is debilitated, has [MEDICAL CONDITION] of .legs and feet and now has a deep wound on the posteriolateral left leg, 'exact cause is unclear,' but I suspect (resident) must have had some kind of injury .may have had a deep injury, which subsequently resulted in necrosis (dead tissue) of the overlying tissue and now has an open wound . Medical record review of a hospital Discharge Summary for Resident #13 dated March 31, 2014, revealed, .Discharge Diagnoses: [REDACTED]. 2. [DIAGNOSES REDACTED] .(Resident) was admitted .Cultures were obtained .placed on empiric (treatment prior to determination of a firm diagnosis) antibiotics .wound care provided .That leg ulcer was not felt typical of decubitus, but likely some injury with deep tissue loss .did have some infection around the wound with proteus and alpha strep .was maintained on antibiotics as appropriate . Continued review revealed the resident was discharged [DATE], back to (facility) and continued to require antibiotics, with orders for [MEDICATION NAME] 500 mg twice a day for seven days. Review of facility policy, Skin Management Standard, revised October 2013 revealed, .Prevention/Body Audits: All residents will be checked for skin condition changes and/or alterations on a daily basis or during routine care by the Certified Nursing Assistant (CNA) .The resident's Physician and Responsible Party shall be notified of a change in the resident's skin condition .Routine Preventative Care: .2. j. Education to resident, family, and caregiver (All Nursing Staff) .Comprehensive Assessment of Wounds: a. Assess the entire resident, not just the wound. B. Consider all factors that can influence healing .equipment factors .Stages and Categories .Purpose .It is the standard of this facility to accurately stage all wounds to represent severity and to implement appropriate wound care protocols .Skin Ulceration Management: .3. The Physician will be contacted and orders obtained for treatment .Stage I: Complete assessment to determine root cause of pressure ulcer .6. The wound(s) will be measured and assessed for size (length, width, depth, undermining, drainage, odor, debris such as slough or eschar (thick, leathery, frequently black or brown in color, necrotic (dead) or devitalized tissue) .8. All wounds will be discussed and reviewed by the Interdisciplinary Team at least weekly . Review of the Manufacturer's Directions for Use, (Offloading Heel Elevator), (no date), revealed, .Place (Offloading Heel Elevator) under the lower legs so that the users heels are fully suspended. The highest portion (of the Offloading Heel Elevator) is at the heel area, with the taper (of the Offloading Heel Elevator) extending beneath the knees (as noted on the cover) (a picture of the Offloading Heel Elevator under the lower part of the legs with the device fully supporting the entire calves of the legs) . Review of a facility in-service, Heel Protect In-Service Training, dated March 21, 2014, with attached illustrations and literature specific to the (Offloading Heel Elevator), revealed, Summary of Topic Covered: The heel positioner (offloading heel elevator) is to be placed from below the bend of the knees down, not across the back of the (arrow indicating upper) legs. The heel positioner is not to be placed in the floor. Continued review revealed only six Certified Nursing Assistants (CNA's), two Licensed Practical Nurses (LPN's), and two Registered Nurses (RN's), for a total of ten nursing staff, attended the training. Further review revealed no documentation of competency being validated. Review of a facility Current Employee Listing (as of April 29, 2014) revealed 59 nursing staff were employed by the facility; and of the 59 nursing staff working as of April 29, 2014, only 9 had been in-serviced on the use of the (Offloading Heel Elevator). Review of the Treatment Nurse's employee file and Record of Counseling dated May 6, 2014, revealed, the Treatment Nurse was discharged (involuntarily terminated) from employment, and stated, Gross misconduct related to failure to follow company policy regarding proper documentation of wounds as evidenced by lack of consistent measurements on patients with wounds, incomplete documentation of patient assessment, lack of reporting a change to Director of Nursing (DON), and inaccurate documentation of patients wound sites. Furthermore, (Treatment Nurse) failed to seek further education regarding implementation of the (Offloading Heel Elevator) before it was placed on the patient, there was a failure to properly educate all nursing staff upon implementation and when the device was found inappropriately placed and (Treatment Nurse) failed to document and report the inappropriately placed (Offloading Heel Elevator) to the DON. Continued review of the file revealed an Allegations Report to the State of Tennessee Board of Nursing, dated May 15, 2014. Further review revealed the facility reported the Treatment Nurse to the (Treatment Nurse's) governing licensing board for the employee's negligence. Observation of Resident #13 on May 7, 2014, at 8:58 p.m., during a dressing change completed by the Assistant Director of Nursing (ADON) and RN #1, confirmed a Stage IV Pressure Ulcer was present on the left lateral calf area of the leg. RN #1 and the ADON raised the bilateral legs and removed the offloading heel elevator. RN #1 held the left leg up to assist the ADON to remove the dressing. Continued observation of the Stage IV Pressure Ulcer confirmed a moderate amount of dark pink serosanguineous drainage and a moderate amount of slough hanging from the ulcer and attached to the dressing as the dressing was removed. Deep tissue, muscle, and tendon were exposed within the ulcer; and bone was exposed at the 3:00 position (facing the wound and viewing it as a clock) of the ulcer. The Stage IV Pressure Ulcer measured 11.5 cm in length x 2.0 cm in width x 1.2 cm in depth. Interview with the Treatment Nurse, on May 2, 2014, beginning at 5:05 p.m., in the Conference Room, confirmed the (Offloading Heel Elevator) was implemented for use on resident #13 on December 31, 2013, and verbal in-servicing on the (Offloading Heel Elevator) was initiated on December 31, 2013 and continued throughout that week for all direct-care nursing staff who was routinely assigned to the resident. Upon requesting copies of the in-services, the Treatment Nurse confirmed the in-servicing was verbal and signatures were not obtained and competency was not validated. Upon the surveyor questioning what stage resident #13's Pressure Ulcer (on the left lateral calf of the leg) was upon identification and the cause, the Treatment Nurse stated, It was a Stage I .I'll just tell you .On multiple occasions I have found the (Offloading Heel Elevator) was placed either incorrectly or not in place at all on the resident .this happened on five-to-ten occasions that I observed when I would go in to assess the resident and do treatments .That wound progressed fast .it scared me. Weekly skin assessments were being done and on March 21, 2014, the wound had progressed from a Stage I to a Stage III measuring 7.4 cm x 1.3 cm x 0.5 cm .the resident was complaining of pain .On March 24 it increased in size to 8.0 cm x 1.0 cm x 0.4 cm and slough was building with a large amount of purulent drainage and a foul odor. The Nurse Practitioner was notified, an x-ray obtained, antibiotics were started, and the treatment was changed. On March 26 the leg bone was visible. The resident was admitted to the hospital on March 26, received IV antibiotics, and returned here on March 31. A second interview was conducted with the Treatment Nurse on May 5, 2014, in the presence of the Interim Director of Nursing (DON), beginning at 1:30 p.m., in the Conference Room. When the surveyor questioned the initial verbal in-servicing the Treatment Nurse conducted when the (Offloading Heel Elevator) was placed on December 31, 2013, the Treatment Nurse confirmed, I did not educate any staff when the (Offloading Heel Elevator) was implemented on December 31, 2013. (Resident) is a resident that doesn't like to get out of bed and usually what's there (device) they (nursing staff) will put back. I just never thought anything about it .I just didn't think about it .I had never used a (Offloading Heel Elevator) before .I had to educate myself on how to use it .I researched online .I first identified the (Offloading Heel Elevator) incorrectly placed two-to-five times between December 31, 2013 and March 17, 2014 . Continued interview with the Treatment Nurse and review of the medical record confirmed the initial onset of the Pressure Ulcer on the Left lateral calf of the leg was identified on as a Stage I on February 13, 2014. Continued interview and review of the medical record with the Treatment Nurse confirmed no assessments or follow-up of the Pressure Ulcer were completed after February 13 until March 17, when the Treatment Nurse identified the Pressure Ulcer as a Stage I and stated, I wrote the order for the Exuderm ([MEDICATION NAME]) without a physician's orders [REDACTED].I can't recall the condition of the left leg (from February 13 until March 17) .nothing stands out in my memory .I didn't assess it .I missed a DTI (Deep Tissue Injury) (Purple or maroon area of discolored intact skin due to damage of underlying soft tissue) . Continued interview confirmed, I observed the device placed incorrectly approximately three-to-five more times between March 17 and March 26 .I observed the (Offloading Heel Elevator) placed incorrectly, above the bend of the knees .to high up, and ending striking the mid-calf .or in the floor .in-services were started on March 21 when the wound deteriorated to a Stage III .the in-services did not include all nursing staff . Continued interview with the Treatment Nurse confirmed the failure to educate, ensure competency, and ensure compliance with the correct placement of the (Offloading Heel Elevator), and the failure to assess the resident's wound initially identified on February 13, 2014, resulted in the resident developing an avoidable DTI, which progressed to a Stage IV Pressure Ulcer, and required admission to the hospital for IV antibiotics and wound care. Interviews on May 7, 2014, with Certified Nursing Assistant (CNA) #1 (1:30 p.m.), #2 (1:47 p.m.), #3 (2:15 p.m.), #4 (3:14 p.m.), #5 (3:35 p.m.), #6 (4:10 p.m.), and #7 (5:05 p.m.), in the Conference Room, confirmed to have received no training on the use and/or placement of the (Offloading Heel Elevator) prior to May 6 and 7, 2014. Continued interviews confirmed CNA's #2, #3, #4, #6, and #7 provided care and assistance to resident #13. Continued interview with CNA #3 on May 7, 2014, beginning at 2:15 p.m., in the Conference Room, confirmed upon CNA #3 arrival to work and entering the resident's room, had observed the (Offloading Heel Elevator) placed under the resident incorrectly two-to-three times. Continued interview confirmed CNA #3 found it (Offloading Heel Elevator) in a chair or in the closet in the resident's room three-to-four times. CNA #3 stated, I found it under (resident's) thighs and ending in (resident's) mid-calf area two-to-three times .I just removed it and did (resident's) morning care, then put it back under (resident) correctly .between the bend of (resident's) knees and ankles. Continued interview confirmed the resident was unable to independently place the (Offloading Heel Elevator) incorrectly under the resident's own legs. Interviews on May 7, 2014, with Registered Nurse (RN) #2 (1:00 p.m.) and #3 (6:09 p.m.), in the Conference Room, confirmed to have received no training on the use and/or placement of the (Offloading Heel Elevator) prior to May 6 and 7, 2014. Continued interviews confirmed RN #2 and #3 provided care and assistance to resident #13. Continued interview with RN #3 on May 7, 2014, beginning at 6:09 p.m., in the Conference Room, confirmed to have observed the (Offloading Heel Elevator) placed under the resident incorrectly during the months of February and March 2014, and stated, I can't recall the exact number of times .at least a couple for sure .one time, it was under the thighs and knees with the edge striking the middle of the calves of the legs .another time it was the same way, just a little farther than half-way down the calves . Interviews on May 7, 2014, with Licensed Practical Nurse (LPN) #1 (3:00 p.m.) and #2 (8:22 p.m.), in the Conference Room, confirmed to have received no training on the use and/or placement of the (Offloading Heel Elevator) prior to May 6 and 7, 2014. Continued interviews confirmed LPN #2 and #3 provided care and assistance to resident #13. Interview with the previous Administrator on May 22, 2014, at 3:11 p.m., in the Conference Room, confirmed the Administrator realized the (Offloading Heel Elevators) were being used and was unable to recall any training prior to using the (Offloading Heel Elevators). Interview with the Interim Director of Nursing (DON) on May 23, 2014, at approximately 12:00 p.m., in the Conference Room, confirmed the DON started as Interim DON on March 19, 2014, and was unaware of the lack of training on the (Offloading Heel Elevators) and was unaware of the (Offloading Heel Elevator) being placed incorrectly under the resident. Continued interview with the DON confirmed the facility failed to ensure training and competency on the correct use of the (Offloading Heel Elevator) and the (Offloading Heel Elevator) had been discontinued for use effective May 22, 2014. Continued interview confirmed the facility has had a lot of turnover in the past few months, especially recently .none of the [MEDICATION NAME], PO or IV, was given on March 24 (at 6:00 p.m.) and March 26, 2014, (at 6:00 a.m., and 12:00 p.m.), as ordered. Continued interview confirmed the facility failed to administer any of the IV [MEDICATION NAME], and the DON stated, It was available in the refrigerator, but it wasn't given. Continued interview confirmed the DON stated, The order for the PICC line was received on March 25, 2014, at 2:35 p.m., but the PICC line wasn't placed until March 26, 2014, at 6:30 a.m. (15.5 - fifteen and one-half hours later). Further interview with the DON confirmed the facility's failure resulted in the resident developing a",2017-05-01
8605,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2014-05-31,333,J,1,0,3X0Q11,"**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 ensure oral and intravenous (IV) antibiotics were administered as ordered for one resident (#13) of nineteen residents reviewed. The facility's failure of resident #13 receiving a delay in the treatment of [REDACTED]. The facility's failure placed resident #13 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) and Corporate Chief Nursing Officer (CCNO) were informed of the Immediate Jeopardy in the Conference Room on May 29, 2014, at 9:00 p.m. F-333 resulted in Substandard Quality of Care. The findings included: Resident #13 was admitted to the facility initially on April 16, 2009, with [DIAGNOSES REDACTED]. Medical record review of a Weekly Wound Progress Note dated March 21, 2014, at 11:58 a.m., and electronically signed by the Treatment Nurse revealed resident #13 had a Stage III (three) Pressure Ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed) on the left lower lateral leg which measured 7.4 cm x 1.3 cm, with 0.0 cm in depth (The Skin/Wound Note dated March 21, 2014, at 12:22 p.m., revealed a depth of 0.3 cm). Continued review revealed the Pressure Ulcer had slough (necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, and stringy, at times) and had a moderate amount of serosanguineous exudate (Any fluid that has been forced out of the tissues or its capillaries because of inflammation or injury. It may contain serum, cellular debris, bacteria and leukocytes) with a foul odor. The peri-wound area had [DIAGNOSES REDACTED] and induration. Medical record review of a Physician's Telephone Order dated March 24, 2014, 12:35 p.m., revealed orders for [MEDICATION NAME] (antibiotic) 300 milligrams (mg) by mouth (PO) every six hours for Left Leg [MEDICAL CONDITION] (bacterial infection just below the skin surface) for 10 days. Medical record review of a Weekly Wound Progress Note dated March 24, 2014, at 4:57 p.m., and electronically signed by the Treatment Nurse revealed the Stage III Pressure ulcer measured 8.0 cm x 1.0 cm x 0.4 cm, with slough, a copious (extensive in quantity) amount of exudate that was purulent (consisting of or containing pus) with a foul odor. The peri-wound area had [DIAGNOSES REDACTED], swelling/[MEDICAL CONDITION], and induration. Medical record review of a typed Nurse Practitioner's Progress Note dated March 25, 2014, dictated at 11:36 a.m., revealed .[MEDICATION NAME] is making (resident) nauseous . There is a copious amount of serosanguineous purulent drainage. It is malodorous (bad, foul odor) .Acute [MEDICAL CONDITION] left leg .Stage III ulceration to left calf .nausea .pain associated with left leg ulceration .Today, I am going to continue the [MEDICATION NAME] therapy. I will in fact change it to IV (intravenous) secondary to the patient's nausea . Medical record review of a Physician's Telephone Order for Resident #13 dated March 25, 2014, with an electronic order entry time of 2:35 p.m., revealed May place PICC (peripherally inserted central catheter) line (to administer [MEDICATION NAME] IV). Medical record review of a Nurse's Note dated May 25, 2014, at 3:00 p.m., revealed the PICC line placement provider was notified to .start PICC line for IV [MEDICATION NAME] to be administered . Medical record review of a Nurse's Note dated March 26, 2014, at 12:00 a.m., revealed the PICC line placement provider was called, the call was not answered, and a message was left with the provider pertaining to f/u (follow-up) on order for PICC line. Continued review revealed the provider called back minutes later, at 12:11 a.m., and informed the nurse it would be early morning before (PICC line placement provider) could send someone to place the PICC line and the nurse stated, Will pass on in report . Continued review revealed no documentation of the date or time of the PICC line placement. Continued review of a Nurse's Note dated March 26, 2014, at 12:11 a.m., revealed the PICC line provider had returned the facility's call and it would be early morning before the PICC line would be placed . Medical record review of a Physician's Telephone Order dated March 26, 2014, with an electronic entry time of 12:11 p.m., revealed, .Continue [MEDICATION NAME] PO until IV medication ([MEDICATION NAME]) is started . Medical record review of a Skin Sweep (tool used to document skin assessments) dated March 26, 2014, and electronically signed by the Treatment Nurse revealed, .Lt (left) Lat (lateral) Leg .Pressure .8.0 cm x 1.0 cm x1.0 cm .Stage IV (full thickness tissue loss with exposed bone, tendon, or muscle) . Medical record review of the March 2014 Medication Administration Records revealed the following: March 24; [MEDICATION NAME] 300 mg PO every six hours at 12:00 a.m., 6:00 a.m., 12:00 p.m., and 6:00 p.m., and the first dose was to start at 6:00 p.m. (order was received on March 24, 2014, at 12:35 p.m.). Continued review revealed the 6:00 p.m., dose was not administered. March 25; [MEDICATION NAME] PO was discontinued on March 25, (at 2:23 p.m.) and [MEDICATION NAME] 300 mg IV every six hours was ordered at the same administration times, and the first IV dose was to start at 6:00 p.m. Continued review revealed the resident was administered [MEDICATION NAME] PO at 6:00 p.m., after the PO had been discontinued, and did not receive the IV [MEDICATION NAME] at 6:00 p.m, as ordered. March 26; [MEDICATION NAME] PO was administered at 12:00 a.m., after the PO had been discontinued, and did not receive the IV [MEDICATION NAME] at 12:00 a.m., as ordered. Continued review revealed no [MEDICATION NAME] (PO or IV) was administered at 6:00 a.m. Continued review revealed an order (at 12:11 p.m.) for [MEDICATION NAME] PO until the [MEDICATION NAME] IV was started. Further review revealed no [MEDICATION NAME] (PO or IV) was administered at 12:00 p.m. Medical record review of a Physician's Telephone Order dated March 26, 2014, (no time), revealed an order to send the resident for Direct Admit to the hospital for Stage IV wound to the left calf. Medical record review of a Nurse's Note dated March 26, 2014, at 2:48 p.m., and electronically signed by the Treatment Nurse revealed the order had been received and report of the resident's wound and history had been given to the hospital, and revealed, .Receiving facility is aware of wound and evaluation for possible surgical intervention . Medical record review of the hospital History and Physical (H&P), dated March 26, 2014, revealed, (resident #13) .does state .leg is painful .Extremities: Left lateral calf with large wound tracking to the bone with surrounding [DIAGNOSES REDACTED] .Diagnosis, Assessment & (and) Plan: .admitted for further evaluation of left lateral leg ulcer. Wound tracks to the bone so will need to treat as osteo[DIAGNOSES REDACTED] for now .consult with ID (Infectious Diseases) and wound care. Will start empirically (treatment prior to determination of a firm diagnosis) on (IV) vanc ([MEDICATION NAME]) (antibiotic) and meropenem (ultra-broad-spectrum antibiotic) .Problem List: 1. Left lateral leg ulcer; 2. [DIAGNOSES REDACTED] . Medical record review of a hospital Discharge Summary, dated March 31, 2014, revealed, .Discharge Diagnoses: [REDACTED]. 2. [DIAGNOSES REDACTED] .(Resident) was admitted .Cultures were obtained .placed on empiric (IV) antibiotics .wound care provided .did have some infection around the wound with proteus and alpha strep . Continued review revealed the resident was discharged [DATE], back to (facility) and continued to require antibiotics, with orders for [MEDICATION NAME] 500 mg twice a day for seven days. Review of facility policy, Medication Administration, dated August 2012 revealed, Policy: Medications are administered as prescribed in accordance with good nursing principles and practices .B. Administration: 2). Medications are administered in accordance with written orders of the attending physician . Observation of the resident on May 7, 2014, at 8:58 p.m., during a dressing change completed by the Assistant Director of Nursing (ADON) and Registered Nurse (RN) #1, confirmed a Stage IV Pressure Ulcer was present on the left lateral calf area of the leg. Continued observation of the Stage IV Pressure Ulcer confirmed a moderate amount of dark pink serosanguineous drainage and a moderate amount of slough hanging from the ulcer and attached to the dressing as the dressing was removed. Deep tissue, muscle, and tendon were exposed within the ulcer; and bone was exposed at the 3:00 position (facing the wound and viewing it as a clock) of the ulcer. The Stage IV Pressure Ulcer measured 11.5 cm in length x 2.0 cm in width x 1.2 cm in depth. The resident continued to receive routine narcotic pain medication and evidenced no pain during the dressing change. Interview with the Interim Director of Nursing (DON) on May 23, 2014, at approximately 12:00 p.m., in the Conference Room, confirmed the facility has had a lot of turnover in the past few months, especially recently .none of the [MEDICATION NAME], PO or IV, was given on March 24 (at 6:00 p.m.) and March 26, 2014, (at 6:00 a.m., and 12:00 p.m.), as ordered. Continued interview confirmed the facility failed to administer any of the IV [MEDICATION NAME], and the DON stated, It was available in the refrigerator, but it wasn't given. Continued interview confirmed the DON stated, The order for the PICC line was received on March 25, 2014, at 2:35 p.m., but the PICC line wasn't placed until March 26, 2014, at 6:30 a.m. (15.5 - fifteen and one-half hours later). Further interview with the DON confirmed the facility's failure resulted in the resident developing an avoidable Stage IV Pressure Ulcer with direct admission to the hospital for IV antibiotics and wound care. Interview with the resident's Physician and Nurse Practitioner on May 23, 2014, at 1:30 p.m., together in the Conference Room, confirmed the Nurse Practitioner stated, .It wasn't until March 24, 2014, notification was received the Pressure Ulcer was a Stage III . Continued interview with the Nurse Practitioner confirmed orders were given initially for PO [MEDICATION NAME], then later on March 25, 2014, the IV [MEDICATION NAME]. The Physician and Nurse Practitioner confirmed they were not notified the resident did not receive all PO [MEDICATION NAME], as ordered; and were not notified the resident did not receive any of the IV [MEDICATION NAME], as ordered . and the Nurse Practitioner stated, I was told the PO was making the resident nauseous, but was not told any doses were missed .I had no idea the IV ([MEDICATION NAME]) had not been given .I was not notified of the delay in placing the PICC line .I would have expected to be notified if the PICC line couldn't be placed within three-to-four hours, so the resident could have been sent out for an alternate plan of care . Interview with the Administrator on May 29, 2014, at 2:55 p.m., in the Conference Room, confirmed the facility failed to administer resident #13's oral and intravenous antibiotics as ordered. In summary, the facility initially received orders to administer oral antibiotics for the resident's infected wound, but the resident became nauseous and the oral antibiotics were changed to IV antibiotics. The facility failed to administer [MEDICATION NAME] on March 24, at 6:00 p.m., March 26, at 6:00 a.m., and 12:00 p.m.; and the facility failed to administer any of the IV [MEDICATION NAME]. On March 26, the Pressure Ulcer was a Stage IV, and the Nurse Practitioner ordered the resident be sent to the hospital where IV antibiotics and wound care was provided. The Immediate Jeopardy was effective from December 31, 2013, through May 29, 2014. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated by the surveyor through review of documents, staff interviews, and observations conducted onsite on May 31, 2014. The surveyor verified the allegation of compliance by: 1. Reviewing the facility's in-service records to ensure nursing staff were educated or re-educated regarding changes to and implementation of the facility's following policies: a. Medication Preparation and Administration (re-educated). 2. Conducted interviews with nursing staff, to include eight Registered Nurses (which included the DON and ADON), and eight Licensed Practical Nurses for a total of twenty-two nursing staff of forty-six licensed and certified nurses on staff to determine the level of comprehension gained through in-service education conducted regarding re-education to the facility's policies, Medication Preparation and General Guidelines to ensure staff recognize and respond to the following: a. The facility's policy and procedural requirement for medication preparation, administration, time-sensitive medications, treatments, services, and Physician orders. Interviews included a verbal explanation on the process for preparing and adminstering medications including transcribing orders, ensuring the availability of medications (pharmacy provider's routine medication delivery schedule; STAT orders (immediately); use of the facility's back-up medications; and notification to the back-up pharmacy); ensuring adequate and timely communication with outside providers; Physician notification if the services cannot be provided timely to ensure an alternate plan of care (PICC line insertion must be inserted within a four-hour window); medication errors and the requirement of Physician notification; and documentation. 2. Observation of a Medication Pass to validate administration and accuracy of medications administered, as ordered by the Physician, with a zero percent error rate. 3. Review of the minutes from an emergency Quality Assurance/Performance Improvement Committee Meeting held on May 7, 2014, with the Administrator, Medical Director, Director of Nursing, Corporate Quality Improvement Consultant, Minimum Data Set Coordinator, Certified Dietary Manager, Therapy Director, and Social Services. Based upon the complaint survey initiated on April 29, 2014, the Committee discussed the areas of concern related to Significant Medication Error (processes to ensure nursing staff are trained and competent in medication preparation and administration) and corrective actions as identified in the Allegation of Compliance. Non-compliance continues at a D level 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-157 (J); F-282 (J); F-309 (J), Substandard Quality of Care; F-314 (J), Substandard Quality of Care",2017-05-01
8606,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2014-05-31,498,J,1,0,3X0Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of manufacturer's information, review of facility training records, review of facility records, observation, and interview, the facility failed to ensure training and competency of Certified Nursing Assistants in the correct placement of a pressure prevention device for one resident (#13) of nineteen residents reviewed. The facility's failure resulted in resident (#13) with a [DIAGNOSES REDACTED].#13 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) and Corporate Chief Nursing Officer (CCNO) were informed of the Immediate Jeopardy in the Conference Room on May 29, 2014, at 9:00 p.m. The findings included: Resident #13 was admitted to the facility initially on April 16, 2009, with [DIAGNOSES REDACTED]. Medical record review of an Annual Minimum Data Set (MDS) dated [DATE], revealed the resident's cognition was moderately impaired with a Brief Interview for Mental Status score of 8 (with zero being the lowest indicating severely impaired cognition and fifteen being the highest indicating intact cognition). Continued review revealed the resident did not reject care. The resident was totally dependent for bed mobility and transfers; and was non-ambulatory. The resident's range of motion in the upper and lower extremities was functionally impaired on both sides. Further review revealed the resident had no pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), but was at risk of developing pressure ulcers. Medical record review of the Pressure Ulcer Risk Assessments (screening tool that is designed to help identify residents who might develop a pressure ulcer) dated December 31, 2013, January 17, 2014, January 24, 2014, February 12, 2014, and March 21, 2014, revealed the resident was at high risk for the development of pressure ulcers. Medical record review of a Skin/Wound Note for resident #13 dated December 31, 2013, at 2:07 p.m., and electronically signed by the Treatment Nurse, revealed an offloading heel elevator (device used to prevent or promote healing, which is designed to suspend the heels off the end of the device to ensure heels are free of the surface of the bed) was placed under the resident (lower extremities) to allow pressure relief of the bilateral (both) heels. Medical record review of the Care Plan dated December 31, 2013, revealed the resident required an (Offloading Heel Elevator) at all times except during ADL (Activities of Daily Living) care to protect the skin (to offload the pressure to the heels) while in bed. Medical record review of a Skin/Wound Note for Resident #13 dated February 13, 2014, at 4:28 p.m., and electronically signed by the Treatment Nurse revealed the development of a Stage I (one) (an observable, pressure-related alteration of intact skin, when compared to an adjacent or opposite area on the body may include changes in skin temperature, tissue consistency, sensation and/or a defined area of persistent redness) area noted to the outer lateral portion of the left calf. Area is red in color with no blanching (reddened areas of tissue that do not turn white or pale when pressed firmly with a finger or device). (Offloading Heel Elevator) in place . Medical record review of a Skin/Wound Note for resident #13 dated March 17, 2014, at 12:44 p.m., and electronically signed by the Treatment Nurse revealed the offloading heel elevator was incorrectly placed under the resident, and stated, .Stage I (Pressure Ulcer) was noted to the left lower lateral leg .(Offloading Heel Elevator) is in place and was repositioned to below the knees to allow better pressure relief to this area as well as pressure free to the heels . Medical record review of a Weekly Wound Progress Note dated March 17, 2014, at 12:53 p.m., and electronically signed by the Treatment Nurse revealed, .Left lower lateral leg .Stage I .Acquired (wound developed in the facility) Peri-Wound (around the pressure ulcer) .Length: 8.0 centimeters (cm) .Width: 1.0 cm .Depth: 0.0 cm .Area: [DIAGNOSES REDACTED] (redness) .induration (abnormal hardness) . Medical record review of a Weekly Wound Progress Note dated March 21, 2014, at 11:58 a.m., and electronically signed by the Treatment Nurse revealed the Stage I on the left lower lateral leg had progressed to a Stage III (three) (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed) from March 19, 2014 to March 21, 2014 and measured 7.4 cm x 1.3 cm, with 0.0 cm in depth (The Skin/Wound Note dated March 21, 2014, at 12:22 p.m., revealed a depth of 0.3 cm). Continued review revealed the Pressure Ulcer had slough (necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, and stringy, at times), a moderate amount of serosanguineous exudate (Any fluid that has been forced out of the tissues or its capillaries because of inflammation or injury. It may contain serum, cellular debris, bacteria and leukocytes) with a foul odor, and the peri-wound area had [DIAGNOSES REDACTED] and induration. Medical record review of a Skin/Wound Note for Resident #13 dated March 21, 2014, at 12:22 p.m., and electronically signed by the Treatment Nurse revealed the offloading heel elevator was incorrectly placed under the resident, and stated, .During treatments this shift, area to left lower lateral leg was noted to advance in stage from a I to a III (three) (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed). Slough .moderate amount of serosanguineous (bloody, thin, and watery) drainage present .area went from measurement of stage I of 8.0 x (by) 1.0 to open with muscle exposure total size of 7.4 (cm) x 1.3 (cm) x 0.3 (cm) (depth). There are a total of 3 (three) open areas to the middle of the area that is red and nonblanching (non-blanching) .(Offloading Heel Elevator) was repositioned to 'proper alignment' to ensure pressure redistribution . Medical record review of a Physician's Telephone Order for resident #13 dated March 24, 2014, 12:35 p.m., revealed orders for an X-Ray of the Left Lower Leg to rule-out [DIAGNOSES REDACTED] and [MEDICATION NAME] (antibiotic) 300 milligrams (mg) by mouth (PO) every six hours for Left Leg [MEDICAL CONDITION] for 10 days. Medical record review of an X-Ray obtained on March 24, 2014, revealed no evidence of [DIAGNOSES REDACTED], but was concluded to have a small pocket of gas next to the fibula (the lateral and smaller of the two bones of the lower leg) which could have been a soft tissue wound versus gas-forming infection (typically, Gangrene). Medical record review of a Weekly Wound Progress Note dated March 24, 2014, at 4:57 p.m., and electronically signed by the Treatment Nurse revealed the Stage III Pressure ulcer measured 8.0 cm x 1.0 cm x 0.4 cm, with slough, and a copious (extensive in quantity) amount of purulent (containing pus) exudate with a foul odor; and the peri-wound area had [DIAGNOSES REDACTED], swelling/[MEDICAL CONDITION], and induration. Medical record review of a Skin Sweep for resident #13 dated March 26, 2014, and electronically signed by the Treatment Nurse revealed the Pressure Ulcer on the left lateral leg had progressed to a Stage IV (full thickness tissue loss with exposed bone, tendon, or muscle) Pressure Ulcer and measured 8.0 cm x 1.0 cm x1.0 cm. Medical record review of a Physician's Telephone Order dated March 26, 2014, (no time), revealed an order to send the resident for Direct Admit to the hospital for Stage IV wound to the left calf. Medical record review of a hospital Discharge Summary for Resident #13 dated March 31, 2014, revealed, .Discharge Diagnoses: [REDACTED]. 2. [DIAGNOSES REDACTED] .(Resident) was admitted .placed on empiric (treatment prior to determination of a firm diagnosis) antibiotics .wound care provided .That leg ulcer was not felt typical of decubitus, but likely some injury with deep tissue loss .did have some infection around the wound with proteus and alpha strep .was maintained on antibiotics . Continued review revealed the resident was discharged [DATE], back to (facility) and continued to require antibiotics, with orders for [MEDICATION NAME] 500 mg twice a day for seven days. Review of facility policy, Skin Management Standard, revised October 2013 revealed, .Routine Preventative Care: .2. j. Education to .and caregiver (All Nursing Staff) .B. Consider all factors that can influence healing .equipment factors .Stages and Categories .Purpose .It is the standard of this facility to accurately .implement appropriate wound care protocols . Review of the Manufacturer's Directions for Use, (Offloading Heel Elevator), (no date), revealed, .Place (Offloading Heel Elevator) under the lower legs so that the users heels are fully suspended. The highest portion (of the Offloading Heel Elevator) is at the heel area, with the taper (of the Offloading Heel Elevator) extending beneath the knees (as noted on the cover) (a picture of the Offloading Heel Elevator under the lower part of the legs with the device fully supporting the entire calves of the legs) . Review of a facility in-service, Heel Protect In-Service Training, dated March 21, 2014, with attached illustrations and literature specific to the (Offloading Heel Elevator), revealed, Summary of Topic Covered: The heel positioner (offloading heel elevator) is to be placed from below the bend of the knees down, not across the back of the (arrow indicating upper) legs. The heel positioner is not to be placed in the floor. Continued review revealed only six Certified Nursing Assistants (CNA's), two Licensed Practical Nurses (LPN's), and two Registered Nurses (RN's), for a total of ten nursing staff, attended the training. Further review revealed no documentation of competency being validated. Review of a facility Current Employee Listing (as of April 29, 2014) revealed 59 nursing staff were employed by the facility; and of the 59 nursing staff working as of April 29, 2014, only 9 had been in-serviced on the use of the (Offloading Heel Elevator). Observation of Resident #13 on May 7, 2014, at 8:58 p.m., during a dressing change completed by the Assistant Director of Nursing (ADON) and RN #1, confirmed a Stage IV Pressure Ulcer was present on the left lateral calf area of the leg. RN #1 and the ADON raised the bilateral legs and removed the offloading heel elevator. RN #1 held the left leg up to assist the ADON to remove the dressing. Continued observation of the Stage IV Pressure Ulcer confirmed a moderate amount of dark pink serosanguineous drainage and a moderate amount of slough hanging from the ulcer and attached to the dressing as the dressing was removed. Deep tissue, muscle, and tendon were exposed within the ulcer; and bone was exposed at the 3:00 position (facing the wound and viewing it as a clock) of the ulcer. The Stage IV Pressure Ulcer measured 11.5 cm in length x 2.0 cm in width x 1.2 cm in depth. Interview with the Treatment Nurse, on May 2, 2014, beginning at 5:05 p.m., in the Conference Room, confirmed the (Offloading Heel Elevator) was implemented for use on resident #13 on December 31, 2013, and verbal in-servicing on the (Offloading Heel Elevator) was initiated on December 31, 2013 and continued throughout that week for all direct-care nursing staff who was routinely assigned to the resident. Upon requesting copies of the in-services, the Treatment Nurse confirmed the in-servicing was verbal and signatures were not obtained and competency was not validated.The Treatment Nurse stated, .On multiple occasions I have found the (Offloading Heel Elevator) was placed either incorrectly or not in place at all on the resident .this happened on five-to-ten occasions that I observed when I would go in to assess the resident and do treatments . A second interview was conducted with the Treatment Nurse on May 5, 2014, in the presence of the Interim Director of Nursing (DON), beginning at 1:30 p.m., in the Conference Room. When the surveyor questioned the initial verbal in-servicing the Treatment Nurse conducted when the (Offloading Heel Elevator) was placed on December 31, 2013, the Treatment Nurse confirmed, I did not educate any staff when the (Offloading Heel Elevator) was implemented on December 31, 2013. I just never thought anything about it .I just didn't think about it .I had never used a (Offloading Heel Elevator) before .I had to educate myself on how to use it .I researched online .I first identified the (Offloading Heel Elevator) incorrectly placed two-to-five times between December 31, 2013 and March 17, 2014 . Continued interview confirmed, I observed the device placed incorrectly approximately three-to-five more times between March 17 and March 26 .I observed the (Offloading Heel Elevator) placed incorrectly, above the bend of the knees .too high up, and ending striking the mid-calf .or in the floor .in-services were started on March 21 when the wound deteriorated to a Stage III .the in-services did not include all nursing staff .I think most of the incorrect placement was from CNA's who weren't used to working that area (with the resident) .when there is a call-out or a vacant position, another CNA will be pulled from their routinely assigned area to cover . Continued interview with the Treatment Nurse confirmed the facility's failure to educate, failure to ensure competency, and failure to ensure compliance with the correct placement of the (Offloading Heel Elevator). Interviews on May 7, 2014, with Certified Nursing Assistant (CNA) #1 (1:30 p.m.), #2 (1:47 p.m.), #3 (2:15 p.m.), #4 (3:14 p.m.), #5 (3:35 p.m.), #6 (4:10 p.m.), and #7 (5:05 p.m.), in the Conference Room, confirmed to have received no training on the use and/or placement of the (Offloading Heel Elevator) prior to May 6 and 7, 2014. Continued interviews confirmed CNA's #2, #3, #4, #6, and #7 provided care and assistance to resident #13. Continued interview with CNA #3 on May 7, 2014, beginning at 2:15 p.m., in the Conference Room, confirmed upon CNA #3 arrival to work and entering the resident's room, had observed the (Offloading Heel Elevator) placed under the resident incorrectly two-to-three times. Continued interview confirmed CNA #3 found it (Offloading Heel Elevator) in a chair or in the closet in the resident's room three-to-four times. CNA #3 stated, I found it under (resident's) thighs and ending in (resident's) mid-calf area two-to-three times .I just removed it and did (resident's) morning care, then put it back under (resident) correctly .between the bend of (resident's) knees and ankles. Continued interview confirmed the resident was unable to independently place the (Offloading Heel Elevator) incorrectly under the resident's own legs. Interview with RN #3 on May 7, 2014, beginning at 6:09 p.m., in the Conference Room, confirmed to have observed the (Offloading Heel Elevator) placed under the resident incorrectly during the months of February and March 2014, and stated, I can't recall the exact number of times .at least a couple for sure .one time, it was under the thighs and knees with the edge striking the middle of the calves of the legs .another time it was the same way, just a little farther than half-way down the calves . Interview with the previous Administrator on May 22, 2014, at 3:11 p.m., in the Conference Room, confirmed the Administrator realized the (Offloading Heel Elevators) were being used and was unable to recall any training prior to using the (Offloading Heel Elevators). Interview with the Interim Director of Nursing (DON) on May 23, 2014, at 12:00 p.m., in the Conference Room, confirmed the DON started as Interim DON on March 19, 2014, and was unaware of the lack of training on the (Offloading Heel Elevators) and was unaware of the (Offloading Heel Elevator) being placed incorrectly under the resident. Continued interview with the DON confirmed the facility failed to ensure training and competency on the correct use of the (Offloading Heel Elevator) and the (Offloading Heel Elevator) had been discontinued for use effective May 22, 2014. Continued interview confirmed the facility has had a lot of turnover in the past few months, especially recently . Further interview with the DON confirmed the facility's failure resulted in the resident developing an avoidable Stage IV Pressure Ulcer with admission to the hospital for IV antibiotics and wound care. Interview with the resident's Physician and Nurse Practitioner on May 23, 2014, at approximately 1:30 p.m., together in the Conference Room confirmed the incorrect placement of the (Offloading Heel Elevator) restricted blood flow to an already compromised extremity, which eventually resulted in a Stage IV Pressure Ulcer. The Physician confirmed, If I had been informed of the incorrect placement of the (Offloading Heel Elevator) I would have ensured nursing was aware of just how dangerous the incorrect placement (of the Offloading Heel Elevator) was .which impeded blood flow with the potential for loss of the extremity and/or life. Further interview with the Physician and Nurse Practitioner confirmed the facility failed to manage the resident's condition and prevent the Stage IV Pressure Ulcer to the left lateral calf of the resident's leg. In summary, the facility failed to ensure all nursing staff were educated and demonstrated competency before using the (Offloading Heel Elevator) on a resident. The Treatment Nurse observed the (Offloading Heel Elevator) placed incorrectly under resident #13 on multiple occasions between December 31, 2013, and March 26, 2014. Further, Registered Nurse #3 observed the (Offloading Heel Elevator) placed incorrectly and did not report it. Registered Nurse #3 confirmed the only time (RN #13) observed the (Offloading Heel Elevator) was when assisting a CNA with a resident (such as during incontinent care), which confirmed failure to assess and/or monitor the resident and the use of the (Offloading Heel Elevators). On March 26, the Pressure Ulcer had progressed to a Stage IV, and orders were received to send the resident to the hospital for evaluation; and was admitted for IV antibiotics and wound care. The Immediate Jeopardy was effective from December 31, 2013, through May 29, 2014. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated by the surveyor through review of documents, staff interviews, and observations conducted onsite on May 31, 2014. The surveyor verified the allegation of compliance by: 1. Reviewing the facility's in-service records to ensure nursing staff were educated or re-educated regarding changes to and implementation of the facility's following policies: a. Use of Offloading Heel Elevators and Pressure Redistribution Surfaces b. Skin Management Standard, including Risk Assessments, Pressure Ulcer Risk Assessments, Prevention/Body Audits (daily by CNA's; weekly by Licensed Nurses; and quarterly Skin Sweeps by Licensed Nurses), Routine Preventative Care, Staging, Documentation, Wound Care Protocol, and Negative Pressure Wound Therapy (re-educated) c. Weekly At-Risk Meetings d. Daily Clinical Wound Reviews e. Weekly Wound Team Rounds f. Change in (Resident) Condition (re-educated) g. Administrative Team Resident Rounds 2. Conducted interviews with administration and nursing staff, to include the Administrator, eight Registered Nurses (which included the DON and ADON), eight Licensed Practical Nurses, and fourteen Certified Nursing Assistants for a total of thirty nursing staff of fifty-four licensed and certified nurses on staff; and one Administrator to determine the level of comprehension gained through in-service education conducted regarding changes to and implementation of the facility's policies, Use of Offloading Heel Elevators and Pressure Redistribution Surfaces; Skin Management Standards; Weekly At-Risk Meetings; Daily Clinical Wound Reviews; Weekly Wound Team Rounds; Change in Resident Condition; and Physician Notification of Delay in Treatment and Services to ensure staff recognize and respond to the following: a. The rationale for an At-Risk assessment, preventative daily and weekly skin assessments, and monitoring of the resident's skin and devices along with skin impairment that warrants Physician notification and intervention. Including but not limited to: the correct use of pressure preventative devices. The interviews included a verbal explanation of when new devices can be implemented; when the DON and Physician are to be notified of device or equipment concerns or errors; and when and by whom are devices assessed, monitored, and documented. b. The facility's educational and procedural requirement for the implementation and monitoring of the (Offloading Heel Elevator) and all future purchases of resident assistive devices, in which staff must be educated prior to the use of any new equipment and upon hire, before working with the resident and the assistive devices. The interviews included the process for education prior to implementing the newly purchased device, implementation, and monitoring. Additional validation included a skills competency demonstration of placing the (Offloading Heel Elevator) to ensure comprehension in the correct placement of the device. c. The facility's Daily Clinical Wound reviews included a verbal explanation of their purpose, when are the reviews held, and who is responsible for the documentation and who oversees the reviews. d. The facility's Weekly Wound Rounds included a verbal explanation of the purpose, when the rounds are conducted, who is required to participate in the rounds, what observation would constitute follow-up, and who oversees the rounds and ensures the follow-up. e. What constitutes a change in a resident's condition and what is required when a change in a resident's condition occurs. Interviews included a verbal explanation of prompts notifications, who is notified and by whom, how soon, and required documentation. f. The facility's policy for Administrative Clinical Rounds included a verbal explanation of the purpose, when the rounds are conducted, who conducts the rounds, what observation would constitute follow-up, and who oversees the rounds and ensures the follow-up. 3. Review of Weekly Wound Progress Notes, the facility's Weekly Wound Report, and observation of respective Pressure Ulcers of four residents to validate accuracy in assessment and documentation. 4. Observation of a dressing change and application of a Negative Pressure Wound Therapy System to validate accuracy in assessment, treatment, and application of the Negative Pressure Wound Therapy System. 5. Observation of four residents requiring offloading of the heels to confirm correct positioning using a regular pillow; the (Offloading Heel Elevators) were discontinued effective May 22, 2014, and none were in use for review. 6. Review of At-Risk Assessments of 13 residents for timeliness and correct implementation of preventative interventions based upon the assessments. 7. Observation of the facility's Clinical Board for wound-related information, used as a tool to ensure focused and effective communication and follow-up during Daily Clinical Wound Reviews (Monday through Friday, during normal work days). 8. Review of the minutes from an emergency Quality Assurance/Performance Improvement Committee Meeting held on May 7, 2014, with the Administrator, Medical Director, Director of Nursing, Corporate Quality Improvement Consultant, Minimum Data Set Coordinator, Certified Dietary Manager, Therapy Director, and Social Services. Based upon the complaint survey initiated on April 29, 2014, the Committee discussed the educational requirements of new devices and corrective actions as identified in the Allegation of Compliance. Non-compliance continues at a D level 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-157 (J); F-314 (J), Substandard Quality of Care",2017-05-01
8607,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2014-05-31,514,J,1,0,3X0Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, medical record review, review of employee personnel files, observation, and interview, the facility failed to ensure accuracy and complete documentation of assessment and staging of pressure ulcers for two residents (#13, #14) of nineteen residents reviewed. The facility's failure to accuately document a suspected deep tissue injury resulted in resident #13's transfer and admission to the hospital for intravenous antibiotics and wound care. The Administrator (NHA) and Corporate Chief Nursing Officer (CCNO) were informed of the Immediate Jeopardy in the Conference Room on May 29, 2014, at 9:00 p.m. The findings included: Review of facility policy, Skin Management Standard, revised October 2013 revealed, .Prevention/Body Audits: All residents will be checked for skin condition changes and/or alterations on a daily basis or during routine care by the Certified Nursing Assistant (CNA) .The resident's Physician and Responsible Party shall be notified of a change in the resident's skin condition .Routine Preventative Care: .2. j. Education to resident, family, and caregiver (All Nursing Staff) .Comprehensive Assessment of Wounds: a. Assess the entire resident, not just the wound. B. Consider all factors that can influence healing .equipment factors .Stages and Categories .Purpose .It is the standard of this facility to accurately stage all wounds to represent severity and to implement appropriate wound care protocols .Skin Ulceration Management: .3. The Physician will be contacted and orders obtained for treatment .Stage I: Complete assessment to determine root cause of pressure ulcer .6. The wound(s) will be measured and assessed for size (length, width, depth, undermining, drainage, odor, debris such as slough or eschar (thick, leathery, frequently black or brown in color, necrotic (dead) or devitalized tissue) .8. All wounds will be discussed and reviewed by the Interdisciplinary Team at least weekly . Resident #13 was admitted to the facility initially on April 16, 2009, with [DIAGNOSES REDACTED]. Medical record review of a Skin/Wound Note dated February 13, 2014, at 4:28 p.m., and electronically signed by the Treatment Nurse revealed Stage I (one) (an observable, pressure-related alteration of intact skin, when compared to an adjacent or opposite area on the body may include changes in skin temperature, tissue consistency, sensation and/or a defined area of persistent redness) area noted to the outer lateral portion of the left calf .Area will be observed daily. Continued review revealed no documentation the Treatment Nurse measured the Stage I Pressure Ulcer area. Medical record review of a Weekly Wound Progress Note dated February 17, 2014, at 3:17 p.m., and electronically signed by the Treatment Nurse revealed no assessment or documentation of the Stage I Pressure Ulcer on the outer lateral portion of the left calf. Medical record review of a Skin Sweep (tool used to document skin assessments) record dated February 18, 2014, and electronically signed by the Treatment Nurse revealed, Left lower leg (rear) .blanching red area . Continued review revealed no further assessments or documentation of the Stage I Pressure Ulcer on the left lateral calf until March 17, 2014. Medical record review of a Skin/Wound Note and Weekly Wound Progress Note, both dated March 17, 2014, and electronically signed by the Treatment Nurse revealed the offloading heel elevator was incorrectly placed under the resident, and stated, .Stage I (Pressure Ulcer) was noted to the left lower lateral leg .Date identified .March 17, 2014 (February 13, 2014) .leg .Stage I .Acquired (wound developed in the facility) . Medical record review of a Skin Sweep record dated March 18, 2014, and electronically signed by the Treatment Nurse revealed, .Right lower leg rear (was left lower lateral leg) .Pressure .Length: 8.0 cm .Width: 1 (1.0) cm .Depth: 0.0 .Stage: I . Medical record review of a Weekly Wound Progress Note dated March 21, 2014, at 11:58 a.m., and electronically signed by the Treatment Nurse revealed the Stage I on the left lower lateral leg had progressed to a Stage III in between dressing changes from March 19, 2014 to March 21, 2014 and measured 7.4 cm x 1.3 cm, with 0.0 cm in depth (The Skin/Wound Note dated March 21, 2014, at 12:22 p.m., revealed a depth of 0.3 cm). Medical record review of a Weekly Wound Progress Note dated March 24, 2014, at 4:57 p.m., and electronically signed by the Treatment Nurse revealed, .Right lateral lower leg (was left lateral lower leg) . Continued review of the Nurse's Notes dated March 26, 2014, at 3:29 p.m., revealed Emergency Medical Services (EMS) arrived at the facility and transported the resident to the hospital. Review of the Treatment Nurse's employee file and Record of Counseling dated May 6, 2014, revealed, the Treatment Nurse was discharged (involuntarily terminated) from employment, and stated, Gross misconduct related to failure to follow company policy regarding proper documentation of wounds as evidenced by lack of consistent measurements on patients with wounds, incomplete documentation of patient assessment .and inaccurate documentation of patient's wound sites . Observation of the resident on May 7, 2014, at 8:58 p.m., during a dressing change completed by the Assistant Director of Nursing (ADON) and Registered Nurse (RN) #1, confirmed a Stage IV Pressure Ulcer was present on the left lateral calf area of the leg. Interview with the Treatment Nurse on May 5, 2014, in the presence of the Interim Director of Nursing (DON), beginning at 1:30 p.m., in the Conference Room, and the Treatment Nurse confirmed, .The initial onset of the Pressure Ulcer on the Left lateral calf of the leg was identified on as a Stage I on February 13, 2014. Continued interview and review of the medical record with the Treatment Nurse confirmed no assessments or monitoring of the Pressure Ulcer was done after February 13 until March 17, when the Treatment Nurse identified the Pressure Ulcer as a Stage I and stated, .I can't recall the condition of the left leg (from February 13 until March 17) .nothing stands out in my memory .I didn't assess it .I missed a DTI (Deep Tissue Injury) (Purple or maroon area of discolored intact skin due to damage of underlying soft tissue) . Continued interview confirmed the Treatment Nurse stated (The Skin Sweep on March 18, 2014, the Weekly Wound Progress Notes on March 21 and 24, 2014) were incorrect .it was the left leg .not the right .and the wound had depth .I documented 0.3 (depth) on the Skin/Wound Note on March 21, 2014, (at 12:22 p.m.), but it seemed deeper than that . Interview with the Interim DON on May 23, 2014, at 12:00 p.m., in the Conference Room, confirmed the Treatment Nurse failed to ensure an accurate and complete medical record for resident #13. Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Pressure Ulcer Risk Assessments dated January 15, 2014, January 22, 2014, January 29, 2014, April 29, 2014, revealed the resident was at high risk for the development of pressure Ulcers. Continued review of an assessment dated [DATE], revealed the resident was at very high risk for the development of pressure ulcers. Medical record review of a Skin Sweep record dated March 20, 2014, revealed the resident had a callous/dry skin-open on the right lateral foot and the area measured 0.8 cm x 0.8 cm x 0 cm. Medical record review of the Weekly Wound Progress Notes revealed the following: March 20, 2014, and electronically signed by the Treatment Nurse; a non-pressure area to the right inner lateral foot, below great toe and measured 0.8 cm x 0.8 cm x 0 cm .area was calloused, (resident) has history of dry skin, skin was flaky and when lotion was applied skin flaked loose from area and revealed an open area .Alginate and Bordered Gauze . March 24, 2014, and electronically signed by the Treatment Nurse; the area continued as a non-pressure with no change in measurements or treatment, but was 80% necrotic. April 9, 2014, and electronically signed by the Treatment Nurse; measurements increased to 1.5 cm x 1.0 cm x 0.3 cm .0 (zero) necrosis. April 18, 2014, and electronically signed by the Treatment Nurse; measurements increased to 2.5 cm x 1.4 cm x 0.2 cm with no change in treatment. April 24, 2014, and electronically signed by the Treatment Nurse; .1.0 cm x 1.8 cm x 0.1 cm, with 80% slough . and no change in treatment. May 6, 2014, and electronically signed by the ADON; .(1) (one) Stage III Pressure Ulcer .3.2 cm x 2.2 cm x 0.1 cm .cleanse area with wound cleanser, pat dry, apply Thera-Honey to Slough, and [MEDICATION NAME] to surrounding tisse; apply soft pad dressing . Observation of the resident on May 28, 2014, at 7:00 p.m., in the resident's room, during a dressing change completed by the ADON, confirmed a Stage III Pressure Ulcer was present on the resident's lateral metatarsal head (the largest metatarsal bone directly at the base of the big toe). The Pressure Ulcer measured 1.0 cm x 1.0 cm x 0 cm, granulation in all quadrants of the wound bed, and had a very small amount of serous drainage on the dressing upon removal. Continued review confirmed the resident was lying on the bed, wore a house slipper on the left foot, and after the dressing change, a loose-fitting cotton sock was placed on the right foot. Interview with the ADON on May 28, 2014, at 9:11 p.m., in the Conference Room, confirmed the Pressure Ulcer resulted from the resident's shoe, which has been removed, and once the Pressure Ulcer has healed, new shoes will be purchased. Continued interview confirmed the resident is non-ambulatory and uses a wheelchair for mobility; and until the Pressure Ulcer heals and new shoes are obtained, the resident wears a house slipper on the left foot and a loose-fitting sock on the right. Continued interview with the ADON confirmed the Treatment Nurse had failed to timely and accurately assess and Stage the resident's Pressure Ulcer on the right lateral metatarsal head. Interview with the Administrator on May 29, 2014, at approximately 2:55 p.m., in the Conference Room, confirmed the facility failed to ensure accurate assessments and Pressure Ulcer Staging. In summary, the facility failed to ensure resident #13 and #14's medical records were complete and accurate. The treatment Nurse failed to accurately document staging for Resident #13, identifying the accurate location, and failed to accurately document a Stage 1 as a deep tissue injury. After identification of the pressure ulcer on February 13, 2014, no further documentation by the Treatment Nurse was completed until March 17, 2014. On March 26, 2014, Resident #13 was hospitialized for intravenous antibiotics and wound care. The Immediate Jeopardy was effective from December 31, 2013, through May 29, 2014. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated by the surveyor through review of documents, staff interviews, and observations conducted onsite on May 31, 2014. The surveyor verified the allegation of compliance by: 1. Reviewing the facility's in-service records to ensure nursing staff were educated or re-educated regarding changes to and implementation of the facility's following policies: a. Use of Offloading Heel Elevators and Pressure Redistribution Surfaces b. Skin Management Standard, including Risk Assessments, Pressure Ulcer Risk Assessments, Prevention/Body Audits (daily by CNA's; weekly by Licensed Nurses; and quarterly Skin Sweeps by Licensed Nurses), Routine Preventative Care, Staging, Documentation, Wound Care Protocol, and Negative Pressure Wound Therapy (re-educated) c. Weekly At-Risk Meetings d. Daily Clinical Wound Reviews e. Weekly Wound Team Rounds f. Change in (Resident) Condition (re-educated) g. Physician Notification of Delay in Treatment and Services (re-educated) h. Administrative Team Resident Rounds 2. Conducted interviews with administration and nursing staff, to include the Administrator, eight Registered Nurses (which included the DON and ADON), eight Licensed Practical Nurses, and fourteen Certified Nursing Assistants for a total of thirty nursing staff of fifty-four licensed and certified nurses on staff; and one Administrator to determine the level of comprehension gained through in-service education conducted regarding changes to and implementation of the facility's policies, Use of Offloading Heel Elevators and Pressure Redistribution Surfaces; Skin Management Standards; Weekly At-Risk Meetings; Daily Clinical Wound Reviews; Weekly Wound Team Rounds; Change in Resident Condition; and Physician Notification of Delay in Treatment and Services to ensure staff recognize and respond to the following: a. The rationale for an At-Risk assessment, preventative daily and weekly skin assessments, and monitoring of the resident's skin along with skin impairment that warrants Physician notification and intervention. Including but not limited to: all Stages of Pressure Ulcers (I, II, III, IV, and Suspected Deep Tissue Injuries) and changes in the Stage of a Pressure Ulcer. The interviews included a verbal explanation of each Pressure Ulcer Stage; when and by who are the At-Risk and preventative skin assessments are completed and documented; what encompasses a Pressure Ulcer assessment; and when and by whom are Pressure Ulcers assessed and documented. b. The facility's educational and procedural requirement for the implementation and monitoring of the (Offloading Heel Elevator) and all future purchases of resident assistive devices, in which staff must be educated prior to the use of any new equipment and upon hire, before working with the resident and the assistive devices. The interviews included the process for education prior to implementing the newly purchased device, implementation, and monitoring. Additional validation included a skills competency demonstration of placing the (Offloading Heel Elevator) to ensure comprehension in the correct placement of the device. c. The facility's Daily Clinical Wound reviews included a verbal explanation of their purpose, when are the reviews held, and who is responsible for the documentation and who oversees the reviews. d. The facility's Weekly Wound Rounds included a verbal explanation of the purpose, when the rounds are conducted, who is required to participate in the rounds, what observation would constitute follow-up, and who oversees the rounds and ensures the follow-up. e. What constitutes a change in a resident's condition and what is required when a change in a resident's condition occurs. Interviews included a verbal explanation of prompts notifications, who is notified and by whom, how soon, and required documentation. f. The facility's policy and procedural requirement for medication administration and time-sensitive treatment, services, and Physician orders. Interviews included a verbal explanation on ensuring adequate and timely communication with outside providers and Physician notification if the services cannot be provided timely to ensure an alternate plan of care (PICC line insertion must be inserted within a four-hour window; if not inserted within four-hours, the Physician must be notified for an alternate plan of care). Further, a review of the Medication Administration Records and a verbal explanation of the standards of practice and facility policy related to Medication Administration. g. The facility's policy for Administrative Clinical Rounds included a verbal explanation of the purpose, when the rounds are conducted, who conducts the rounds, what observation would constitute follow-up, and who oversees the rounds and ensures the follow-up. 3. Review of Weekly Wound Progress Notes, the facility's Weekly Wound Report, and observation of respective Pressure Ulcers of four residents to validate accuracy in assessment and documentation. 4. Observation of a dressing change and application of a Negative Pressure Wound Therapy System to validate accuracy in assessment, treatment, and application of the Negative Pressure Wound Therapy System. 5. Observation of four residents requiring offloading of the heels to confirm correct positioning using a regular pillow; the (Offloading Heel Elevators) were discontinued effective May 22, 2014, and none were in use for review. 6. Review of At-Risk Assessments of 13 residents for timeliness and correct implementation of preventative interventions based upon the assessments. 7. Observation of a Medication Pass to validate administration and accuracy of medications administered, as ordered by the Physician. 8. Observation of the facility's Clinical Board for wound-related information, used as a tool to ensure focused and effective communication and follow-up during Daily Clinical Wound Reviews (Monday through Friday, during normal work days). 9. Review of the minutes from an emergency Quality Assurance/Performance Improvement Committee Meeting held on May 7, 2014, with the Administrator, Medical Director, Director of Nursing, Corporate Quality Improvement Consultant, Minimum Data Set Coordinator, Certified Dietary Manager, Therapy Director, and Social Services. Based upon the complaint survey initiated on April 29, 2014, the Committee discussed the areas of concern and corrective actions as identified in the Allegation of Compliance. Non-compliance continues at a D level 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-157 (J); F-282 (D); F-309 (J), Substandard Quality of Care; F-314 (J), Substandard Quality of Care; F-333 (J), Substandard Quality of Care; F-498 (J)",2017-05-01
8608,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2014-05-31,520,J,1,0,3X0Q11,"Based on medical record review, review of facility policies, review of manufacturer's information, review of facility training records, review of facility records, review of employee personnel files, observation, and interview, the facility's Quality Assurance (QA) Committee failed to ensure Physician notification of a change in condition and delay in treatment, failed to ensure care and services were provided by qualified staff according to the care plan, and failed to administer antibiotics for an infected Pressure Ulcer, as ordered; and failed to ensure training and competency on new equipment for one resident (#13) of nineteen residents reviewed; and failed to prevent an avoidable Pressure Ulcer for one resident (#13) of six resident reviewed. The facility's failure resulted in resident (#13) developing a Stage IV (four) (full thickness tissue loss with exposed bone, tendon, or muscle) Pressure Ulcer with a transfer and admission to the hospital for intravenous (IV) antibiotics and wound care. The facility's failure placed resident #13 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) and Corporate Chief Nursing Officer (CCNO) were informed of the Immediate Jeopardy in the Conference Room on May 29, 2014, at 9:00 p.m. The findings included: Interview with the Treatment Nurse on May 5, 2014, beginning at 1:30 p.m., in the presence of the Interim Director of Nursing (DON), in the Conference Room, revealed when the surveyor questioned in-servicing (of nursing staff on the use of the offloading heel elevator (pressure prevention device), prior to use) the Treatment Nurse confirmed, I did not educate any staff when the (Offloading Heel Elevator) was implemented on December 31, 2013. (Resident) is a resident that doesn't like to get out of bed and usually what's there (device) they (nursing staff) will put back. I just never thought anything about it .I just didn't think about it .I had never used a (Offloading Heel Elevator) before .I had to educate myself on how to use it .I researched online .I first identified the (Offloading Heel Elevator) incorrectly placed two-to-five times between December 31, 2013 and March 17, 2014 .and approximately three-to-five more times between March 17 and March 26 .in-services were started on March 21 when the wound deteriorated to a Stage III .the in-services did not include all nursing staff . Continued interview with the Treatment Nurse confirmed the failure to educate and ensure competency with the correct placement of the (Offloading Heel Elevator) resulted in the resident developing an avoidable DTI (Deep Tissue Injury) (Purple or maroon area of discolored intact skin due to damage of underlying soft tissue), which progressed to a Stage IV Pressure Ulcer, and required direct-admission to the hospital for IV antibiotics and wound care. Interview with the Assistant Director of Nursing on May 29, 2014, at 2:55 p.m., confirmed the facility had no formal processes in place to ensure training and competency for all staff who would be using a new treatment device and no formal systems for the daily monitoring of the residents' skin or pressure prevention devices, and stated, It was more of a 'Hey, come here and look at this' .or tell or leave 'a note' for the (Treatment Nurse) .I didn't find any of this to be a problem at the time, but in retrospect it was a big problem. Interview with the Administrator on May 30, 2014, at 10:21 p.m., in the Conference Room, confirmed, the (Offloading Heel Elevator) was implemented for use on resident #13 on December 31, 2013. The Administrator confirmed all nursing staff were not trained and competency was not verified prior to use of the (Offloading Heel Elevator). Continued interview with the Administrator confirmed the facility's Quality Assurance (QA) Committee met monthly. Continued interview confirmed the incorrect placement of the (Offloading Heel Elevator) was not reviewed in the monthly QA meetings, prior to the complaint survey initiated on April 29, 2014. Further interview confirmed the Administrator could find no documentation of a plan or discussion in the minutes of previous QA meetings regarding education and competency prior to the implementation of new resident equipment. Continued interview confirmed the facility held an emergency QA meeting on May 7, 2014, and the incorrect placement of the (Offloading Heel Elevator), required training and competency was discussed, along with other areas of concerns identified, based upon the complaint survey. In summary, the facility's QA Committee failed to ensure a process was in place to ensure the identification and implementation of systems to ensure consistency and compliance with the facility's policies and procedures and Federal Regulations regarding Physician notification in a resident's change in condition and delay in treatment, qualified staff provide resident care in accordance with the care plan, Skin Management Standards, administering medications as ordered by the Physician, training and competency for all staff using new equipment, and completeness and accuracy of medical records. The Immediate Jeopardy was effective from December 31, 2013, through May 29, 2014. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated by the surveyor through review of documents, staff interviews, and observations conducted onsite on May 31, 2014. The surveyor verified the allegation of compliance by: 1. Reviewing the facility's in-service records to ensure nursing staff were educated or re-educated regarding changes to and implementation of the facility's following policies: a. Use of Offloading Heel Elevators and Pressure Redistribution Surfaces b. Skin Management Standard, including Risk Assessments, Pressure Ulcer Risk Assessments, Prevention/Body Audits (daily by CNA's; weekly by Licensed Nurses; and quarterly Skin Sweeps by Licensed Nurses), Routine Preventative Care, Staging, Documentation, Wound Care Protocol, and Negative Pressure Wound Therapy (re-educated) c. Weekly At-Risk Meetings d. Daily Clinical Wound Reviews e. Weekly Wound Team Rounds f. Change in (Resident) Condition (re-educated) g. Physician Notification of Delay in Treatment and Services (re-educated) h. Administrative Team Resident Rounds 2. Conducted interviews with administration and nursing staff, to include the Administrator, eight Registered Nurses (which included the DON and ADON), eight Licensed Practical Nurses, and fourteen Certified Nursing Assistants for a total of thirty nursing staff of fifty-four licensed and certified nurses on staff; and one Administrator to determine the level of comprehension gained through in-service education conducted regarding changes to and implementation of the facility's policies, Use of Offloading Heel Elevators and Pressure Redistribution Surfaces; Skin Management Standards; Weekly At-Risk Meetings; Daily Clinical Wound Reviews; Weekly Wound Team Rounds; Change in Resident Condition; and Physician Notification of Delay in Treatment and Services to ensure staff recognize and respond to the following: a. The rationale for an At-Risk assessment, preventative daily and weekly skin assessments, and monitoring of the resident's skin along with skin impairment that warrants Physician notification and intervention. Including but not limited to: all Stages of Pressure Ulcers (I, II, III, IV, and Suspected Deep Tissue Injuries) and changes in the Stage of a Pressure Ulcer. The interviews included a verbal explanation of each Pressure Ulcer Stage; when and by who are the At-Risk and preventative skin assessments are completed and documented; what encompasses a Pressure Ulcer assessment; and when and by whom are Pressure Ulcers assessed and documented. b. The facility's educational and procedural requirement for the implementation and monitoring of the (Offloading Heel Elevator) and all future purchases of resident assistive devices, in which staff must be educated prior to the use of any new equipment and upon hire, before working with the resident and the assistive devices. The interviews included the process for education prior to implementing the newly purchased device, implementation, and monitoring. Additional validation included a skills competency demonstration of placing the (Offloading Heel Elevator) to ensure comprehension in the correct placement of the device. c. The facility's Daily Clinical Wound reviews included a verbal explanation of their purpose, when are the reviews held, and who is responsible for the documentation and who oversees the reviews. d. The facility's Weekly Wound Rounds included a verbal explanation of the purpose, when the rounds are conducted, who is required to participate in the rounds, what observation would constitute follow-up, and who oversees the rounds and ensures the follow-up. e. What constitutes a change in a resident's condition and what is required when a change in a resident's condition occurs. Interviews included a verbal explanation of prompts notifications, who is notified and by whom, how soon, and required documentation. f. The facility's policy and procedural requirement for medication administration and time-sensitive treatment, services, and Physician orders. Interviews included a verbal explanation on ensuring adequate and timely communication with outside providers and Physician notification if the services cannot be provided timely to ensure an alternate plan of care (PICC line insertion must be inserted within a four-hour window; if not inserted within four-hours, the Physician must be notified for an alternate plan of care). Further, a review of the Medication Administration Records and a verbal explanation of the standards of practice and facility policy related to Medication Administration. g. The facility's policy for Administrative Clinical Rounds included a verbal explanation of the purpose, when the rounds are conducted, who conducts the rounds, what observation would constitute follow-up, and who oversees the rounds and ensures the follow-up. 3. Review of Weekly Wound Progress Notes, the facility's Weekly Wound Report, and observation of respective Pressure Ulcers of four residents to validate accuracy in assessment and documentation. 4. Observation of a dressing change and application of a Negative Pressure Wound Therapy System to validate accuracy in assessment, treatment, and application of the Negative Pressure Wound Therapy System. 5. Observation of four residents requiring offloading of the heels to confirm correct positioning using a regular pillow; the (Offloading Heel Elevators) were discontinued effective May 22, 2014, and none were in use for review. 6. Review of At-Risk Assessments of 13 residents for timeliness and correct implementation of preventative interventions based upon the assessments. 7. Observation of a Medication Pass to validate administration and accuracy of medications administered, as ordered by the Physician. 8. Observation of the facility's Clinical Board for wound-related information, used as a tool to ensure focused and effective communication and follow-up during Daily Clinical Wound Reviews (Monday through Friday, during normal work days). 9. Review of the minutes from an emergency Quality Assurance/Performance Improvement Committee Meeting held on May 7, 2014, with the Administrator, Medical Director, Director of Nursing, Corporate Quality Improvement Consultant, Minimum Data Set Coordinator, Certified Dietary Manager, Therapy Director, and Social Services. Based upon the complaint survey initiated on April 29, 2014, the Committee discussed the areas of concern and corrective actions as identified in the Allegation of Compliance. Non-compliance continues at a D level for monitoring the effectiveness of corrective actions for effectiveness and evaluation of monitoring by the Quality Assurance (QA) Committee. The facility is required to submit a plan of correction. Refer to F-157 (J), F-224 (J), Substandard Quality of Care; F-278; F-309 (J), Substandard Quality of Care; F-314 (J), Substandard Quality of Care; and F-333 (J), Substandard Quality of Care; F-498 (J); F-514 (D)",2017-05-01
9513,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2013-04-10,241,E,0,1,W6SO11,"Based on observation and interview, the facility failed to provide a homelike environment conducive to dining and resident dignity on four dining observations in the Ruby Room dining area. The findings included: Observation in the Ruby Room dining area on April 8, 2013, at 11:59 a.m., revealed square and round dining tables with table cloths on them. Observation revealed two semi-circle tables in the middle of the room without table cloths. Further observation revealed the Certified Nursing Assistants (CNA) were placing clothing protectors on the residents without first asking the resident if they wished to have a clothing protector. Observation revealed CNA #2 was heard asking what's .name again while putting a clothing protector on a resident who was asleep at the table. One resident asked CNA #2, what is this for? when CNA #2 placed the clothing protector on the resident and CNA #2 replied to keep your clothes clean. Continued observation revealed one resident requested apple juice and was told by staff .only have sweet tea and milk because it is lunch. The resident asked again about apple juice, and one staff member stated they already told .couldn't have it, the other staff member went and obtained a carton of apple juice and gave it to the resident. Interview with CNA #2 in the Ruby dining area, on April 8, 2013, at 12:05 p.m., confirmed clothing protectors were placed on residents without asking permission, the two semi-circle tables did not have tablecloths, and some of the staff did not check availability of a beverage request before telling the resident requesting there was none. Observation of dining on April 8, 2013, at 11:50 a.m., in the Ruby dining room revealed: CNA #1 placed clothing protectors on eight of twenty- three residents without asking permission. Interview with CNA #1 in the Ruby Dining room, at 1:12 p.m., confirmed the CNA had not asked permission to place clothing protectors on the residents. Further observation of dining on April 8, 2013, at 12:35 p.m., in the Ruby Dining room revealed Licensed Practical Nurse (LPN) #1 gave medicine to resident # 60 in the dining room. Interview with LPN #1 on April 8, 2013, at 12:40 p.m., confirmed medication was given in the dining room. Observation of breakfast in the Ruby Dining Room, on April 10, 2011, at 7:45 a.m., revealed a CNA placing clothing protectors on five residents without asking them first if they wanted one. Continued observation in the Ruby Dining Room revealed a CNA going from table to table pouring syrup onto the residents' waffles but failed to ask the residents first if they wanted any syrup.",2016-11-01
9514,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2013-04-10,242,D,0,1,W6SO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to allow the resident the right to chose a bathing schedule for three (#46, #115, #47) of seventeen residents interviewed regarding bathing schedule. The findings included: Resident #46 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 cognitively intact for daily decision making; required extensive assistance for personal hygiene, and required one person physical assistance for bathing. Medical record review of the annual MDS dated [DATE], revealed it was very important for resident #46 to have choice in bathing. Medical record review of the Care Plan dated March 12, 2013, revealed, .resident is to receive showers 2x's per week Q (every) Wed on 3-11 shift and Saturday on 7-3 shift . Medical record review of the Flow Sheet Record for resident #46 revealed, the resident received seven showers between March 1-31, 2013. The resident received four showers between February 1-28, 2013. Interview with resident #46 in the resident's room, on April, 8, 2013, at 4:22 p.m., revealed the resident does not have a choice between bed bath, tub bath, or a shower; and does not choose how many times a week a bath or shower is taken. Continued interview revealed the resident preferred a shower each night. Observation of the resident on April 10, 2013, at 7:58 a.m., in the resident's room revealed the resident seated in the wheelchair and was getting ready to get a bath. Review of the of the Patient Nursing Evaluation for resident #46 dated June 25 and November 25, 2012, revealed a section titled, 'Personal Habits' which had a check box for alcohol and tobacco use and sleep pattern. Review of the evaluation revealed there is no inquiry of the bathing preference (shower or bath) or the frequency of the bathing schedule. Interview with Certified Nursing Assistant (CNA #4) on the Nightingale hallway on April 10, 2013, at 2:00 p.m., revealed showers are twice per week .they are assigned shower times. Interview with the Director of Nursing (DON) on April 10, 2013, at 2:05 p.m. in the DON's office, revealed the facility does not have a system in place to determine the resident's preference of bathing style or frequency; and confirmed the facility does not have a plan in place to promote the resident's choice in their bathing. Resident #115 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. and Hypertention. Medical record review of the quarterly MDS dated [DATE], revealed the resident was cognitively intact for daily decision making; required extensive assistance for personal hygiene; and required physical assistance of one person for bathing. Medical record review of the annual MDS dated [DATE], revealed it was very important for this resident to make bathing choices. Medical record review of the Care Plan dated September 27, 2011, revealed the resident was to have two showers a week; one on Wednesday 3-11 shift and one on Saturday 7-3 shift. Interview with resident #115 on April 8, 2013, at 5:02 p.m., revealed the resident did not have choice in bed bath, tub bath or shower; and did not have choice in how many times a week a bath or shower was given. Observation and interview of resident #115 on Wednesday April 10, 2013, at 7:52 a.m., in the resident's room, revealed the resident was expecting to receive a shower later in the day. Interview with DON on April 10, 2013 at 2:33 p.m., in the DON's office, revealed the Care Plan for resident #115 does not reflect the resident's wishes; and confirmed the facility failed to promote the resident's choices in bathing option or frequency. Resident #47 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Interview with resident #47 on April 8, 2013, at 3:36 p.m., and April 11, 2013, at 3:00 p.m., in the resident's room, revealed the resident preferred a shower daily. Review of the quarterly MDS dated [DATE], revealed the resident was cognitively intact, required extensive assistance with one person physical assistance for bed mobility, transfers, toilet use, and bathing. Review of the March 2013 Flow Sheet Record revealed the resident was to receive a shower two times a week. Review of the Care Plan dated January 30, 2013 revealed the resident needed .assistance with bathing .Approaches: .shower and shampoo 2 x/week (2 times per week), bedbath on all other days . Review of the Patient Nursing Evaluation dated August 20, 2012, revealed the resident's personal habit section did not include bathing preferences or frequency. Interview with CNA #2 on April 10, 2013, at 12:40 p.m., in the Ruby Dining Room, revealed the CNA was not aware the resident preferred daily showers. Interview with the DON on April 10, 2013, in the DON's office at 3:15 p.m., confirmed the Patient Nursing Evaluation failed to address the resident's bathing preference and frequency and failed to honor the resident's bathing preference.",2016-11-01
9515,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2013-04-10,279,D,0,1,W6SO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to develop an individualized care plan with specifics of care for one (# 31) of thirty residents reviewed. The findings included: Resident #31 was admitted to the facility with [DIAGNOSES REDACTED]. Medical record review of the Weekly Pressure Ulcer BWAT Report dated February 25 - March 18, 2013, revealed the resident had a stage III pressure ulcer on the left heel. Continued review of the Ulcer Report revealed the wound measured 2 cm (centimeters) x 1 cm x 0.2 cm with undermining Medical record review of an Interdisciplinary Note dated April 1, 2013, revealed .left heel is showing improvement. It does have about 50 - 75% loose yellow slough to the wound bed at this time. We are cleansing with wound cleanser; applying hydrogel; and covering with a dry dressing daily. I am not sure the wound will heal completely with the vascular inefficiency in the leg. There is also a wound to the outer aspect of the left lower extremity which we cleanse with wound cleanser; apply hydrogel to wound bed; packing with gauze strips; and covering with dry dressing . Medcial record review of the Care Plan revealed skin integrity was addressed but did not specify where the resident's wounds were located; any description of the wounds; specific treatment for [REDACTED]. Interview with the Director of Nursing (DON) on April 10, 2013, at 3:30 p.m., in the DON's office confirmed the Care Plan had not been revised to reflect the location, stage, specific treatment, and nursing precautions of the Pressure Ulcer to the heel.",2016-11-01
9516,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2013-04-10,309,D,0,1,W6SO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, and interview, the facility failed to follow physician's orders; failed to notify the physician in a timely manner; and failed to document actions taken for one (#164) of fifty residents reviewed. The findings included: Resident #164 was admitted to the facility on [DATE], following a hospital stay with [DIAGNOSES REDACTED]. Medical record review of Physician's Orders dated September 11, 2012, revealed among the discharge medications for the resident was NaCl (sodium chloride - salt) 1 gram three times daily. Continued review of Physician's Orders dated September 13, 2012, revealed D/C (discontinue) NaCl 1 gram TID (three times daily). Start V8 juice 3 cans daily. Further review of Physician's Orders dated September 14, 2012, (no time), revealed .Start peripheral IV (intravenous). Infuse NS (normal saline) at 70/hr (milliliters per hours) for 2 liters. Na level after 1 liter of NS . Continued review of Physician's Orders dated September 14, 2012, (no time), revealed .Stat Na level. NaCl tabs I po (orally) TID . Further review of Physician's Orders dated September 14, 2012, (no time), revealed .Continue with V8 juice 1 can QID (four times daily) until NaCl tabs arrive. Call stat Na level. Call ANP (Advanced Nurse Practitioner) if NaCl tabs do not arrive today . Continued review of Physician's Orders dated September 14, 2012, (no time), revealed .D/C home, Na 123 (normal 135 - 145). Medical record review of the Medication Administration Record [REDACTED]. Continued review of the MAR for September 2012 revealed the Nurse's initials were circled (to denote medication was held) on September 12, 2012, at 8:00 a.m., 2:00 p.m., and 9:00 p.m. Review of the back side of the MAR indicated [REDACTED]. Further review of the September 2012 MAR indicated [REDACTED]. Continued review of the September 2012 MAR indicated [REDACTED]. Medical record review of a Nursing Note dated September 12, 2012 at 12:20 a.m., revealed .called .(named Physician) related to medication did come from Pharmacy except [MEDICATION NAME] x10. Give as soon as they arrive from backup pharmacy. Do not hold meds. Pharmacy is out of Democlocycline 150 mg will bring in tomorrow . Continued review of Nursing Notes revealed no documentation the Physician was notified the NaCl was not delivered by Pharmacy. Further review of a Nursing Note dated September 14, 2012, with no time, revealed .ANP (Advanced Nurse Practitioner) called D/T (due to) critical NaCl at 119. Infuse 2 L (liters) NS @ 70/hr. Na level after first liter . Medical record review of an entry by the ANP dated September 14, 2012, with no time, revealed .NaCl 1 gram po TID ordered from hospital. I was notified at 1900 (7:00 p.m.) September 13, 2012, that NaCl tabs have not been given since admission. Physician ordered V8 juice 1 can TID. I was notified today (9/14/12) that V8 juice had not been given and Na level was 119. Order for NS @ 70/hr x 2L. When I arrived at facility Nurse unable to obtain access (unable to start IV) . Medical record review revealed the resident was discharged home on September 14, 2012, with orders to follow up with personal Physician. Review of facility policy, Medication Ordering and Receiving, revealed .if the medication is not available in the emergency kit or through the provider pharmacy, contact the back-up pharmacy for the medication. If the medication continues to be unavailable, contact the physician for further instructions . Interview with the Director of Nursing on April 10, 2013, at 8:30 a.m., in the Director's office, confirmed the medication was not given as ordered, the juice was not given as ordered, and the staff had failed to notify the Physician. C/O #",2016-11-01
9517,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2013-04-10,315,D,0,1,W6SO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide a toileting program for incontinence for one resident (#118) of fifty residents reviewed. The findings included: Resident #118 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Three Day Voiding Pattern Assessment Form dated November 2012 revealed the resident was always incontinent. Further review revealed incontinence program to be initiated. Medical record review of the Care Plan revealed a program for incontinence had been placed on an incontinence program. Interview with the Director of Nursing (DON) on April 10, 2013, at 1:40 p.m., confirmed the facility does not have a Bowel & Bladder program in place currently, but does have toileting and incontinence care programs. Further interview revealed the form now being used for the toileting program was not in place during this resident's admission.",2016-11-01
9518,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2013-04-10,364,E,0,1,W6SO11,"Based on observation, facility policy review, and interview, the facility failed to serve pureed vegetables at a pudding or mashed potato consistency per policy for one meal on two of three tray lines. The findings included: Observation of the tray lines in process on April 10, 2013, at 12:06 p.m., in the dietary department and at 12:44 p.m., in the Ruby Dining Room, revealed the pureed spinach covered the surface of the plate provided to the resident. Review of facility policy, Food Preparation and Presentation, effective November 18, 2005, revealed .4. Puree foods should be of the consistency of pudding or mashed potatoes and served on a regular plate . Interview with Dietary Staff #2 serving the food on April 10, 2013, at 12:44 p.m., in the Ruby Dining Room, confirmed the pureed spinach was runny. Interview with the Registered Dietitian in the Diamond Dining Room, on April 11, 2013, at 7:45 a.m., confirmed pureed vegetables should be a soft mound on the plate and not cover the surface of the plate.",2016-11-01
9519,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2013-04-10,371,E,0,1,W6SO11,"Based on observation, facility policy review, and interview, the dietary employees failed to restrain their hair during the meal service on two of three tray lines of two meals observed. The findings included: Observation on April 8, 2013, at 12:06 p.m., of the dietary department tray line in process, revealed Dietary Staff #1's bangs were not restrained under the hair covering. Observation on April 9, 2013, at 7:50 a.m., of the Diamond Dining Room tray line in process, revealed Dietary Staff #2's bangs were not restrained under the hair covering. Review of facility policy, Principles of Safe Food Handling, effective April 28, 2011, revealed .1.c. Restrain hair appropriately. Hair restraints such as hats, hair covering or nets are worn to effectively keep hair from contacting food and keep food handlers from touching their hair . Interview with the Nutrition Services Manager on April 8, 2013, at 12:15 p.m., at the dietary department tray line in process, confirmed the hair was to be totally under the hair covering.",2016-11-01
9520,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2013-04-10,372,E,0,1,W6SO11,"Based on observation and interview, the facility failed to maintain the grounds around the exterior dumpsters in a sanitary manner for one of two dumpsters. The findings included: Observation and interview with the Nutrition Services Manager, on April 8, 2013, at approximately 12:20 p.m., of the exterior facility dumpster, confirmed the grounds around one of two dumpsters had three plastic gloves and various paper debris items present.",2016-11-01
9521,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2013-04-10,441,D,0,1,W6SO11,"Based on observation and interview, the facility failed to provide sanitary handling of food. The findings included: Observation on April 8, 2013, at 12:55 p.m., in the Ruby Room dining area revealed Certified Nursing Assistant (CNA) #2 feeding a resident. continued observation revealed CNA #2 took a spoon of food and blew on it before feeding it to the resident. Interview with CNA #2 on April 8, 2013, at 1:08 p.m., confirmed CNA #2 did it without thinking and then realized what had happened.",2016-11-01
9522,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2013-04-10,514,E,0,1,W6SO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure medical records were complete and accurate for seven (#18, #59, #70, #108, #127, #141, #66) of thirty resident closed records reviewed. The findings included: Resident #18 was admitted to the facility on [DATE], and discharged on [DATE]. Medical record review of the Interdisciplinary Discharge Summary revealed the section on Final Summary of the Resident's Status was not completed. Continued review of the Discharge Summary revealed no assessment was documented by Social Services, Nursing, Activities, and Therapy. Further review of the Discharge Summary revealed the Dietary section was documented on [DATE]. Resident #59 was admitted to the facility on [DATE], and discharged on [DATE]. Medical record review of the Interdisciplinary Discharge Summary revealed the section on Final Summary of the Resident's Status was not completed. Continued review of the Discharge Summary revealed no documentation by Social Services, Nursing, Activities, and Therapy. Further review of the Discharge Summary revealed the dietary section was documented on [DATE]. Resident #70 was admitted to the facility on [DATE]. Medical record review of the Interdisciplinary Discharge Summary revealed no date of discharge, reason for admission, progress, and reason for discharge were documented. Continued review of the Discharge Summary revealed the section on Final Summary of Resident's Status was not completed. Further review of the Discharge Summary revealed no documentation by Social Services, Nursing, Activities, and Therapy. Continued review of the Discharge Summary revealed the dietary section was documented on [DATE]. Resident #108 was admitted to the facility on [DATE]. Medical record review of the Interdisciplinary Discharge Summary revealed no date of discharge, no progress, or no reason for discharge were documented. Continued review of the Discharge Summary revealed the section on Final Summary of the Resident's Status was not completed by Social Services; Nursing section was incomplete and dated [DATE]; Dietary section was documented on [DATE]. 2013. Further review of the Discharge summary revealed there was no documentation from Activities and Therapy. Resident #127 was admitted to the facility on [DATE], and discharged on [DATE]. Review of the Interdisciplinary Discharge Summary revealed the section on Final Summary of the Resident's Status was not completed. Continued review of the Discharge Summary revealed no documentation by Social Services, Nursing, Activities, and Therapy. Further review of the Discharge Summary revealed the dietary section was documented on [DATE]. Resident #141 was admitted to the facility on [DATE] and discharged on [DATE]. Medical record review of the Interdisciplinary Discharge Summary revealed the section on Final Summary of the Resident's Status was not completed. Continued review of the Discharge Summary revealed no documentation by Social Services, Nursing, Activities, and Therapy. Further review of the Discharge Summary revealed the dietary section was documented on [DATE]. Interview with the Director of Nursing on [DATE], at 9:00 a.m., in the Director's office, confirmed the discharge summary was incomplete for these residents. Resident #66 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Medical record review of the Interdisciplinary Discharge Summary dated February 10, 2013, revealed .reason for discharge .expired .vital signs at time of discharge .temp 97, pulse 74, resp 26, B/P ,[DATE] . Interview with the Director of Nursing (DON) on [DATE], at 2:30 p.m., in the DON's office, confirmed the resident should not have vital signs if had expired.",2016-11-01
9903,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2013-09-16,425,D,1,0,FIKF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide pharmacy services for three residents (#5, #6, #10) of twelve residents reviewed. The findings included: Resident #5 was admitted to the facility on [DATE], and readmitted [DATE], with [DIAGNOSES REDACTED]. Medical record review of readmission physician's orders [REDACTED]. Medical record review of the Medication Administration Records (MARS) dated August 2013 revealed no medications were administered on August 9, 2013. Medical record review of a Physician's Telephone Order dated August 10, 2013, revealed .Hold meds (medications) that are not available at this time - Resume meds when they arrive from pharmacy may (change) med times if necessary . Medical record review of a Physician's Telephone order dated August 11, 2013, revealed .All meds arrived along with box of Exelon Patches - meds resumed . Interview with the Director of Nursing (DON) on September 10, 2013, at 10:45 a.m., in the DON's office revealed the facility had a change in pharmacy providers in August and the resident's medication ordered on August 9, 2013, did not arrive until August 11, 2013. Continued interview revealed the resident missed two doses of Norco 10-325 mg, two doses of Seroquel 50 mg, and two Exelon Patches 4.6 mg/hr. Further interview confirmed the facility had failed to provide pharmacy services. Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of an Interim Care Plan dated August 21, 2013, revealed .Comfort Care .at risk for pain . Medical record review of a Physician's Telephone Order dated August 22, 2013, at 7:00 p.m., revealed .Roxanol (pain) 2.5 ml (milliliter) Q (every) 1 (hour) prn (as needed) Air Hunger, SOB (shortness of breath), pain . Medical record review of a Nurse's Note dated August 22, 2013, at 7:45 p.m., revealed .went into med select to obtain Roxanol. Med select stated insufficient quantity - call placed to back up pharmacy to (check) on situation awaiting return call . Medical record review of a Nurse's Note written by Licensed Practical Nurse #1 (LPN #1) dated August 22, 2013, at 8:10 p.m., revealed .Call received from pharmacy re (regarding) meds (medications) . Interview with LPN #1 on September 10, 2013, at 10:08 a.m., in the DON's office revealed the pharmacy informed LPN #1 the Roxanol would not be available for two hours. Continued interview revealed the DON had been notified and the Roxanol had been borrowed from another resident. Interview with the DON on September 9, 2013, at 4:00 p.m., in the Conference Room revealed the pharmacy had informed the facility the Roxanol would not be delivered for two hours. Continued interview revealed the resident had been in pain and the DON instructed the nurse to borrow the pain medication. Further interview confirmed the facility had failed to provide pharmacy services. Resident #10 was admitted to the facility on [DATE], at 2:30 p.m., with [DIAGNOSES REDACTED]. Medical record review of the Interim Care Plan dated September 2, 2013, revealed .Surgical wound abdomen, pain meds as ordered, diabetic, and colostomy . Medical record review of the admission Physician order [REDACTED].Heparin 5000 units subcutaneously (SQ) every 8 hours for DVT (Deep Vein Thrombosis) prophylaxis .Metoprolol (blood pressure) 25 mg (milligram) by mouth every 8 hours . Medical record review of the Medication Administration Records dated August 2013 revealed no documentation Heparin 5000 units SQ, and the Metoprolol 25 mg had been given on August 28, 2013. Interview with LPN #2 on September 10, 2013, at 7:30 a.m., at the nurse's station revealed Metoprolol and Heparin had not been administered to the resident on the evening of August 28, 2013. Continued interview revealed LPN #2 had been waiting on approval and clarification of the orders and the medications had not arrived to the facility before the nurse's shift ended. Interview with the DON on September 10, 2013, at 9:05 a.m., in the DON's office confirmed the facility had failed to provide pharmacy services. C/O #",2016-09-01
9904,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2013-09-16,514,D,1,0,FIKF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to document administration of pain medication for one resident (#6) of twelve residents reviewed. The findings included: Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of an Interim Care Plan dated August 21, 2013, revealed .Comfort Care .at risk for pain . Medical record review of a Physician's Telephone Order dated August 22, 2013, at 7:00 p.m., revealed .[MEDICATION NAME] (pain) 2.5 ml (milliliter) Q (every) 1 (hour) prn (as needed) Air Hunger, SOB (shortness of breath), pain . Medical record review of a Nurse's Note dated August 22, 2013, at 7:45 p.m., revealed .went into med select to obtain [MEDICATION NAME]. Med select stated insufficient quantity - call placed to back up pharmacy to (check) on situation awaiting return call . Medical record review of a Nurse's Note dated August 22, 2013, at 8:10 p.m., revealed .Call received from pharmacy re (regarding) meds (medications) . Medical record review of the Medication Administration Records dated August 2013 revealed no documentation the [MEDICATION NAME] had been administered on August 22, 2013. Interview with Licensed Practical Nurse #1 on September 10, 2013, at 10:08 a.m., in the Director of Nursing (DON) office, revealed the pharmacy informed the nurse the [MEDICATION NAME] would not be available for two hours. Continued interview revealed the DON had been notified and the [MEDICATION NAME] had been borrowed from another resident and administered to Resident #6. Further interview confirmed the [MEDICATION NAME] had not been documented as given in Resident #6's medical record. Interview with the DON on September 9, 2013, at 4:00 p.m., in the Conference Room revealed the pharmacy had informed the facility the [MEDICATION NAME] would not be delivered for two hours. Continued interview revealed the resident had been in pain and the DON instructed the nurse to borrow the pain medication from another resident. Further interview confirmed the facility failed to document the administration of the [MEDICATION NAME] to the resident. C/O #",2016-09-01
11728,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2011-08-10,157,D,0,1,BKKQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, and interview, the facility failed to notify the physician of a change in behavior for one resident (# 19) of twenty-one residents reviewed. The findings included: Resident #19 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a nurse's note dated May 7, 2011, revealed, .discovered an oral thermometer probe cover inserted into.penis.box of probe covers discovered at bedside. Medical record review of the facility policy for Resident Exhibiting Challenging Behaviors revealed, .notification of physician of behavior symptoms. Interview with the Assistant Director of Nursing (ADON) in the Director of Nursing office on August 10, 2011, at 2:30 p.m., verified the self-inflicted behavior was a change for resident #19; and confirmed the facility failed to notify the physician of a change in behavior. complaint #",2015-11-01
11729,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2011-08-10,250,D,0,1,BKKQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, and interview, the facility failed to timely obtain mental health services after a self-inflicted behavior had developed for one resident (# 19), of twenty-one residents reviewed. The findings included: Resident #19 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a nurse's note dated May 7, 2011, revealed, .discovered an oral thermometer probe cover inserted into.penis.box of probe covers discovered at bedside. Medical record review of the Nurse Practitioner's note dated June 8, 2011 revealed Staff request consult d/t (due to) recent incident 6/6/11 in which tech (technician) caught resident sticking thermometer inside his urethra, which has happened on a previous occasion. Patient has also had prior incidents of inappropriate sexual remarks toward staff and fondling other residents, though specific incidents are not charted. Medical record review revealed a physician's telephone order, dated June 9, 2011 stating, Refer to psychologist for counseling r/t (related to) inappropriate sexual behaviors. Medical record review of the facility policy # PRO for Resident Exhibiting Challenging Behaviors revealed, 8. Notifify mental health professional. Interview with the Social Services Director on August 10, 2011, at 1:30 p.m., in the dining area, confirmed the facility delayed in obtaining mental health services for the resident. complaint #",2015-11-01
11730,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2011-08-10,279,D,0,1,BKKQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review and interview, the facility failed to update the care plan to reflect a change in behavior for one resident (#19) of twenty-one residents reviewed. The findings included: Resident #19 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a nurse's note dated May 7, 2011, revealed, .discovered an oral thermometer probe cover inserted into.penis.box of probe covers discovered at bedside. Medical record review of the facility policy for Resident Exhibiting Challenging Behaviors revealed, .update care plan. Interview and medical record review with the Assistant Director of Nursing (ADON) in the conference room on August 10, 2011, at 5:05 p.m., confirmed the care plan had not been updated to reflect the change in behavior. complaint #",2015-11-01
11731,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2011-08-10,281,D,0,1,BKKQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to obtain oxygen saturations as ordered by the physician for one (#16) and the facility failed to ensure medications were secure for one resident (#12) of twenty-one residents reviewed. The findings included: Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED]. Interview with the Director of Nursing (DON) in the conference room on August 8, 2011, at 1:15 p.m., revealed the nurses work 8 hour shifts (three shifts per 24 hours). Medical record review revealed no documentation of a recorded oxygen saturation level after July 29, 2011. Observation on August 9, 2011, at 3:45 p.m., revealed the resident in the room receiving physical therapy while sitting upright in a gerichair. Observation revealed the resident was receiving humidified oxygen at 35% [MEDICAL CONDITION]; and had a [MEDICAL CONDITION] secured by a neck collar via Velcro straps. Medical record review and interview with the Director of Nursing in the DON's office on August 10, 2011, at 9:15 a.m., confirmed the facility failed to obtain and document an oxygen saturation level from July 29 until August 10, 2011; a period of 11 days. Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation on August 9, 2011, at 8:35 a.m., in the resident's room, revealed Licensed Practical Nurse (LPN) #2 crushed a multivitamin and a B-1 vitamin, placed the medications into separate plastic souffle cups, and walked into the resident's room to administer the medications. Continued observation revealed LPN # 2 placed the plastic souffle cups on the resident's over bed table, walked into the resident's bathroom and then walked outside the resident's room down the hallway to wash the hands, leaving the medications out of the eyesight of the LPN. Interview with LPN #2 outside the resident's room, on August 9, 2011 at 8:42 a.m., confirmed the LPN left the medications at the bedside and exited the room, leaving the medications unsupervised.",2015-11-01
11732,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2011-08-10,322,D,0,1,BKKQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, facility policy review and interview, the facility failed to ensure staff raised the head of bed for prevention of aspiration for one (#12) resident receiving a tube feeding, of twenty-one residents reviewed. The findings included: Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Review of the facility's Enteral Feeding Administration policy revealed, .Elevate the head of the bed 30-45 degree angle during feeding. Observation on August 9, 2011, at 8:35 a.m., in the resident room, revealed resident #12 lying flat in bed. Continued observation revealed Licensed Practical Nurse (LPN #2) administered the enteral feeding to the resident via the nasogastric tube (tube from nose to stomach). Observation revealed, LPN #2 placed a 60 ml syringe into the NG tube and administered the complete volume of enteral feeding fluid into the NG tube. Continued observation revealed the LPN failed to elevate the head of the bed 30-45 degrees. Interview with LPN #2 outside the resident's room, on August 9, 2011 at 8:42 a.m., confirmed the HOB was not elevated during the tube feeding and not for 30-45 minutes after the feeding for the prevention of aspiration.",2015-11-01
11733,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2011-08-10,323,D,0,1,BKKQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a facility investigation, observation, and interview, the facility failed to ensure a safety device was in place for one (#14) of twenty-one residents reviewed. The findings included: Resident #14 was admitted to the facility on [DATE], with History of Osteoporosis, Congestive Heart Failure, Diabetes Mellitus, L1-L2 Fracture with Vertebroplasty, and Dementia. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had severe cognitive impairment; required extensive assistance with one person physical assist for mobility, transferring, ambulating in the room, dressing, toileting, personal hygiene and bathing. Further review revealed the resident had experienced a fall both with and without injury. Medical record review of the admission nursing assessment dated [DATE], revealed the resident was at high risk for falls. Medical record review and review of a facility investigation, revealed the resident fell on [DATE], resulting in a skin tear; was discharge from physical therapy; and was referred to restorative nursing care. Medical record review revealed on April 27, 2011, the resident was found on the floor in front of the wheelchair, with a complaint of right hip pain. Further review revealed the immediate intervention was to add a personal tab alarm when in bed and wheelchair. Review of the x-ray dated April 27, 2011, revealed .chronic healed proximal right femur fracture status [REDACTED]. Medical record review of the care plan initiated on March 18, 2011, revealed a problem of a.history of falls with hip fracture, cognitive deficits, decreased physical mobility r/t (related to).balance/gait are unsteady.attempt to transfer and ambulate unassisted. Further review revealed an approach added on May 12, 2011,.personal tab alarm on.bed and.wheelchair. Observation on August 10, 2011, at 8:30 a.m., revealed the resident in bed eating breakfast. Further observation revealed no alarm was present and no alarm was attached to the resident in the bed. Interview with Certified Nurse Aide (CNA) #1 on August 10, 2011 at 10:00 a.m., in the resident's room, revealed the CNA had transferred the resident from the bed to the wheelchair this morning. Further interview confirmed the resident did not have an alarm on the bed or attached to the resident when the resident was in the bed prior to the transfer. Interview with the Licensed Practical Nurse Case Manager on August 10, 2011 at 10:48 a.m., in the conference room, confirmed the resident was care-planned to have a personal tab alarm when in bed and while in the wheelchair. Continued interview confirmed the facility failed to ensure the safety device was in place.",2015-11-01
11734,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2011-08-10,328,D,0,1,BKKQ11,"**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 ensure staff performed sterile tracheal suctioning for one (#16) of twenty-one residents reviewed. The findings included: Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation on August 9, 2011, at 3:45 p.m., revealed the resident sitting upright in a gerichair. Observation revealed the resident was receiving humidified oxygen at 35% [MEDICAL CONDITION]; and had a [MEDICAL CONDITION] with a Tracheal tube secured by a neck collar via Velcro straps. Observation revealed the resident moved head from left to right and mouthed no when asked are you okay? The resident's cough indicated secretions were loose. Observation revealed Licensed Practical Nurse (LPN #1) was in the room and stated, I will suction (the resident). The LPN #1 donned unsterile gloves and picked up the [MEDICATION NAME] (suction device used to remove mucus from the mouth) which was attached to the resident's gown, and inserted the [MEDICATION NAME] into the tracheal tube until resistance was met (3/4 of an inch); and applied suction to remove a small amount of secretions. Observation revealed the LPN #1 put the [MEDICATION NAME] in a cup of water to clear the secretions, and replaced the [MEDICATION NAME] on the resident's gown. Interview with LPN #1 outside the resident's room on August 9, 2011, at 4:12 p.m., revealed the resident independently used the [MEDICATION NAME] to remove the secretions from the oral cavity. Review of the facility policy number PRO titled [MEDICAL CONDITION] Care, revealed a sterile suction catheter kit (containing sterile gloves, sterile water, and sterile catheter) was required for suctioning, and the procedure was to be performed in a sterile manner. Interview with the Director of Nursing (DON) in the DON's office on August 9, 2011, at 5:10 p.m., verified the [MEDICATION NAME] suction was to be used for oral secretions (not for tracheal suctioning), and confirmed the facility policy was for the LPN to use a sterile suction catheter that would fit into the tracheal tube to allow for appropriate, deeper suctioning.",2015-11-01
11735,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2011-08-10,371,F,0,1,BKKQ11,"Based on observation, review of chemical sanitizer recommendation for the three compartment sink, and interview, the facility dietary department failed to sanitize pots, pans and utensils per the manufacturer's recommendations and failed to maintain sanitary dietary equipment. The findings included: Observation on August 8, 2011, beginning at 10:50 a.m., with the Registered Dietitian present, revealed the following: 1. The three compartment sink was in operation. Further observation revealed cooking and portion control serving utensils in the sanitizer sink and dietary items on the drain board. Further observation revealed the dietary staff member checking the sanitizer level. Further observation revealed the quaternary test strip did not change colors (indicating insufficient level of sanitizer). 2. The four burner range top, spill pan, and back splash had a heavy accumulation of sticky, blackened debris. Observation on August 9, 2011, at 7:48 a.m., with the Registered Dietitian, confirmed the range top, spill pan and back splash had a heavy accumulation of sticky, blackened debris. Review of the three compartment sink poster for sanitizer level recommendation revealed the quaternary chemical sanitizer level was 150 to 400 parts per million. Interview, with the Registered Dietitian in the dietary department on August 8, 2011 at 10:50 a.m., and on August 9, 2011, at 7:48 a.m., confirmed the quaternary test strip did not change color indicating the sanitizer level was less than 150 parts per million for sanitizing equipment. Further interview confirmed the facility failed to maintain the dietary department/equipment in a sanitary manner.",2015-11-01
11736,SIGNATURE HEALTHCARE OF MADISON,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2011-08-10,514,D,0,1,BKKQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, and interview, the facility failed to have accurate medical records for two (#2, #18) of twenty-one residents reviewed. The findings included: Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the pharmacy recommendation dated June 3, 2011, revealed .resident followed by hospice has monthly [MEDICATION NAME] ordered.indicate if you wish to continue monthly-or-schedule with other lab work ordered q6M (every six months). Further review revealed the physician agreed with the recommendation with the notation q 6 months dated June 21, 2011. Review of the physician phone order dated June 21, 2011, revealed clarification order-it is recommended for [MEDICATION NAME] order to be drawn q 6 (hour) (hospice resident). Review of the July 2011 Recapitulation Physician Order signed by a facility nurse on June 29, 2011, and signed by the physician on July 11, 2011, revealed [MEDICATION NAME] level monthly. Interview with the Director of Nursing on August 9, 2011, at 2:25 p.m. at the north nursing station, confirmed the June 21, 2011, physician agreement with the pharmacy recommendation did not match the June 21, 2011, phone order. Continued interview confirmed the July 2011 Recapitulation Physician Order did not reflect the change from monthly to every six month [MEDICATION NAME] level. Resident #18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed the resident was discharged to home on June 10, 2011, with home health. Medical record review revealed the Discharge Summary was not completed; and not signed by the physician. Review of the facility policy Closing a Medical Record revealed .resident's medical record is completed and closed within 30 days after discharge.17. Obtain the signatures of both the Administrator and Medical Director on the (discharge) summary.19. Review the discharge summary completed by the attending physician for the discharge diagnoses. Interview with the District Director of Clinical Operation on August 9, 2011, at 9:50 a.m., in the conference room, confirmed the physician failed to complete and failed to sign the discharge summary.",2015-11-01
12371,SIGNATURE HEALTHCARE AT LARKIN SPRINGS,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2012-07-24,425,E,1,0,GIT811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review,medication/drug destruction logs, medical record review, observation, and interview, the facility failed to ensure that discontinued, expired controlled medications and control medications for discharged residents were destroyed monthly per facility policy, failed to ensure medications were available to meet the needs of three (#1, #2, #6) and one (Random Resident (RR) #6) of sixteen residents reviewed and failed to ensure controlled reconciliation for 1 (RR #6)of sixteen residents reviewed. The findings included: Review of facility policy, Medication Destruction, dated August 31, 2011 revealed ""...Discontinued medications and medications left in the Center after a resident's discharge which do not qualify for return to the pharmacy for credit, are destroyed routinely (e.g. (for example), at least monthly, unless destruction is required more frequently...)"" Review of the Medication/Drug Destruction Logs revealed controlled medications that were expired or belonged to discharged residents were destroyed on March 5, 2012, May 3, 2012, and June 5, 2012. Observation of a locked safe located in the Director of Nurses' (DON) office, under the DON's desk on July 11, 2012, at 10:45 AM, with the DON present, revealed the safe contained the following: Forty Cards of multiple dose controlled drugs of various strength and various number of tablets/capsules per card that included: Oxycontin - four cards, Ambien - two cards, Ativan - six cards, Lortab - ten cards, Hydromorphone - one card, Norco - two cards, Klonpin - four cards, MS Contin - two cards, Valium - two cards, Xanax - three cards, Marinol - one card, Ultram - one card and Percocet - one card. Nine prescription 30 milliliter (ml) bottles of liquid Morphine. One prescription 30 ml bottle of liquid Lorazapem. Three Fentanyl Patches. Ten prescription bottles containing controlled drugs from at least three different Pharmacies. Medical Record review revealed the following residents were discharged from the facility before the last medication destruction on June 5, 2012 and controlled drugs belonging to them were in the safe in the DON's office: Resident #5 - discharged [DATE] - Hydrocodone/APAP (acetaminophen) 5 milligrams (mg)/325 mg tablets, 3 tablets in the safe. Hydrocodone/APAP 10 mg/325 mg tablets, 3 tablets in the safe. Hydrocodone/APAP 7.5 mg/325 mg tablets, 6 tablets in the safe. Random Resident (RR) #1 discharged [DATE] - Oxycodone 10 mg/235 mg, 5- ? 10 mg tablets in the safe. RR #2 - deceased [DATE] - Morphine Sulfate 100 mg/5 ml, 30 ml bottle, 18 ml in the safe RR #3 - deceased [DATE] - Lorazepam solution 2 mg/2 ml, 30 ml bottle, 8 ml in the safe. Morphine Sulfate solution 100 mg/5 ml 30 ml bottle, in the safe. RR #4 - deceased [DATE] - Morphine Sulfate solution 20 mg/ml, 30 ml bottle, 24 ml in the safe. RR #7 - deceased [DATE] - Ativan/Haloperidal Gel - 10 doses in the safe. RR #8 - unable to determine discharge date . Lorazepam 1 mg tablets - 9 tablets in the safe. (Observation of the prescription medication bottle revealed 10 Lorazepam tablets were dispensed 7/23/10). RR #9 - deceased [DATE] - Morphine Sulfate 100 mg/5 ml 30 ml bottle - 11 ml in the safe. Lorazepam 1 mg tablets- 8 tablets in the safe. Interview with Licensed Practical Nurse (LPN) #1 on July 11, 2012, at 8:45 a.m., on the North Hall, revealed LPN #1 stated ""Expired narcotics are given to (named DON). We (floor nurses) don't destroy medications."" Interview with LPN #8 on July 11, 2012, at 8:58 a.m., on the East Hall, revealed LPN #8 stated ""I take the card (medication card) and the narcotic Count Sheet to the Director of Nursing."" Interview with LPN #10 on July 11, 2012, at 9:25 a.m., on the South Hall, revealed LPN #10 stated ""The DON will remove the narcotics and sign out on the Narcotic Sheet."" Interview with the DON on July 11, 2012, at 10:45 a.m., in the DON's office, revealed the DON was asked what happened to the narcotics collected from the nurses; the DON responded ""I log them on the Pharmacy Sheet. Take the labels off the medication and put it on the sheet (destruction sheet). (Named Pharmacist and I destroy together every other month."" Interview with the Consultant Pharmacist on July 11, 2012, at 11:50 a.m., in the conference room, revealed the Pharmacist stated ""We destroy narcotics every other month here (facility)...I don't know the reason (why narcotics are not destroyed monthly). I am available every month. The facility let me know when they want drug destruction. I've never checked the safe, I just destroy what the DON gives me to destroy."" Interview with the DON on July 11, 2012, at 5:30 p.m., in the conference room, confirmed the DON stated ""They were putting medication in the safe when I arrived (started as DON) and started during drug destruction. I knew old drugs were there, I just didn't destroy them."" Resident #1 was admitted to the facility from the hospital following a hospital stay for a Right intertrochanteric fracture on May 23, 2012, with [DIAGNOSES REDACTED]. Review of the hospital's discharge medications dated May 23, 2012, revealed ""Lanoxin 0.25 mg daily (given for heart failure and atrial fibrilation), Cardizem 60 mg every 6 hours (given for elevated blood pressure) and Lovenox (given to prevent developement of blood clots in persons with irregular heart beat) 30mg SQ (subcutaneous) Q 12 (symbol for hours)."" There was no documentation when or if these medications were given in the hospital prior to discharge. Review of the facility's admission orders [REDACTED]."" Review of a Physician Telephone Order dated May 23, 2012, at 1800 (6:00 p.m.), revealed for ""Xanax 1mg PO HS (at bedtime) (symbol for times) 1 tonight and Hydrocodone/APAP 7.5/325 PO TID (three times a day). Record review of the Nurses' Admit Note revealed Resident #1 was admitted to the facility on [DATE] at 19:30 (7:30 p.m.), an hour and a half after the new physician's orders [REDACTED]. Review of the Medication Record (MAR) for Resident #1 revealed the following: Digoxin 0.5 mg due to be given at 9:00 a.m., on May 24, 2012, was not documented as given. The Cardizem 60 mg due to be given at 2400 (12:00 a.m.), 0600 (6:00 a.m.), 1200 (Noon) and 1800 (6:00 p.m.) on May 24, 2012, was documented as given only at 6:00 a.m., on May 24, 2012. The Lovenox 30mg was to be given on May 23, 2012 at 2100 (9:00 p.m.), 0900 (9:00 a.m.) and 2100 (9:00 p.m.) on May 24, 2012, was documented given only at 0900 on May 24, 2012. Review of the Nurses Medication Notes for May 24, 2012, revealed the Digoxin and Lovenox due at 9:00 a.m., and the Cardizem due at 12:00 a.m. and 12:00 p.m. was listed as ""on order."" Review of the Pharmacy Shipping Manifest documented the Digoxin, Lovenox and Cardizem left the pharmacy on May 24, 2012, at 18:51 (6:51 p.m.). There was no documentation that the physician was notified of Resident's #1 missed medications or that the facility attempted to contact the pharmacy to ensure that the Resident's medications were available as ordered. Medical record review revealed Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #2's Controlled Drug Record for Oxycodone-Acetaminophen 5/325 milligrams (mg) tablets for June 13 to June 18, 2012, revealed seven ( two on June 15, three on June 17 and two on June 18) of thirty tablets, delivered on June 13, 2012, were borrowed for Resident #6. Resident #6 was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #6's Controlled Drug Record for Oxycodone-Acetaminophen 5/325 (mg) tablets for May 28 to June 13, 2012, revealed nine (two on May 26, two on May 30, two on June 2, two on June 12 and three on June 13) of thirty tablets delivered on May 27, 2012, were borrowed for Resident #2. Random Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RR #6 expired on February 7, 2012. Review of RR #6's Controlled Drug Records for Oxycodone-Acetaminophen 5/500 (mg) tablets for November 5, 2011 to December 2, 2012, revealed three tablets were borrowed (one on November 6, one on November 7 and one on Novemeber 9), for other residents, of the thirty tablets delivered on November 5, 2012. Review of RR #6's MAR indicated [REDACTED]. An empty Ziploc bag labeled by the Pharmacy with RR #6's name on it was found in the DON's safe. The pharmacy label, dated January 31, 2012, documented the bag had contained Morphine Sulfate (Roxanol) 100 mg/5 ml - one 30 ml bottle. The facility could not find a controlled drug record for the Morphine nor could it produce a record of drug destruction indicating the drug was destroyed. Review of the Quarterly Pharmacy Report dated December 11, 2011, revealed under Narcotic Audit ""Some evidence of borrowing."" Interview with the Consultant Pharmacist in the conference room, on July 11, 2012, at 11:50, revealed the Pharmacist stated ""I look for evidence of borrowing, it's usually written on the Controlled Drug Sheet. I do quarterly audits and then do a summary of my findings."" Interview with the DON on July 12, 2012, at 5:45 p.m., in the conference room, confirmed the DON stated ""I expect for nurses to call (the pharmacy) and make sure medications are here for the residents. I don't know why they would just circle it as not given and not tell anyone."" Interview with the DON on July 13, 2012, at 9:37 a.m., in the conference room, confirmed the DON stated: ""I don't know where they (nurses) got the Roxanol (given to Resident #1) from before the pharmacy delivered it for (resident)."" Interview with LPN #4 on July 12, 2012, at 11:34 a.m., in the conference room, revealed LPN #4 stated: ""I was told to borrow medications if I needed to and to replace it when the medications come (from the pharmacy). I would go to the box (emergency box) first. I saw other staff borrow medications from others (residents)."" Interview with the Administrator and Corporate Regional Nurse on July 13, 2011, at 5:10 p.m., in the conference room, confirmed when asked about the policy on drug borrowing, the Regional Nurse stated ""We don't. That is our policy, so there is no written policy for it."" C/O #",2015-08-01
13760,MADISON HEALTHCARE AND REHABILITATION CENTER,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2010-07-15,248,D,0,1,9GDN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to provide assistance needed to attend activites, for one resident (#5), of twenty residents reviewed. The findings included: Resident #5 was admitted to the facility, on August 12, 2009, with [DIAGNOSES REDACTED]. Medical record review of the care plan dated June 30, 2010, revealed ""...observe for resident up in electric wheelchair and encourage participation in special events and activities of interest such as bingo...Coordinate with nursing for resident to be up and ready for Friday morning Bingo..."" Medical record review of a Social Services note dated June 23, 2010, revealed ""...upset that (resident) can't be up for preferred activities somedays...This has been dealt with so (resident) can be up when (resident) wants to."" Interview with the resident on July 13, 2010, at 2:00 pm, in the resident's room, revealed the resident wanted to attend the Bingo games at 10:00 a.m., on Saturday, Monday, and Friday. Continued interview with the resident revealed the resident had been rarely able to attend the bingo games related to staff not getting the resident dressed and transferred to the power wheelchair by 10:00 a.m., to participate on the mornings of the scheduled bingo. Interview with the Activity Director, in the activities room, on July 14, 2010, at 1:45 p.m., revealed bingo games were scheduled at 10:00 a.m., on Mondays, Fridays, and most Saturdays. Continued interview with the activity director confirmed the resident did like to attend bingo games, but required staff to dress and transfer the resident into the power wheelchair. Further interview with the activity director confirmed the resident was able to drive the chair independently to the bingo game. Interview with the activity director confirmed since June 23, 2010, the resident had attended the bingo games only one time (July 2, 2010).",2014-09-01
13761,MADISON HEALTHCARE AND REHABILITATION CENTER,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2010-07-15,371,F,0,1,9GDN11,"Based on observation and interview, the facility failed to maintain kitchen equipment in a sanitary manner; failed to maintain resident tray line food at or above 140 degrees Fahrenheit (F); and failed to sanitize dishes processed through the dish machine. The findings included: Observation on July 13, 2010, beginning at 10:28 a.m., and 3:45 p.m., of the dietary department equipment revealed the following: 1.) The can opener blade and slot had a build-up of dried and sticky debris. The can opener base was not attached flush to the table top and had a build-up of dried and greasy debris on the underside of the base and the table surface. 2.) The slicer was covered with a plastic bag. Further observation revealed the slicer had dried debris attached to both sides of the blade. The food slide had a black greasy smear. The food holder attachment and cleats had dried particles attached. 3.) The range top, burners and back-splash had a thick accumulation of blackened debris. The range spill pan had a deep layer of dried, burnt food debris including a heavy accumulation of black debris on the surface of the foil lining and the surface of the spill pan. 4.) The reach-in refrigerator, with built-in racks, containing tray line food items and produce had an accumulation of debris built-up on the floor of the refrigeration unit. Interview, with the Dietary Manager, present during the above observations on July 13, 2010, beginning at 10:28 a.m., and 3:45 p.m., confirmed the can opener blade, slot and underside of the base and table surface had dried, sticky, and greasy debris present. Further interview revealed the slicer was covered with plastic because it was clean and ready to use. Further interview confirmed both sides of the slicer had dried debris attached to the blade. Continued interview confirmed the slicer food slide had a black greasy smear and the food holder attachment and cleats had dried particles attached. Continued interview confirmed the range top, burners and back-splash had a thick accumulation of blackened debris. Further interview confirmed the range spill pan had a deep layer of dried, burnt food debris including a heavy accumulation of black debris on the surface of the foil and the surface of the spill pan. Further interview confirmed the reach-in refrigerator, with built-in racks, had an accumulation of debris on the unit floor. Observation on July 14, 2010, at 11:34 a.m., in the Ruby Room dining room revealed the dietary cook obtaining the food temperatures. Observation revealed the chicken livers in gravy were 130 degrees F, potato wedges were 140 degrees F, pureed potatoes and pureed meat were 120 degrees F. The food items were removed at 11:43 a.m. to be reheated in the main kitchen. Observation on July 14, 2010, at 11:54 a.m., revealed the food items placed back in the Ruby Room dining room steam table. Observation revealed the dietary cook obtaining the following temperatures: potato wedges and pureed meat were 120 degrees F. Further observation revealed two steam table wells were set on 4 and the center well was set on 5 of 7 levels (7 being the hottest setting). Further observation revealed the wells and burners were not hot to the touch. Observation on July 14, 2010, at 12:05 p.m., revealed the Maintenance Director checking the operational status of the steam table in the Ruby Room dining room. Interview, with the Dietary Manager, present during the obtaining of food temperatures, and the cook obtaining the temperatures, in the Ruby Room on July 14, 2010, beginning at 11:34 a.m., confirmed the chicken livers in gravy were 130 degrees F, potato wedges were 140 degrees F, pureed potatoes and pureed meat were 120 degrees F. Further interview revealed the potato wedges had been removed to be reheated because they were at the lowest acceptable temperature. Further interview confirmed the food was reheated, returned to the dining room steam table with temperatures of 120 degrees F for the potato wedges and the pureed meat. Continued interview confirmed the steam table wells were set on 4 and 5 of 7 and the wells and burners were not hot to the touch. Interview, with the Maintenance Director at 12:05 p.m., and the Administrator at 1:30 p.m., on July 14, 2010, in the Ruby Room dining room, revealed the steam table was operating properly but needed fifteen minutes to heat before food was placed in wells in order to maintain the temperature. Observation, on July 14, 2010, at 1:38 p.m., revealed the dish machine was in operation and staff were stacking dishes into storage units. Observation of the manufacturer's recommendation revealed the chlorine sanitizer was to be a minimum of 50 ppm (parts per million). Observation revealed the dietary employee working the dirty side of the machine obtained a test strip which yielded no results. Observation revealed the same employee repeating the test with a new test strip which also yielded no results. Interview, with the dietary employee obtaining the sanitizer results, on July 14, 2010, at 1:38 p.m., confirmed both test strips did not yield results. Further interview revealed this employee ""had ruined a vial of test strips about three days ago and had not tested the dish machine in those three days."" Further interview revealed this employee had not informed the Dietary Manager of the the ""ruined strips."" Continued interview revealed the dish machine temperatures and test results were to be documented three times daily, with every meal cycle. Interview, with the Dietary Manager, present during the dish machine operation observations, on July 14, 2010, at 1:38 p.m., confirmed the test strips revealed no results indicating no sanitizer in the sanitizer cycle of the dish machine operation. Further interview confirmed there were no dish machine log documentation of the wash and rinse temperatures or the test strip results. Interview, with the Maintenance Director, on July 14, 2010, at 1:40 p.m., revealed the dish machine sanitizer mechanism had malfunctioned and was not pumping the santizer into the machine.",2014-09-01
13762,MADISON HEALTHCARE AND REHABILITATION CENTER,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2010-07-15,281,D,1,1,9GDN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to obtain a physician's order for oxygen administration for one resident (#7) and failed to obtain and follow physician's orders for one resident (#17) of twenty residents reviewed. The findings included: Resident #7 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Resident Progress Note, dated June 1, 2010, at 12:05 a.m., revealed ""...O2 (oxygen) @ (at) 2L (liters) / (per) minute via N/C (nasal cannula)..."" Medical record review of a Resident Progress Note dated June 1, 2010, at 10:30 a.m., revealed ""...O2 conts (continuously) @ 2L pm (per minute)..."" Medical record review of a Resident Progress Note dated June 4, 2010, 10:15 a.m., revealed ""...on O2 @ 2L..."" and on June 18, 2010, 10:30 a.m., ""...on O2 @ 2L/via N/C..."" Medical record review of Physician's Orders Dated June 1, 2010, through June 30, 2010, revealed no order for oxygen administration. Observation on July 14, 2010, at 9:10 a.m., in the resident's room revealed, the resident lying in bed watching television. Continued observation revealed, an oxygen concentrator at the bedside, oxygen tubing in a plastic bag hanging from the front of the concentrator. Observation revealed the oxygen tubing was dated 7/8/10 and the concentrator was turned off. Interview with the resident on July 14, 2010, at 10:10 a.m. revealed, ""...I use it (oxygen) sometimes when I need it. They turn it on for me..."" Interview with the Director of Nursing on July 14, 2010, at 10:20 a.m., at the Nurses Station, confirmed the resident had received intermittent oxygen without physician's order. Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Resident Progress Note dated May 28, 2010, revealed ""...c/o (complaints of) Abdominal [MEDICATION NAME] was given prior to shift start...then [MEDICATION NAME] at 2100 (9:00 p.m.)-no relief-call oncall...send to ER (emergency room )..."" Medical record review of a Resident Progress Note dated June 4, 2010, revealed ""...Clarification of Entry 5/30 Pt's mother called from ER and stated...'had a prescription of [MEDICATION NAME]-and Pt (patient) was Dx (diagnosed ) (with) ulcers'...inquired about filling prescription which I stated that was not our policy and it would not take as long to fill this through us-no paperwork was sent when patient arrived from ER. No orders or prescription delivered...Pt arrived close to 5 AM..."" Medical record review of the Discharge Instructions dated May 29, 2010, from the emergency room , revealed ""[MEDICAL CONDITION] Ulcer Disease VS (versus) Gastritis...Your Prescriptions: [MEDICATION NAME] Oral Suspension 1 GM (gram)/10 ml (milliliters) 2 teaspoonsful before meals and at bedtime...Follow Up Information on 5/29/2010 this patient was treated in the Emergency Department...The patient was asked to follow up in 3 to 5 days..."" Interview on July 14, 2010, at 9:45 a.m., with the Director of Nursing, in the conference room, confirmed the order for the [MEDICATION NAME] had not been obtained by the facility and the [MEDICATION NAME] was never administered to the resident. C/O #",2014-09-01
13763,MADISON HEALTHCARE AND REHABILITATION CENTER,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2010-07-15,456,E,0,1,9GDN11,"Based on observation and interview, the facility failed to maintain a dietary department two door reach-in refrigerator in a safe operational manner. The findings included: Observations on July 13, 2010, at 10:30 a.m., and 3:45 p.m., and July 14, 2010, at 7:53 a.m., and 1:40 p.m., revealed a two door reach-in refrigerator, with built-in racks, containing tray line items and produce, had pooled water on the floor of the unit and on the rungs of the racks. Further observation revealed water on the floor of the unit was coming over the lip of the floor and coming out of the bottom of the door onto the floor in front of the unit. Interview with the Dietary Manager, present during the observation, on July 13, 2010, at 10:30 a.m., confirmed the two door reach-in refrigerator, with built-in racks, containing tray line items and produce, had pooled water on the floor of the unit and on the rungs of the racks and had water coming out of the door onto the floor. Further interview revealed the maintenance staff had worked on it prior and the problem was condensation build-up. Interview with the Maintenance Director, on July, 13, 2010, at 3:45 p.m., and July 14, 2010, at 1:38 p.m., in front of the two door reach-in refrigerator, with built-in racks, containing tray line items and produce, confirmed the unit was not processing the condensation and the condensation was building up and pooling on the floor and rungs.",2014-09-01
13764,MADISON HEALTHCARE AND REHABILITATION CENTER,445075,431 LARKIN SPRING RD,MADISON,TN,37115,2010-07-15,514,D,1,1,9GDN11,"**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 complete documentation in the medical record for one resident (#17) of twenty residents reviewed. The findings included: Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician's admission orders [REDACTED]""[MEDICATION NAME]...10mg po qd... "" Medical record review of the Medication Record dated May 1, 2010, through May 31, 2010, revealed the 9:00 a.m., doses of [MEDICATION NAME] 10 mg po on May 29, 30, and 31, blank as not administered. Medical record review of the Nurse's Medication Notes (back of medication record) dated May 1, 2010, through May 31, 2010, revealed no documentation related to the administration of the Clairitin. Medical record review of the Medication Record dated June 1, 2010, through June 30, 2010, revealed the 9:00 a.m., doses of [MEDICATION NAME] 10 mg po qd on June 4, 5, 6, and 12, 2010, circled as not administered, the 9:00 a.m. doses of [MEDICATION NAME] 10mg po qd on June 8, 2010, and June 10, 2010, blank as not administered. Medical record review of the Nurse's Medication Notes (back of medication record) revealed no documentation why the [MEDICATION NAME] was circled as not administered on June 4, 5, 6, and 12, 2010. Medical record review of a Resident Progess Note dated May 28, 2010, revealed, ""...Resident c/o nausea...given [MEDICATION NAME] 4mg (with) good [MEDICATION NAME] (at) 2100 (9:00 p.m.)..."" Medical record review of the Medicaton Record dated May 28, 2010, revealed no documentation the [MEDICATION NAME] or [MEDICATION NAME] was administered. Medical record review of the Flow Sheet Record dated June 1, 2010, through June 30, 2010, revealed, ""...Showers 2 x's per week Q (every) Sat (Saturday)..."" Medical record review of the Flow Sheet Record dated June 1, 2010, through June 30, 2010, revealed no documentation on Saturday, June 12, 2010, a shower had been given. Review of facility policy, Medication Administration, revealed ""...Documentation on the resident's MAR (medication administration record) by...the person administering the medication in the space provided under the date and on the line for that specific medication dose administered...if PRN (as needed) medication is administered, initial space provided and on the back of MAR...Document date, time of administration, dose, route...Document withheld, refused...by circling initialed space and providing an explanation of the reverse side of MAR..."" Interview on July 15, 2010, at 8:00 a.m., in the conference room, with the Director of Nursing, confirmed the documentation was not complete on the Medication Record or the flow sheet record. C/O #",2014-09-01
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
3592,"NHC HEALTHCARE, MCMINNVILLE",445076,928 OLD SMITHVILLE RD,MC MINNVILLE,TN,37110,2017-04-19,312,D,1,0,VHKY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, facility documentation, observation, and interview, the facility failed to provide assistance for toileting for 1 resident (#31) of 2 residents reviewed for incontinence care of 28 residents sampled. The findings included: Review of the facility policy Bowel and Bladder Guidelines, undated, revealed .a resident who is incontinent of bowel and bladder receives appropriate treatment and services . Medical record review revealed Resident #31 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 3 (severe cognitive impairment) on the Brief Interview of Mental Status (BIMS). Continued review revealed the resident required extensive assistance with toileting and was always incontinent of urine. Medical record review of a Nursing Summary Report dated 4/15/17 revealed the resident did not have any excoriation or pressure ulcers. Observation of Resident #31 on 4/17/17 at 11:40 AM, in the resident's room, revealed a strong odor was present. Observation and interview with Resident #31 on 4/18/17 at 9:03 AM, in the resident's room, revealed the resident was lying in bed and a strong odor was present. Interview with the resident revealed she had urinated and the staff rolled up a blanket and placed it between the resident's upper thighs. Further interview revealed the .the nurses do it to catch the urine . Observation and interview with Certified Nursing Assistant (CNA) #2 and Licensed Practical Nurse (LPN) #1 on 4/18/17 at 9:20 AM, in the resident's room, confirmed the strong odor was urine. Observation and interview with the Director of Nursing (DON) on 4/18/17 at 9:30 AM, in the resident's room, confirmed the strong odor was urine and the rolled up blanket was not to be used. Interview with the DON on 4/19/17 at 11:42 AM, in the conference room, confirmed the facility failed to provide ADL care for Resident #31 and failed to follow facility policy.",2020-08-01
5335,"NHC HEALTHCARE, MCMINNVILLE",445076,928 OLD SMITHVILLE RD,MC MINNVILLE,TN,37110,2016-04-13,364,E,0,1,IVE311,"Based on facility policy review, observation and interview, the facility failed to provide food at a palatable temperature on the 400 hall for 1 of 2 meal observations. The findings included: Review of the facility policy entitled Safety & Sanitation Best Practices Guidelines dated 1/2011, revealed .Danger Zone: Temperatures above 41 degrees F (Fahrenheit) .allow the rapid growth of pathogenic microorganisms that could cause food borne illness .Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) Food: Food that requires time/temperature control for safety to limit growth of pathogens .Ex (Example) Milk, dairy products, eggs . Further review revealed .Holding (of food): .Cold food must be kept at a minimum of 41 degrees or lower . Further review revealed .Serving (the food): .Cold food should be held at 41 degrees or lower throughout the serving process . Observation on 4/11/16 from 11:27 AM to 11:55 AM in the dietary department, with the Dietary Manager (DM) present, revealed the resident mid-day meal service was in operation. Further observation revealed the morning cook obtaining the temperatures of the eclairs (a food containing dairy products), stored on a rack by the tray line, was 45 degrees Fahrenheit (F). Further observation revealed there were 4 full size sheet pans of eclairs stored on the rack. Further observation revealed the dietary staff continued to place the eclairs onto individual resident trays in 2 resident delivery carts after the temperature was obtained. Further observation revealed the fried breaded fish was 153 degrees F, fries were 150 degrees F, and the slaw was 40 degrees F. Interview with the DM on 4/11/16 at 11:55 AM in the dietary department, by the resident tray line, confirmed the facility failed to maintain cold food at or less than 41 degrees F and continued to serve it to the residents. All eclair desserts were removed from the delivery carts and tray line and placed in the walk-in refrigerator. Observation on 4/11/16 beginning at 11:59 AM on the 400 hall revealed the open resident delivery cart contained 11 resident trays, no facility staff present and 2 call lights were activated. Further observation at approximately 12:02 PM revealed 2 dietary staff employees placing 2 resident trays onto the cart (for a total of 13 trays) and shut the cart door. Further observation revealed 1 housekeeper (HK) #1 answering the 2 call lights then delivering trays to a total of 3 individual resident rooms from 11:59 AM to 12:05 PM. Further observation at 12:10 PM revealed a dietary staff member delivering the eclair dessert to the residents rooms. Further observation revealed Certified Nurse Aide (CNA) #4 delivering and assisting residents with eating from 12:05 PM to 1:07 PM. Further observation revealed CNA #5 came on the 400 hall at 12:08 PM , provided personal care to a resident, then started delivering and providing eating assistance to residents from 12:26 PM to 1:09 PM. Further observation revealed CNA #5 left the 400 hall and went to the dining room to assist a 400 hall resident (usually ate in room) with eating. Further observation revealed CNA #1 came on the 400 hall at 1:09 PM, delivered 1 resident tray at 1:12 PM and provided eating assistance. Further observation at 1:12 PM revealed 1 tray was left on the cart and it was for the resident already eating and being assisted in the dining room by CNA #5. In summary, the 400 hall resident meal service was from 11:59 AM to 1:12 PM,1 hour and 13 minutes, for 12 trays. Observation on 4/11/16 at 1:15 PM on the 400 hall revealed the DM taking temperatures of the unserved resident tray remaining on the 400 cart as follows: fried breaded fish was 83 degrees F (dropped 70 degrees), fries were 83 degrees F (dropped 67 degrees), slaw was 65 degrees F (increased 25 degrees) and eclair was 54 degrees F. Interview with the DM on 4/11/16 at 1:15 PM on the 400 hall at the resident delivery cart confirmed the food temperatures obtained from the unused resident tray were not acceptable. Further interview revealed the eclairs removed from the 2 delivery carts and the eclairs from the rack on the tray line were initially placed in the walk-in refrigerator but the temperature was not decreasing fast enough to serve. Further interview revealed the eclairs were then moved to the walk-in freezer and served when the temperature reached 40 degrees. Interview on 4/11/16 at 2:59 PM with the DM and Registered Dietitian (RD), in the RD office, revealed 13 residents always eat in their room at lunch on the 400 hall. Interview with the Director of Nursing on 4/13/16 at 3:50 PM in the Classroom confirmed the 400 hall had 12 residents requiring eating assistance from the facility staff.",2019-03-01
5336,"NHC HEALTHCARE, MCMINNVILLE",445076,928 OLD SMITHVILLE RD,MC MINNVILLE,TN,37110,2016-04-13,371,F,0,1,IVE311,"Based on facility policy review, observation and interview, the facility failed to prevent debris accumulation in the walk-in freezer and walk-in refrigerator condenser fan grates and ceiling areas, thereby, possibly contaminating food stored in these units; failed to prevent the walk-in freezer from developing ice build-up; failed to dispose expired food and prevent it from being available for resident use; failed to maintain the dish machine wash temperature at the manufacturer's recommended minimum temperature of 160 degrees Fahrenheit (F) in 2 separate observations of 6 consecutive cycles each observation; failed to maintain cold food at or less than 41 degrees F on the resident tray line; failed to maintain food preparation and storage equipment in a sanitary manner; and failed to maintain the sanitizer level in the 3 compartment sink at 150-400 parts per million per the manufacturer's recommendation. The findings included: Review of the facility policy entitled Safety & Sanitation Best Practices Guidelines dated 1/2011, revealed .Danger Zone: Temperatures above 41 degrees F (Fahrenheit) .allow the rapid growth of pathogenic microorganisms that could cause food borne illness .Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) Food: Food that requires time/temperature control for safety to limit growth of pathogens .Ex (Example) Milk, dairy products, eggs . Further review revealed .Holding (of food): .Cold food must be kept at a minimum of 41 degrees or lower . Further review revealed .Serving (the food): .Cold food should be held at 41 degrees or lower throughout the serving process . Observation and interview on 4/11/16 at 9:12 AM in the dietary department, with the Dietary Manager (DM) present during the observation, revealed the walk-in freezer and walk-in refrigerator condenser fan grates and the ceiling area in front of the grates had an accumulation of hanging black and/or white debris. Further observation in the walk-in freezer revealed a heavy accumulation of ice down the pipe from the condenser unit to a pan stored on the top shelf of a rack. Further observation revealed the pan was filled with ice from the condenser unit. Further observation in the walk-in refrigerator revealed two 5 pound containers labeled Protein Salad. One container was 2/3 empty and had an expiration date of 12/17/15 and the second unopened container had an expiration date of 3/10/16. Further observation revealed 1 flat (approximately 2 dozen) uncovered fresh eggs stored in the walk-in refrigerator that could be contaminated by the debris on the condenser fan grate and ceiling. Interview with the DM confirmed both walk-in units had an accumulation of hanging debris on the condenser fan grates and ceiling area, fresh eggs were uncovered and could be contaminated by the debris from the condenser fan grate and ceiling debris, there was ice built-up in the freezer, and the 2 containers of Protein Salad were expired and available for resident use. Observation and interview on 4/11/16 at 9:30 AM and on 4/12/16 at 1:38 PM in the dietary department, with the DM present during the observation, revealed the dish machine was in operation. Observation of the posted manufacturer's recommendation revealed the minimum wash temperature was 160 degrees F. Observation on 4/11/16 at 9:30 AM and on 4/12/16 at 1:38 PM, of 6 consecutive operations of the machine each day observed, revealed the wash temperature was 148 degrees F each operation and the wash gauge never moved. Further observation revealed the dietary staff removed the cleaned dishes and placed them in a storage unit. Interview with the DM confirmed the dish machine failed to reach a minimum of 160 degrees F per the manufacturer's recommendation, for the wash temperature for each operation observed on both days. Further observation on 4/11/16 at 9:30 AM and on 4/12/16 at 1:38 PM revealed the top of the dish machine was covered with debris and rust which could contaminate the cleaned dishes. Observation on 4/11/16 from 11:27 AM to 11:55 AM in the dietary department, with the DM present, revealed the resident mid-day meal service was in operation. Further observation revealed the morning cook obtaining the temperatures of the eclairs (a food containing dairy products), stored on a rack by the tray line, was 45 degrees F. Further observation revealed there were 4 full size sheet pans of eclairs stored on the rack. Further observation revealed the dietary staff continued to place the eclairs onto individual resident trays in 2 resident delivery carts after the temperature was obtained. Interview with the DM on 4/11/16 at 11:55 AM in the dietary department, by the resident tray line, confirmed the facility failed to maintain cold food at or less than 41 degrees F and continued to serve it to the residents. Observation and interview on 4/12/16 beginning at 1:43 PM in the dietary department, with the DM present during the observation, confirmed the facility failed to maintain sanitary food preparation and storage equipment by the following: 1. Toaster conveyor and spill pan had a heavy accumulation of crumbs. 2. Ice maker intake filter grate had an accumulation of sticky dusty debris. 3. 2 heat lamps, located next to the fryer, exterior surfaces had an accumulation of greasy residue. 4. Grill trough and waste slot had a greasy residue and food debris present. 5. Grill and range top spill pan were filled with food debris and liquid. 6. Grill spill pan handle had an accumulation of sticky dusty residue. 7. Grill back splash had an accumulation of greasy residue. 8. The 4 gas range burners had a very heavy accumulation of blackened debris present. 9. Can opener base, slot, and area by the blade had a very heavy accumulation of blackened sticky debris. 10. Can opener blade had shavings present that could fall into the food. 11. 2 stacked convection ovens interior and racks, including the doors, had an accumulation of blackened debris. 12. 11 full size sheet pans, stacked and stored on a rack and ready to use, exterior outer corners had a very heavy accumulation of blackened debris. 13. 21 full size steam table pans, stacked and stored on a rack and ready to use, exterior outer corners had a very heavy accumulation of blackened debris. 14. Rack, next to the 3 compartment sanitizer sink, used to store cleaned ready to use steam table pans, lids, pitchers and various items, was covered with an accumulation of sticky dusty debris. 15. Large Robo Coup (food blender) base exterior had an accumulation of sticky dusty debris. 16. Can rack, in the dry goods store room, was covered with a very heavy accumulation of greasy dusty debris. 17. 7 racks with total of 13 shelves, in the dry goods storage room, had a very heavy accumulation of greasy dusty debris and food debris. Observation and interview on 04/12/16 at 1:53 PM, with the DM and the evening cook present during the observation, in the dietary department revealed the 3 compartment sink was set up and in use by the evening cook. Observation revealed the posted manufacturer's recommended sanitizer level was 150-400 parts per million for a Quaternary sanitizer. Observation revealed the evening cook washing, rinsing and sanitizing various items. Further observation revealed numerous items were on the drying shelf next to the sanitizer sink. Further observation revealed the evening cook checked the sanitizer level and the test strip did not change. Observation of a new unopened test strip pack used to do a second sanitizer level test revealed the test strip did not change. Interview with the evening cook and the DM confirmed the test strip did not change and the facility could not verify the sanitizer was effective in the 3 compartment sink.",2019-03-01
5337,"NHC HEALTHCARE, MCMINNVILLE",445076,928 OLD SMITHVILLE RD,MC MINNVILLE,TN,37110,2016-04-13,456,D,0,1,IVE311,"Based on observation and interview, the facility dietary department failed to maintain the dish machine wash temperature at the manufacturer's recommended minimum 160 degrees Fahrenheit (F); failed to maintain the exterior and interior of the dish machine in a safe operating condition; and failed to maintain 1 of 3 trash can lids in a safe operating manner. The findings included: Observation and interview on 4/11/16 beginning at 9:30 AM and on 4/12/16 beginning at 1:38 PM, with the Dietary Manager (DM) present during the observation, in the dietary department, revealed the dish machine was in operation. Observation of the posted manufacturer's recommendation revealed the minimum wash temperature was 160 degrees F. Further observation of 6 consecutive operations of the machine on each day observed, revealed the wash temperature was 148 degrees F each operation and the wash gauge never moved. Further observation on both days revealed the top of the dish machine was covered with rust; and the exterior and interior surfaces, the interior curtains and heating coils were white with calcium deposits. Interview with the DM confirmed the dish machine failed to reach a minimum of 160 degrees F per the manufacturer's recommendation for the wash temperature for each operation observed on both days. Further interview confirmed the facility failed to maintain the exterior and interior of the dish machine in a safe operating condition. Observation and interview on 4/11/16 beginning at 9:30 AM and at 11:20 AM and on 4/12/16 beginning at 1:38 PM, with the DM present during the observations, confirmed 1 of 3 trash can lids, stored in the dish room area, had a cracked lid and approximately 1/2 of the lid's lip was missing making it impossible to seal the trash can properly.",2019-03-01
6592,"NHC HEALTHCARE, MCMINNVILLE",445076,928 OLD SMITHVILLE RD,MC MINNVILLE,TN,37110,2015-04-01,371,F,0,1,B1PG11,"Based on facility policy, observation and interview, the facility failed to maintain sanitary conditions in one of one kitchen and failed to document the monitoring of temperatures for one of one walk-in refrigerator and one of one walk-in freezer. The findings included: Review of the untitled facility policy revealed, .HAIR NETS OR CAPS MUST BE WORN AT ALL TIMES IN THE KITCHEN. (COMPLETELY COVERING THE HAIR) . Observation and interview during the initial tour of the kitchen, with the Dietary Manager on 3/30/15, at 9:20 AM, revealed one walk-in refrigerator and one walk-in freezer. Further observation revealed the freezer and refrigerator both had internal and external temperature thermometers. When the Dietary Manager was asked for documentation of the monitoring of the freezer and refrigerator temperatures, she replied We check the temperatures everyday but we don't record the temperatures. Further interview confirmed the facility failed to maintain temperature control logs for the walk-in refrigerator and walk-in freezer. Continued observation during initial tour revealed Dietary Staff #1 during food preparation, with her hair exposed from her forehead to mid-crown. Interview with the Dietary Manager, on 3/30/15, at 11:30 AM, in her office, confirmed Dietary Staff #1 had failed to completely cover her hair while in the kitchen. Continued interview confirmed the facility had failed to maintain sanitary conditions in the kitchen.",2018-05-01
8609,"NHC HEALTHCARE, MCMINNVILLE",445076,928 OLD SMITHVILLE RD,MC MINNVILLE,TN,37110,2014-01-29,323,D,0,1,QH3H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure the bed brakes were functional for one (#29) of three residents reviewed for accidents of thirty-two residents reviewed. The findings included: Resident #29 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 transferred and ambulated with supervision, and had experienced two falls without injury since the prior assessment. Medical record review of the Fall Risk Evaluation dated May 21, 2013, revealed the resident was at high risk for falls Medical record review of a Post Falls Nursing Assessment revealed the resident experienced a fall on December 20, 2013, at 10:30 p.m., while ambulating without assistance. Continued review of the Post Falls Nursing Assessment revealed the intervention put into place was to have maintenance repair the bed brakes. Observation on January 29, 2014, at 7:50 a.m., revealed the resident lying on the bed feeding self the breakfast meal. Interview on January 28, 2014, at 5:20 p.m., with the Administrator, in the conference room, revealed the Administrator had spoken with the nurse who was present at the time of the resident's fall on December 20, 2013, and confirmed the bed had rolled due to the bed brakes did not work, and maintenance had repaired the bed brakes after the resident's fall.",2017-05-01
9523,"NHC HEALTHCARE, MCMINNVILLE",445076,928 OLD SMITHVILLE RD,MC MINNVILLE,TN,37110,2013-11-07,242,D,1,0,E97P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a facility investigation, and interview, the facility failed to allow the choice of having no male caregivers providing personal care for one resident (#7) of twelve residents reviewed. The findings included: Resident #7 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 was severely impaired for daily decision making, required extensive assistance for all Activities of Daily Living (ADL's) and was incontinent of bowels. Medical record review of the care plan dated February 2012 revealed the resident preferred female caregivers for personal care. Review of a facility investigation dated February 13, 2013, revealed a male Certified Nurse Aide (CNA) had showered the resident and the resident had alleged the male CNA inserted his finger into the resident's rectum. Review of a facility investigation and the Administrator's statement (no date) of the alleged incident on February 13, 2013, revealed .approximately six months prior, the patient's son had requested no male CNAs (provide personal care). The center complied until a recent return from the hospital . Interview with the resident's daughter on November 5, 2013, at 2:33 p.m., by telephone revealed the son and resident had requested no male caregivers provide personal care prior to the incident and the resident never wanted males to see .naked. Interview with the Director of Nursing on November 5, 2013, at 4:15 p.m., in the conference room revealed the resident was a no male caregiver and after a hospitalization the no male caregiver was not continued. Continued interview confirmed the facility had failed to allow the resident a choice of having no male caregivers providing personal care. C/O #",2016-11-01
10619,"NHC HEALTHCARE, MCMINNVILLE",445076,928 OLD SMITHVILLE RD,MC MINNVILLE,TN,37110,2012-08-02,278,D,0,1,QPRE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure accuracy of the Minimum Data Set (MDS) for Urinary Continence for one resident (#5) of twenty-four residents reviewed. The findings included: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE], revealed the resident was always continent of urine. Interview with the MDS Coordinator on July 31, 2012, at 1:39 p.m., in the 400 wing activity room, confirmed the MDS assessment failed to indicate the resident had a [MEDICATION NAME] and the MDS assessment was inaccurate.",2016-05-01
10620,"NHC HEALTHCARE, MCMINNVILLE",445076,928 OLD SMITHVILLE RD,MC MINNVILLE,TN,37110,2012-08-02,281,D,0,1,QPRE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, facility policy review, and interviews, the facility failed to follow accepted standards of practice for ensuring an indwelling peripheral catheter is changed in a timely manner, failed to follow a physician's orders [REDACTED].#7),and timely administration of medication for one (A) of twenty-four residents reviewed. The findings included: Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of nurse's notes from July 15, 2012, through August 1, 2012, revealed no documentation of the date of the initial placement or date of a peripheral INT (an indwelling intravenous (I.V.) catheter placed in a vein to administer medications or fluids) being changed. Observation on July 31, 2012, at 7:40 a.m., in the resident's room, revealed an INT taped to the resident's right forearm with no date on the tape indicating the date of placement in the resident's arm or when changed last. Review of facility policy, I.V. Dressing and Cannula Site Care, revealed .8. Standard peripheral I.V. access sites should be changed every 72 hours unless specified by a physician's orders [REDACTED]. Interview on July 31, 2012, at 8:30 a.m., with Licensed Practical Nurse (LPN) #3 in the 300 Hallway, confirmed the dressing of the INT had no date indicating the day the INT was placed. Continued interview with LPN #3 confirmed the facility policy is to date the dressing of the INT to ensure the INT is changed every 72 hours per facility policy. Interview on August 2, 2012, at 8:50 a.m., with the Director of Nursing (DON), at 300 Unit Nurse's Station, confirmed the facility failed to date the dressing of the resident's INT, and failed to follow the facility's policy by ensuring the dressing of the INT is dated upon insertion. Medical record review of the physician's recapitulation orders signed and dated July 25, 2012, revealed O2 (oxygen) @ (at) 2 LPM (liters per minute) BNC (by nasal cannula) PRN (as needed) SOB (shortness of breath). Medical record review of a nursing note dated July 30, 2012, at 10:15 a.m., revealed: Con't (continue) on O2 at 2-3 LPM BNC. Observation on July 30, 2012, at 2:45 p.m., in the resident's room, revealed the resident lying in the bed, receiving oxygen by nasal cannula at 2.5 liters per minute. Observation on July 31, 2012, at 7:40 a.m., in the resident's room, revealed the resident lying in the bed, receiving oxygen by nasal cannula at 2.5 liters per minute. Interview on July 31, 2012, at 8:30 a.m., with LPN #3, in the resident's room, confirmed the resident was receiving oxygen via nasal cannula at 2.5 liters per minute and the physician's orders [REDACTED]. Observation of the medication pass, on July 30, 2012, at 8:50 a.m., on the 200 hallway revealed, Licensed Practical Nurse (LPN) #4 prepared a dose of [MEDICATION NAME] 100 mg (milligram) oral tablet and administered the tablet to resident #A. Medical record review of the Physician's Recapitulation Orders dated July 2012, revealed, .[MEDICATION NAME] 100 mg (milligram) PO (orally) every HS (bedtime) Depression . Interview with LPN #4 on July 30, 2012 at 10:15 a.m., in the 200 hall nursing station, confirmed the medication was to be given at bedtime daily and the medication was administered during the morning medication pass.",2016-05-01
10621,"NHC HEALTHCARE, MCMINNVILLE",445076,928 OLD SMITHVILLE RD,MC MINNVILLE,TN,37110,2012-08-02,315,D,0,1,QPRE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, facility policy review, and interview, the facility failed to provide appropriate incontinence care for one (#12) of twenty-four residents reviewed. The findings included: Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set, dated dated dated [DATE], revealed the resident required extensive assistance with decision making, total assistance with personal hygiene, extensive assistance with all activities of daily living, and was incontinent of bladder and bowel. Observation on August 1, 2012, at 7:58 a.m., in the resident's room, revealed Certified Nursing Assistant (CNA) #3 providing hygiene care following an episode of bowel and bladder incontinence. While performing perineal care, the CNA removed the soiled linens, cleaned the resident's perineal area front to back, turned the resident to the left side, and cleaned the rectal area front to back. Continued observation, at that time, revealed visible stool on the wash cloth. CNA #3 obtained a clean wash cloth, rinsed and dried the rectal area front to back, leaving a small amount of feces on rectal area. CNA #3 positioned the resident on back and applied a clean gown. Review of the facility's Perineal Policy revealed, Spray soiled and /or odorous areas (or wet washcloth) with product. Gently wipe clean with washcloth, using one area of washcloth for each cleansing stroke. Repeat as necessary, using as many washcloths as needed . Interview with CNA #3 on August 1, 2012, at 8:15 a.m., in the hall, confirmed feces was left on the resident's rectal area and perineal care was not performed appropriately.",2016-05-01
10622,"NHC HEALTHCARE, MCMINNVILLE",445076,928 OLD SMITHVILLE RD,MC MINNVILLE,TN,37110,2012-08-02,318,D,0,1,QPRE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to apply palm guards for one resident (#8) of twenty-four residents reviewed. The findings included: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a physician's recapitulation orders dated July 2012, revealed .palm guards on in the morning .off at bedtime . Observation on July 31, 2012, at 10:00 a.m., revealed the resident lying in bed with palm guards off. Observation on July 31, 2012, at 12:50 p.m., revealed the resident lying in bed with palm guards off. Interview with Registered Nurse #1 on July 31, 2012, at 12:50 p.m., confirmed palm guards were off and palm guards are to be on after (resident's) bath has had bath .they should be on at this time.",2016-05-01
10623,"NHC HEALTHCARE, MCMINNVILLE",445076,928 OLD SMITHVILLE RD,MC MINNVILLE,TN,37110,2012-08-02,323,D,0,1,QPRE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This REQUIREMENT is not met as evidenced by: Based on medical record review, facility documentation, and interview, the facility failed to ensure appropriate assistance with transfer into a wheelchair van was provided, resulting in a fall without injury for one resident (#10) of twenty-four residents reviewed. The findings included: Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident was cognitively intact (scored a 14 out of 15 indicating a high level of cognitive functioning) Further review of the MDS revealed the resident required the assistance of two people for transfers. Review of facility documentation dated March 6, 2012, revealed resident #10 fell while being loaded onto the van for transportation to Dialysis. Further review revealed the resident was being loaded into the van by the driver, with no assistance from the facility, the resident's wheelchair flipped backwards, resulting in a fall with no apparent injury. Interview with the resident on August 1, 2012, at 1:40 p.m., in the Activities Office, revealed the resident had fallen backwards when being loaded onto the van, because the driver had to take off the anti-tipping wheels from the back of the resident's wheelchair in order to transverse the lip of the ramp onto the van, and lost control of the resident's wheelchair. Interview with the Director of Nursing (DON) on August 1, 2012, at 11:25 a.m., in the conference room, confirmed that the facility had failed to provide the assistance required when loading the resident onto the van.",2016-05-01
10624,"NHC HEALTHCARE, MCMINNVILLE",445076,928 OLD SMITHVILLE RD,MC MINNVILLE,TN,37110,2012-08-02,371,F,0,1,QPRE11,"Based on observation and interview, the facility failed to provide sanitary storage of food and equipment. The findings included: Observation of the dietary department on July 30, 2012, from 10:00 a.m. until 11:15 a.m., revealed: 1. Two seven pound cans of Pork and Beans were dented and were available for use; 2. Eight wet pans stored under the steamer were wet and were available for use; 3. A box of crackers opened and not labeled with date when opened; 4. A stand up mixer had food debris on the lip and top of the machine and was available for use; 5. A dirty ice cream scoop had dried Pimento Cheese on it and was available for use; 6. Four wet ladles were found in the drawer available for use; 7. The bottom plate warmer holder had crumbs under the three lids that were falling onto the plate warmers that were available for use; 8. The sanitizer section of the three compartment sink tested at 75 p.p.m. (parts per million) instead of the required 200 p.p.m. The staff continued to use this section of the sink for sanitizing the pots and pans. Interview with the dietary manager on July 30, 2012, at 11:15 a.m., in the dietary department, confirmed dented cans were to be removed from stock, the ladles and pans needed to dry completely before being stored for use, all open food was to be labeled with the date and closed completely prior to storage, the stand up mixer was to be cleaned completely after each use before storage, the ice cream scoop used for Pimento Cheese was to be cleaned prior to storage, the bottom plate warmer storage container was to be clean from debris at all times, and the three compartment sink sanitizer section was to be kept at the acceptable sanitizer level at all time. Continued observation of the dietary department on July 31, 2012, from 8:00 a.m. to 9:35 a.m., revealed: 1. Two staff bottle drinks were found in the first floor dietary freezer; 2. The floor in the dishwasher section of the main dietary department had free standing water on it without a Wet Floor Sign present. Interview with the dietary manager on July 31, 2012, at 9:40 a.m., in the dietary department, confirmed the staff drinks were not to be in the dietary freezer, and there needed to be a Wet Floor Sign in the dishwasher area of the kitchen.",2016-05-01
10625,"NHC HEALTHCARE, MCMINNVILLE",445076,928 OLD SMITHVILLE RD,MC MINNVILLE,TN,37110,2012-08-02,431,D,0,1,QPRE11,"Based on observation and interview, the facility failed to properly store medical supplies in one medication storage room of four medication storage rooms reviewed. The findings included: Observation on July 30, 2012, at 8:50 a.m., in the 200 hall medication room, revealed one 30ML (milliliter) bottle of 0.9 percent normal saline, opened and unlabeled and ready for resident use. Continued observation revealed one box of cornstarch powder opened and unlabeled, ready for resident use. Continued observation revealed a sterile urinary catheter tray, opened and stored in the sterile supply cabinet, ready for resident use. Interview with LPN #4, on July 30, 2012, at 9:00 a.m., in the 200 hall nursing station, confirmed the supplies were unlabeled and available for resident use, and the sterile contents of the urinary catheter tray were compromised and the tray was available for resident use.",2016-05-01
10626,"NHC HEALTHCARE, MCMINNVILLE",445076,928 OLD SMITHVILLE RD,MC MINNVILLE,TN,37110,2012-08-02,441,E,0,1,QPRE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to maintain infection control measures for four resident's (#10, #14, #B, #12) of twenty-four residents reviewed, The findings included: Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation of catheter care for resident #10 on July 31, 2012, revealed the Certified Nursing Assistant (CNA) #2 had donned gloves after washing hands. CNA #2 proceeded to draw the curtains, close the blinds, turn the resident, remove the resident's soiled brief, perform catheter care,, and put away supplies with the same pair of dirty gloves. Interview with CNA #2 on July 31, 2012, at 1:53 p.m., confirmed the CNA had proceeded with catheter care and clean-up with the same pair of soiled gloves. Observation of resident #10 during medication pass conducted on July 31, 2012, at 11:00 a.m., on the 300 corridor, revealed Licensed Practical Nurse (LPN) #3 withdrew six units of [MEDICATION NAME] R (short acting insulin used for the treatment of [REDACTED]. Continued observation revealed LPN #3 entered the resident's room, and administered the injection. Interview with LPN #3 on July 31, 2012, at 11:25 a.m. in the 300 hallway corridor confirmed the medication was withdrawn from the medication vial without cleansing the vial prior to accessing it with the sterile needle. Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) dated , June 23, 2012, revealed the resident was severely cognitively impaired, and dependent for activities of daily living. Observation of Resident #14 on July 30, 2012, at 11:40 a.m., in the resident's room, during initial tour, revealed the resident lying supine on the bed. Observation revealed a dislodged gauze dressing, above the resident's left temple. Continued observation revealed, beneath the dislodged dressing a golf ball sized black tumor extending upward from the resident's temple exposed to open air. Yellow drainage was visible on the dislodged dressing. Medical record review of the Physician's Recapitulation Orders dated July 2012, revealed orders to keep the tumor site covered with gauze dressings, and to change the dressings daily, and as needed when soiled. Interview with LPN #2, on July 30, 2012, at 11:45 a.m., in the resident's room, confirmed the dressing on the resident's head did not cover the tumor. Resident B was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation of Resident B during the medication pass on July, 31, 2012, at 11:20 a.m., revealed LPN #3 failed to wash the hands prior to donning gloves and administering three units of subcutaneous [MEDICATION NAME] R ( short acting insulin used to treat elevated blood sugar levels) to the resident. Interview with LPN #3 on July 31, 2012, at 11:25 a.m., in the hallway outside the resident's room, confirmed the hands were not washed prior to donning gloves and administering the injection. Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set, dated dated dated [DATE], revealed the resident required extensive assistance with decision making, total assistance with personal hygiene, extensive assistance with all activities of daily living, and was incontinent of bladder and bowel. Observation on August 1, 2012, at 7:58 a.m., in the resident's room, revealed Certified Nursing Assistant (CNA) #3 providing hygiene care following an episode of bowel and bladder incontinence. While performing perineal care, the CNA removed the soiled linens, placed linens in a plastic bag, cleaned the resident's perineal area front to back, positioned resident on left side, and rolled the soiled bed pads under the resident's buttocks. CNA #3 placed two clean pads under the resident's buttocks. Continued observation, at that time, revealed a pillow fell to the floor. CNA #3 picked the pillow up from the floor, placed it on a chair, touched the rail of the bed, touched the resident, and continued with hygiene care without changing gloves. Interview with CNA #3 on August 1, 2012, at 8:15 a.m., in the hall, confirmed the soiled gloves were not removed before applying the clean pads, picking the pillow off floor, touching the bed rail and the resident. Continued interview confirmed appropriate infection control was not maintained.",2016-05-01
10627,"NHC HEALTHCARE, MCMINNVILLE",445076,928 OLD SMITHVILLE RD,MC MINNVILLE,TN,37110,2012-08-02,514,D,0,1,QPRE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to maintain an accurate clinical record for one (#7) resident of twenty-four residents reviewed. The findings included: Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of nurse's notes from July 15, 2012, through August 1, 2012, revealed no documentation of the date of the initial placement or date of a peripheral INT (an indwelling intravenous (I.V.) catheter placed in a vein to administer medications or fluids) being changed. Observation on July 31, 2012, at 7:40 a.m., in the resident's room, revealed an INT taped to the resident's right forearm with no date on the tape indicating the date of placement in the resident's arm or when changed last. Interview on August 2, 2012 at 8:50 a.m., with the Director of Nursing (DON), at 300 Unit Nurse's Station, confirmed the facility failed to accurately document the status of the resident's INT placement, and failed to accurately reflect the status of the resident's INT in the clinical record.",2016-05-01
13160,"NHC HEALTHCARE, MCMINNVILLE",445076,928 OLD SMITHVILLE RD,MC MINNVILLE,TN,37110,2011-02-17,276,D,0,1,FCHW11,"**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 review within three months from the prior review for one (#5) of twenty-five residents reviewed. The findings included: Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the medical record revealed the Initial Minimum Data Set (MDS) was dated August 2, 2010, and a Quarterly MDS was dated October 28, 2010. Interview, with Licensed Practical Nurse #3, who was the MDS nurse, on February 16, 2011, at 11:00 a.m., in the MDS office, confirmed the quarterly MDS was not completed in January 2011.",2015-04-01
13161,"NHC HEALTHCARE, MCMINNVILLE",445076,928 OLD SMITHVILLE RD,MC MINNVILLE,TN,37110,2011-02-17,176,D,0,1,FCHW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to assess for self-administration of medication for one resident (#17) of twenty-five residents reviewed. The findings included: Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident scored 13 out of 15 on the Brief Interview for Mental Status (0=severe cognitive impairment and 15=intact cognition), was independent with eating, and required extensive assistance with all other activities of daily living. Medical record review of a physician's orders [REDACTED]. Medical record review of a physician's orders [REDACTED]. Observation on February 15, 2011, at 9:30 a.m., revealed the resident was sitting in a chair in the resident's room and an Atrovent inhaler, dated January 11, 2011, was setting on the over bed table. Interview with the resident on February 15, 2011, at 9:30 a.m., in the resident's room, revealed a nurse brought the inhaler in for the resident to use and the resident kept it in the room for use when needed. Continued interview revealed ""I think it's out"" and the resident did not feel the inhaler was helping with shortness of breath. Interview with LPN (Licensed Practical Nurse) #5 on February 15, 2011, at 9:50 a.m., outside the resident's room, confirmed the LPN let the resident keep the inhaler in the room and stated the resident knew how to use the inhaler. Continued interview confirmed the physician's orders [REDACTED]."" Observation of LPN #5 on February 15, 2011, at 9:55 a.m., revealed the LPN entered the resident's room and stated, ""Now remember you only use that twice a day now."" Interview and observation with LPN #4 on February 17, 2011, at 8:15 a.m., near the medication cart in the hallway, confirmed the resident had not been on any inhalers until a recent decline ""...back in the Fall."" Continued interview confirmed the resident had recently experienced severe shortness of breath and anxiety, with each exacerbating the other. Continued observation and interview confirmed the inhaler was, at the time of the interview, locked in the drug cart, and the resident did not have orders and had not been assessed for self-administration of the inhaler.",2015-04-01
13162,"NHC HEALTHCARE, MCMINNVILLE",445076,928 OLD SMITHVILLE RD,MC MINNVILLE,TN,37110,2011-02-17,281,D,0,1,FCHW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to follow the physician's order for aspiration precaution for one (#15) of twenty-five residents reviewed. The findings included: Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed resident #15 was hospitalized from January 21-26, 2011, with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed resident #15 required extensive assistance for eating, dressing, and activities of daily living. Medical record review of the physician's orders signed by the physician February 2, 2011, revealed an order dated January 26, 2011, for ""Thin liquids and no straws."" Observation on February 16, 2011, at 8:00 a.m., revealed the Licensed Practical Nurse (LPN #1) administered crushed medications mixed in pudding via a spoon. Continued observation revealed the nurse placed a straw to the resident's mouth and assisted the resident to drink 150 cc (cubic centimeters) of water. Continued observation revealed the resident did cough once to clear the throat after drinking through the straw. Interview with the Speech Therapist on the 1st floor on February 16, 2011, at 9:35 a.m., revealed resident #15 was evaluated and determined to be a high risk for aspiration on October 7, 2009. Continued interview revealed a recommendation was made to include no straws to be used; and revealed there had been no improvement in the resident's functional abilities. Interview with LPN #1 at the nurses' station on February 16, 2011, at 1:10 p.m., verified the resident was on aspiration precautions, was ordered to not have a straw, and confirmed did have liquids through the straw after medication administration. Interview with the Director of Nursing on the 1st floor on February 16, 2011, at 2:20 p.m., confirmed the facility failed to follow the physician's order for aspiration precautions.",2015-04-01
13163,"NHC HEALTHCARE, MCMINNVILLE",445076,928 OLD SMITHVILLE RD,MC MINNVILLE,TN,37110,2011-02-17,314,D,0,1,FCHW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide a weekly evaluation including ulcer type, staging, and characteristics for one resident (#4) of twenty-five residents reviewed. The findings included: Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident as severely impaired with cognitive skills and required total assistance by staff with all activities of daily living. Medical record review of an Occupational Therapy Evaluation and Discharge summary dated February 2010 revealed ""...(B) (bilateral) hands flexed & elbow...Pt. (patient) to wear (B) palm guard..."" Medical record review of a dietary progress note dated June 5, 2010, revealed the resident had been placed on ""[MEDICATION NAME], snacks, NIP (nutrition intervention program) food provided for added Kcal, protein...no current skin breakdown noted...change diet to regular puree..."" Medical record review of a dietary progress note dated December 2, 2010, revealed ""...Pt. intake of puree diet was 43% per nsg (nursing)...pt. swallowing impaired...dependent diner...no skin breakdown noted...wt (weight) 8/6 106.2# (pounds)...wt. loss of 5.5% past 30 days...13% past 180 days...wt. loss possible with dementia progression...will continue with NIP food along with shakes TID (three times a day)...family aware of wt. loss...no aggressive nutrition therapy, DNR (do not resuscitate), comfort [MEDICATION NAME] (antidepressant medication to increase appetite)..."" Medical record review of a care plan updated on December 14, 2010, revealed ""...resident has the potential risk for alteration in skin integrity...identify potential causative factors and rectify when possible...use caution during transfers and bed mobility...keep nails short...notify MD PRN (as needed) of any problems...apply lotion to skin as needed...encourage nutritional and po (by mouth) fluid intake...provide po intake assist...assist with repositioning as needed...incontinent care after each episode...moisture barrier applied as needed...observe for s/s (signs and symptoms) of infection...RD/DT (Registered Dietician, Dietary Manager) to assess protein, calorie, vitamin and fluid needs PRN...educate family on risk factors and preventative measures in place...keep HOB (head of bed) at lowest position to decrease shear and friction...obtain labs as ordered...palm guard to hands after bath remove at bedtime...place rolled [MEDICATION NAME] in both palms after palm guards removed and hands washed and dryed..."" Medical record review of weekly skin assessments progress notes dated December 15, 2010, revealed Braden score 12 (high risk)...con't (continue) [MEDICATION NAME] (preventative) to toes & (and) heels BID (twice a day)...con't buttocks with [MEDICATION NAME] breakdown noted...con't to enc. (encourage) adequate intake, snacks & supplements provided..."" Medical record review of a weekly skin assessment progress note dated December 22, 2010, revealed ""...continues [MEDICATION NAME] to toes, heels, & buttocks no excoriation noted...staff continues to encourage adequate intake, snacks and supplements..."" Medical record review of a weekly skin assessment progress note dated December 28, 2010, revealed ""...Approx. (approximately) ? inch open area to area below coccyx between buttocks...tx in [MEDICATION NAME] to toes & heels...Staff continues to encourage snacks and supplements..."" Medical record review of a nurse's note dated December 30, 2010, at 2:00 p.m., revealed ""...new order noted for tx (treatment) of small open area between buttocks...pt. up in geri chair for hairdresser then back to bed after lunch...staff positioning pt. side to side to keep pressure off area...no s/s of pain noted..."" Medical record review of a nurse's note dated January 2, 2011, at 5:00 p.m., revealed ""...Drsg (dressing) changed to open area between buttocks...no redness or drainage at site...wound bed [MEDICATION NAME] ointment applied & Polymem foam drsg to cover...tolerated tx well...will T & P (turn and position) side to side to reduce pressure...heels floated on pillows..."" Medical record review of a nurse's note dated January 2, 2011, at 11:30 p.m., revealed ""...drsg changed to open area between buttocks...no drainage [MEDICATION NAME] & foam drsg applied as ordered...new open area to inner region of (L) (left) thumb...cleansed with wound [MEDICATION NAME] applied & padded [MEDICATION NAME] & P side to side..."" Medical record review of nurse's notes dated January 3 through February 16, 2011, and weekly skin assessment progress notes dated January 5, 12, 19, 26, 2011, and February 2 and 9, 2011, revealed no documentation of the wound sites characteristics, progress and complications including reassessment, staging, and any progress toward healing. Observation on February 15, 2011, at 9:30 a.m., revealed the resident in bed and contractures noted of the bilateral hands. Observation on February 16, 2011, at at 10:25 a.m., revealed the resident in a geri chair. Observation revealed the Wound Care Specialist removed a dressing from a pressure ulcer on the left thumb. Continued observation revealed the dressing with a scant amount light brown colored drainage. Observation on February 16, 2011, at 1:55 p.m., revealed three Certified Nursing Assistants transferring the resident to bed. Observation revealed the resident with a dressing dated February 16, 2011, on the coccyx area. Continued observation with the Wound Care Specialist revealed a 2 - 3 cm (centimeter) open area when the dressing was removed. Interview with the Wound Care Specialist on February 16, 2011, at 8:50 a.m., in the hallway on the 100 hall revealed the Wound Care Specialist when asked about the pressure ulcer on the resident's left thumb stated ""...was not following or doing the treatment...aware of the area..."" Continued interview revealed the Wound Care Specialized had not considered the open area a pressure ulcer and had not been providing weekly updates on the progression of the area. Further interview revealed the Wound Care Specialist stated the pressure ulcer on the buttocks was ""...healed..."" Interview on February 17, 2011, at 9:55 a.m., with the Administrator, Director of Nursing, and the Regional Nurse, in the director of Nursing's office confirmed the nursing staff were completing weekly skin assessments and providing the treatment for [REDACTED].",2015-04-01
13164,"NHC HEALTHCARE, MCMINNVILLE",445076,928 OLD SMITHVILLE RD,MC MINNVILLE,TN,37110,2011-02-17,441,D,0,1,FCHW11,"**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 perform hand hygiene during observation of a dressing change for one resident (#7) of twenty five residents reviewed. The findings included: Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's order dated February 1, 2011, revealed an order for [REDACTED]. Observation of a dressing change on February 16, 2011, at 8:50 a.m., in the resident's room, revealed the Wound Care Specialist with gloved hands, removed the wound vac and dressing from the sacral area. Continued observation revealed the Wound Care Specialist removed gloves, sprayed hands with a hand sanitizer, donned gloves, then cleaned the sacral area with a 4X4 gauze and wound cleanser. Observation revealed a moderate amount of blood colored drainage present on the 4X4. Further observation revealed the Wound Care Specialist placed the 4X4 gauze and gloves in a biohazard bag, sprayed hands with hand sanitizer and reapplied the wound vac to the sacral area. Review of the facility policy for non-sterile dressing changes revealed ""...11. Put on gloves and remove soiled dressing and discard in appropriate container. 12. Remove and discard gloves. 13. Wash your hands. 14. Put on a clean pair of gloves..."" Interview with the Wound Care Specialist, on February 16, 2011, at 9:20 a.m., outside of resident #7's room confirmed the Wound Care Specialist failed to follow the facilities policy for hand hygeine during a dressing change.",2015-04-01
14259,"NHC HEALTHCARE, MCMINNVILLE",445076,928 OLD SMITHVILLE RD,MC MINNVILLE,TN,37110,2010-01-28,315,D,,,VI5B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, observation, and interview, the facility failed to provide incontinence care for one incontinent resident (#17) of seven incontinent residents reviewed. The findings included: Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had short term memory deficits with moderately impaired cognitive skills for daily decision making. Continued review revealed the resident required extensive assistance for transfers, was dependent on staff for personal hygiene and bathing and was incontinent of bowel and bladder. Observation on January 27, 2010, at 8:50 a.m., in the resident's room revealed Certified Nurse's Aide (CNA) #1 provided incontinence care to the resident after the resident had voided. Observation revealed CNA #1 positioned the resident on the left side, sprayed peri-wash on the resident's buttocks, and wiped the area with a dry towel. Observation revealed CNA #1 changed the incontinence pad, repositioned the resident in a supine position, and covered the resident with the sheet and blanket. Review of the facility policy, Perineal Care, revealed,""Purpose: Perineal cleansing will be done after incontinent episodes ..."" Interview with CNA #1 on January 27, 2010, at 9:00 a.m., in the resident's bathroom, confirmed the resident had not been cleansed from the front and the incontinence care was incomplete. Interview with the Corporate Nurse in the Director of Nurses office on January 28, 2010, at 8:30 a.m., confirmed the facility policy for providing incontinence care had not been followed.",2014-02-01
14260,"NHC HEALTHCARE, MCMINNVILLE",445076,928 OLD SMITHVILLE RD,MC MINNVILLE,TN,37110,2010-01-28,252,D,,,VI5B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide an odor-free environment for two residents (#8, #17) of twenty-five residents reviewed. The findings included: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had bowel and bladder incontinence daily, and required extensive assistance with personal hygiene and bathing. Review of the nurse's note dated January 5, 2010, revealed,"" ...Remains totally incontinent and urinates on each turn also - Has a constant dribble and foul smell to urine. Often with loose stools ..."" Review of the nurse's note dated January 13, 2010, revealed,"" ...Foul odor to urine ..."" Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident required extensive assistance for transfers, and was dependent on staff for personal hygiene and bathing. Continued review of the same MDS revealed the resident was incontinent of bowel and bladder daily. Observation during the initial facility tour on January 26, 2010, at 10:20 a.m., revealed resident #8 and #17 were roommates. Observation at this time revealed a strong, stale, pungent, urine odor present in the residents' room. Observation on January 26, 2010, at 1:30 p.m., and January 27, 2010, at 8:50 a.m., revealed the strong, stale, urine odor remained. Observation on January 27, 2010, at 8:50 a.m., revealed resident #17 and resident #8 had breakfast trays on their over-bed tables. Observation revealed resident #17 complained twice about the odor stating, ""It is not very appetizing trying to eat when it smells so bad."" Interview with Licensed Practical Nurse #1 on January 27, 2010 at 9:30 a.m., at the 200 hall nurses station, confirmed the room of resident #8 and #17 had a chronic foul odor; sometimes worse than others. Interview on January 27, 2010, at 4:45 p.m., in the hall, with a family member, confirmed,"" ...the room has had a foul odor for sometime ..."" Continued interview confirmed the family member visited resident #17 on a weekly basis.",2014-02-01
14261,"NHC HEALTHCARE, MCMINNVILLE",445076,928 OLD SMITHVILLE RD,MC MINNVILLE,TN,37110,2010-01-28,312,D,,,VI5B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide nail care for one (#6) of twenty-five residents reviewed. The findings included: Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had impaired short and long term memory and required assistance with all activities of daily living including nail care. Observation on January 26, 2010, at 10:30 a.m., in the resident's room revealed the resident in bed receiving a bed bath from a Certified Nurse Assistant. Observation on January 27, 2010, at 9:15 a.m., and 1:00 p.m., in the resident's room revealed the resident in bed, eyes closed, and scratching the nose with the right index fingernail. Observation revealed the fingernail was jagged and soiled with dark debris under the fingernail tip. Observation revealed the remaining fingernails on the right hand also had dark debris under the finger nails; the left hand was under the covers. Observation on January 28, 2010, at 12:15 p.m., in the resident's room revealed the resident in bed feeding self with the right hand using the fingers and a fork; the five right hand finger nails were soiled with dark debris; and the index finger nail was jagged; the left hand middle and thumb nails were soiled with dark debris. Interview on January 28, 2010, at 12:20 p.m., with Licensed Practical Nurse #2 in the resident's room confirmed the resident's finger nails were soiled with dark debris and required cleaning and trimming.",2014-02-01
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
4911,UNICOI CO NURSING HOME,445077,100 GREENWAY CIRCLE,ERWIN,TN,37650,2016-05-04,323,E,0,1,U2BM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide supervision in the dining room during the noon meal for 2 residents with swallowing difficulty (#2, #7) of 3 residents observed. The findings included: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 required a mechanically altered diet (thickened liquids) and set up assistance for meals. Medical record review of a swallowing study dated 4/17/14 revealed Resident #2 had a history of [REDACTED]. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed Resident #7 required extensive assistance with eating and had episodes of coughing or choking during meals. Medical record review of a Speech Therapy note dated 2/15/16 revealed the resident had intermittent aspiration with thin liquids.",2019-06-01
6593,UNICOI CO NURSING HOME,445077,100 GREENWAY CIRCLE,ERWIN,TN,37650,2015-05-06,203,D,1,1,GYWE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy Transfer/Discharges, medical record review and interview, the facility failed to provide provide the family and or the resident with written notice of the discharge that included:Reason for transfer/discharge; he effective date of the transfer or discharge; the location to which the resident was transferred or discharged ; right of appeal; and how to notify the ombudsman (name, address, and telephone number), prior to discharge from the facility for 1 resident (#61) of 27 residents reviewed. The findings included: Review of the facility policy Transfer/Discharges revealed the notification to the resident or family should include: Reason for transfer/discharge; the right of appeal; and how to notify the ombudsman (name, address, and telephone number), Medical record review revealed Resident #61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Orders and Progress Notes dated 3/5/15 at 3:00 PM revealed .Transfer to .(local nursing facility) cont (continue) current medications . Medical record review of the Free Text Charting assessment dated [DATE] at 7:28 PM by Minimum Data Set (MDS) Coordinator revealed .I inform my DON (Director of Nursing) .and she instructed me to call (resident's) family and let them know they needed to come and get her that we could not keep her here and her being so aggressive and violent toward the other residents and staff .I called her .and explained what had happened .I went into detail and explained that we have 44 other residents that we have to keep safe and protect and with her acting out like that we could not let her stay here and he stated he understood and agreed that the other resident could not be put at risk of her possibly harming them .He arrived approx. 1 hour after or phone conversation and asked if it would be ok for her to stay here tonight because he did not have a car and his .didn't get off work until late tonight. The (DON)agreed that this would be ok. I explained in detail that she would be going home with home health and that medications would be sent the pharmacy of choice at time of d/c . Interview with the MDS Coordinator on 5/5/15 at 2:35PM in the activity office revealed the MDS Coordinator is responsible for discharging residents from the facility. Continued interview confirmed the facility failed to provide a written notice of the discharge to the resident and or family prior to the time of discharge. Interview with the Director of Nursing (DON) on 5/5/2015 at 3:20 PM in the activity office confirmed the facility failed to provide the family and or the resident with written notice of the discharge that included: Reason for transfer/discharge; the effective date of the transfer or discharge; the right of appeal; and how to notify the ombudsman (name, address, and telephone number), prior to discharge from the facility.",2018-05-01
6594,UNICOI CO NURSING HOME,445077,100 GREENWAY CIRCLE,ERWIN,TN,37650,2015-05-06,204,D,1,1,GYWE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy Transfer/Discharges, medical record review and interview, the facility failed to provide provide the resident with sufficient preparation and orientation to ensure safe and orderly transfer from the facility, for 1 resident (#61) of 27 residents reviewed. The findings included: Review of the facility policy Transfer/Discharges revealed .Orientation: The resident shall receive sufficient preparation and orientation to ensure safe and orderly transfer from the facility . Medical record review revealed Resident #61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Orders and Progress Notes dated 3/5/15 at 3:00 PM revealed .Transfer to .(local nursing facility) cont (continue) current medications . Medical record review of the Free Text Charting assessment dated [DATE] at 7:28 PM by Minimum Data Set (MDS) Coordinator revealed .I inform my DON (Director of Nursing) .and she instructed me to call (resident's) family and let them know they needed to come and get her that we could not keep her here and her being so aggressive and violent toward the other residents and staff .I called her .and explained what had happened .I went into detail and explained that we have 44 other residents that we have to keep safe and protect and with her acting out like that we could not let her stay here and he stated he understood and agreed that the other resident could not be put at risk of her possibly harming them .He arrived approx. 1 hour after or phone conversation and asked if it would be ok for her to stay here tonight because he did not have a car and his .didn't get off work until late tonight. The (DON)agreed that this would be ok. I explained in detail that she would be going home with home health and that medications would be sent the pharmacy of choice at time of d/c . Interview with the MDS Coordinator on 5/5/15 at 2:35PM in the activity office revealed the MDS Coordinator is responsible for discharging residents from the facility. Continued interview confirmed the facility had failed to provide sufficient preparation and orientation to the resident to ensure safe and orderly transfer prior to discharge. Interview with the Director of Nursing (DON) on 5/5/2015 at 3:20 PM in the activity office confirmed the facility had failed to provide sufficient preparation and orientation to the resident to ensure safe and orderly transfer prior to discharge.",2018-05-01
6595,UNICOI CO NURSING HOME,445077,100 GREENWAY CIRCLE,ERWIN,TN,37650,2015-05-06,323,D,1,1,GYWE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure supervision of a Resident during bathing for 1 resident (#70) of 30 residents reviewed. The findings included: Medical record review revealed Resident #70 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Nurse's Note dated 9/20/14 revealed .CNA (Certified Nursing Assistant) was giving resident a bed bath and turned resident and resident rolled out of bed landing on her knees. She received a skin tear on both knees and right elbow .Daughter and MD (Medical Doctor) notified. Daughter asked if she wanted to send resident to ER (Emergency Department). She told this nurse not right now . Medical record review of a Daily Progress Note dated 9/23/14 revealed .Patient with fall causing multiple abrasions worst being L (left) knee also has candidacies in mouth daughter request that I see her .pupils reactive but sluggish .Plan send to ER for head exam due to fall .wound care cleanse areas with wound cleanser apply Bactroban (Antibiotic) cover with Vaseline gauze 2 x 2's wrap with kerlix (type of guaze) .Diflucan (antibiotic) .QD (every day) . Medical record review of a hospital Teleradiology Preliminary Report dated 9/23/14 revealed .CT of head .no acute finding .no fracture . Continued review of a Right knee and Right elbow x-ray revealed .no fracture . Review of the hospital Physician discharge order dated 9/23/14 revealed .may return to NH (nursing home) . Interview with CNA #1 on 5/6/15 at 8:10 AM by phone revealed, .I had resident put hand on bed side rail and went to get linens from side of bed and noticed resident rolled out of bed . Interview with Nurse Practitioner (NP) #1 on 5/6/15 at 8:55 AM in the Director of Nursing (DON) office revealed the NP was asked to see the Resident by Resident daughter on 9/23/14 and sent out as Progress Note stated due to resident assessment. Interview revealed Resident had very thin skin and was prone to skin tears and was in a declining state when entered the building in May and both NP and Physician asked family to suggest hospice, which the family declined. Continued interview and medical record review of the hospital ER records revealed the Resident was negative for any fractures. Interview with the DON on 5/6/15 at 7:45 AM, in the DON office confirmed the facility failed to ensure adequate supervision during bathing resulting in a fall.",2018-05-01
6596,UNICOI CO NURSING HOME,445077,100 GREENWAY CIRCLE,ERWIN,TN,37650,2015-05-06,425,D,1,1,GYWE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to assure medications were administered as ordered for 1 Resident (#70) of 30 residents reviewed. The findings included: Medical record review revealed Resident #70 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Daily Progress Note dated 10/30/14 revealed .Patient with S/S (signs and symptoms) of cold versus URI ( upper respiratory infection) has low grade fever nasal congestion sore throat will assess .Plan .Azithromycin (antibiotic) 250 mg (milligrams) for 5 days .Vancomycin (antibiotic) .for 7 days . Medical record review of a Physician order [REDACTED].Azithromycin .for 5 days .Vancomycin for 7 days . Medical record review of the Residents Medication Administration Record [REDACTED]. Interview and medical record review of a Nurse's note dated 11/1/14 with Registered Nurse (RN) #1 on 5/6/15 at 7:40 AM, in the Director of Nursing (DON) office revealed .Patient lying in bed. Alert and confused at times. Able to make needs known. Started on Antibiotics . Continued interview revealed the RN #1 noticed antibiotics Vancomycin and Azithromycin had not been administered as ordered on [DATE] and asked Licensed Practical Nurse (LPN) #1 to obtain and administer medications. Interview with LPN #1 on 5/6/15 at 11:03 AM by phone revealed the LPN obtained and started the medications on 11/1/14. Interview with the DON and medical record review of the Resident MAR's on 5/6/15 at 11:40 AM, in the DON office confirmed the medications (antibiotics Vancomycin and Azithromycin) had not been obtained or administered until 11/1/14.",2018-05-01
8610,UNICOI CO NURSING HOME,445077,100 GREENWAY CIRCLE,ERWIN,TN,37650,2014-02-20,323,D,0,1,M85K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility documents, observation and interview, the facility failed to ensure safety devices were in place and functioning to prevent falls, and failed to implement recommended new interventions to prevent falls, for one resident (#54) of three residents reviewed for falls, of twenty four residents reviewed; and failed to secure one of two facility supply closets observed. The findings included: Resident #54 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Significant Change Minimum Data Set (MDS) dated [DATE], revealed the resident was cognitively impaired, required extensive assistance with activities of daily living and transfers, and was considered at risk for falls Medical record review of the physician's orders [REDACTED]. Review of facility documents dated February 10, 2014, revealed .resident found on floor by CNA (Certified Nurse Aide) No alarm was going off, no call light used, resident stated .was going to the BSC (bedside commode) and fell , helped resident to bed, skin assessment, resident stated .did not hit head, no head injury, skin tears on right arm . Observation and interview of the resident, on February 19, 2014, in the resident's room during wound care, revealed the resident with three small skin tears to the right forearm. The resident reported during interview no significant pain, and no complications related to the injuries. The resident stated I got up and I fell and cut it Interview with the MDS Coordinator and Patient Safety Officer, on February 20, 2014, at 12:52 p.m., in the MDS office confirmed at the time of the fall the resident alarm was in use and did not sound. Observation on initial tour February 18, 2014, at 11:20 a.m., revealed the door to the supply room in the main hallway was unlocked. Inside the room were stored four Total Body Shampoo 4 ounce (oz.) bottles, four Hand and Body Lotion 4 oz. bottles, five Johnson Baby Shampoo 1.5 oz. bottles, and seven Baby Powder 4 oz. bottles. All items were labeled Keep out of reach of children. Continued observation revealed several residents in wheelchairs traveling between the main dining room and the main hallway, passing the storage room. Interview with the Director of Nursing (DON) on February 18, 2014, at 11:22 a.m., confirmed the door was unlocked and residents could enter the room.",2017-05-01
8611,UNICOI CO NURSING HOME,445077,100 GREENWAY CIRCLE,ERWIN,TN,37650,2014-02-20,441,D,0,1,M85K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility policy and interview, the facility failed to maintain hand hygiene during the meal pass on one of two wings observed. The findings included: Observation on the 100 wing, on February 18, 2014, from 12:35 p.m. to 1:05 p.m., revealed two Certified Nursing Aides (CNAs) distributing meal trays to the residents. Observation of CNA #1 from 12:45 p.m. to 12:55 p.m. revealed CNA #1 entered room [ROOM NUMBER] and set up a meal tray for a resident, made contact with the resident's over bed table, and clothing, exited the room without washing the hands, returned to the meal cart, accessed the ice cooler beside the meal cart, obtained ice from the cart with a scoop, and returned to room [ROOM NUMBER]. Continued observation revealed CNA #1 exited room [ROOM NUMBER] a second time without washing the hands, returned to the meal cart, obtained a food tray from the cart, and entered room [ROOM NUMBER]. Continued observation revealed CNA #1 set up the meal tray for the resident in room [ROOM NUMBER] and touched the resident, and exited the room, without washing the hands. Continued observation on the 100 wing, from 12:55 p.m. to 1:10 p.m. revealed CNA #2 entered room [ROOM NUMBER], touched the resident, and exited the room without washing the hands. Continued observation revealed CNA #2 next entered room [ROOM NUMBER], touched the resident, picked up the meal tray, exited the room with the tray, delivered it to the meal cart, and proceeded to the nursing station without washing the hands. Continued observation at 1:00 p.m. revealed CNA #2 picked up an ink pen lying on a clipboard, documented care on a clipboard, and then entered room [ROOM NUMBER] without washing the hands. Continued observation revealed CNA #2 exited room [ROOM NUMBER], and proceeded to room [ROOM NUMBER] and entered without washing the hands, picked up a meal tray, delivered it to the meal cart in the hallway, and proceeded to the staff lounge, without washing the hands. Continued observation at 1:10 p.m. in the 100 hallway nursing station revealed CNA #1 documenting care on the same clipboard, using the same pen lying atop it, used previously by CNA #2. Review of the facility policy Infection Control for Long Term Care Residents and Staff, effective August 1985, reviewed May 23, 2011, revealed, . hand hygiene is practiced between each resident . Interview with the 100 hallway charge nurse, at 1:11 p.m., in the nursing station, confirmed hands were to be washed upon entering and exiting resident rooms or between resident contacts, or when hands were visibly soiled, and confirmed the facility failed to maintain hand hygiene during the lunch tray pass.",2017-05-01
8612,UNICOI CO NURSING HOME,445077,100 GREENWAY CIRCLE,ERWIN,TN,37650,2014-02-20,514,F,0,1,M85K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to maintain resident records in a systematically organized, complete, accurate, and readily accessible format for four residents, (#37, #53, #54 and #58) of sixty resident records reviewed, and for five of thirty closed records for residents (#18, #32,#46, #66, #68) reviewed. The findings included: Resident #37 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the care plan dated February 18, 2013, revealed .care plan developed pt (patient) cont (continues) on soft mech (mechanical) diet .supplements will be added . Medical record review of the care plan dated March 14, 2013, revealed .supplements were added . Medical record review of the physician order [REDACTED].ensure (supplement) liq (liquid) vanilla give by mouth with meals 3 times daily . Medical record review of the care plan dated January 3, 2014, revealed .cont on soft diet /c (with) supplementation . Observation of the resident on February 18, 2014, at the lunch meal in the dining room revealed the resident at the dining table eating pizza that had been brought in by a visitor for a couple of residents. The resident consumed one slice of pizza. The Certified Nurse Aide (CNA) brought the residents tray to the resident at the table. The resident refused the tray and said was eating pizza for lunch. The supplement and a milkshake were on the tray. The CNA offered the supplement and the milkshake to the resident who refused and stated will drink them at supper Resident #53 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician orders [REDACTED].add glucerna (a supplement) to meals twice daily per dietician recommendation . Medical record review of the dietary assessment dated [DATE], revealed .diet regular /c glucerna bid (twice a day) . Medical record review of the nursing monthly summary dated January 19, 2014, revealed .eating habits usually good appetite Medical record review of the physician progress notes [REDACTED].appetite is good and has started some supplements to aid in weight . Interview with Licensed Practical Nurse #2, on February 19, 2014, at 9:30 a.m., in the side two nursing station revealed nursing doesn't document the supplement intakes, dietary puts them on the meal trays and delivers them. The CNA's add up the fluid intake and count it all together. Interview with CNA #3 on February 21, 2014, at 12:30 p.m., in the side two nursing station revealed we add all the liquids together and count them, we don't separate them. Interview with the Director of Nursing (DON) on February 21, 2014, at 12:50 p.m., in the DON office revealed .supplements aren't documented anywhere, they come on the trays labeled what they are but then all the liquids are added together for intake . Resident #54 was admitted to the facility on [DATE], with diagnoses, including Dementia, [MEDICAL CONDITION] Fibrillation, [MEDICAL CONDITION], and End Stage [MEDICAL CONDITION]. Medical Record review of the Significant Change Minimum Data Set (MDS) dated [DATE], revealed the resident was cognitively impaired, required extensive assistance with activities of daily living and transfers, and was considered at risk for falls. Continued review of the physician's orders [REDACTED]. Review of facility document dated February 10, 2014, revealed the consultant pharmacist reviewed the resident medications and recommended evaluation of the resident's blood pressure for symptoms of orthostatic [MEDICAL CONDITION] (a sudden drop in blood pressure caused by change in body position associated with some combinations of medications). Continued medical record review revealed no indication the facility carried out the consultant pharmacist's recommendations to evaluate the resident for symptoms of orthostatic [MEDICAL CONDITION] after the fall. Interview with the MDS Coordinator and Patient Safety Officer, on February 20, 2014, at 12:52 p.m., in the MDS office revealed, the recommendations of the pharmacist were made in an electronic format, which was not accessible to the facility clinical staff. Continued interview revealed the electronic communications and recommendations made by the consultant pharmacist could not be printed by the facility management, or clinical staff. Continued interview revealed the recommendations were to have been transcribed by the MDS coordinator into a written format and included in the facility's paper medical record for review by the clinical staff. Continued interview revealed the MDS coordinator was unaware of the recommendations made by the pharmacist as no electronic means to alert the MDS coordinator of the recommendations was in place. Continued interview revealed the recommendations were forwarded electronically to the facility risk management department, and were not transcribed into the facility clinical staff's paper medical records, nor were those recommendations from the risk management department electronically accessible to the clinical staff. Continued interview confirmed the MDS coordinator had failed to forward the consultant pharmacist's recommendations to the nursing staff, and the facility failed to implement the new intervention to prevent falls. Continued interview confirmed the facility's medical record for resident was incomplete, not systematically organized, accurate, or readily accessible. Closed record review of thirty residents' charts revealed five closed records of thirty closed records reviewed contained only printed partial MDS information and had to be returned to the Medical Record department to retrieve the full closed records. Interview with the Safety Officer, in the conference room on February 20, 2014, at 1:30 p.m, in the conference room confirmed the records were not complete and records were unorganized and often difficult to access, We know we have a problem. Resident #58 was admitted to the facility December 13, 2013, with [DIAGNOSES REDACTED]. Medical record review of the Dietary Progress Notes dated December 23, 2013, revealed .only eating 40% at meals .Rec (receives) glucerna TID (three times daily) to .(increase) cal/protein intake . Medical record review of the Flowsheet View Report dated December 13, 2013 to February 7, 2014, revealed no entry for Glucerna (a diabetic protein and calorie supplement) nor the specific amount of the Glucerna consumed by the resident. Interview with the Registered Dietician, (RD) on February 20, 2014, at 1:10 p.m., in the conference room, confirmed supplement consumption was not documented by the nursing staff and the Registered Dietician was unable to determine if the supplement was effective or ineffective unless the resident continued to lose weight.",2017-05-01
10628,UNICOI CO NURSING HOME,445077,100 GREENWAY CIRCLE,ERWIN,TN,37650,2012-09-12,280,D,0,1,ZXCY11,"**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 to reflect change in the residents' status for two residents (#1, #7) of eleven residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation on September 10, 2012, at 3:20 p.m., in the resident's room, revealed the resident in a geri chair with a pressure pad alarm in place. Continued observation revealed a pressure pad alarm on the resident's bed. Medical record review of the care plan last updated on August 15, 2012, revealed no documentation of the placement of a pressure pad alarm to the geri chair or the bed. Interview with the Director of Nursing (DON), on September 11, 2012, at 2:00 p.m., in the Conference Room, confirmed the resident's care plan had not been updated to reflect the use of the pressure pad alarm on the resident's Geri-chair or bed. Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident was cognitively impaired and dependent for activities of daily living. Observation on September 10, 2012, at 10:42 a.m., in the facility day area, revealed the resident in a wheelchair with a pommel cushion (a chair cushion with elevated center to limit forward movement of the pelvis while seated) and a soft restraint belt secured to the back of the wheelchair. Medical record review of the care plan (undated) revealed .self release belt while in w/c (wheelchair) . Medical record review of the Physical Device and Physical Restraint assessment dated [DATE], revealed standard w/c (wheelchair) .with soft posey belt for mobility .pommel cushion for comfort and positioning .have spoken with family .they agree to restraint . Continued medical record review of the Physicians Verbal Orders dated August 27, 2012, revealed .soft restraint and pommel (cushion) while in w/c (wheelchair) . Interview with the MDS Coordinator on September 11, 2012, at 8:15 a.m., in the Conference Room, confirmed the care plan had not been updated to reflect changes in the resident's status.",2016-05-01
10629,UNICOI CO NURSING HOME,445077,100 GREENWAY CIRCLE,ERWIN,TN,37650,2012-09-12,323,D,0,1,ZXCY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility investigations, and interview, the facility failed to implement measures to prevent falls for two residents (#7, #8) of eleven sampled residents. The findings included: Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident was cognitively impaired and dependent for activities of daily living. Medical record review revealed the resident was involved in falls without injury on August 25, 2012, and August 26, 2012. Review of a facility investigation dated August 26, 2012, revealed .CNA (Certified Nursing Assistant) notified .resident was found in floor .observed .lying in the floor beside .bed .bed alarm was not going off .replaced batteries in bed alarm .placed resident back to bed . Interview with Licensed Practical Nurse (LPN #1) on September 11, 2012, at 1:50 p.m., in the conference room, confirmed at the time of the fall, the bed alarm malfunctioned due to dead batteries, and the facility failed to implement the measure to prevent falls for the resident. Resident #8 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed, the resident was independent in decision making and required assistance with activities of daily living. Review of facility investigations revealed the resident was involved in falls without injury on September 26, 2011, December 17, 2011, and July 27, 2012. Review of a facility investigation dated December 19, 2011, revealed .resident was observed sitting in the floor between .dresser and the bed .had self release belt that was released by the resident .alarm was in wheel chair and was turned off .will re-educate staff on alarm use .place in day area when out of bed . Interview with the Director of Nursing (DON) on September 12, 2012, at 10:20 a.m., in the DON's office, confirmed the bed alarm was turned off at the time of the fall, and the facility failed to implement measures to prevent falls for the resident.",2016-05-01
10630,UNICOI CO NURSING HOME,445077,100 GREENWAY CIRCLE,ERWIN,TN,37650,2012-09-12,371,F,0,1,ZXCY11,"Based on observation and interview, the facility failed to provide sanitary storage of food and equipment. The findings included: Observation of the dietary department on September 10, 2012, from 10:45 a.m. until 12:00 p.m., revealed: 1. Two employee can drinks were setting on the counters; 2. Employees had the following foods stored in the resident refrigerators: -24 ounce bottle of soft drink; -2 liter bottle of soft drink (2); -16.9 ounce bottle of water; -5 ounce bottle of steak sauce that expired 6-18-12; -14 ounce bottle of Ketsup that expired April 2012; -2 grilled cheese sandwiches wrapped in plastic wrap; -bottle of sports drink; -lunch meat sandwich 3. A stand up electric slicer had food debris on the lip, the blade, and the top of the machine, and was available for use; 4. Seven expired,September 1, 2012, whole eggs in the walk in refrigerator that were available for use; 5. The stand up mixer was dirty and dusty, and was available for use; 6. Two packages of carrots were in the walk in refrigerator that expired on 5-27-12 and 7-28-12, and were available for use; 7. One open container of marsh mellows in the walk in refrigerator expired on July 28, 2012, and was available for use; 8. One large container of soup beans in the walk in refrigerator was unlabeled and undated, and was available for use; 9. One container of diced tomatoes in the walk in refrigerator was unlabeled and undated, and was available for use; 10. The vent hood over the stove was dirty and greasy, and was available for use; 11. Paprika bottle was open and not dated, and was available for use; 12. The following spices were opened and out dated above the prep table, and were available for use: a. Ground Nutmeg, 2-20-08; b. Meat Tenderizer, 11-11; c. Celery Seed, 4-21-11; d. Onion Powder, 5-7-11; e. Dill Weed, 10-11-09; f. Chili Powder, 5-23-11; g. Ground Oregano, 4-28-09; 13. Instant Mashed Potatoes, 57 ounce container was open and not dated, and was available for use; 14. Vinegar, one gallon container was open and not dated, and was available for use; 15. Imitation Vanilla Extract, 32 ounce bottle, expired on 11-23-10, and was available for use; 16. Steam table is not large enough to hold all the food prepared for the meals which can produce unsafe temperatures in those served from outside the steam table; 17. Flours and sugar are stored in their original paper wrappers instead of being stored in large sealable plastic containers. Interview with the Dietary Manager on September 10, 2012, at 12:00 p.m., in the dietary department, confirmed employee drinks were not to be in the kitchen prep area, employee food was to be stored separately from the resident's food, the stand up slicer and mixer were to be cleaned prior to storage, all items stored in the walk in refrigerator, dry storage area, and spice storage area were to be labeled with the date once they were opened and be disposed of after their expiration date, the vent hood over the stove needed to be cleaned and checked daily, flour and sugar needed to be stored in sealable plastic containers, and a larger steam table was needed to ensure that food temperatures were maintained during the entire serving process.",2016-05-01
10631,UNICOI CO NURSING HOME,445077,100 GREENWAY CIRCLE,ERWIN,TN,37650,2012-09-12,502,D,0,1,ZXCY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to obtain laboratory tests as ordered by the physician for two (R #A, R #B) of nine residents reviewed. The findings included: Resident #A was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician order, dated July 11, 2012, revealed .[MEDICATION NAME] (medication for [MEDICAL CONDITION] Disorder) level in 2 wks (weeks) . Medical record review of lab reports revealed no documentation of a completed [MEDICATION NAME] level. Interview with the Director of Nursing on September 12, 2012, at 8:00 a.m., in the Day Room by the Station 1 Nursing Station, confirmed the facility had failed to obtain lab work as ordered by the physician for Resident #A. Resident #B was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].HgbA1C (laboratory order to test sugar in Diabetics) .Q (every) 3 months . Medical record review of laboratory reports revealed an HgbA1C level was documented on April 13, 2012. Further review revealed no other documentation of a completed a HgbA1C level after April 13, 2012. Interview with the Director of Nursing on September 12, 2012, at 8:00 a.m., in the Day Room by the Station 1 Nursing Station, confirmed the facility had failed to obtain a HgbA1C (since April 13, 2012) as ordered by the physician.",2016-05-01
10632,UNICOI CO NURSING HOME,445077,100 GREENWAY CIRCLE,ERWIN,TN,37650,2012-09-12,520,F,0,1,ZXCY11,"Based on review of facility documentation and interview, the facility failed to ensure the Quality Assurance Committee was meeting quarterly. The findings included Review of the facility's Quarterly Assurance committee's sign-in sheets, revealed the facility's Quality Assurance committee met on July 18, 2011, January 17, 2012, and August 2 and 23, 2012. Interview with the Director of Nursing (DON) and Administrator on September 12, 2012, at 10:00 a.m., in the Administrator's office, confirmed the facility's Quality Assurance committee had not been meeting quarterly.",2016-05-01
12984,UNICOI CO NURSING HOME,445077,100 GREENWAY CIRCLE,ERWIN,TN,37650,2011-04-14,242,D,0,1,Z9J211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure the resident's right to make choices on when to use a personal telephone for one resident (#4) of fifteen residents reviewed. The findings included: Resident #4 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident scored twelve out of fifteen (fifteen being the highest cognitive status) on the Brief Interview for Mental Status (cognitive status). Continued review of Section G of the MDS revealed, ""...Res interview: use phone in private: (1) Very important..."" Medical record review of a nurse's note dated March 26, 2011, at 2110 (9:10 p.m.), revealed, ""...resident became very upset when (resident's) phone was unplugged as requested by family...wanted to speak with family...Refused to accept that it had been being unplugged at 2100 (9:00 p.m.), each night..."" Observation and interview in the resident's room on April 12, 2011, at 1:00 p.m., revealed a cordless phone on the overbed table and the resident stated, ""I do not want my phone unplugged; you never know when somebody may need me and if my phone is unplugged, they can't reach me."" Interview in the MDS Coordinator's office with the Social Services Director and Director of Nursing on April 12, 2011, at 3:15 p.m., confirmed the facility unplugged the resident's phone each night. Continued interview confirmed the facility failed to ensure the resident's choice to keep the phone plugged up at night. .",2015-05-01
13917,UNICOI CO NURSING HOME,445077,100 GREENWAY CIRCLE,ERWIN,TN,37650,2010-07-22,323,D,1,0,JFRY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a facility investigation, and interview, the facility failed to ensure personal safety devices were in place for one resident at high risk for falls (#1) of five residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short-term memory problems and difficulty with decision-making in new situations only; had no indicators of depression, anxiety or sad mood and no wandering behaviors; required limited assistance with bed mobility, transfers and ambulation; had partial loss of range of motion in one arm, hand and leg; and had no falls in the prior one-hundred-eighty days. Medical record review of the fall risk assessments dated June 13, 2009, September 30, 2009, and December 25, 2009, revealed the resident was at high risk for falls. Medical record review of elopement risk assessments dated June 13, 2009, September 30, 2009, and December 25, 2009, revealed the resident was not at risk for elopement. Medical record review of the care plan dated December 23, 2009, revealed the resident was at risk for falls and had a pad alarm and clip alarm. Medical record review of the Certified Nursing Assistant (CNA) ""worklist"" dated March 1-31, 2010, revealed alarms were to be checked every shift and revealed no documentation the pad and clip alarms were checked during the 3:00 p.m., to 11:00 p.m., shift on March 15, 2010. Medical record review of a nurse's note dated March 15, 2010, (no time given) revealed, ""Ambulated in hall to little day room. When rechecked dayroom, the resident was missing. Found outside ...lying ...on right side. No bruising was noted or tenderness ...x-ray ordered ..."" Review of documentation of the facility's investigation revealed the resident was observed in the day room on March 15, 2010, at 6:55 p.m., and safety alarms were not in place. Continued review revealed at 7:00 p.m., (five minutes later), on March 15, 2010, staff observed the resident had fallen outside the facility. Continued review revealed the physician was notified, and x-rays were ordered. Review of a physician's progress note dated March 15, 2010, revealed the right hip and femur, both feet and the pelvis were x-rayed, and the results revealed no fracture. Medical record review revealed the resident was transferred on March 16, 2010, to another long-term care facility with a secured unit. Interview on July 21, 2010, at 11:55 a.m., in the office, with the Director of Nursing (DON) confirmed the facility's policy required safety alarms be checked every shift and confirmed no documentation the presence of safety alarms for resident #1 had been checked by the 3:00 p.m., to 11:00 p.m., CNA on March 15, 2010. Continued interview with the DON confirmed the safety alarms were not in place at the time the resident exited the facility and fell and confirmed the CNAs and RN on duty at the time of the fall had knowledge the alarms were not in place. Telephone interview on July 21, 2010, at 1:50 p.m., with the Registered Nurse on duty 3:00 p.m., to 11:00 p.m., on March 15, 2010, confirmed safety alarms were not in place at 6:55 p.m., on March 15, 2010, at the time the resident exited the building and fell . C/O #",2014-07-01
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
4615,"NHC HEALTHCARE, SPRINGFIELD",445088,608 8TH AVE EAST,SPRINGFIELD,TN,37172,2016-05-19,371,F,0,1,U7XM11,"Based on document review, observation, and, interview the facility failed to store and prepare food under sanitary conditions to prevent foodborne illnesss with potential to affect 86 of the 94 (non-tube fed) facility residents. The findings include: 1. Review of the facilities document titled Safety and Sanitation Best Practice Guidelines (1/2011) states 6. Foods will be stored in their original packages, if possible. If opened, packages should be closed securely to protect product . Review of the facilities document titled, Refrigerated Food Storage Guide Refrigerator temperature forty-one (41) degrees Fahrenheit (Reference 2001 Food Code 3-501.17) states, Food-Cooked Meats .Storage Time -seven (7) days Special Instructions .covered securely .Eggs, fresh-Special Instructions .bottom shelf, Milk-storage time-Manufacturers expiration date, Mayonnaise .Special Instructions Refrigerate immediately c. Cold foods will be held at 41 degrees Fahrenheit or lower .Cold items should be left in refrigerator and pulled one tray at a time during service .to help maintain temperatures. 2. Review of the facility training roster titled, Dating food items when opened, FIFO, cleanliness of food items, correct way to clean floors and walls, correct way to clean kitchen equipment, wet nesting, correct way to thaw food, chemical storage, hair restraints and weekly cleaning schedule was presented to the dietary staff on 5/25/15 and 5/29/15 with an additional Check-Up Inservice provided on 7/3/15 and 7/7/15. 3. Observation on 05/16/16 at 9:45 AM during the initial tour of the kitchen/kitchen area revealed three (3) previously opened and used bottles of Heinz tartar sauce 12.5 ounce - sitting on counter adjacent to the steam tables, the bottles were warm to touch. Temperature of the tartar sauce per the Dietary Director was seventy (70) degrees Fahrenheit. Interview at this time with the Director of Dietary stated the containers of tartar sauce may have been sitting out since 5/14/16 at noon, but states he/she was unsure. The Dietary Director stated it was the morning cook who should be monitoring this item to make sure it was stored properly in the refrigerator. Interview with the morning cook on 5/16/16 at 10:30 a.m. revealed he/she was unsure of how long the tartar sauce had been sitting out or where it came from. The morning cook stated it was not good for tartar sauce to sit out and not be refrigerated because it would not be cool and fresh, and could make you sick. The morning cook stated he/she had received education on proper storage of foods in the past, but it has been awhile. 4. Additional observation during the initial tour of the kitchen, revealed a nutrition refridgerator #1 in which the bottom shelf had standing water of approximately one quarter (1/4 ) inch. Also observed was a carton of rolls with a completely wet and soggy cardboard type container. Interview with the kitchen manager at this time revealed the water was coming from soup that was being thawed from a frozen state in it's original cardboard type delivery box. The Dietary Manager stated the soup should have been placed in a bowl rather than a box to thaw out. 5. Observation at this same time revealed a cooked ham that was loosely wrapped in a clear and aluminum type of cover. The ham was noted to be stored on the middle shelf of the refrigerator #1 and clear drippings were noted on the ham cover wrap. The date on the ham revealed a storage date of (MONTH) 4th, (YEAR). Interview with the Dietary Manager at this time revealed the ham would be safe to serve to the residents for at least two (2) weeks. 6. Continued observation of the same nutrition refrigerator #1 revealed a bag of kale that was loosely closed up in it's original packaging by a hand tied knot at the top of the bag. Several of the leafs of the kale appeared yellow/dark green/soggy. Interview with the Dietary Manager and the Dietary Director at this time revealed the kale was not stored properly and should have been stored in airtight containers or containers with sealed lids. 7. Observation of the same nutrition refrigerator #1 revealed a carton of heavy whipping cream which expired on 5/5/16, a carton of reduced fat milk which expired on 5/5/16. 8. Observation of refrigerator #1 also revealed a carton of unpasteurized eggs which were not stored on the lowest level of the refrigerator. Interview with the Dietary Manager at this time revealed the eggs should always be stored on the lowest level of the refrigerator, along with the meats in order to avoid cross contamination of the products onto other foods. 9. Observation of the resident reach in refrigerator #2 located behind the steam table revealed seven (7) cartons of Buttermilk with an expiration date of 5/14/16. 10. Observation on 05/16/16 12:20 PM revealed the resident reach in refrigerator #2, located directly behind the steam table , had it's door propped open with a cart. The temperature reading on the outside of the refrigerator read 72 degrees Fahrenheit. Residents were receiving milk and butter products from this refrigerator with their noon meals. Interview with the Dietary Manager at that time revealed random milk temperatures were 42.3 degrees F, 46.2 degrees F, and 48 degrees F. All the milk in the refrigerator was removed and disposed of at this time by the Dietary Manager. Continued interview with the kitchen manager revealed the milk temperatures should never exceed forty (40) degrees F. Interview at this time with the dietary worker #1 revealed he/she was aware that the resident refrigerator should be kept closed, but he/she kept it open anyway as it was an easier and quicker way to serve the milk and butter products to the residents. He/ She stated that there had been training on safe food temperatures and was able to state unsafe food temperatures could make a resident ill. Interview with Dietary Worker #2 at this same time revealed that the refrigerator should always be kept closed in order to maintain product freshness and to avoid a food borne illness. Interview with the Dietary Director on 5/16/16 at 12:30 PM revealed the employee had received education in the past on the importance of maintaining safe food temperatures and the resident refrigerator should always be kept closed. Interview on 05/18/16 11:35 AM with Dietary Worker #3 revealed when food needs to be thawed, the food should always be taken out of the original boxes and put in a pan in the refrigerator so it won't un-thaw and leak all over. Dietary Worker #3 went on to state that eggs should be stored in the middle of the refrigerator on a higher shelf so that they will not get broken. The dietary worker stated that cooked meats should be thrown away after at least 7 days, but he/she has never really been trained on it. Continued interview with Dietary Worker #3 revealed that certain employees would always want to leave the dining room refrigerator open, but I don't. We keep milk products, butter and cream in it. It should never be left open. Milk products should be stored at around 35 or 36 degrees. It is not safe to serve milk products when the temperature is higher than 40 degrees. It can make people sick, we have been taught that. The dietary aides are responsible to remove out dated food items. That's the problem, no one is checking. Interview on 05/18/16 11:53 AM with dietary worker #4 revealed the dietary worker had been trained on food safety in the past. He/She stated, All foods should be stored securely by a wrap or zip lock bag and most foods should only be stored about three (3) to five (5) days, but I'm not sure exactly, I'd have to ask someone. All refrigerators should be kept at 35 to 40 degrees. I do get the milk out of the front refridgerator on the line. The refridgerator door should always be kept shut, so that the milk does not spoil. On 05/18/16 12:05 PM an interview with Dietary Aide # 2 revealed, We are supposed to put frozen soups in the bottom of the fridge but it should be in a pan, not the original box. The box may get wet. All foods should be thrown out after three (3) days. We really not receive much education anymore on food safety. All eggs and meats should be stored on the bottom shelf, so to avoid Salmonella. It could drip down on other foods. It's the manager and the Dietary Director to maintain the refridgerator, but it's really everyone's responsibility. 10. Observation on 05/16/16 at 10:45 AM revealed Direct Care Staff #17 fed two (2) residents who were attempting to self feed at a table together. Staff touched the utensils the male resident had been touching to assist that resident with eating, then picked up the utensils the other resident had been touching and continued to feed both residents without using any hand sanitizer or washing hands. Staff then cleared the dirty dishes off of the table then went to another table and fed another resident without washing hands or using hand sanitizer. Duing interview on 05/16/16 at 11:00 AM Direct Care Staff #17 reported no hand sanitizer was used between going from one resident to the next or after clearing the dirty dishes because the hand sanitizer was not with staff, but was left over there and not in that dining area. During interview on 5/19/16 at 10:00 A.M. the Director of Nursing reported if staff assisted two residents with eating who had been self feeding at times, then that staff member should sanitize their hands between resident contact or contact with their utensils. Staff should also use sanitizer after cleaning dirty dishes off of a table and prior to feeding another resident.",2019-08-01
4616,"NHC HEALTHCARE, SPRINGFIELD",445088,608 8TH AVE EAST,SPRINGFIELD,TN,37172,2016-05-19,463,D,0,1,U7XM11,"Based on policy review, observation, and interview the facility failed to provide resident call systems for 2 of 2 bathrooms (1 labeled men and the other labeled women). The bathrooms were located across from the nurses station on the West Wing where residents resided. Findings include: Review of the facility policy (no date) titled Call Lights confirmed the facility will provide functioning call light systems to any resident rooms and bathrooms that can be occupied by residents. Observations upon entering the ladies room on the West Wing on 5/16/16 at approximately 10:35 AM revealed the ladies restroom had no call system installed and that any resident who utilized the restroom had no way to summon for help if needed. The West Wing housed residents or any resident passing by the restroom could enter the restroom and be unable to send a signal to the nurse's station for help if an emergency occurred. On 05/17/16 at 3:46 PM an interview was conducted with LPN #1 and the DON regarding the missing call light situation. LPN #1 agreed that any resident in the area who needed to use the restroom in an emergency could become ill and require the need to summon for assistance. The DON also agreed that a call system was needed in both restrooms. On 5/17/16 3:52 PM, an interveiw was conducted with the Administrator regarding the need for call light systems in both bathrooms. The Administrator immediately checked the men's restroom and confirmed there was no call light system there as well. The concensus from all satff interviewed revealed a need for a call light system in both bathrooms.",2019-08-01
6160,"NHC HEALTHCARE, SPRINGFIELD",445088,608 8TH AVE EAST,SPRINGFIELD,TN,37172,2015-05-13,253,E,0,1,XJU711,"Based on policy review, observation and interview, the facility failed to provide an effective maintenance and housekeeping services to maintain a sanitary, orderly and comfortable environment as evidenced by dirty, stained thresholds leading into bathrooms, dirty grout and dirty caulk around commode bases, brown substance on the bathroom wall beside commode, dirt and lint on the floor between air conditioner unit and box around unit, handrail in bathroom with missing plate over screws and privacy curtain hanging off track in 13 of 53 (Rooms on 6, 27, 37, 41, 42, 45, 46, 24, 8, 48, 9, 11 and 12) resident rooms and bathrooms. The findings included: 1. Review of the facility's basic housekeeping procedure documented, .C. Restrooms . h. Using a wet mop and cleaner -disinfectant solution, damp-mop the entire floor surface . 2. Weekly . a. Spot Scour ceramic tile surfaces with lotion cleanser . 2. Observations in rooms 6, 27, 37, 41, 42, 45 and 46 on 5/11/15 at 11:00 AM, revealed dirt and stains on the thresholds going into the bathrooms. 3. Observations in room 24 on 5/11/15 at 11:00 AM, revealed the privacy curtain around bed A was hanging off the track, and the handrail in the bathroom was missing a plate over the screws. 4. Observations in room 8A on 5/11/15 at 2:58 PM, revealed caulk around the commode base dirty and stained, dirt and grime buildup on the threshold going into the bathroom and a brown substance on the wall beside the commode. 5. Observations in room 48C on 5/11/15 at 2:58 PM, revealed a dirt and lint between the air conditioner unit and the box around unit. 6. Observations in room 9B, 11A and 12B on 5/11/15 at 2:58 PM, revealed dirt and stains on the thresholds going into the bathrooms, and a dirt and grime buildup on the bathroom floor and in the corners of the bathrooms. 7. Interview with the Administrator and the Maintenance Supervisor (MS) on 5/12/15 at 5:10 PM, during walking rounds, the Administrator and the MS validated there were stains, dirt and grime buildup on the thresholds and the floors leading in the bathrooms. In room #24 the MS was asked, Are the curtains off track and is the plate over the handrail screws missing. The MS stated, Yes.",2018-09-01
6161,"NHC HEALTHCARE, SPRINGFIELD",445088,608 8TH AVE EAST,SPRINGFIELD,TN,37172,2015-05-13,280,D,0,1,XJU711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to ensure the care plan was revised to include a Foley catheter and Foley catheter care for 1 of 1 (Resident #110) sampled residents with a Foley catheter of the 40 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #110 was admitted on [DATE] with readmitted s of 4/14/15, 4/24/15 and 5/1/15 with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Review of the care plan dated 3/20/15 with revisions 5/1/15 did not reflect the Foley catheter or Foley catheter care. The resident returned from the hospital on [DATE] with a Foley catheter. Observations in Resident #110's room on 5/11/15 at 2:58 PM, on 5/11/15 at 5:02 PM and on 5/12/15 at 11:12 AM and 4:22 PM, revealed Resident #110 had a Foley catheter. Interview with Registered Nurse (RN) #1 on 5/12/15 at 6:10 PM, in the conference room, RN #1 was asked who updates the care plans. RN #1 stated, I do when it is time for the update or a significant change which I did do that today, but the nurses would update the care plan when they return from the hospital. RN #1 was asked to look at the chart and see if Resident #110 had a care plan for a Foley catheter and catheter care. RN #1 stated, No, there is not a care plan for Foley catheter and catheter care.",2018-09-01
6162,"NHC HEALTHCARE, SPRINGFIELD",445088,608 8TH AVE EAST,SPRINGFIELD,TN,37172,2015-05-13,315,D,0,1,XJU711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medicak record review, observation and interview, the facility failed to ensure urinary catheters were maintained in a manner to prevent the spread of infection when the foley bag and tubing were touching the floor for 1 of 1 (Resident #110) sampled residents with a foley catheter of the 40 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #110 was admitted on [DATE] with readmitted s of 4/14/15, 4/24/15 and 5/1/15 with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Observations in Resident #110's room on 5/11/15 at 2:58 PM, on 5/11/15 at 5:02 PM and on 5/12/15 at 11:12 AM, revealed Resident #110's foley catheter tubing was touching the floor. Observations in Resident #110's room on 5/12/15 at 4:22 PM, revealed part of the foley catheter bag was touching the floor. Interview with Licensed Practical Nurse (LPN) #1 on 5/12/15 at 4:25 PM in Resident #110's room, LPN #1 was asked if Resident #110 had a catheter. LPN #1 stated, She does have a catheter. LPN #1 was asked if the catheter bag and tubing should be touching the floor. LPN #1 stated, No ma'am, it should not be on the floor. Interview with the Director of Nursing (DON) on 5/12/15 at 5:43 PM, in the conference room, the DON was asked if it is acceptable for a resident with a catheter and a history of urinary tract infections to have the catheter bag and the tubing to be touching the the floor. The DON stated, Shouldn't be on the floor.",2018-09-01
6163,"NHC HEALTHCARE, SPRINGFIELD",445088,608 8TH AVE EAST,SPRINGFIELD,TN,37172,2015-05-13,325,D,0,1,XJU711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, closed medical record review and interview, the facility failed to assess the nutritional status of 1 of 3 (Resident #104) sampled residents of the 40 residents included in the stage 2 review. The findings included: Review of the facility's Nutritional Services policy documented, .A note recording the first meeting with the patient, the diet order, and any pertinent information concerning the patient's nutritional needs . should be written within 24 hours of center admission for Sunday through Thursday admissions and within 72 hours for Friday and Saturday admissions . Closed medical record review revealed Resident #104 was admitted on [DATE] with [DIAGNOSES REDACTED]. Interview with the Regional Registered Dietician (RRD) on 5/13/15 at 8:45 AM, in the conference room, the RRD was asked when was it appropriate for the RD to evaluate a new resident. The RRD stated, The dietician should see the resident within 14 days. The kitchen manager may be the first to visit the resident for preferences with in a couple of days, preferably within the first 24 hours. The RRD was informed the kitchen manager visited Resident #104 within 4 days after her admission and was asked if that was acceptable. The RRD stated, No it's not. Interview with the Director of Nursing (DON) on 5/13/15 at 9:45 AM, in the conference room, the DON was asked when was Resident #104 seen by dietary. The DON stated, (MONTH) 26, 14 (2014). The DON was asked if that was acceptable. The DON stated, Not per our policy. Sometimes we just mess up. Resident #104 was admitted on a Monday and a nutritional assessment was not completed within 24 hours of admission according to the facility's policy.",2018-09-01
6164,"NHC HEALTHCARE, SPRINGFIELD",445088,608 8TH AVE EAST,SPRINGFIELD,TN,37172,2015-05-13,371,F,0,1,XJU711,"**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 open food items with no open date, expired food, food containers with dust, dirt and dry substance on the containers, thick dirt around the baseboard in the storage area, dirt under storage racks in the storage room, the walls with splatters of dry substance in storage room, a mop bucket with dirty water and a mop sitting in the dirty water, pots and pans with carbon build-up and wet nested pans, a mixer with dried food particles and chipped paint, frozen food in the sink thawing with cleaning solution sitting on the ledge of the sink and a pipe draining water from a steam table into the same sink as the thawing meat, staff entered kitchen not wearing hair covers and no working cleaning schedule on 3 of 3 (5/11/15, 5/12/15, and 5/13/15) days of survey. The facility had a census of 88, with 85 of those residents receiving a meal tray from the kitchen. The findings included: 1. Observations in the kitchen on 5/11/15 at 11:25 AM and on 5/12/15 at 3:45 PM, revealed the following: a. 2-13 ounce (oz.) bottles of mustard open with no open date. b. 1-bag of gelatin wrapped in clear plastic wrap with no open date. c. 1-bag wheat bread open with no open date. d. 1-bag potato chips open with no open date. e. 2-16 oz. jars roasted garlic open with no open date. Interview with the Dietary Manager (DM) on 5/11/15 at 11:40 PM, and on 5/12/15 at 3:50 PM, the DM was asked if she could find opened dates on the food items. The DM stated, No. The DM was asked if it was acceptable to have food products open with no open date written on the containers. The DM stated, No. 2. Observations in the kitchen on 5/11/15 at 11:35 AM, revealed 4-1 gallon containers of apple cider vinegar with an expiration date of 4/5/15. Observation in the kitchen on 5/12/15 at 3:45 PM, revealed 1-16 count pack White [MEDICATION NAME] Hamburger Buns with an expiration date of 5/11/15. Interview with the DM in the kitchen on 5/11/15 at 11:40 AM, in the kitchen, and 5/12/15 at 3:50 PM, in the kitchen, the DM was asked if it was acceptable to have expired foods on the shelves. The DM stated, No. 3. Observations in the kitchen on 5/11/15 at 11:35 AM, revealed the following food items covered in dust, dirt and dry substance on the sides of the containers: a. 2-1 gallon containers Burgundy Cooking Sauce. b. 1-1 gallon Imitation Vanilla. c. 1-1 gallon Soy Sauce. Interview with the DM on 5/11/15 at 11:40 AM, in the kitchen, the DM was asked if it was acceptable for the food containers to be dirty. The DM stated, No, ma'am, it's not. 4. Review of the facility's .CLEANING PR[NAME]EDURES . FLOORS . policy documented, .Frequency: Sweep and spot mop after each meal and as needed; thorough mopping daily; scrubbing/brushing weekly . Method . 2.sweep under all equipment, around legs, and in corners . Use push broom to sweep remaining floor to remove all loose soil/debris . 4. Scrub floor with deck brush, including base tiles . Mopping method . 8 .Change both cleaner solution and rinse water when it becomes dirty. 9. Mop well under all stationary equipment . 11. Empty mop water . Rinse mop bucket thoroughly and drain . 12. Mops should be cleaned well after each use. Rinse until water is clear. Squeeze dry and hang to completely dry or remove and send to laundry . Storage of Cleaning Equipment: After use, mops shall be placed in a position that allows them to air-dry . Observations in the kitchen on 5/11/15 at 11:35 AM, and on 5/12/15 at 3:45 PM, revealed the following: a. Splatters of dried substance and dirt on the walls in storage room. b. Dirt build-up around baseboards and under storage shelves. c. A mop bucket, with a mop sitting in the dirty water. Interview with the DM on 5/11/15 at 11:40 PM, in the kitchen, the DM was asked if it was acceptable for the kitchen to have dirt build-up and dirty walls. The DM stated, No ma'am, it's not. Interview with the DM on 5/12/15 at 3:50 PM, in the kitchen, the DM was asked if it was acceptable for a mop to be left sitting in a bucket of dirty water. The DM stated, No, ma'am. 5. Observations in the kitchen on 5/11/15 at 12:30 PM revealed the following: a. Dried food particles and chipped paint on a mixer. b. Pans used for cooking with splotches of black build-up inside pans and thick black build-up around edges of pan. c. Pans stacked the pans with water between the pans (wet nesting). Interview with the DM on 5/11/15 at 12:35 PM, in the kitchen, the DM was asked what the black build-up was. The DM stated, Not sure. The DM was asked if the black build-up was carbon. The DM stated, Yes, ma'am. The DM was asked if it was acceptable to use the pans with carbon build-up on them. The DM stated, No, ma'am. The DM was asked if that was water between the pans. The DM stated, Yes, ma'am. The DM was asked if it was acceptable to stack dishes wet. The DM stated, No, ma'am. The DM was asked if that was dried food on the mixer and if the paint was chipped. The DM stated, Yes ma'am. The DM was asked if it was acceptable for the mixer to have dried food. The DM stated, No, ma'am. 6. Review of the facility's .HAZARDOUS MATERIALS (MSDS) . policy, 4 . Remove food from the area being cleaned/sanitized to avoid chemical contamination of the food. (Food Code 7-102.11) Observations in the kitchen on 5/11/15 at 12:40 PM, revealed a frozen chicken sitting in the 2- compartment sink, without a pan, under running water. On the ledge of the sink, on same side as the chicken, was a green bucket with a light blue liquid, and a pipe running from the steamer into the same sink compartment that the chicken was sitting in, with water dripping out of the pipe and some type of material was hanging out of the pipe. Interview with the DM on 5/11/15 at 12:45 PM, in the kitchen, the DM was asked what the liquid in the green bucket was. The DM stated, Comet with bleach. The DM was asked if it was acceptable to have chemicals sitting so close to the chicken thawing in the sink. The DM replied, But the bags not open. The DM was asked if it was acceptable to have pipe draining water into the sink with the thawing chicken. The DM stated, The chicken is in a bag and the pipe is just running from the steam table. 7. Review of the facility's NHC Safety & (and) Sanitation Best Practice Guidelines .PERSONAL HYGIENE policy documented, .3. Hair Restraints: (Food Code 2-402.11) (a.) Dietary partners shall wear hair restraints such as hats, hair coverings, or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles . Observations in the kitchen revealed the following: a. On 5/12/15 at 4:12 PM, Maintenance Supervisor (MS), walked through the kitchen without a facial covering. MS did have a beard and mustache. b. On 5/13/15 at 5:15 PM, MS walked through kitchen without a facial covering over his beard and mustache. c. On 5/13/15 at 5:15 PM, another male with a beard and mustache walked through the kitchen and did not have a facial covering over his beard and mustache. Interview with the DM on 5/13/15 at 5:15 PM, in the kitchen, the DM was asked if it was acceptable for men to walk through the kitchen without facial coverings. The DM stated,No, ma'am, it's not. 8. Review of the facility's, Weekly Cleaning Schedule form documented, You must sign that the objective has been completed. If you do not sign . it was not done . There was no documentation provided that cleaning had been completed. Interview with the DM on 5/13/15 at 5:00 PM, in the kitchen, the DM was asked how she knew that the cleaning schedule was being followed. The DM stated, We sign off on it after we do it. The DM was asked if she had the copies of the cleaning schedule that had been signed off on by the dietary staff. The DM stated, I can't find my copies where we signed off on them.",2018-09-01
6165,"NHC HEALTHCARE, SPRINGFIELD",445088,608 8TH AVE EAST,SPRINGFIELD,TN,37172,2015-05-13,441,D,0,1,XJU711,"**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 spread of infection and cross contamination were maintained during the washing of resident's personal clothing in residential type washers and the facility failed to ensure urinary catheters were maintained in a manner to prevent the spread of infection when a Foley bag and catheter tubing were touching the floor for 1 of 1 (Resident #110) residents reviewed with a Foley catheter. The findings included: 1. Review of the facility's NHC (National Health Care) Laundry: Washing Infected Material policy documented, .Studies have shown that a satisfactory reduction of microbial contamination can be achieved at water temperatures lower than 160 F (Fahrenheit) if laundry chemicals suitable for low-temperature washing are used at proper concentrations . Observations in the laundry room on 5/13/15 at 1:15 PM, revealed two residential washing machines. Observations in the laundry room on 5/13/15 at 2:25 PM, revealed the MS testing the water temperatures of the residential type washing machines. The MS confirmed the temperature of the washer's full drum of water was 113.2 degrees F. There was no chemicals used to off set the water temperature to reduce microbial contaminates in the laundry. Interview with Laundry Technician (LT) #1 on 5/13/15 at 1:18 PM, in the laundry room, was asked what the residential type washers were used for. LT #1 stated, We wash the resident's personal clothing in them . their colored items. The LT #1 was asked what type of detergent was used in the washers. LT #1 stated, Tide is all. LT #1 was asked if a sanitizer or bleach was used in the washers. LT #1 stated, No. Interview with the Maintenance Supervisor (MS), on 5/13/15 at 2:15 PM, in the conference room, the MS was asked if he checked the temperatures of the residential washing machines in the laundry room. The MS stated, Yes, I make sure they get to 140 degrees (F). Interview with LT #2 on 5/13/14 at 3:00 PM, outside the laundry room, LT #2 was asked if she ever used the residential type washing machines. LT #2 stated, Yes, for the resident's personal laundry. LT #2 was asked what type of detergent was used in these washers. LT #2 stated, Tide or Dreft. LT #2 was asked if she ever used bleach or sanitizer in these washers. LT #2 stated, No. Interview with the MS on 5/13/15 at 5:34 PM, on the back patio, the MS was asked how he was going to remedy the temperatures of the residential type washing machines. The MS stated, I'm gonna call (named a company) to see if there is a color safe sanitizer to use on colored clothes. 2. Medical record review revealed Resident #110 was admitted on [DATE] with readmitted s of 4/14/15, 4/24/15 and 5/1/15 with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Observations in Resident #110's room on 5/11/15 at 2:58 PM, on 5/11/15 at 5:02 PM and on 5/12/15 at 11:12 AM, revealed Resident #110's Foley catheter tubing was touching the floor. Observations in Resident #110's room on 5/12/15 at 4:22 PM, revealed part of the Foley catheter bag was touching the floor. Interview with Licensed Practical Nurse (LPN) #1 on 5/12/15 at 4:25 PM in Resident #110's room, LPN #1 was asked if Resident #110 had a catheter. LPN #1 stated, She does have a catheter. LPN #1 was asked if the catheter bag and tubing should be touching the floor. LPN #1 stated, No ma'am, it should not be on the floor. Interview with the Director of Nursing (DON) on 5/12/15 at 5:43 PM, in the conference room, the DON was asked if it is acceptable for a resident with a catheter and a history of urinary tract infections to have the catheter bag and the tubing to be touching the the floor. The DON stated, Shouldn't be on the floor.",2018-09-01
7885,"NHC HEALTHCARE, SPRINGFIELD",445088,608 8TH AVE EAST,SPRINGFIELD,TN,37172,2013-10-30,225,G,0,1,X3OS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of a personnel file, review of the facility's investigation, medical record review, observation and interview, it was determined the facility failed to protect residents from abuse by failing to ensure that all allegations of mistreatment or abuse, were reported immediately to the Administrator of the facility and a thorough investigation was conducted for 1 of 35 (Resident #156) sampled residents. The failure of the facility to ensure allegations were reported and thoroughly investigated resulted in actual harm to Resident #156 who became emotionally upset when asked if she had ever been abused by staff. The findings included: 1. Review of the facility's Patient Protection and Response Policy for Allegations / Incidents of Abuse, Neglect and Misappropriation of Property policy documented, .Abuse, Neglect, and Misappropriation of Patient Property . will not be tolerated by anyone, including staff, patients, consultants, volunteers, family members or legal guardians, friends, visitor or any other individual in this center. The center administrator is responsible for assuring that patient safety, including freedom from risk of abuse or neglect, holds the highest priority . The center will train all partners, through orientation and ongoing in-services, on the prevention, identification, investigation and reporting of abuse, neglect, and misappropriation of patient property . In-service training wilt included . What constitutes abuse, neglect and misappropriation of patient property . The reporting obligation of each partner . Investigative system established by the center . All supervisory partners who receive reports of and/or identify inappropriate behaviors will take immediate steps to correct such behaviors . The center will seek and accept complaints from patients, patient families and partners without reprisal . The right to report a concern or incident is not limited to a formal, written grievance process but includes any verbalized complaint to any center partner . Any patient event that is reported to any partner by patient, family, other partner or any other person will be considered an allegation of either abuse, neglect, or misappropriation of patient property if it meets any of the following criteria . Any patient or family complaint of physical or verbal harm, pain or mental anguish resulting from the actions of others . Any complaint of the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to patients or families or within their hearing distance . Any instances of hitting, slapping, pinching, or kicking or other potentially harmful action . 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. All allegations of possible abuse, neglect, or misappropriation of patient property will be immediately assessed to determine the appropriate direction of the investigation . All alleged violations and all substantiated incidents will be reported immediately to the Administrator or her/his designated representative and to other officials in accordance with state and Federal law . All events reported as possible abuse, neglect, or misappropriation of patient property will be investigated to determine whether the alleged abuse, neglect, or misappropriation of patient property did or did not take place . The investigation is conducted immediately under the following circumstances: I. When it is identified that an alleged incident may have occurred, ii. As soon as any partner has knowledge and reports an alleged event . Any individual found to be in danger of injury will be removed from the source of the suspected abusive behavior . Partner(s) suspected of taking actions that would cause potential harm to a patient or other patients will be immediately placed on administrative leave . 2. Medical record review for Resident #156 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set Assessment ((MDS) dated [DATE] documented the resident with a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident cognition is intact. During an interview in Resident #156's room on 10/28/13 at 9:11 AM, Resident #156 was asked if staff, resident or anyone else here had abused you? Resident #156 paused, then began crying and stated, Yes, I was verbally abused by (named certified nursing assistant (CNA) #10), she was on one side of my bed and threw my hairbrush across the room, (named CNA #9) was on the other side of my bed. Husband told the Administrator and the employee was fired. When asked if she had told staff? Resident #156 stated, Yes, (named CNA #9). A Nurse (unable to name) was told, and the Administrator was told by my husband. Observations in Resident #156's room on 10/28/13 at 9:11 AM, revealed Resident #156 in her room, in bed and began crying when asked about being abused. During an interview at the nurses' station on 10/29/13 at 2:30 PM, CNA #9 was asked about the incident with Resident #156. CNA #9 stated, (Named CNA #10) was being verbally abusive to me in front of (Named Resident #156) . She (CNA #10) was brushing (Named Resident #156's) hair and threw the brush across the room. I reported it to a Supervisor but don't remember who it was . During an interview in the Social Service's office on 10/29/13 at 4:15 PM, the Social Services Director (SSD) and Abuse Prevention Coordinator was asked for investigations of allegation of abuse. The SSD stated, We have not had an allegation of abuse in over 2 years. During an interview in the Director of Nursing's (DON) office on 10/29/13 at 4:00 PM, the DON was asked for investigations of allegations of abuse from Resident #156. The DON stated, I am not aware of any abuse allegations. During an interview in the Administrator's office on 10/29/13 at 5:00 PM, the Administrator was asked if an allegation of abuse on Resident #156 had been reported. The Administrator stated, No allegation of abuse had been reported. Review of the CNA #10's personnel file revealed a handwritten note of resignation dated 8/16/13 and documented, found another job closer to home . last day worked is 8-25-13 . There was no documentation of the incident/investigation with Resident #156. Review of the facility's investigation conducted after the Administrator was made aware of allegation revealed a statement dated 10/29/13 and signed by the Administrator that documented an interview with the resident's son. There was no indication the son was aware of the allegation. Another statement dated 10/29/13 and signed by the Administrator documented an interview with CNA #9 who reported to the Administrator the incident between her and CNA #10 of speaking inappropriate in front of Resident #156. There was no documentation in the investigation of interviews with Resident #156, Resident #156's husband, other residents or other staff members. The facility failed to protect residents from abuse by failing to ensure staff reported allegations of abuse/inappropriate behavior per facility protocol and failed to thoroughly investigate allegation of abuse which resulted in actual harm to Resident #156, who became emotionally upset when asked of any abuse.",2017-09-01
7886,"NHC HEALTHCARE, SPRINGFIELD",445088,608 8TH AVE EAST,SPRINGFIELD,TN,37172,2013-10-30,226,D,0,1,X3OS11,"Based on policy review, review of new employee personnel files and interviews, it was determined the facility failed to train a new employee on the facility's abuse policy and procedures for 1 of 5 (Nurse #7) new employee files reviewed. The findings included: Review of the facility's Patient Protection and Response Policy for Allegations / Incidents of Abuse, Neglect and Misappropriation of Property policy documented, .Abuse, Neglect, and Misappropriation of Patient Property . will not be tolerated by anyone, including staff, patients, consultants, volunteers, family members or legal guardians, friends, visitor or any other individual in this center . The center will train all partners, through orientation and ongoing in-services, on the prevention, identification, investigation and reporting of abuse, neglect, and misappropriation of patient property . In-service training will include . What constitutes abuse, neglect and misappropriation of patient property . The reporting obligation of each partner . Review of Nurse #7's personnel file documented a hire date of 8/1/13. The facility was unable to provide documentation that Nurse #7 was given abuse training. During an interview in the Rehabilitation Director's office on 10/29/13 at 11:25 AM, Employee #1 was asked what the facility's procedure for a new employee's orientation and training. Employee #1 stated, (Named Nurse #7) has not received orientation or abuse training at this time period. During interview in the Rehabilitation Directors' office on 10/30/13 at 4:25 PM, the Administrator stated, (Named Nurse #7) has not had orientation nor abuse training at this time.",2017-09-01
7887,"NHC HEALTHCARE, SPRINGFIELD",445088,608 8TH AVE EAST,SPRINGFIELD,TN,37172,2013-10-30,241,D,0,1,X3OS11,"**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 residents were treated with dignity and respect when staff used referred to residents as feeders and residents were served juice and milk in cartons during 2 of 2 (10/27/13 lunch meal and 10/29/13 breakfast meal) dining observations. The findings included: 1. Review of the facility's USE OF COURTESY TITLES policy documented, It is the policy of this center to use courtesy titles (Mr., Ms.) when addressing patients in all written records and communication . Observations of the lunch meal on 10/27/13 at 12:13 PM, the Social Services Director (SSD) delivered a tray to room [ROOM NUMBER]. The SSD asked a resident, Would you like some lunch sweetheart? Observations of the breakfast meal on 10/29/13 at 8:08 AM, Nurse #1 stuck her head in room [ROOM NUMBER] and asked certified nursing assistant (CNA) #1, if the feeders were the only trays left. CNA #1 retrieved the last meal tray and took it into room [ROOM NUMBER]. During an interview in the conference on 10/31/13 at 9:00 AM, the Director of Nursing (DON) was asked what she expected the staff to call residents. The DON stated Mr., Mrs. (NAME REDACTED) Miss. 2. Observations of the lunch meal on 10/27/13 at 12:52 PM, revealed a tray was delivered to room [ROOM NUMBER] with juice served in carton without a glass on the tray. Observations of the breakfast meal on the 40 hall on 10/29/13 at 8:05 AM, revealed trays were served with milk and juice in cartons without glasses.",2017-09-01
7888,"NHC HEALTHCARE, SPRINGFIELD",445088,608 8TH AVE EAST,SPRINGFIELD,TN,37172,2013-10-30,280,D,0,1,X3OS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, it was determined the facility failed to ensure the care plan was revised to reflect all interventions implemented to address falls for 1 of 35 (Resident #184) sampled residents included in the stage 2 review. The findings included: Review of the facility's .Falls Program policy documented, .To identify patients at risk for falling and to implement the appropriate interventions . To reduce the patients' risk of falling and related injuries . Complete the Fall Risk Assessment . Initiate a falls care plan . Implement appropriate interventions . Evaluate the effectiveness of the interventions. Medical record review for Resident #184 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) dated 10/14/13 documented the resident with a summary score of 5 indicating the resident with severe mental impairment. The fall risk evaluation completed on 10/8/13 documented a score of 19 indicating the resident was a high risk for falls. Review of the POS [REDACTED] a. 10/8/13 at 5:00 PM fall - .Pt (patient) placed back in low bed with all interventions in place . All appropriate interventions in place . b. 10/12/13 at 3:45 PM fall - .Pt not to be left unattended in dining room . c. 10/15/13 at 11:30 AM fall - .Urine obtained in AM for UA / C&S (urinalysis / culture and sensitivity) D/T (due to) increased confusion . and Pt not to be up in WC (wheelchair) in room alone . d. 10/15/13 at 7:45 PM fall - .ABT (antibiotic) started for UTI ( urinary tract infection) . clip alarm to WC e. 10/23/13 at 7:45 AM - .fell from bed to go to bathroom . Resident was redirected towards an activity to keep his attention . The care plan dated 10/8/13 and revised on 10/24/13 did not include the intervention of laboratory tests and an antibiotic implemented after the fall on 10/15/13 and did not document the diversional activities intervention implemented after the 10/23/13 fall. During an interview in the conference room on 10/29/13 at 10:40 AM, the Licensed Practical Nurse (LPN) Risk Manager was asked about Resident #184 falls and interventions. The LPN Risk Manager stated, Regarding fall #1 we had put fall matts, bed alarm and low bed in place prior to his admission due to info (information) from the hospital that he was a high fall risk, no other interventions were put in place due to these were appropriate . Regarding fall #4 - the nurse was watching him, he was in the entrance to the dining room, she just could not get to him, he had 2 falls on that day (10/15/13). I put in place on the 17th to change alarms out due to him leaning . Regarding fall #5 he fell trying to go to the bathroom, his interventions were all in place and appropriate. We put in place the diversional activities . I see that addressing going to the bathroom should be addressed . yes, we do try to determine the cause of the falls.",2017-09-01
7889,"NHC HEALTHCARE, SPRINGFIELD",445088,608 8TH AVE EAST,SPRINGFIELD,TN,37172,2013-10-30,282,D,0,1,X3OS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of tray cards, medical record review, observation and interview, it was determined the facility failed to follow and provide interventions on the care plans for nutrition for 2 of 19 (Residents #120 and 129) sampled residents of the 35 residents included in the stage 2 review. The findings included: 1. Review of the facility's Weights: Monthly and Significant Change of Status policy documented, .Weights will be obtained on all patients monthly . Weights will be obtained, following the determination of a significant change of status, on a weekly basis times four . Weigh Patient . Reweigh within 24 hours if significant change is noted (5% (percent) in 30 days) . Document in chart percentage of significant loss, observations, plans or interventions to occur in next 14 days . Progress notes and care plans should reflect current plan of care . Screen patients with significant weight loss and implement nutritional intervention . 2. Medical record review for Resident #120 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The record documented the resident went to the hospital on [DATE] due to increased International Ratios and returned to the facility on [DATE]. Review of the admission physician orders [REDACTED]. Physician orders [REDACTED]. Review of Resident #120's weight record documented the following weights: a. 8/30/13 - 102 pounds. b. 9/11/13 - 104 pounds. c. 10/6/13 - 96.7 pounds - indicating a 7.01% significant weight loss in less than one month. The care plan dated 9/3/13 and revised 9/23/13 documented the problem / need of At risk for malnutrition . and Intervention .Weigh weekly / monthly and prn (as needed) and intervene if significant weight loss occurs . The facility was unable to provide documentation of weekly weights per the facility's protocols and care plan. There were no new interventions documented after the 10/6/13 significant weight loss as indicated on the care plan. Observations in Resident #120's room on 10/27/13 at 5:10 PM, revealed Resident #120 was thin and confused. Observations in Resident #120's room on 10/28/13 at 8:00 AM, revealed a cooler at Resident #120's bedside with nectar thick water in it. Observations of the breakfast tray in Resident #120's room on 10/30/13 at 8:35 AM, revealed Resident #120 was served and ate her egg, bacon and approximately 75% of the oatmeal. Resident #120 did not drink the thickened orange juice or eat the toast. There were no supplements or high calorie / protein milkshakes on the tray per the initial nutritional assessment. 3. Medical record review for Resident #129 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of care plan dated 6/11/13 and updated 9/11/13 documented at risk for malnutrition . with goals . will maintain CBW (current body weight) + /- (plus or minus) 5 # (pounds) through 9/30/13 with intervention . weigh weekly / monthly and prn (as needed) and intervene if significant weight loss occurs . Review of the dietary progress notes did not document any entries form 6/13/13 through 9/12/13. Review of the tray card dated 10/30/13 documented Regular, Nutrition Intervention Program (NIP) for breakfast, lunch and dinner. Review the facility's The Weight List dated August 2013 and September 2013 documented Resident #129's weight on 8/6/13 was 135 pounds and on 9/21/13 was 111 pounds indicating a loss of 24 pounds a 17.7 % weight loss in 45 days. Review of the DIET RECORD dated October 2013 was blank for HS snack. The facility was unable to provide documentation of Resident #129's food and fluid intake consumed for August 2013 and September 2013. During an interview in the conference room on 10/29/13 at 4:00 PM, the Director of Nursing (DON) was asked why were weekly weights not being done and what interventions were put in place for residents with weight loss. The DON stated, We were not aware of the weight loss until she was weighed 9/21/13 . at risk residents are put on the Nutrition Intervention Program (NIP) . the committee discusses weight loss and interventions . we do not keep the documentation's from the meetings . we keep intake percentages of meals for 30 days then they are shredded. During an interview in the conference room on 10/29/13 at 4:30 PM, the DON was asked where was the documentation for meal intake for the months of August and September 2013. The DON stated, We shred them after 30 days . we do not have them . During an interview in the hall by the conference room on 10/29/13 at 6:05 PM, Nurse #8 was asked what she did she expect the Certified Nursing Assistants (CNA) or nurses to do if a resident was not eating and where would it be documented. Nurse #8 stated .I would expect the CNA to report that to the charge nurse . it would have documented on the intake sheet which is summarized in the nurse's charting . During an interview in the conference room on 10/30/13 at 9:30 AM, the DON was asked why this resident was not weighted in 45 days and was she made aware that she was not eating. The DON stated, I did not realize she was had not been eating . We realized there was a breakdown in the way we do weights . weights were not getting charted . we were not getting notified when there changes noted in the weight or resident's intake had decreased .",2017-09-01
7890,"NHC HEALTHCARE, SPRINGFIELD",445088,608 8TH AVE EAST,SPRINGFIELD,TN,37172,2013-10-30,323,D,0,1,X3OS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, it was determined the facility failed to ensure the residents' environment remains as free of accident hazards as is possible; and each resident received adequate supervision and assistance to prevent potential accidents for 2 of 4 (Residents #95 and 184) sampled residents of the 35 residents included in the stage 2. The findings included: 1. Review of the facility's .Falls Program policy documented, .To identify patients at risk for falling and to implement the appropriate interventions . To reduce the patients' risk of falling and related injuries . Complete the Fall Risk Assessment . Initiate a falls care plan . Implement appropriate interventions . Evaluate the effectiveness of the interventions. Review if the facility's Meal Rounds policy documented, .Check to see if the patients are positioned appropriately for eating. Note appropriate table height, bedside table within reach, head of bed elevated . 2. Medical record review for Resident #95 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. A fall risk assessment last updated 7/15/13 documented Resident #95's score as 22 indicating the resident was at high risk for falls. Observation and interview in Resident #95's room of the lunch meal on 10/27/13 at 12:13 PM, the Social Service Director (SSD) delivered a tray to the resident. Resident #95 was sitting up on the side of the bed with her legs dangling. Resident #95 was unable to touch her feet to the floor. The surveyor located Nurse #9 and asked her to come to Resident #95's room. Nurse #9 was asked if Resident #95's position was appropriate. Nurse #9 stated, No, It's a little high .feet should touch floor . During an interview in the conference room on 10/29/13 at 11:05 AM, Nurse #9, the west unit manager, was asked what position Resident #95 should be placed in when eating meals in her room. Nurse #9 stated, She likes to sit up on the side of her bed . put it up to a comfortable height for her . Nurse #9 was asked if it was appropriate for the resident's feet to hang off the bed and not reach the floor. Nurse #9 stated, No, her feet should be able to touch the floor. During an interview in the conference room at 4:01 PM, the Director of Nursing (DON) was asked if all staff should follow the Meal Rounds policy when serving trays to residents. The DON stated, Yes. The DON was asked if Resident #95's feet should touch the floor when sitting on the side of the bed to eat. The DON stated, Yes, feet should touch the floor. 3. Medical record review for Resident #184 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) dated 10/14/13 documented the resident with a summary score of 5 indicating the resident with severe mental impairment. The fall risk evaluation completed on 10/8/13 documented a score of 19 indicating the resident was a high risk for falls. Review of the post falls nursing assessment's and the post falls investigations documented the following falls and interventions implemented: a. 10/8/13 at 5:00 PM fall - .Pt (patient) placed back in low bed with all interventions in place . All appropriate interventions in place . b. 10/12/13 at 3:45 PM fall - .Pt not to be left unattended in dining room . c. 10/15/13 at 11:30 AM fall - .Urine obtained in AM for UA / C&S (urinalysis / culture and sensitivity) D/T (due to) increased confusion . and Pt not to be up in WC (wheelchair) in room alone . d. 10/15/13 at 7:45 PM fall - .ABT (antibiotic) started for UTI ( urinary tract infection) . clip alarm to WC e. 10/23/13 at 7:45 AM - .fell from bed to go to bathroom . Resident was redirected towards an activity to keep his attention . There was no documentation of a new intervention implemented after the 10/8/13 fall. The intervention implemented after the 10/23/13 fall was inappropriate and did not address the root cause of that fall (resident going to the bathroom). During an interview in the conference room on 10/29/13 at 10:40 AM, the Licensed Practical Nurse (LPN) Risk Manager was asked about Resident #184 falls and interventions. The LPN Risk Manager stated, Regarding fall #1 we had put fall matts, bed alarm and low bed in place prior to his admission due to info (information) from the hospital that he was a high fall risk, no other interventions were put in place due to these were appropriate . Regarding fall #4 - the nurse was watching him, he was in the entrance to the dining room, she just could not get to him, he had 2 falls on that day (10/15/13). I put in place on the 17th to change alarms out due to him leaning . Regarding fall #5 he fell trying to go to the bathroom, his interventions were all in place and appropriate. We put in place the diversional activities . I see that addressing going to the bathroom should be addressed . Yes, we do try to determine the cause of the falls.",2017-09-01
7891,"NHC HEALTHCARE, SPRINGFIELD",445088,608 8TH AVE EAST,SPRINGFIELD,TN,37172,2013-10-30,325,G,0,1,X3OS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of a tray card, medical record review, observation and interview, it was determined the facility failed to maintain acceptable parameters of nutritional status for 2 of 4 (Residents #120 and 129) sampled residents reviewed of the 7 residents reviewed with nutritional issues. The failure of the facility to implement interventions to prevent a significant weight loss resulted in actual harm to Resident #120. Resident #120 was assessed as malnourished and at a high risk for weight loss and had a significant weight loss. The findings included: 1. Review of the facility's policy provided by the Director of Nursing on 10/29/13 and entitled previous weight procedure documented, RD (Registered Dietician) would make recommendations and send to MD (Medical Doctor). MD would agree or disagree and send back to RD. If MD agreed with RD recommendations, the RD would write the task on the MAR (Medication Administration Record). RD would continue to observe the patient's weight and intake and communicate to the MD as needed. Review of the facility's Nutrition Intervention Program (NIP) policy documented, .Patients will receive the highest practicable level of nutritional care through aggressive interventions . An initial assessment will be completed on all patients by the Registered Dietitian or designee. Each patient will be reviewed for the risk factors . Patients who demonstrate one or more of the following risk factors will be considered for inclusion in the Nutrition Intervention Program: 1. Meal intake less than 50% (percent) for 7 days, 2. Pressure ulcers, other wounds, or delayed wound healing . 5. BMI (Basal Metabolic Indicator) (greater than) 3% during the past 30 days . Review of the facility's percent meal intake policy documented, .Patients' percent meal intake will be properly evaluated . appropriate nursing partner will evaluate the patient's meal tray after meal is finished being consumed . Partner will estimate the amount of total meal consumed and will record the amount of the total meal consumed on appropriate worksheet . Review of the facility's Weights: Monthly and Significant Change of Status policy documented, .Weights will be obtained on all patients monthly . Weights will be obtained, following the determination of a significant change of status, on a weekly basis times four . Weigh Patient . Reweigh within 24 hours if significant change is noted (5% in 30 days) . Document in chart percentage of significant loss, observations, plans or interventions to occur in next 14 days . Progress notes and care plan should reflect current plan of care . Screen patients with significant weight loss and implement nutritional intervention . 2. Medical record review for Resident #120 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The record documented the resident went to the hospital on [DATE] due to increased International Ratios and returned to the facility on [DATE]. Review of the admission physician orders [REDACTED]. Physician orders [REDACTED]. Review of Resident #120's weight record documented the following weights: a. 8/30/13 - 102 pounds. b. 9/11/13 - 104 pounds. c. 10/6/13 - 96.7 pounds - indicating a 7.01% significant weight loss in less than one month. The Registered Dietician (RD) documented an initial nutritional assessment dated [DATE] assessed Resident #120 with a .current body weight of 104 pounds . BMI of 17.849 . Underweight . Mech (Mechanical) soft Nectar thick liquids . House supplement BID . RD offers high cal (calorie) / pro (protein) milkshake . MNA (mini-nutritional assessment) indicates pt (patient) is malnourished, Interventions: Will add scheduled HS (bedtime) snack for add'l (additional) cal (calories) . The most current dietary progress notes were dated 9/23/13 by the RD and documented, 5-day complete & (and) accurate . There were no other dietary progress notes or assessments in the medical record. There was no documentation the resident had been placed on the NIP program per protocol. There was no documentation of weekly weights per facility protocols. There were no new interventions documented after the 10/6/13 significant weight loss. There was no documentation the Physician or RD were aware of the significant weight loss. Observations in Resident #120's room on 10/27/13 at 5:10 PM, revealed Resident #120 was thin and confused. Observations in Resident #120's room on 10/28/13 at 8:00 AM, revealed a cooler at Resident #120's bedside with nectar thick water in it. Observations of the breakfast tray in Resident #120's room on 10/30/13 at 8:35 AM, revealed Resident #120 was served and ate her egg, bacon and approximately 75% of the oatmeal. Resident #120 did not drink the thickened orange juice or eat the toast. There were no supplements or high calorie / protein milkshakes on the tray per the initial nutritional assessment. On 10/30/13 the surveyor requested Resident #120 be weighed and her weight was recorded at 95.8 pounds indicating additional weight loss. Review of the tray cards used in dietary to prepare the trays revealed no documentation of nourishments or scheduled of HS snacks for Resident #120. Review of the September 2013 and October 2013 diet records completed by the Certified Nursing Assistants (CNA) revealed the HS snack areas were blank for both months. During an interview in the conference room on 10/30/13 at 9:30 AM, the Director of Nursing (DON) was asked to describe the facility's weight loss prevention program. The DON stated, Weekly weights are gotten weekly times 4 and/or til (until) a stable weight. Our procedure was the RD and weight tech (technician) worked together obtaining weights and reviewing weights. If the RD was not here the weight tech notified the charge nurse of weight loss. RD was here 3 days a week on Monday, Tuesday and Thursdays. She left in late September of this year and at the same time the weight tech also left. At that point communications fell off. We identified we had a problem with the weights. We were not getting weights in the charts, we have today revised our procedure . The DON was asked for the monthly significant weight loss report and proactive weight loss report per facility protocol. The DON stated, The significant weight loss report is for residents with significant weight loss. The proactive weight loss reports are for residents trending down on their weights, those reports are not actively being done at present, not sure when the last one was done. Not sure if I kept copies of any . Med Pass . is given during medication pass by the nurses. The house supplement is mighty shakes and put on their trays by the kitchen. HS snacks are routinely offered to all residents at HS. We do have some that get specific HS snacks from the kitchen. The CNA's document meal intake on the meal cards and they document meal and HS snack intake on the diet record. These are only kept for 30 days . During an interview in the conference room on 10/30/13 at 10:30 AM, the DON confirmed the resident had a significant weight loss with additional weight loss noted on 10/30/13 and no interventions had been put in place. The facility failed to ensure Resident #120, who was assessed as malnourished and at a high risk for nutritional complications on admission, received interventions to prevent a significant weight loss which resulted in actual harm for Resident #120. 3. Medical record review for Resident #129 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of care plan dated 6/11/13 and updated 9/11/13 documented at risk for malnutrition . with goals . will maintain CBW (current body weight) + /- (plus or minus) 5 # (pounds) through 9/30/13 with intervention . weigh weekly / monthly and prn (as needed) and intervene if significant weight loss occurs . Review the facility's The Weight List dated August 2013 and September 2013 documented Resident #129's weight on 8/6/13 was 135 pounds and on 9/21/13 was 111 pounds indicating a loss of 24 pounds a 17.7% weight loss in 45 days. Review of the diet record dated October 2013 was blank for HS snack. The facility was unable to provide documentation of Resident #129's food and fluid intake consumed for August 2013 and September 2013. Review of the dietary progress notes did not document any entries form 6/13/13 through 9/12/13. Review of the tray card dated 10/30/13 documented Regular, Nutrition Intervention Program (NIP) for breakfast, lunch and dinner. During an interview in the conference room on 10/29/13 at 4:00 PM, the DON was asked why were weekly weights not being done and what interventions were put in place for residents with weight loss. The DON stated, We were not aware of the weight loss until she was weighed 9/21/13 . at risk residents are put on the Nutrition Intervention Program (NIP) . the committee discusses weight loss and interventions . we do not keep the documentation's from the meetings . we keep intake percentages of meals for 30 days then they are shredded. During an interview in the conference room on 10/29/13 at 4:30 PM, the DON was asked where was the documentation for meal intake for the months of August and September 2013. The DON stated, We shred them after 30 days . we do not have them . During an interview in the hall by the conference room on 10/29/13 at 6:05 PM, Nurse #8 was asked what she did she expect the CNAs or nurses to do if a resident was not eating and where would it be documented. Nurse #8 stated .I would expect the CNA to report that to the charge nurse . it would have documented on the intake sheet which is summarized in the nurse's charting . During an interview in the conference room on 10/30/13 at 9:30 AM, the DON was asked why this resident was not weighted in 45 days and was she made aware that she was not eating. The DON stated, I did not realize she was had not been eating . We realized there was a breakdown in the way we do weights . weights were not getting charted . we were not getting notified when there changes noted in the weight or resident's intake had decreased .",2017-09-01
7892,"NHC HEALTHCARE, SPRINGFIELD",445088,608 8TH AVE EAST,SPRINGFIELD,TN,37172,2013-10-30,371,E,0,1,X3OS11,"**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 food was protected from sources contamination by failing to serve food under sanitary conditions during 2 of 2 (10/27/13 lunch meal and 10/29/13 breakfast meal) dining observations. The findings included: 1. Review of the facility's HANDWASHING policy documented, .1. When to wash hands . d. After any contaminated contact . 2. Observations of the lunch meal on 10/27/13 at 12:13 PM, the Social Services Director (SSD) delivered a tray to room 41. The SSD touched the resident's linens; raised the bed and set up the tray without washing his hands. 3. Observations of the lunch meal served on the 30 hall on 10/27/13 beginning at 12:25 PM revealed the following: a. Certified nursing assistant (CNA) #1 entered room 26, moved items off the table, touched the resident to awaken and then set up the tray without performing proper hand hygiene. b. CNA #1 entered room 36, set up the tray and removed paper from the straw and handled the mouthpiece of the straw using bare hands. c. CNA #2 entered room 39, placed the tray on the table top, removed lids and covers and placed plate covers on the bed and leaving it there exiting the room. 4. Observations of the lunch meal on the 40 hall on 10/27/13 beginning at 12:52 PM revealed the following; a. CNA #5 entered room 41, touched the wheelchair then set up the tray without washing hands. b. CNA #6 entered room 44, with only gloves and mask in the contact isolation room. The tray was not disposable and CNA #6's clothing touched the bed linens. c. CNA #6 dropped a bottle of hand sanitizer bottle on floor picked it up and placed it in her pocket without washing her hands and preceded to set up a tray. d. CNA #6 removed a tray from the cart with one hand adjusted the bottom of her shirt with the other hand and entered room 48 to deliver and set up the tray. e. CNA #6 entered room 46 adjusted resident in the bed then assisted the resident with eating without washing her hands. 5. Observations of the breakfast meal on the 40 hall on 10/29/13 at 8:05 AM revealed the following: a. Nurse #6 entered room 46, adjusted the bed and did not wash hands. b. CNA #6 entered room 44 (contact isolation room) with mask and gloves only. During an interview on the 40 hall on 10/29/13 at 8:05 AM, Nurse #8 was asked about the type of isolation in room 44. Nurse #8 stated .MRSA ([MEDICAL CONDITION] resistant [DIAGNOSES REDACTED] aureus) in the sputum . contact isolation . During an interview in the Director of Nursing's (DON) office on 10/30/13 at 7:00 PM, the DON was asked what her expectations were for staff hand hygiene during dining. The DON stated, If they (staff) come into contact with any items on the overbed table or in the room or the patient they should wash there hands.",2017-09-01
7893,"NHC HEALTHCARE, SPRINGFIELD",445088,608 8TH AVE EAST,SPRINGFIELD,TN,37172,2013-10-30,431,D,0,1,X3OS11,"Based on policy review, observation and interview, it was determined the facility failed to ensure internal and external medications and preparations for human use were not stored together in 2 of 8 (15 hall medication cart and Baby cart) medication storage areas. The findings included: 1. Review of the facility's medication storage policy documented, .Orally administered medications are kept separate from externally used medications . Potentially harmful substances such as . cleaning supplies, disinfectants are . stored in a locked area separately . Outdated . medications . are immediately removed from stock . 2. Observations and interview on the the 15 hall on 10/29/13 at 5:22 PM, revealed the 15 Hall medication cart had one tube of KY Jelly with an expiration date of Dec (December) 05 in the 8th drawer. Nurse #4 confirmed the date on the KY jelly was December 2005. The 9th drawer had snack food items stored with sanicloth cleaner. Nurse #4 was asked if it was appropriate to store chemical items with food items. Nurse #4 stated, No. 3. Observations on the 14 hall on 10/29/13 at 5:30 PM, revealed the Baby Cart (medication cart for 14 hall rooms 11 through 106) had Vaseline and two suppositories stored with pills in the top right drawer. Nurse #14, was asked if these items should be stored together. Nurse #14 stated, No, they shouldn't be (stored) together. 4. During an interview in the Director of Nursing's (DON) office on 10/29/13 at 5:45 PM, the DON confirmed internal and external medications should be stored separately, chemicals and food should not be stored together and expired medications should not be stored on the medication carts.",2017-09-01
7894,"NHC HEALTHCARE, SPRINGFIELD",445088,608 8TH AVE EAST,SPRINGFIELD,TN,37172,2013-10-30,518,D,0,1,X3OS11,"Based on review of a new employee's personnel file and interview, it was determined the facility failed to train new employees on emergency preparedness for 1 of 5 (Nurse #7) new employee files reviewed. The findings included: Review of Nurse #7's personnel file documented a hire date of 8/1/13. The facility was unable to provide documentation that Nurse #7 received training on emergency preparedness. During an interview in the Rehabilitation Director's office on 10/29/13 at 11:25 AM, Employee #1 was asked what the procedure was for a new employee's orientation and training. Employee #1 stated, (Named Nurse #7) has not received orientation or training on emergency preparedness at this time period. During interview in the Rehabilitation Directors' office on 10/30/19 at 4:25 PM, the Administrator stated, (Named Nurse #7) has not had orientation . training at this time.",2017-09-01
10129,"NHC HEALTHCARE, SPRINGFIELD",445088,608 8TH AVE EAST,SPRINGFIELD,TN,37172,2011-10-26,278,D,0,1,QLUH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, it was determined the facility failed to accurately complete the Minimum Data Set (MDS) to reflect the status of oxygen (O2) therapy, cognitive status and/or pressure ulcers for 2 of 21 (Residents #3 and 8) sampled residents. The findings included: 1. Medical record review for Resident #3 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a Physician order [REDACTED].O2 at 2 liter per mask . Review of a Physician order [REDACTED].O2 2- (to) 4 L/min (liters per minute) NC (nasal cannual) or mask . Review of a significant change MDS dated [DATE] for Resident #3 revealed the Section 0 . 0100 Respiratory Treatments C. Oxygen Therapy . was not marked. Observations in Resident #3's room on 10/24/11 at 11:15 AM, 4:15 PM and on 10/25/11 at 8:15 AM, 10:45 AM and 11:00 AM, revealed Resident #3 in bed receiving O2 at 4 L/min per mask. During an interview in the conference room on 8/17/11 at 9:00 AM, MDS Coordinator #2 confirmed the 9/23/11 MDS was not coded correctly for O2. 2. Medical record review for Resident #8 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an assessment reference date (ARD) of 6/18/2011, documented Resident #8 was assessed as able to complete the brief interview for mental status (BIMS) with a score of 15. The score range of 00 to 15 indicates no memory problems. Review of the quarterly MDS with an ARD of 9/18/2011, revealed section C for cognitive patterns, that Resident #8 was assessed as unable to complete the BIMS. The staff assessment for mental status was also not completed, but Resident #8 was assessed with [REDACTED]. During an interview at the east hall nurses' station on 10/25/2011 at 9:35 AM, the Social Worker (SW) was asked if Resident #8 had a change in cognitive status. The SW stated Resident #8 had no change in his cognitive status since admission and that he is alert, oriented and able to remember the memory words associated with the BIMS. During an interview in the conference room on 10/25/11 at 2:45 PM, MDS Coordinator #1 verified Section C - Cognitive Status on the quarterly MDS dated [DATE] was not accurate. During an interview in the conference room on 10/25/11 at 3:10 PM, the SW verified that section C - cognitive status on the quarterly MDS dated [DATE] was not accurate and he had been unable to find additional information. Review of the discharge assessment MDS with an ARD of 7/18/11, documented Resident #8 was assessed with [REDACTED]. Review of the quarterly MDS with an ARD of 9/18/11 documented in Section M 0900 that Resident #8 had no pressure ulcers present on the prior assessment (OBRA (Omnibus Budget Reconciliation Act) , PPS (Prospective Payment System), or Discharge). This assessment failed to document the presence of the pressure ulcer that was present on the prior assessment of 7/18/11. During an interview in the conference room on 10/25/11 at 2:24 PM, MDS Coordinator #1 verified the MDS assessment previous to the quarterly assessment of 9/18/11 was the discharge assessment of 7/18/11, and that Resident #8 had no other assessments between these two assessments. Resident #8 was transferred to the hospital on [DATE], but had no significant change and was not Medicare skilled upon return to the facility; therefore an assessment was not completed until the next scheduled quarterly assessment on 9/18/11. During an interview in the conference room on 10/25/11 at 2:30 PM, the Wound Care Nurse (WCN) stated she was responsible for completion of Section M - Skin Conditions on the MDS. The Wound Care Nurse verified Resident #8 had a Stage 2 pressure ulcer when transferred to the hospital 7/18/11, which was documented on the discharge assessment. The WCN verified the quarterly MDS dated [DATE] documented .no pressure ulcers were present on the prior assessment .",2016-07-01
10130,"NHC HEALTHCARE, SPRINGFIELD",445088,608 8TH AVE EAST,SPRINGFIELD,TN,37172,2011-10-26,315,D,0,1,QLUH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, it was determined the facility failed to ensure there was a physician's order to change a foley catheter and failed to ensure the correct size foley was used on 1 of 2 (Resident #5) sampled residents with foley catheters. The findings included: Medical record review for Resident #5 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's order dated 8/3/11 documented, .18 FR (french)/ (with) 10CC (cubic centimeters) FOLEY CATH (catheter) TO BSB (bedside bag) FOR [MEDICAL CONDITION] . Review of Resident #3's nurse's notes dated 8/8/11 at 4:45 PM documented, .Urinary catheter came out . replaced c (with) 18 f (french) catheter . There was no order documented to change the foley catheter. Review of Resident #3's nurse's notes Resident #3 dated 9/29/11 at 1:00 AM documented, .16 FR foley catheter was inserted . The physician's order was not followed related to the size of the catheter and there was no order to change the catheter. Observations in Resident #5's room on 10/24/11 at 11:25 AM and 4:05 PM, revealed Resident #3's catheter bag was hanging on the left side of the bed in a black bag. During an interview in the facility rehabilitation coordinator's office on 10/26/11 at 9:15 AM, the Director of Nursing confirmed there should be an order to change the foley catheter and the correct size and bulb should be used.",2016-07-01
10131,"NHC HEALTHCARE, SPRINGFIELD",445088,608 8TH AVE EAST,SPRINGFIELD,TN,37172,2011-10-26,333,D,0,1,QLUH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the GERIATRIC MEDICATION HANDBOOK provided by the American Society of Consultant Pharmacists, review of the facility's HIGHLIGHTS OF PRESCRIBING INFORMATION, observation and interview, it was determined the facility failed to ensure 1 of 7 (Nurse #1) nurses administered medications without a significant medication error. Nurse #1 failed to administer insulin within the proper time frame related to meals for Random Resident (RR) #1. The findings included: Review of the GERIATRIC MEDICATION HANDBOOK provided by the American Society of Consultant Pharmacists for typical administration of insulin related to meals documented, .Humalog . DRUG TYPE Rapid-Acting . ONSET (in Hours, Unless Noted) 15 min (minutes) . TYPICAL ADMINISTRATION / COMMENTS 15 minutes prior to meals . Review of the facility's HIGHLIGHTS OF PRESCRIBING INFORMATION documented, .The dosage of HUMALOG . Administer within 15 minutes before meals . Medical record review for RR #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].Humolog for sliding scale insulin . Observation in RR #1's room on 10/24/11 at 11:58 AM, Nurse #1 administered 8 units of Humolog to RR #1. RR #1 did not received her meal until 12:28 PM. The failure to provide the meal within 15 minutes after Humolog insulin was administered resulted in a significant medication error. During an interview in the conference room on 10/26/11 at 1:15 PM, the Director of Nursing (DON) was asked how long after giving Humolog insulin would you expect the resident to have something to eat. While reviewing the highlights of prescribing information for Humalog insulin dosage, the DON stated, says 15 minutes .",2016-07-01
10132,"NHC HEALTHCARE, SPRINGFIELD",445088,608 8TH AVE EAST,SPRINGFIELD,TN,37172,2011-10-26,514,D,0,1,QLUH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to ensure medical records were complete for 2 of 21 (Residents #8 and 19) sampled residents. The findings included: 1. Medical record review for Resident #8 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Tube Feeding Records dated September 2011 and October 2011 documented an order to .FLUSH TUBE Q (every) 6 HRS (hours) WITH 200 CC (cubic centimeters) OF WATER . There was incomplete documentation of the water flushes on 30 of 30 days for September 2011 and 25 of 25 days for October 2011. During an interview at the east hall nurses station on 10/26/11 at 2:45 PM, while reviewing the Tube Feeding Records the Director of Nursing (DON) stated, it was expected the amount of water flushes administered to be documented each shift and totaled at 6 PM daily. The DON confirmed the records were incomplete. 2. Medical record review for Resident #19 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the medical record revealed Date Death 10-1-11 Time of Death 819 (8:19) AM Date of Body Release 10-1-11 Time of Body Release 950 (9:50) AM . to be delivered to (Name of) Funeral Home . There was no order to release the body. During an interview in the health information management office on 10/26/11 at 11:16 AM, the Health Information Director was asked for the order to release the body signed by the physician. The Health Information Director stated, We checked the computer. There's not one.",2016-07-01
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
5338,"NHC HEALTHCARE, LEWISBURG",445094,1653 MOORESVILLE HIGHWAY,LEWISBURG,TN,37091,2016-04-07,241,D,0,1,6R3N11,"Based on policy review, observation and interview, the facility failed to ensure the dignity/privacy was maintained when 1 of 1 Random Resident (Resident #34) was observed being transported through the hallway from the shower without having a cover, leaving the resident's buttock exposed. The findings included: The facility's PRIVACY policy documented, .we provide you with privacy so that you may maintain a dignified existence . Privacy is also maintained during toileting, bathing and other activities of personal hygiene . Observations on the 100 hall on 4/4/16 at 8:45 PM, revealed Resident #34 being transported down the 100 hall in a shower chair by Certified Nursing Assistance (CNA) #1 with no covering, wearing a hospital gown with her left buttock not covered. Interview with the Director of Nursing (DON) on 4/7/16 at 11:50 AM,in the DON's office, the DON was asked what are your expectations for residents being transported down the hallway from the shower room. The DON stated, To be covered, not be exposed.",2019-03-01
5339,"NHC HEALTHCARE, LEWISBURG",445094,1653 MOORESVILLE HIGHWAY,LEWISBURG,TN,37091,2016-04-07,247,D,0,1,6R3N11,"**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 resident's family of room change for 1 of 4 (Resident #84) resident families interviewed during the stage 1 review and the facility failed to give advance notification of a new roommate for 1 of 16 (Resident #166) sampled residents who were interviewed about a room or roommate change. The findings included: 1. The facility's ROOM ASSIGNMENTS/ROOM CHANGES policy documented, .All room changes are thoroughly discussed with patient and patient is given reasonable prior notice and an explanation of the reason for change . 2. Medical record review revealed Resident #84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A family interview with Resident #84's wife on 4/4/16 at 1:21 PM, in Resident #84's room, Resident #84's wife was asked whether her husband had been moved to a different room within the past few months. Resident #84's wife stated he had. Resident #84's wife was asked whether she received notice of explanation before the move. Resident #84's wife stated, No, I came in and went to his room and he wasn't there and staff took me to him in another room. 3. Medical record review revealed Resident #166 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with Resident #166 on 4/5/16 at 10:04 AM, in Resident #166's room, Resident #166 was asked if she had been moved to a different room or had a roommate change in the last nine months. Resident #166 stated, Yes. Resident #166 was asked if she was given notice before a room change or a change in a roommate. Resident #166 stated, No. Interview with the Social Worker (SW) on 4/7/16 at 4:40 PM, in the SW's office, the SW was asked if the residents are informed when they get a new roommate. The SW stated, We don't chart when they get a new admission in their room. The SW was asked was a new admission was a new roommate. The SW stated, You are right. 4. Interview with the Administrator on 4/7/16 at 5:18 PM, in the Administrator's office, the Administrator was asked if Resident #84 had a recent room change. The Administrator stated, Wife was not happy, didn't like the roommate situation. The facility was unable to provide documentation that notification was given for room change for Resident #84 and a new roommate change for Resident #166.",2019-03-01
5340,"NHC HEALTHCARE, LEWISBURG",445094,1653 MOORESVILLE HIGHWAY,LEWISBURG,TN,37091,2016-04-07,278,D,0,1,6R3N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure the comprehensive assessments were accurate related to diagnosis, hospice, and/or pressure ulcers for 3 of 19 (Residents #21, 65 and 70) sampled residents included in the stage 2 review. The findings included: 1. Medical record review revealed Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] did not document a [DIAGNOSES REDACTED]. The physician's recertification orders for 12/1/15 to 12/31/15, documented, .[MEDICATION NAME] 10 MG (milligram) TAB (tablet) . ONE-HALF . BY MOUTH DAILY . PSYCH (Psychiatric) SERVICES TO TREAT . A psychiatric services note dated 3/28/16 documented, .[DIAGNOSES REDACTED]. Interview with the Director of Health Information Management (DHIM) on 4/7/16 at 1:35 PM, in the medical records office, the DHIM was asked if a resident receiving an antidepressant medication should have a [DIAGNOSES REDACTED]. The DHIM stated, Should be coded for depression if you found in the record she had depression. Interview with the MDS Coordinator on 4/7/16 at 2:30 PM, in the MDS office, the MDS Coordinator was asked if a resident who received an antidepressant and has a [DIAGNOSES REDACTED]. The MDS Coordinator stated, I would think so. 2. Medical record review revealed Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].HOSPICE SERVICES TO TREAT . The quarterly MDS dated [DATE] did not document hospice care. Interview with the Director of Nursing (DON) on 4/7/16 at 8:40 AM, in the DON's office, the DON was asked if the quarterly MDS should be coded for hospice care. The DON stated, It should. 3. Medical record review revealed Resident #70 was admitted to the facility with [DIAGNOSES REDACTED]. The weekly wound assessment record dated 2/26/16 documented left heel pressure ulcer. The admission MDS dated [DATE] documented, .None of the Above . for tissue type related to the left heel pressure ulcer. The weekly wound assessment record dated 3/3/16 documented, .length . 5.5 cm (centimeter) . width . 6.5 cm . related to the left heel pressure ulcer. The 14 day MDS dated [DATE] documented, .05.7 cm (centimeters) . length . 06.6 cm . width . related to the left heel pressure ulcer. Interview with the MDS coordinator on 4/7/16 at 5:40 PM, in the MDS office, the MDS coordinator was asked if the admission MDS for 3/3/16 documented the tissue type correctly related to the left heel pressure ulcer. The MDS coordinator stated, No. The MDS coordinator was asked if the 14 day MDS was coded correctly for measurements related to the left heel pressure ulcer. The MDS Coordinator stated, No.",2019-03-01
5341,"NHC HEALTHCARE, LEWISBURG",445094,1653 MOORESVILLE HIGHWAY,LEWISBURG,TN,37091,2016-04-07,309,D,0,1,6R3N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure physician orders [REDACTED].#102) sampled residents included in the stage 2 review. The findings included: Medical record review revealed Resident #102 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].LAB . INR (International Normalized Ratio) WEEKLY . Review of the medical record revealed no lab values for INR from 1/13/16 to 1/27/16. Interview with the Director of Nursing (DON) on 4/7/16 at 11:00 AM, in the conference room, the DON was asked if you would expect the lab work to be on the chart. The DON stated, Oh, yeah.",2019-03-01
5342,"NHC HEALTHCARE, LEWISBURG",445094,1653 MOORESVILLE HIGHWAY,LEWISBURG,TN,37091,2016-04-07,314,D,0,1,6R3N11,"**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 correct documentation of wound assessments and failed to provide wound care for 1 of 2 (Resident #70) sampled residents reviewed of the 2 residents with a pressure ulcer. The findings included: Medical record review revealed Resident #70 was admitted to the facility with [DIAGNOSES REDACTED]. The admission nursing assessment report dated 2/25/16 revealed a body diagram that included a 2 by (x) 6 (no metric measurement identified) open area on the left heel. The admission nursing assessment report dated 2/25/16 revealed a body diagram that included a 2 centimeter (cm) open area to the left buttock. The weekly wound assessment record revealed an unstageable pressure ulcer on the right heel on 2/26/16, 3/3/16, 3/18/16, and 3/25/16. There was no documentation of the wound on the left buttock from 2/26/16 to 3/11/16 and 3/8/16 to 4/1/16. There were no physician orders for treatment for [REDACTED]. Observations in Resident #70's room on 4/7/16 at 12:35 PM, revealed the resident had an unstageable pressure ulcer to the left heel and a pressure ulcer to the left buttock. Interview with the Assistant Director of Nursing (ADON) on 4/7/16 at 6:00 PM, in the conference room, the ADON was asked if the diagram should document the left heel. The ADON stated, Yes, she got it mixed up. The ADON was asked if there was documentation of the pressure ulcer on the left buttock from 2/26/16 to 3/11/16 and from 3/18/16 to 4/1/16. The ADON stated, No.",2019-03-01
5343,"NHC HEALTHCARE, LEWISBURG",445094,1653 MOORESVILLE HIGHWAY,LEWISBURG,TN,37091,2016-04-07,322,D,0,1,6R3N11,"**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 Licensed Practical Nurse (LPN) #1 administered medications by gravity, through a Percutaneous Endoscopy Gastrostomy (PEG) tube. The findings included: The facility's SPECIFIC MEDICATION ADMINISTRATION PR[NAME]EDURES . ENTERAL TUBE MEDICATION ADMINISTRATION . policy documented, .Remove plunger from the 60ml (milliliter) syringe and connect syringe to clamped tubing .pour dissolved . medication in syringe and unclamp tubing, allowing medication to flow by gravity . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #2's room on 4/4/16 beginning at 3:28 PM, revealed LPN #1 connected the 60 ml syringe to the PEG tube, added dissolved medication to the syringe, inserted the piston into the syringe, and pushed the medication into the PEG tube with the piston. LPN #1 removed the piston, poured 30 mls of water into the syringe and allowed it to flow into the PEG tube by gravity. LPN #1 then removed the piston, poured the next dissolved medication into the syringe, reinserted the piston and pushed the medication into the PEG tube with the piston. Interview with the Director of Nursing (DON) on 4/7/16 at 3:40 PM, in the Minimum Data Set office, the DON was asked how medication should be administered through a PEG tube. The DON stated, By gravity. The DON was asked if a piston should be used to push the medication into the PEG tube. The DON stated, No.",2019-03-01
5344,"NHC HEALTHCARE, LEWISBURG",445094,1653 MOORESVILLE HIGHWAY,LEWISBURG,TN,37091,2016-04-07,441,D,0,1,6R3N11,"Based on policy review, observation, and interview, the facility failed to ensure infectious waste was stored in a manner which prevented the spread of infections and decreased the potential of exposure during 1 of 1 (Resident #169) wound care observation. The findings included: The facility's INFECTION CONTROL MANUAL policy documented, .Handling and transportation of infectious waste . Storage Infectious waste must be stored in a manner which preserves the integrity of the packaging (biohazardous box), inhibits rapid microbial growth and minimizes the potential of exposure or access by unknowing persons. (Area kept secure, charge nurse has access) . Observations in Resident #169's room revealed the Assistant Director of Nursing (ADON) gathered up the trash bag after wound care was performed and carried the small trash bag to the Bio Hazard room. The ADON retrieved the key and unlocked the door to the Bio Hazard room where 2 biohazardous storage boxes were sitting on the floor. A large red biohazard plastic bag and 3 clear large trash bags with yellow isolation gowns and other trash inside were on top of the two biohazardous storage boxes. Interview with the Director of Nursing (DON) on 4/7/16 at 11:52 AM, in the DON's office, the DON was asked what are your expectation for the isolation items to be stored in the biohazard room. The DON stated, To be put in bins in the biohazard room.",2019-03-01
6597,"NHC HEALTHCARE, LEWISBURG",445094,1653 MOORESVILLE HIGHWAY,LEWISBURG,TN,37091,2015-03-19,176,D,0,1,1R1P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation and interview, the facility failed to ensure 1 of 1 (Resident #178) resident observed self administering a medication had been determined safe to self administer medications of the 27 residents included in the stage 2 review. The findings included: Review of the facility's self administration of medications policy documented, Residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility . Medical record review revealed Resident #178 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the current physician's orders [REDACTED].#178 to be allowed to self administer medications. Review of the medical record had no documentation of an assessment where the interdisciplinary team had determined the resident was safe to self administer medications. Observations in Resident #178's room on 3/16/15 beginning at 4:56 PM, revealed Resident #178 with binasal oxygen on at 2 liters per minute with a nebulizer treatment being administered by the resident and unattended by a nurse. The nebulizer treatment was being administered via mask and over the binasal oxygen nasal prongs by the resident. Licensed Practical Nurse (LPN) #1 was not observed to enter Resident #178's room until 5:55 PM. Interview with LPN #1 on 3/16/15 at 5:55 PM, in Resident #178's room, LPN #1 was asked if the Resident had received a nebulizer treatment. LPN #1 stated, Yes, It was [MEDICATION NAME]. In interview with the Director of Nursing (DON) on 3/19/15 at 2:20 PM, in the DON's office, the DON was asked the procedure for administering a nebulizer treatment. The DON stated, Nurse is there while resident is receiving the treatment. The DON was asked if a resident should be left alone while receiving a nebulizer treatment. The DON stated, No, resident should not be left unattended while administering (nebulizer treatment) [MEDICATION NAME] .",2018-05-01
6598,"NHC HEALTHCARE, LEWISBURG",445094,1653 MOORESVILLE HIGHWAY,LEWISBURG,TN,37091,2015-03-19,241,E,0,1,1R1P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to enhance each resident's dignity and respect when staff referred to residents as feeders and/or stood to feed 3 of 27 (Residents #47, 50 and 62) residents included in the stage 2 review and 2 random residents. The findings included: 1. Observations on 3/18/15 during the lunch meal at 1:25 PM, revealed the Assistant Director of Nursing (ADON) stood and fed Resident #47. 2. Observations in Resident #50's room on 3/17/15 at 8:18 AM, revealed certified nursing assistant (CNA) #1 entered Resident #50's room and stated, (Named Resident #50) is a feeder. There were 2 residents observed in the room. 3. Observations in Resident #62's room during the supper meal on 3/16/15 at 5:47 PM, revealed CNA #2 stood to fed Resident #62. 4. Observation on the 200 hall on 3/17/15 at 8:17 AM, revealed CNA #1 was walking down the hall and stated, She is a feeder (referring to a resident). 5. Observations in room [ROOM NUMBER] on 3/18/15 at 1:28 PM, revealed the Director of Nursing (DON) stood to fed a resident residing in room [ROOM NUMBER]. 6. Interview with the Director of Nursing (DON) on 3/19/15 at 1:30 PM, in the DON's office, the DON was asked if it was acceptable for staff to stand over a resident to feed them. The DON stated, No, need to be at eye level. Interview in the DON's office on 3/19/15 at 1:30 PM, the DON was asked if it was acceptable to call residents feeders. The DON stated, No .",2018-05-01
6599,"NHC HEALTHCARE, LEWISBURG",445094,1653 MOORESVILLE HIGHWAY,LEWISBURG,TN,37091,2015-03-19,278,D,0,1,1R1P11,"**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 assessments were accurate for hospice care for 1 of 27 (Resident #113) sampled residents of the 27 residents included in the stage 2 review. The findings included: Review of facility's unscheduled Medicare Prospective Payment System (PPS) Assessments policy documented, .When indicated, a provider must complete the following unscheduled assessments: 1. Significant change in Status Assessment . Complete when the SNF (skilled nursing facility) interdisciplinary team has determined that a resident meets the significant change guidelines for either improvement or decline . Review of facility's Minimum Data Set (MDS) correction policy documented, .The MDS must be accurate as of the ARD (assessment reference date). Medical record review revealed Resident #113 was admitted on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #113's room on 3/17/15 at 8:15 AM, revealed Resident #113 awake but would not respond to verbal questions. Observations in Resident #113's room on 3/18/15 at 2:45 PM, revealed Resident #113 in bed lying on left side in a fetal position. Review of a physician's orders [REDACTED].#113 was to be admitted to hospice. The hospice plan of care documented a start of care date to hospice on 1/28/15. The significant change Minimum Data Set ((MDS) dated [DATE] did not document the resident received hospice services. Interview with the Director of Nursing (DON) on 3/19/15 at 10:30 AM, the in the conference room, the DON was asked if hospice should be on the MDS. The DON stated, Yes, I would expect hospice to be on the MDS. Interview with the MDS coordinator on 3/19/15 at 10:40 AM, in the conference room, the MDS coordinator was asked about the significant change MDS documentation. The MDS coordinator stated, I did a significant change MDS because she went on hospice. I failed to mark hospice.",2018-05-01
6600,"NHC HEALTHCARE, LEWISBURG",445094,1653 MOORESVILLE HIGHWAY,LEWISBURG,TN,37091,2015-03-19,280,D,0,1,1R1P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to revise the care plan for 1 of 27 (Resident #50) sampled residents. The findings included: Medical record review revealed Resident #50 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan initiated 2/5/15 documented .Unstageable Pressure Ulcer to Coccyx (5.4cm (centimeters) x (by) 3.4cm) . Review of the weekly wound assessment record documented, . Pressure Ulcer . 3/12/15 . Stage III . length 0.9cm . width 0.4 cm . Review of physician's orders [REDACTED].C(NAME)CYX STAGE III PRESSURE CLEAN WITH NORMAL SALINE APPLY SKINPREP TO PERIWOUND APPLY DERAGINATE AG TO WOUND BED, COVER WITH DRESSING CHANGE EVERY 3 DAYS AND PRN (as needed) -- Diagnosis: [REDACTED]. Interview with Licensed Practical Nurse (LPN) #4, on 3/18/15 at 3:55 PM, in the main dining room, LPN #4 was asked about Resident #50's pressure ulcer. LPN #4 stated, Has characteristics of stage II now . Interview with the Minimum Data Set (MDS) coordinator on 3/19/15 at 8:20 AM, in the Director of Nursing's (DON) office, the Minimum Data Set (MDS) coordinator was asked about the documentation of the wound on the care plan as unstageable pressure ulcer to coccyx. The MDS coordinator stated, This is from previous stay. I didn't go down and delete that. The MDS coordinator was asked if Resident #50 had a Stage III with the characteristics of Stage II. The MDS Coordinator stated, Yes.",2018-05-01
6601,"NHC HEALTHCARE, LEWISBURG",445094,1653 MOORESVILLE HIGHWAY,LEWISBURG,TN,37091,2015-03-19,281,D,0,1,1R1P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Medication Guide for the Long-Term Care Nurse, observation and interview, the facility failed to ensure that acceptable standards of practice were followed while administering medications per Percutaneous Gastrostomy Tube (PEG) for 1 of 6 (Resident #2) sampled residents observed receiving medications per PEG. The findings included: Review of the Medication Guide for the Long-Term Care Nurse, fourth edition, Administration of Medication Via Feeding Tube, page 68 documented, Different medications should not be mixed together for administration. Observations in Resident #2's room on 3/17/15 at 12:23 PM, revealed Licensed Practical Nurse (LPN) #2 prepared and mixed [MEDICATION NAME], Multivitamin with Mineral, Vitamin D3 and [MEDICATION NAME] together in the same cup and administered these medications via PEG tube to Resident #2. Interview with the Director of Nursing (DON) on 3/19/15 at 4:10 PM, in the DON's office, the DON was asked about LPN #2 mixing medications (meds) together and administering them via feeding tube. The DON stated, If tube is big enough staff can mix meds. Really do not know if meds should be mixed together or not.",2018-05-01
6602,"NHC HEALTHCARE, LEWISBURG",445094,1653 MOORESVILLE HIGHWAY,LEWISBURG,TN,37091,2015-03-19,371,F,0,1,1R1P11,"Based on policy review, observation and interview, the facility failed to ensure food was protected from sources of contamination in the kitchen as evidenced by carbon buildup on pots, pans and stove, dirty fan in the kitchen, cross contamination of thermometer, and lack of hair and beard restraint observed in use in the kitchen on 3 of 4 (3/16/15, 3/18/15 and 3/19/15) days of the survey and failed to ensure handwashing was performed during 1 of 3 (lunch meal on 3/18/15) dining observations. The facility had a census of 88 residents with 3 residents in isolation. The findings included: 1. Review of the Safety & (and) Sanitation Best Practice Guidelines documented, .Sanitation Of Thermometers . Thermometers should be washed rinsed or sanitized . Prior to taking any temperatures or before storing . When the thermometer probe has been touched, makes contact with an unsanitized surface, or otherwise contaminated . 2. Observations in the kitchen on 3/16/15 beginning at 2:00 PM revealed the following: a. Air curtain door was coated with a white substance. b. Uncovered scoop in bin on top of the ice machine. c. Three stock pots had a carbon buildup. d. Stove eyes and backsplash had a black build up. e. Three baking sheets had a carbon buildup. f. Four baking sheets with a carbon buildup. g. Sauce pan sitting on shelf above stove had a carbon buildup. h. Fan on the wall next to dish room had dirty, dusty blades. i. The Plant Operations Manager entered the kitchen without the hair net completely covering his head, nor did he have a beard cover over his facial hair. 3. Observations in the kitchen on 3/18/15 at 11:45 AM revealed the following: a. Uncovered scoop in bin on top of the ice machine. b. A baking sheet with a carbon buildup. c. Baking sheet on dessert rack with a carbon buildup. Tray line temperatures were performed on 3/18/15 at 11:53 AM by Dietary Cook #1 on food items being served as follows: cheddar cheese soup, Scandinavian vegetables, ranch chicken patty, pureed meat ranch chicken, mechanical chopped chicken, gravy, potatoes, ground meat ranch chicken, and mashed potatoes. Temperatures were performed using the same alcohol prep pad to clean the thermometer and the pad was laid on the counter between use. 4. Observations in the kitchen on 3/19/15 at 1:15 PM revealed the Plants Operation Manager entered the kitchen without a cover over his facial hair. 5. Observations during the lunch meal on 3/18/15 at 12:25 PM in the front dining room revealed the Plant Operations Manager opened the chest drawer, served a tray then scratched his face and served 3 more trays without performing hand hygiene. 6. Interview the Certified Dietary Manager (CDM) on 3/16/15 at 2:05 PM, in the kitchen, the CDM was asked what the buildup was on the pots and pans. The CDM stated, That is carbon. The CDM was asked if it needed to be cleaned. The CDM stated, Yes. The CDM was asked about the dirty, dusty fan blades. The CDM stated, No, has not been cleaned. Interview with the CDM on 3/19/15 at 1:10 PM, in the kitchen, the CDM was asked if the stock pots, baking sheets, sauce pan and small baking sheets should have a carbon buildup on them. The CDM stated, No. The CDM was asked if hair restraints and beard covers should be worn in the kitchen. The CDM was asked if the alcohol wipe should be laid on the tray line between taking tray line temperatures. The CDM stated, No. Interview with the Director of Nursing (DON) on 3/19/15 at 1:30 PM, in the DON's office, the DON was asked if it was acceptable to open the chest in the dining room and pass trays without washing hands before starting the tray pass. The DON stated, Would expect to wash hands.",2018-05-01
6603,"NHC HEALTHCARE, LEWISBURG",445094,1653 MOORESVILLE HIGHWAY,LEWISBURG,TN,37091,2015-03-19,441,D,0,1,1R1P11,"Based on policy review, observation and interview, the facility failed to ensure acceptable infection control practices during medication administration when 1 of 5 (Licensed Practical Nurse (LPN) #3) nurses observed administering medications placed a bottle of eye drops in her pocket. The facility failed to ensure food was protected from sources of contamination when 1 of 12 staff members (Plant Operations Manager) failed to wash his contaminated hands before serving meal trays. The findings included: 1. Review of Medication Administration Eye Drops policy documented, .13. Clean and return reusable items . Observation in Resident #16's room on 3/17/15 at 10:44 AM, revealed LPN #3 administered eye drops to Resident #16. LPN #3 was observed to place the bottle of eye drops in her pocket before and after administration of the eye drops. Interview with the Director of Nursing (DON) on 3/19/15 at 3:50 PM, in the DON's office, the DON was asked what her expectation was regarding staff placing resident medication (meds) bottles in their pockets. The DON stated, Staff should never place meds in his or her pocket. 2. Observations during the lunch meal on 3/18/15 at 12:25 PM, in the front dining room, revealed the Plant Operations Manager opened the chest drawer, served a tray then scratched his face and served 3 more trays without performing hand hygiene. Interview with the Director of Nursing (DON) on 3/19/15 at 1:30 PM, in the DON's office, the DON was asked if it was acceptable to open the chest in the dining room and pass trays without washing hands before starting the tray pass. The DON stated, Would expect to wash hands.",2018-05-01
8743,"NHC HEALTHCARE, LEWISBURG",445094,1653 MOORESVILLE HIGHWAY,LEWISBURG,TN,37091,2013-09-12,371,D,0,1,RUM011,"Based on observation and interview, it was determined the facility failed to ensure that food was stored, prepared and distributed under sanitary conditions as evidenced by staff coming into the kitchen without hair covers during 1 of 4 (9/11/13) days of the survey. The findings included: Observations in the kitchen on 9/11/13 at 11:55 AM, revealed staff members entering the kitchen without hair covers. During an interview in the kitchen on 9/11/13 at 12:15 PM, the Dietary Manager (DM) was asked about the absence of hair covers on employees entering the kitchen area. The DM stated, It is corporate policy.",2017-04-01
10512,"NHC HEALTHCARE, LEWISBURG",445094,1653 MOORESVILLE HIGHWAY,LEWISBURG,TN,37091,2012-06-13,280,D,0,1,FQMT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, it was determined the facility failed to revise care plans to reflect the current status of a Foley catheter and contact isolation for 2 of 19 (Residents #8 and 14) sampled residents. The findings included: 1. Review of the facility's care plan development policy documented, .Care plans are updated as needed . New problems are handled as they arise, and are added to the current care plan . 2. Medical record review for Resident #8 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].Clarification order for 5/21/12 Foley cath (catheter) #16 Fr (french) c (with) 5 cc (cubic centimeters) bulb to BSB (beside bag) . Review of the care plan dated 3/26/12 updated 5/15/12 contained no documentation of current Foley catheter status. Observation in Resident #8's room on 6/11/12 at 3:05 PM, revealed Resident #8 sitting in a rock and go chair with a Foley catheter in place. During an interview in the conference room on 6/13/12 at 12:00 PM, the Assistant Director of Nursing (ADON) confirmed the current care plan was not revised to reflect the current status of Resident #8's Foley catheter. The ADON stated, .It (Foley catheter) is not documented (on the current care plan) . 3. Medical record review for Resident #14 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].CONTACT ISOLATION FOR SHINGLES . A nurses' notes dated 6/6/12 documented, 9:30 (AM) Pt (patient) c (with) Shingles: moved to room [ROOM NUMBER] - Contact Isolation - started on [MEDICATION NAME] 800 mg (milligrams) po (by mouth) Q (every) 4 hours x (times) 7 days. A physician progress notes [REDACTED].severe pain lower R (right) back and buttock with rash . Shingles herpetic rash . There was no documentation of contact isolation for shingles on the care plan dated 4/17/12. Observations in Resident #14's room on 6/12/12 at 4:30 PM and 6/13/12 at 9:00 AM, revealed Resident #14 was in contact isolation. During an interview in the nursing's office on 6/13/12 at 10:00 AM, Nurse #2 stated, .Nurses update the care plan when they get an order . I don't see it (documentation of contact isolation for shingles on the care plan) .",2016-06-01
10513,"NHC HEALTHCARE, LEWISBURG",445094,1653 MOORESVILLE HIGHWAY,LEWISBURG,TN,37091,2012-06-13,362,D,0,1,FQMT11,"Based on observation and interview, it was determined the facility failed to deliver meal trays in a timely manner during 1 of 2 (supper 6/11/12) dining observations. The findings included: Observations on the 100 hall on 6/11/12 at 6:21 PM, revealed the meal cart arrived and the staff began to deliver the meal trays to the residents. The last tray was delivered to room 118 by Certified Nursing Assistant (CNA) #2 at 7:05 PM. A total of 44 minutes had lapsed since the meal cart had arrived on the hall. During an interview in Resident #6's room on 6/11/12 at 5:30 PM, Resident #6 stated, .The supper meal trays are usually delivered late . During an interview on 100 hall on 6/11/12 at 7:00 PM, CNA #2 was asked how many trays were left to be served and why those trays were still on the cart. CNA #2 stated, .lacks 4 more trays and just because where they (the residents' rooms) are located on the floor, not because of special needs .",2016-06-01
10514,"NHC HEALTHCARE, LEWISBURG",445094,1653 MOORESVILLE HIGHWAY,LEWISBURG,TN,37091,2012-06-13,371,E,0,1,FQMT11,"Based on policy review, observation and interview, it was determined the facility failed to store, prepare and serve food under sanitary conditions as evidenced by tray line hot food temperatures were below 135 degrees Fahrenheit (F), chipped dinnerware, dirty dishes stored with clean dishes, unsanitary meat slicer, opened food not dated and food stored out of date. The findings included: 1. Review of the facility's Temperature Control policy documented, .Minimum Internal Temperatures: Poultry 165 (degree symbol), Pork 145 (degree symbol), Vegetables 135 (degree symbol) . Observations during tray line temperature measurement on 6/12/12 at 12:04 PM, revealed the following hot food temperatures: a. Chopped pork chops 130 degrees F. b. Macaroni and Cheese 120 degrees F. c. Chopped Chicken 120 degrees F. During an interview in the kitchen on 6/12/12 at 12:04 PM, the Director of Dietary (DM) confirmed the low tray line temperatures and attempted to reheat the food 4 times to get the proper temperature. The DM stated, .Yes, too low . 2. Review of the facility's Slicer policy documented, .After each use, wash all removable parts in detergent solution . rinse in clear water and sanitize in sanitizing solution . use brush or thick cloth pad to clean stationary parts of slicer with mild detergent solution . Review of the facility's Safety Practices policy documented, .Dishes will be checked for cracks and chips and discarded . Review of the facility's Refrigerator and Freezer Storage policy documented, .Leftovers will be placed in NSF (National Sanitation Foundation) approved containers, covered, labeled, dated, and stored in refrigerator or freezer at correct temperature . A. Observations during the initial tour of the kitchen on 6/11/12 at 11:30 AM, revealed the following: a. Dried brown substance in the meat slicer. b. Three chipped plates in the clean plate storage area. c. Reach in cooler had water leaking into a pan on the top shelf. Bottom two shelves contained prepared salads with lettuce, eggs, onions partially covered with paper. Reach in cooler had cheese opened with no date. d. Walk in cooler with tuna fish (not in original container) open date 6/6/12, cottage cheese (not in original container) open date 6/6/12, ground beef open date 6/6/12. e. Clean cereal bowls stored in open bin in dish washer room with water spraying out onto area from dish washer during cycle. A bowl with a dried green substance on the bottom stored in the clean cereal bowl bin. During an interview in the kitchen on 6/11/12 at 11:30 AM, the DM was asked what was the brown substance in the meat slicer. The DM stated, .Looks like dried turkey to me . the meat slicer has not been used in at least 5 days . The DM was asked about the water leak in the reach in cooler. The DM stated, .We use this pan to catch the water . We still use the cooler . Maintenance knows we have a leak . The DM confirmed the opened cheese with no date and tuna fish, cottage cheese and ground beef exceeded the open date of 3 days. The DM stated, .No, the cheese is not dated . The DM was asked about the clean dishes stored in the dishwasher room. The DM stated, .Yeah, they should not be stored in here and the water spraying on them . Yes, I see the green dried substance on the bowl . B. Observations during the kitchen tour on 6/13/12 at 11:21 AM, revealed the following: a. Yellow dried substance and flecks of dried beige substance on a plate stored in the clean plate holder. b. Two chipped plates in the clean plate storage area. c. Moderate amount of a dried beige substance on a plate stored in the clean plate holder picked up by the tray line employee to be plated with food and surveyor stopped the employee prior to plating food. During an interview in the kitchen on 6/13/12 at 11:21 AM, the DM was asked about the spraying water from the dishwasher out into the room and on the clean dish storage area. The DM stated, .Unacceptable . The DM confirmed the chipped plates and and plates with dried substances on them were stored in the clean plate holder for lunch meal service (6/12/12).",2016-06-01
10515,"NHC HEALTHCARE, LEWISBURG",445094,1653 MOORESVILLE HIGHWAY,LEWISBURG,TN,37091,2012-06-13,441,D,0,1,FQMT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, it was determined the facility failed to ensure practices to prevent the spread of infection for 1 of 3 (Resident #1) residents in isolation and during 1 of 2 (6/11/12 Supper) dining observations. The findings included: 1. Review of the facility's INFECTION CONTROL MANUAL documented, CONTACT PRECAUTIONS - In addition to Standard Precautions, 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 or patient care equipment . gloves are worn when in contact with patients or infectious material . Remove gloves before leaving room and wash hands immediately with an antimicrobial agent . Medical record review for Resident #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].Contact Isolation For[DIAGNOSES REDACTED] . Observations in Resident #1's room on 6/11/12 beginning at 6:05 PM, revealed Certified Nursing Assistant (CNA) #1 to remove her gloves and exit the contact isolation room without washing her hands. CNA #1 went to the linen closet to get a wash cloth and returned to Resident #1's room. CNA #1 did not put on gloves, but entered the room and went in the bathroom to wet the cloth to give to the resident. During an interview in the conference room on 6/12/12 at 4:00 PM, when asked about the procedure for[DIAGNOSES REDACTED] isolation, Nurse #1 stated, .(staff to wear) gloves, gowns, wash with soap and water, no hand sanitizer because it won't kill the spores . should not come out of the room (without washing hands) . 2. Review of the facility's Dining Program policy documented, .To prevent cross-contaminatin (contamination), in-room trays and soiled dishes should not be placed on carts with clean food and trays that have not been served . Observations in the small dining room on the 100 hall on 6/12/12 at 1:10 PM, revealed Director of Environmental Services (ES) removed the meal tray from the rolling cart, propped the tray on the table and removed the plate and dinner ware from the tray laying it on the table. The ES Director removed the dome cover from the plate, placed the cover on the tray then placed the tray back on the rolling meal cart with the trays that had not been served. The ES Director continued this process 6 times. During an interview in the conference room on 6/13/12 at 8:30 AM, the Administrator confirmed once a tray had been delivered, the tray was not to be placed back on the rack with trays that had not been served.",2016-06-01
10516,"NHC HEALTHCARE, LEWISBURG",445094,1653 MOORESVILLE HIGHWAY,LEWISBURG,TN,37091,2012-06-13,504,D,0,1,FQMT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to obtain a physician's order for a laboratory test that was done for 1 of 19 (Resident #3) sampled residents. The findings included: Medical record review for Resident #3 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a laboratory report dated 6/6/12 documented Resident #1 had received a [MEDICATION NAME] time test (PT) with an international normalized ratio (INR). The facility was unable to provide documentation of a physician's order for the PT/INR that was done on 6/6/12. During an interview in the conference room on 6/13/12 at 2:10 PM, the Director of Nursing confirmed there was no physician's order for the PT/INR that was obtained on 6/6/12.",2016-06-01
10517,"NHC HEALTHCARE, LEWISBURG",445094,1653 MOORESVILLE HIGHWAY,LEWISBURG,TN,37091,2012-06-13,514,D,0,1,FQMT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to ensure medical records were maintained accurately and completely for 2 of 19 (Residents #3 and 9) sampled residents. The findings included: 1. Medical record review for Resident #3 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the May 2012 Medication Administration Record [REDACTED]. The facility was unable to provide documentation of a physician's orders [REDACTED]. During an interview in the Director of Nursing's office on 6/13/12 at 11:00 AM, Nurse #3 stated she called the physician on 5/30/12 and received an order to discontinue the Jantoven 5 mg but failed to write the telephone order. 2. Medical record review for Resident #9 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].Diet Clarification: Regular with thin liquids . Review of a dietary progress note dated 4/30/12 documented, .Regular diet with thin liquids . Review of the patient plan of care (PPOC) signed 2/27/12, 3/28/12, 4/28/12, 5/8/12 and 5/29/12 documented, .Diet orders Mech (mechanical) Soft, Chopped Meat . During an interview at the 100 hall nurses' station on 6/11/12 at 3:52 PM, the Assistant Director of Nurses (ADON) confirmed inaccurate medical record related to diet order for Resident #9. The ADON stated, .She (Resident #9) is receiving regular diet with thin liquids, the PPOC was not updated to reflect the diet order .",2016-06-01
12902,"NHC HEALTHCARE, LEWISBURG",445094,1653 MOORESVILLE HIGHWAY,LEWISBURG,TN,37091,2011-03-16,441,E,0,1,S8XT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of the ""Long-Term care Pocket Guide for Infection Control"", observation, and interview, it was determined the facility failed to ensure 4 of 9 nurses (Nurses #3, 5, 6 and 7) and 4 of 5 Certified Nursing Assistants (CNAs #2, 3, 4 and 5) practiced measures to prevent the potential spread of infection by not cleaning equipment, not washing their hands, not placing a soiled dressing in a red bag, not applying ointment to the wound with a tongue blade or Q-tip or not changing gloves when indicated. The findings included: 1. Review of the facility's storage and securing biomedical waste policy documented, ""...Infectious waste includes waste from isolation units and soiled dressings. *Infectious waste materials are to be bagged inside resident's unit in a single thick (at least 2 mm (millimeters) thick) bag or double bagged appropriately. *Infectious waste bag is taken directly to collection area and placed in collection container until pickup day..."" Review of the facility's dressing change policy documented, ""...Prepare ointments on sterile dressings before entering the patient's room, also, ointments in jars are removed with a sterile tongue blade or Q-tip and applied to sterile dressing... Establish the working area, use red bag as barrier and place needed supplies on the barrier... Tape 2nd red bag to side of working area to dispose of the soiled dressings... dispose soiled dressing in red bag..."" Observations in Resident #13's room on 3/15/11 at 3:45 PM, Nurse #3 performed wound care on Resident #13's left heel. Nurse #3 placed her supplies on the overbed table without cleaning the table, then removed gloves from her pocket and proceeded to remove the soiled dressing from the resident's left heel. Nurse #3 placed the soiled dressing along with her gloves into the trash can beside the bed. Nurse #3 donned a clean pair of gloves from a box in Resident #13's nightstand, removed the ointment from her pocket, applied the ointment on two fingers, and proceeded to apply the ointment to Resident #13's left heel. During an interview at the 200 hall nurses station on 3/15/11 at 4:15 PM, Nurse #3 stated, ""I should have placed the soiled dressing in the red bag and used a Q-tip to apply the ointment."" During an interview in the conference room on 3/15/11 at 4:20 PM, the surveyor asked the DON if she had read the new regulations on infection control. The DON stated, ""I have not read it lately."" 2. Review of the ""Long-Term Care Pocket Guide for Infection Control"", page 88, documented, ""...Equipment and other articles... Reusable equipment is disinfected after use..."" a. Observations in Random Resident (RR) #6's room on 3/14/11 at 7:40 PM, Nurse #5 obtained RR #6's nebulizer machine, opened up the chamber where the medication is placed, poured out a clear liquid, then poured in a unit dose of [MEDICATION NAME] into the chamber, put the mask over RR #6's face and turned the machine on. After the treatment was completed, Nurse #5 placed the mask back into the bag without cleaning the chamber. b. Observations in Resident #2's room on 3/14/11 at 8:20 PM, Nurse #7 obtained Resident #2's nebulizer machine, opened up the chamber where the medication is placed and poured in a unit dose of [MEDICATION NAME] into the chamber, put the mask over Resident #2's face and turned the machine on. After the treatment was completed Nurse #7 placed the mask back into the bag without cleaning the chamber. During an interview in the conference room on 3/15/11 at 4:20 PM, the Director of Nurses (DON) confirmed that the chamber of the nebulizer machine should be rinsed out after each use. 3. Review of the facility's ""HANDWASHING"" policy documented, ""When to wash hands... d. After any contaminated contact, whether or not gloves are worn. e. Before donning gloves and as soon as feasible after removal of gloves or other personal protective equipment. f. Before and after caring for each patient. g. During medication pass... i. Before passing out trays or handling food. j. Between tasks/procedures on the same patient to prevent cross-contamination..."" a. Observations in RR #7's room on 3/14/11 at 8:00 PM, Nurse #6 picked up the bed control from the floor and placed it back on the bed railing. Nurse #6 administered medication to RR #7. Nurse #6 did not perform hand hygiene after she picked the bed control up from the floor or before administering medications to RR #7. During an interview in the 300 hall on 3/14/11 at 8:05 PM, Nurse #6 stated, ""I should have washed my hands."" b. Review of the facility's ""MEDICATION ADMINISTRATION INTRANASAL SPRAY"" policy documented, ""...5. Wash your hands and put on gloves..."" Observation in RR #8's room on 3/14/11 at 8:15 PM, Nurse #7 used hand foam to clean his hands, put on gloves and administered [MEDICATION NAME] 0.005 percent (%) eye drop (gtt), 1 gtt in RR #8's right eye and with the same gloved hand placed 1 gtt in RR #8's left eye. Nurse #7 removed her gloves then removed the oxygen (O2) cannula from RR #8's nostrils. Nurse #7 removed the cap from the Deep Sea 0.65% nose spray and placed 1 spray in RR #8's right nostril then 1 spray in RR #8's left nostril and repeated the process. Nurse #7 did not wash his hands between the eye gtts and nasal spray, and did not change gloves when he administered nasal spray. c. Observations during tray pass on the 100 hall on 3/14/11 at 8:40 AM, CNA #2 touched the resident's reclining chair control, rolled the overbed table in front of the resident, placed the tray on the overbed table, opened the plate cover, opened the milk, and silverware without using hand hygiene before setting up the meal tray. During an interview on 100 hall on 3/14/11 at 8:47 AM, CNA #2 stated, ""You know I was thinking that I should have washed my hands first."" d. Observations during tray pass on the 100 hall on 3/14/11 at 8:50 AM, CNA #3 wheeled the resident into her room and rolled he overbed table in front of the resident, placed the tray on the overbed table, removed the plate cover, opened the silverware, orange juice and milk without using hand hygiene before setting up the meal tray. During an interview on the 100 hall on 3/14/11 at 8:55 AM, CNA #3 stated, ""You are right I should have washed my hands after I touched the wheelchair and overbed table."" e. Observations in room [ROOM NUMBER] on 3/16/11 at 6:05 PM, CNA #4 delivered a meal tray to the resident in room [ROOM NUMBER]. CNA #4 applied a clothing protector to the resident, then set up the resident's meal tray. CNA #4 donned gloves, cut this resident's sandwich, then removed her gloves. CNA #4 left the room, walked to the cart, obtained a meal tray, delivered and set up the tray for the resident in room [ROOM NUMBER]. CNA #4 left the room, walked to the cart, obtained a meal tray, delivered and set up the tray for the resident in room [ROOM NUMBER]. CNA #4 did not perform hand hygiene before or after donning gloves, or between delivering the meal trays. Observations in room [ROOM NUMBER] on 3/16/11 at 6:25 PM, CNA #4 delivered a meal tray and set up the resident's meal tray. CNA #4 donned gloves, cut this resident's burger, then removed her gloves. CNA #4 left the room, walked to the cart, obtained a meal tray, delivered and set up the tray for the resident in room [ROOM NUMBER]. CNA #4 did not perform hand hygiene after removing gloves and prior to serving the meal tray. f. Observations in room [ROOM NUMBER] on 3/17/11 at 8:50 AM, CNA #5 delivered and set up the resident's meal tray, opened the resident's drawer and obtained sugar this resident requested. CNA #5 left the room, walked to the cart, obtained a meal tray, delivered and set up the tray for the resident in room [ROOM NUMBER]. CNA #5 touched this resident on the shoulder, then applied gloves, assisted this resident to apply dentures, then removed her gloves. CNA #5 did not perform hand hygiene before or after donning gloves, or between delivering the meal trays. During an interview in the conference room on 3/15/11 at 4:15 PM, the DON stated, ""...They (CNAs) should be washing their hands between trays, touching residents, and after wearing gloves. They know to do this.""",2015-06-01
12903,"NHC HEALTHCARE, LEWISBURG",445094,1653 MOORESVILLE HIGHWAY,LEWISBURG,TN,37091,2011-03-16,312,D,0,1,S8XT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, it was determined the facility failed to ensure staff assisted residents with activities of daily living (ADL) by not assisting with meals for 1 of 17 (Resident #10) observed sampled residents observed. The findings included: Medical record review for Resident #10 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 12/16/10 documented, ""...At risk for Swallowing Problems *hx (history) of Dysphagia *dx (diagnosis) of [MEDICAL CONDITION] **GOAL** Patient will tolerate present diet consistency without s/s (signs and symptoms) aspiration... **APPROACHES** Provide diet as ordered- CCHO (Consistent Carbohydrates) regular... Check patient for pocketing of food in cheek... Keep patient focused on chewing and swallowing... Monitor diet texture tolerance... Upright for po (by mouth) intake... Observe for s/s aspiration and intervene as needed... Encourage/assist patient to eat slowly and carefully..."" Observations in Resident #10's room on 3/15/11 at 8:10 AM, revealed Resident #10 was sitting up in bed with his breakfast tray in front of him, barely within his reach and no one present to assist him. During an interview on the 200 hall on 3/15/11 at 8:15 AM, Nurse #9 stated, ""They (staff) set up his tray and he usually feeds himself."" Observations in Resident #10's room on 3/16/11 at 8:25 AM, 8:35 AM, 8:50 AM and 9:00 AM, revealed Resident #10 sitting up in bed, eyes closed with his breakfast tray in front of him, untouched and no one present to assist him. During an interview on the 200 hall on 3/16/11 at 9:00 AM, Nurse Assistant (NA #1) who was working on the 200 hall stated she was not familiar with him and that his meal was set up. During an interview on the 200 hall on 3/16/11 at 9:10 AM, the surveyor read the documentation on Resident #10's care plan dated 12/16/10 to Nurse #9. Nurse #9 stated, ""have to check into it.""",2015-06-01
12904,"NHC HEALTHCARE, LEWISBURG",445094,1653 MOORESVILLE HIGHWAY,LEWISBURG,TN,37091,2011-03-16,315,D,0,1,S8XT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation and interview, it was determined the facility failed to provide appropriate treatment for [REDACTED].#10) observed sampled residents receiving a bath or pericare. The findings included: Review of the facility's bed bath policy documented, ""...Procedure ...3. Explain procedure to the patient."" Review of the facility's perineal care for males documented, ""...Explain to patient what you would like to do... Wash perineal area starting with the urethra and working outward... b. Wash and rinse the urethral area using a circular motion. c. Continue to wash the perineal area including the penis, scrotum and inner thighs. Do not reuse the same washcloth or water to clean the urethra. 11. Thoroughly rinse the perineal area in the same order, using fresh water and clean washcloth... 12. Gently dry perineum following same sequence... 16. Wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks..."" Observations in Resident #10's room on 3/16/11 at 10:55 AM, revealed Nurses Assistant (NA) #1 and Certified Nurses Assistant (CNA) #1 were in the room to give Resident #10 a bed bath. After the pan was filled with water CNA #1 took a wet cloth and started to wash Resident #10's face. CNA #1 did not tell the resident what she was going to do and the resident became combative. Next the resident's wet (from urine) yellow stained looking t-shirt was removed and placed in a drawer in the bedside stand. CNA #1 washed Resident #10's arms and torso. The resident complained of not being covered up. A clean t-shirt was put on. Resident #10's legs and the top of his feet were washed, between toes and under feet were not washed. Resident #10 had a large soft bowel movement (BM). CNA #1 took a wet washcloth with soap and washed Resident #10's groin area and perineal area back and forth with the same washcloth that was soiled with BM. Different parts of the wash cloth were not always used. NA #1 and CNA #1 turned Resident #10 on his right side. CNA #1 washed the resident's buttocks. An upward motion was not always used and the cloth was soiled (with BM). The pad and the fitted sheet under the resident had a large yellow ring. After the soiled linen was removed, the surveyor observed that the mattress was wet with urine. The clean linen was put over the wet area of the mattress. The soiled linen was then placed on top of the trash can until it was taken out of the room. During an interview in room [ROOM NUMBER] (was empty) on 3/16/11 at 1:20 PM, when asked about the yellow ring on Resident #10's pad and sheet. CNA #1 stated, ""That means he was wet for a long time... They wipe down the mattress twice a week..."" The surveyor asked CNA #1 what she would have done different during Resident #10's bath. CNA #1 stated, ""...made sure he was more calm.""",2015-06-01
12905,"NHC HEALTHCARE, LEWISBURG",445094,1653 MOORESVILLE HIGHWAY,LEWISBURG,TN,37091,2011-03-16,514,D,0,1,S8XT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to maintain medical records that were complete and accurate by not reconciling physician's orders [REDACTED].#3 and 12) sampled residents. The findings included: 1. Medical record review for Resident #3 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's telephone order dated 12/17/10 documented ""[MEDICATION NAME] level Q (every) Day until therapeutic..."" Review of the physician's re-certification orders dated 12/17/10 documented ""[MEDICATION NAME] level daily..."" Review of documentation in the medical record revealed [MEDICATION NAME] levels were not being done daily. During an interview on the 200 hall near the nurses' station on 3/15/11 at 2:40 PM, Nurse #9 stated, ""The [MEDICATION NAME] levels are daily... will seek clarification from her doctor."" 2. Medical record review for Resident #12 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. During an interview at the back nurses' station on 3/16/11 at 10:30 AM, the Nurse Manager stated, ""[MEDICATION NAME], it should not be PO. This nurse (the nurse that reviews re-cert orders to make sure that they are right) did not make sure it was right...""",2015-06-01
12906,"NHC HEALTHCARE, LEWISBURG",445094,1653 MOORESVILLE HIGHWAY,LEWISBURG,TN,37091,2011-03-16,332,D,0,1,S8XT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of ""Nasal Spray Administration Procedure for Adults"" provided by the American Society of Consultant Pharmacists, medical record review, observations and interviews, it was determined the facility failed to ensure the medication error rate was less than five percent (%). Two (2) of 9 medication nurses (Nurses #2 and #7) made 4 errors out of 46 opportunities for error which resulted in a medication error rate of 8.65%. The findings included: 1. Review of the facility's ""PROCEDURE MEDICATION ADMINISTRATION PER FEEDING TUBE"" policy documented, ""...6. Flush with a minimum of 30 cc (cubic centimeters) water to assure patency of tube. 7. Administer medications..."" Medical record review for Resident #12 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]."" Observations in Resident #12's room on 3/14/11 at 6:10 PM, revealed Nurse #2 administered [MEDICATION NAME] per PEG tube to Resident #12. Nurse #2 did not flush the tube with water before administering the [MEDICATION NAME]. The failure to flush the PEG tube resulted in medication error #1. 2. Review of the ""Nasal Spray Administration Procedure for Adults"" provided by the American Society of Consultant Pharmacists documented, ""...have the patient gently blow their nose to remove excess mucous before administering the nasal spray..."" Medical record review for Resident #2 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Observations in Resident #2's room on 3/14/11 at 8:20 PM, Nurse #7 administered [MEDICATION NAME] 30 units to Resident #2. Nurse #7 did not roll the insulin vial before the medication was drawn up in the syringe, which resulted in medication error #2. Observations in Resident #2's room on 3/14/11 at 8:20 PM, revealed Nurse #7 administered [MEDICATION NAME] nasal spray 2 sprays in each nostril and Deep Sea nasal spray 2 sprays in each nostril. Nurse #7 did not instruct the resident to blow their nose to remove excess mucus and did not wait between each medication. This resulted in medication errors #3 and #4. During an interview on the 200 hall on 3/14/11 at 8:30 PM, Nurse #7 stated, ""...should have waited at least 5 minutes between sprays... same thing for eye drops.""",2015-06-01
12907,"NHC HEALTHCARE, LEWISBURG",445094,1653 MOORESVILLE HIGHWAY,LEWISBURG,TN,37091,2011-03-16,431,D,0,1,S8XT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, it was determined 2 of 6 (200 hall medication cart and 300 hall medication cart) medication storage areas failed to have medication stored properly when medication was left on top of a medication cart and a medication cart was left unlocked and unattended. The findings Included: 1. Review of the facility's ""Medication Storage"" policy documented, ""...5. Individual patient medications shall be stored in an orderly manner in locked unit dose carts... 10. Medication rooms, carts and treatment carts or trays shall be kept locked when it is not in a nurse's immediate view..."" 2. Observations in the 200 hall on 3/14/11 at 12:05 PM, revealed the 200 hall medication cart was left unlocked, unattended and out of the nurse's view. Nurse #2 came out of room [ROOM NUMBER] and stated, "" Oh! I'm sorry..."" 3. Observations in the 300 hall on 3/14/11 at 5:45 PM, revealed Nurse #4 left a single dose vial of Albuterol Sulfate on top of the 300 hall medication cart unattended and out of the nurse's view. During an interview in the 300 hall on 3/14/11 at 5:50 PM, Nurse #4 stated, ""...I was going to put it (Albuterol Sulfate) back up, I just did not do it...""",2015-06-01
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
3898,"NHC HEALTHCARE, KNOXVILLE",445098,809 EAST EMERALD AVE,KNOXVILLE,TN,37917,2016-10-20,167,C,0,1,N3NC11,"Based on observation and interview, the facility failed to label and place the state survey results in a readily accessible location for resident use. The findings included: Observation of the first floor lobby on 10/19/16 at 10:00 AM, revealed the state survey results were in an unlabeled basket attached to the wall above the chair rail. Further observation revealed the first floor contained the kitchen, bookkeeping, business office, and laundry room. Interview with the Administrator on 10/19/16 at 1:25 PM, on the first floor, confirmed the facility failed to label and place the results of the state survey in a location readily accessible to residents.",2020-01-01
3899,"NHC HEALTHCARE, KNOXVILLE",445098,809 EAST EMERALD AVE,KNOXVILLE,TN,37917,2016-10-20,176,D,0,1,N3NC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to evaluate one resident (#137) of 34 residents reviewed for safe self-administration of medications. The findings included: Observation on 10/20/16 at 8:10 AM, in Resident #137's room, revealed 2 over-the-counter medications on the bedside table; a generic calcium based antacid and a topical [MEDICATION NAME] for muscle soreness. Interview with the resident on 10/20/16 at 8:10 AM, in the resident's room, confirmed .I have indigestion sometimes and I take those and the other one I rub on my feet when they hurt. My sister brought it for me. Interview with Licensed Practical Nurse #2 on 10/20/16 at 8:25 AM, in the 2 West hall, confirmed the resident had not been assessed for safe self-administration of drugs.",2020-01-01
3900,"NHC HEALTHCARE, KNOXVILLE",445098,809 EAST EMERALD AVE,KNOXVILLE,TN,37917,2016-10-20,225,D,0,1,N3NC11,"**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 identify, investigate, and report an allegation of abuse for one resident (#137) of 19 residents reviewed. The findings included: Review of the facility policy Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, and Misapporiation of Property Section Number 610, revised 9/1/16, revealed, .Verbal Abuse: the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance .Mental Abuse: includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation .All supervisory partners who receive reports of and/or identify inappropriate behaviors will take immediate steps to correct such behaviors .The right to report a concern or incident is not limited to a formal, written grievance process but includes any verbalized complaint to any center partner .Any patient event that is reported to any partner by patient, family, other partner or any other person will be considered an allegation of either abuse .if it meets any of the following criteria .Any patient or family complaint of physical or verbal harm, pain, or mental anguish resulting from the actions of other .Any complaint of the use of oral .or gestured language that willfully includes disparaging and derogatory terms to patient or families or within their hearing distance .Any complaint of humiliation, harassment, threats of punishment or deprivation .Any partner having either direct or indirect knowlege of any event that might constitute abuse .must report the event immediately. All allegations of possible abuse .will be immediately assessed to determine the appropriate direction of the investigation .All alleged violations .will be reported immediately to the Adminsitrator or her/his designated representative and to other officials in accordance with State and Federal law (including to the State survey and certification agency) .The investigation is conducted immediately under the following circumstances: i. When it is identified that an alleged incident may have occurred. ii. As soon as any partner has knowledge and reports an alleged event. When there is a question as to whether to conduct an investigation, it is best to do so .The results of all investigations will be completed within five working days . Resident #137 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) of 15/15, showing her to be cognitively intact. Interview with Resident #137 on 10/18/16 at 8:30 AM, in the resident's room, revealed when the resident asked the night nurse for pain medication, the nurse brought two over-the-counter pills, which the resident refused, and the nurse threw the pills in the trash and brought a stronger pain medication. .(I)t made me feel like I was lying .the nurse had been told not to come back into (the resident's room) but came back anyway and asked me why I was upset . Interview with the Director of Nursing (DON) on 10/18/16 at 9:15 AM, in the DON's office, confirmed the resident's Power of Attorney (POA) came to the office last week and told the day shift House Supervisor about 2 episodes of Licensed Practical Nurse (LPN) #1 being hateful about giving the resident pain medication. Continued interview revealed the DON left phone messages for LPN #1 to return her call and left a message for the night House Supervisor on 10/15/16 to change LPN #1's assignment to exclude resident #137 from LPN #1's assignment. Telephone interview with LPN #1 on 10/19/16 at 2:37 PM, revealed .in report, day nurse (LPN #2) told me .(Resident #137) was upset with me and I should stay out of the resident's room. I thought she was confused about who I was so I went in there to let her see me and remind her who I was. I had no intention of upsetting her but I'd been taking care of her a lot and thought we had a good relationship. I had no advance notice that I was not supposed to go into (the resident's) room other than the day nurse's suggestion. I had a message on my phone from the DON to call her but did not get to return the call until Friday and she wasn't at work. So I didn't know I wasn't supposed to go in there. Interview with the day shift House Supervisor for Saturday 10/15/16, on 10/19/16 at 3:00 PM, confirmed the supervisor had no knowledge of the incident or any assignment change for LPN #1 on Saturday,10/15/16. Telephone interview with the night shift House Supervisor LPN #4, on 10/19/2016 at 7:55 PM, confirmed she had no knowledge of the incident or any assignment change for LPN #1 on Saturday, 10/15/16. Interview with LPN #2 on 10/20/16 at 7:50 AM, confirmed the resident's POA telephoned on Sunday 10/16/16 and told him LPN #1 went into the resident's room last night, after the DON had assured the POA LPN #1 would not be assigned to care for her sister. Continued intervew confirmed LPN #2 called the DON at home and immediately notified the DON of the POA's call. Interview with the DON on 10/20/16 at 9:00 AM, in the DON's office, confirmed the facility did not did not treat the POA's concerns as allegations of abuse.",2020-01-01
3901,"NHC HEALTHCARE, KNOXVILLE",445098,809 EAST EMERALD AVE,KNOXVILLE,TN,37917,2016-10-20,241,D,0,1,N3NC11,"Based on review of employee standards of conduct, observation, and interview, the facility failed to promote resident dignity in dining for 1 of 3 dining rooms and 1 of 5 hallways for 2 resident meals observed. The findings included: Review of the Standards of Conduct for Staff, undated, revealed .Partners will treat patients/residents with dignity and respect in a manner that is in the best interests of the patients/residents, including state and federal legislation regarding patient/resident rights . Observation on 10/17/16 from 12:16 PM to 12:45 PM, in the 2nd floor dining room, revealed 7 of 26 residents drinking milk from cartons. There were no observations of residents being asked their preference for a cup. Observation on 10/18/16 from 7:30 AM to 7:45 AM, in the 2nd floor dining room, revealed 1 of 4 residents drinking milk from a carton. Observation revealed the resident was not asked about their preference for a cup. Interview with the Certified Dietary Manager on 10/18/16 at 7:45 AM, in the 2nd floor dining room, confirmed the residents had not been asked if they wanted a cup for their milk. Observation of the breakfast service on 10/18/16 at 8:25 AM, on the front hallway, revealed the Vice-President Regional Administrator delivered a resident tray with 2 milk cartons and no cup. Further observation revealed Certified Nursing Assistant (CNA) #1 delivered 2 breakfast trays on the front hallway with 2 cartons of milk each, but no cups. Interview with CNA #1 on 10/18/16 at 8:30 AM on the front hallway, confirmed no cup was provided on the breakfast tray, the CNA did not ask the residents if they wanted the milk poured into a cup, and the CNA had not been instructed to pour the milk from the carton into a cup until this morning. Interview with the Vice-President Regional Administrator on 10/18/16 at 8:35 AM, on the front hallway, confirmed no cup was present on the resident breakfast tray and he did not offer a cup to the resident.",2020-01-01
3902,"NHC HEALTHCARE, KNOXVILLE",445098,809 EAST EMERALD AVE,KNOXVILLE,TN,37917,2016-10-20,253,D,0,1,N3NC11,"Based on observation and interview the facility failed to keep 1 of 3 air intake vents clean and free of dust, lint, and debris. The findings included: Observation on 10/17/16 at 9:05 AM, on the 3rd floor hallway, revealed accumulated dust, lint, and debris on the air handler vent. Interview with Housekeeping/Laundry Supervisor on 10/17/16 at 10:00 AM, on the 3rd floor hall, confirmed the vent was dirty and needed to be cleaned.",2020-01-01
3903,"NHC HEALTHCARE, KNOXVILLE",445098,809 EAST EMERALD AVE,KNOXVILLE,TN,37917,2016-10-20,309,G,0,1,N3NC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide continuing neurological assessments after a resident on anticoagulant medication fell , resulting in Harm for one resident (#53) of 34 residents reviewed. The findings included: Medical record review revealed Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the resident's Medication Administration Record [REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE], revealed the resident's score on the Brief Interview for Mental Status (BIMS) was 11/15, indicating moderate impaired cognition. Medical record review of a Post Falls Nursing assessment dated [DATE], revealed Resident #53 was found face down on the floor in her room on 6/27/16 at 7:30 AM, was unable to explain what she was doing at the time of the fall but, .finally said 'I am OK . Vital signs were taken and the physician was notified by phone with no orders received. A personal alarm was attached to alert staff if the resident decided to ambulate without assistance again while in her room. Medical record review of the Neurological Flow Sheet, dated 6/27/16, revealed Form to be used for incidents/accidents with possible head injury: [NAME] Initial assessment followed by: B. Every hour times 3 hours followed by: C. Once per shift for 72 hours . Continued review revealed the neuro checks (a timed series of neurological assessments performed and documented to ensure the injured person has not suffered severe head injury requiring emergency intervention) started with the post fall assessment at 7:30 AM and was repeated at 8:00 AM, 8:30 AM, and 9:00 AM, with no further neuro checks completed. Nurse's Notes on the back of the form revealed, 6/27/16 Unsure of blood from nose was due from fall- on [MEDICATION NAME] (blood thinning medication) but bleeding stopped immediately. Per therapy resident had some nasal bleeding possible due to oxygen usage via nasal canula. Neurochecks DC'd (discontinued) . Medical record review of a Nurse's Note dated 6/27/16 at 4 PM: Fall follow-up from 6/27/16 @ (at) 7:30 AM - awake, alert with confusion noted, has hx (history) of hallucinations and dementia .[DIAGNOSES REDACTED], uses pen and paper for most communication .UTI (urinary tract infection) protocol initiated . Medical record review of the Daily Skilled Nurse's Note dated 6/28/16 7A-7P resident seen by NP (Nurse Practitioner). Send to ER (emergency room ) .Resident presented with decreased mental status 7A-7P. Sent to ER per NP to eval & tx (evaluate and treat). Resident admitted for subdural hematomas . Medical record review revealed a note indicating the resident was sent to theER on [DATE] at 12:45 PM. Medical record review of the hospital Discharge Summary revealed Date of Admission: 06/28/16 .Date of Discharge: 07/01/16 .Admission Diagnosis: [REDACTED].#53 .was trying to get up to go to the bathroom when she had a fall .she had a CT scan (computed tomography), which demonstrated a small subdural hematoma along the frontoparietal falx, roughly 6 mm (millimeters) in thickness as well as a thin density subdural collection over the left posterior frontoparietal lobe roughly 9 mm in thickness .she is alert and oriented x0 (times zero, not alert or oriented) .she does not follow commands .she does spontaneously wave her left lower extremity .was admitted to the Neuro ICU (intensive care unit) .The patient was taking [MEDICATION NAME] .we did obtain a second CT 6 hours after the first one due to use of anticoagulation; at that time, the CT reading showed the subdural hematoma slightly increased .We did obtain a second CT on 6/29/16, approximately 6 hours after. At that time, the CT showed stable right posterior parietal subdural fluid collection and stable falx hematoma. There was no worrisome interval change . Further review revealed the resident was discharged back to the facility on [DATE] with orders not to resume anticoagulation therapy until a repeat CT scan was done in 2 weeks. Interview with the NP on 10/19/16 at 2:10 PM, in the conference room, confirmed I was not consulted until the 28th. I thought she had fallen that morning (morning of 6/28/16). I'm glad I sent her out, on [MEDICATION NAME], on a lot of medicine, her baseline cognition pretty demented all the way along. It would have been appropriate to ask the physician to evaluate anyway given the resident's history. Three .neuro checks is not the normal protocol. In summary, Resident #53, who was receiving anticoagulation therapy, had an unwitnessed fall on 6/27/16 at 7:30 AM, when she was found lying face down with a small amount of bleeding from the nostril. The facility did a total of 4 neuro checks that ended at 9:00 AM, 1 1/2 hours after the fall, with no further neuro checks. The next day, on 6/28/16, the resident was found with altered mental status, sent to the hospital at 12:45 PM, and susequently admitted to the ICU for subdural hematomas.",2020-01-01
3904,"NHC HEALTHCARE, KNOXVILLE",445098,809 EAST EMERALD AVE,KNOXVILLE,TN,37917,2016-10-20,323,D,0,1,N3NC11,"Based on observation and interview the facility failed to maintain a resident room free of hazards on one hallway of five hallways observed. The findings included: Observation on 10/20/16 at 8:10 AM, in a resident's room, revealed 2 over-the-counter medications on the bedside table, a generic calcium based antacid and a topical analgesic for muscle soreness. Interview with Licensed Practical Nurse #2 on 10/20/16 at 8:25 AM, in the 2 West hall, confirmed the medications were accessible to any resident and should have been locked in the medication cart.",2020-01-01
3905,"NHC HEALTHCARE, KNOXVILLE",445098,809 EAST EMERALD AVE,KNOXVILLE,TN,37917,2016-10-20,441,D,0,1,N3NC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of professional standards for infection control, medical record review, observation, and interview, the facility failed to establish and maintain standard precautions during a pressure ulcer dressing change for 1 (#226) of 3 residents reviewed for pressure ulcers, of 34 residents reviewed. The findings included, Review of the Facility's Infection Control Manual revised 10/1/08 revealed .Standard Precautions apply to .all bodily fluids .nonintact skin . Review of the Lippincott Manual of Nursing Practice 10th Edition revealed .Gloves are worn to provide a protective barrier and prevent gross contamination of the hands of health care workers .Wearing gloves does not replace the need for hand hygiene because gloves may have small defects or may be torn during use, and hands can become contaminated from those leaks .Gloves also must be changed between procedures on the same patient . Medical record review revealed Resident #226 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician's History and Physical dated 9/25/16 (at the hospital prior to resident's facility admission) revealed .She brought in today by her son secondary to sacral decubitus, which has been progressively worse over time occurs in the setting of very poor mobility and chronic pressure to the area associated with foul-smelling odor and surrounding redness .infected sacral decubitus . Observation on 10/19/16 at 4:04 PM, in Resident #226's room with the Wound Care Nurse, revealed the Wound Care Nurse provided wound care to the Stage 4 sacral pressure ulcer. Continued observation revealed the wound care nurse washed his hands, applied hand sanitizer, moved the resident curtain, applied gloves, placed a barrier next to the wound, cut silver alginate into a rope for packing, opened an applicator, placed packing into the wound, opened a dressing, applied the dressing to the resident's sacrum, and removed gloves into a biohazard bag. The Wound Care Nurse put the packages in the biohazard bag and took the biohazard bag to the wound care cart. Continued observation revealed the Wound Care Nurse removed the top of the biohazard trash bin (on the wound care cart) and placed it on top of the wound care scissors that were laying on top of the wound care cart. He then disposed of the biohazard bag and placed the top of the biohazard trash bin back on the trash bin. The wound care scissors were then placed back into the wound care cart, without cleaning the scissors or the top of the wound care cart (where the dirty biohazard top had been placed). Interview with the Wound Care Nurse on 10/19/16 at 4:34 PM, in the third floor dining room, confirmed . the packing was saturated .my hands were dirty after touching the curtain .the top of the cart is dirty .the scissors were placed in the cart . Interview with the Wound Care Nurse on 10/20/16 at 7:32 AM, by the conference room, confirmed .I did not follow infection control standards . Interview with the Director of Nursing on 10/20/16 at 8:07 AM, in the DON's office, confirmed . I would expect clean technique and washing hands during a pressure ulcer dressing .",2020-01-01
5564,"NHC HEALTHCARE, KNOXVILLE",445098,809 EAST EMERALD AVE,KNOXVILLE,TN,37917,2015-10-21,157,D,0,1,HQMH11,"**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 notify a resident's family/legal representative, of a resident's injury, for 1 resident (#93), of 3 residents reviewed for accidents, of 30 residents reviewed. The findings included: Review of the facility's Policies and Procedures Regarding Change in Patient Status, revised 3/6/13 revealed . B. Notification of Family/Legal Representative; 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's extender and the patient's family/legal representative . Medical record review revealed Resident #93 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS), was 00, indicating the resident was severely cognitively impaired. Medical record review of a facility investigation dated 9/15/15, revealed Resident #93, had been involved in an unwitnessed accident that resulted in an injury to the resident's left great toe, resulting in the removal of the resident's toenail. The injury was assessed by the resident's nurse, the Nurse Practitioner, the wound care nurse, and the Nursing supervisor. The charge nurse recorded orders for dressing changes, but failed to notify the resident's family/legal representative of the accident. Interview with the Director of Nursing (DON) on 10/21/15 at 10:10 AM, in the conference room, confirmed the facility failed to notify the family/ legal representative of Resident #93's injury.",2019-01-01
5565,"NHC HEALTHCARE, KNOXVILLE",445098,809 EAST EMERALD AVE,KNOXVILLE,TN,37917,2015-10-21,278,D,0,1,HQMH11,"**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 accurately perform a Minimum Data Set (MDS) assessment for dental needs for 1 resident (#100) of 2 residents reviewed for dental needs, of 30 residents reviewed. The findings included: Review of facility policy, Patient Care Policies, Nursing Services, revised 11/14, revealed .patients are assessed initially and at regular intervals using a state specified, standardized, comprehensive resident assessment instrument to identify functional capacity and health status . Medical record review revealed Resident #100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission MDS dated [DATE] and the quarterly MDS dated [DATE] revealed the Oral/Dental Status was marked none of the above to indicate no dental problems. Observation of Resident #100 on 10/19/15 at 9:20 AM in the resident's room, revealed the resident with missing upper teeth. Further observation revealed the remaining teeth were yellowed and discolored. Interview with the MDS Coordinator on 10/20/15 at 6:20 PM in the MDS office, confirmed she did not perform a physical assessment or interview nursing staff for the MDS and oral/dental problems for Resident #100, and the admission and quarterly MDS assessments had not been accurate.",2019-01-01
5566,"NHC HEALTHCARE, KNOXVILLE",445098,809 EAST EMERALD AVE,KNOXVILLE,TN,37917,2015-10-21,282,G,0,1,HQMH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to follow the care plan to use a mechanical lift to provide safe transfers, resulting in harm for 1 resident (#213) of 3 residents reviewed for accidents, of 30 residents reviewed. The findings included: Medical record review revealed Resident #213 was admitted to the facility 4/09/09 with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 11/20/14 for Resident #213 revealed .Risk for Falls r/t (related to) muscle weakness, adult failure to thrive, Alzheimer's dementia,[MEDICAL CONDITION]([MEDICAL CONDITION]/stroke) with R (right) sided weakness .Mech (mechanical) lift with 2 (person) assist for transfers . Facility record review of the Initial 24-hour Report dated 2/27/15 revealed .Pt (patient) found to have fx (fracture) of R (right) humerus (upper arm bone) 2/27/15. This was after CNAs (Certified Nurses' Aides) .found arm in different position . Medical record review of the x-ray report dated 2/27/15 at 10:15 AM, revealed .An acute angulated humeral shaft fracture is identified .no significant [MEDICAL CONDITION] changes are seen . Interview on 10/19/15 at 2:50 PM, in the Director of Nursing's (DON) office with the two shower team CNAs (CNAs #1 and #2) who discovered the injury on 2/27/15 revealed We lifted the resident (Resident #213) out of bed and when we got the resident into the shower room and took her gown off her, right arm was very bruised and hanging limp. She usually kept her arms folded and held close to her. We called the nurse and took the resident back to her room and bed. Telephone interview on 10/20/15 at 2:40 PM with the CNA (#3) who was assigned to Resident #213 on 2/26/15 and put Resident #213 to bed at the end of the shift, revealed .resident was in geri-chair, I took off her shirt, put a gown on her and got a male nurse to help me lift her back to bed. We just lifted her the way we always did. She was a small woman. We never used the mechanical lift to lift her, didn't know we were supposed to . Telephone interview with LPN #1 at 5:38 PM revealed I just helped the CNA lift the resident back to bed. There was no lift pad under the resident. We just put our arms under hers, supported her back and slid her into the bed .She was a candidate for a mechanical lift, but I didn't ask, I just helped. Interview with the shower team CNAs on 10/21/15 at 1:50 PM, in the conference room confirmed .we did not use a lift to transfer the resident from the bed to the shower chair, we used a gait belt and pad to scoot resident to the edge of the bed and then into the chair. We didn't see the bruise until we got to the shower room. We took her back to the room and used a sheet to transfer her back to bed. We didn't know we were supposed to use a mechanical lift and didn't know to ask. Interview with the DON on 10/21/15 at 3:10 PM, in the conference room, confirmed a mechanical lift was care planned for Resident #213, and should have been used by staff for the resident for every transfer. Continued interview confirmed the staff failed to follow the care plan when transferring Resident #213 on 2/26-27/15, resulting in harm to Resident #213.",2019-01-01
5567,"NHC HEALTHCARE, KNOXVILLE",445098,809 EAST EMERALD AVE,KNOXVILLE,TN,37917,2015-10-21,323,G,0,1,HQMH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to use a mechanical lift to provide safe transfers, resulting in harm for 1 resident (#213) of 3 residents reviewed for accidents, of 30 residents reviewed. The findings included: Medical record review revealed Resident #213 was admitted to the facility 4/09/09 with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] and the annual MDS dated [DATE] revealed the resident had severe cognitive impairment, did not speak or walk, and required extensive assistance with all activities of daily living. Medical record review of the Care Plan dated 11/20/14 revealed .Risk for Falls r/t (related to) muscle weakness, adult failure to thrive, Alzheimer's dementia, CVA (cerebral vascular accident/stroke) with R (right) sided weakness .Mech (mechanical) lift with 2 (person) assist for transfers . Facility record review of the Initial 24-hour Report dated 2/27/15 revealed .Pt (patient) found to have fx (fracture) of R (right) humerus (upper arm bone) 2/27/15. This was after CNAs (Certified Nurses' Aides) .found arm in different position . Medical record review of the x-ray report dated 2/27/15 at 10:15 AM, revealed .An acute angulated humeral shaft fracture is identified .no significant degenerative changes are seen . Interview on 10/19/15 at 2:50 PM, in the Director of Nursing's (DON) office with the two shower team CNAs (CNAs #1 and #2) who discovered the injury on 2/27/15 revealed We lifted the resident out of bed and when we got the resident into the shower room and took her gown off her, right arm was very bruised and hanging limp. She usually kept her arms folded and held close to her. We called the nurse and took the resident back to her room and bed. Telephone interview on 10/20/15 at 2:40 PM with the CNA (#3) who was assigned to the resident on 2/26/15 and put the resident to bed at the end of the shift, revealed .resident was in geri-chair, I took off her shirt, put a gown on her and got a male nurse to help me lift her back to bed. We just lifted her the way we always did. She was a small woman. We never used the mechanical lift to lift her, didn't know we were supposed to . Telephone interview with LPN #1 at 5:38 PM revealed I just helped the CNA lift the resident back to bed. There was no lift pad under the resident. We just put our arms under hers, supported her back and slid her into the bed .She was a candidate for a mechanical lift, but I didn't ask, I just helped. Interview with the shower team CNAs on 10/21/15 at 1:50 PM, in the conference room confirmed .we did not use a lift to transfer the resident from the bed to the shower chair, we used a gait belt and pad to scoot resident to the edge of the bed and then into the chair. We didn't see the bruise until we got to the shower room. We took her back to the room and used a sheet to transfer her back to bed. We didn't know we were supposed to use a mechanical lift and didn't know to ask. Interview with the DON on 10/21/15 at 3:10 PM, in the conference room, confirmed the facility failed to use a mechanical lift to provide safe transfers, resulting in harm to Resident #213.",2019-01-01
7558,"NHC HEALTHCARE, KNOXVILLE",445098,809 EAST EMERALD AVE,KNOXVILLE,TN,37917,2014-08-06,309,D,0,1,NDS211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, interview, and facility policy review, the facility failed to administer/and or withhold medication as ordered by the physician for one (#13) of four residents with blood pressure parameters reviewed. The findings included: Resident #13 was admitted on [DATE], with [DIAGNOSES REDACTED]. Medical Record Review of the Minimum Data Set (MDS) dated [DATE], revealed resident #13 was moderately cognitively impaired and required extensive assistance for activities of daily living. Observation of resident #13 on August 6, 2014, at 3:30 p.m., in the resident's room revealed the resident sitting in a wheelchair with head in hand, alert, oriented to self only. Continued observation revealed the resident was confused and not able to engage in a simple conversation. Medical record review of a physician's orders [REDACTED].[MEDICATION NAME] 0.1 mg (milligram) tablet .Give 1 tablet by mouth three times daily if systolic >155, diastolic >95 . ([MEDICATION NAME] is a medication to treat high blood pressure (BP) and the number on top is the systolic and the bottom number is diastolic.) Medical record review of the Medication and Treatment Administration Record Reports dated June, July and August 2014, revealed the following blood pressure results and if [MEDICATION NAME] 0.1 mg was administered: June 1: 10 a.m. (130/68) 10 p.m. (133/92) June 2: 10 p.m. (117/73) June 3: 10 a.m. (153/79) June 4: 10 a.m. (138/68) 10 p.m. (154/84) June 5: 10 a.m. (148/74 10 p.m. (121/70) June 6: 10 a.m. (128/70) 10 p.m. (153/86) June 7: 10 p.m. (137/75) June 8: 10 p.m. (134/86) June 9: 10 p.m. (117/70) June 10: 10 a.m. (136/74) 10 p.m. (138/72) June 11: 10 p.m. (111/67) June12: 10 p.m. (132/80) June 13: 4 p.m. (138/60) June 14: 10 a.m. (138/60) 4 p.m. (130/58) June 15: 10 a.m. (138/76) 4 p.m. (132/66) 10 p.m. (143/79) June 17: 10 a.m. (120/54) 4 p.m. (124/66) 10 p.m. (132/68) June 18: 4 p.m. (136/68) 10 p.m. (134/52) June 19: 10 a.m. (142/74) 4 p.m. (132/62) 10 p.m. (153/69) June 20: 4 p.m. (138/74) 10 p.m. (138/54) June 21: 10 a.m. (148/80) 4 p.m. (136/74) June 22: 10 a.m. (150/83) 4 p.m. (138/76) June 23: 4 p.m. (154/78) 10 p.m. (110/70) June 24: 10 p.m. (132/71) July 1: 10 a.m. (152/89) 2 p.m. (139/84) 10 p.m. (130/78) July 2: 2 p.m. (138/76) [MEDICATION NAME] 0.1 mg was omitted on the following dates: July 5: 10 a.m. (153/99) July 10: 10 p.m. (160/90) July 17: 10 p.m. (168/94) July 20: 10 p.m. (167/82) July 24: 10 a.m. (163/84) August 3: 10 a.m. (158/98) August 4: 10 p.m. (175/92) Interview with the Physician on August 6, 2014, at 9:50 a.m., at the 3rd floor nursing station confirmed the [MEDICATION NAME] order was a PRN (as needed) order with blood pressure parameters necessary before administering the medication. Interview with Licensed Practical Nurse (LPN #3), on August 6, 2014, at 4:36 p.m., in the Director of Nursing's (DON) office, confirmed LPN (#3) administered the [MEDICATION NAME] and was not administered in accordance to the prescribed parameters. Interview with the DON on August 6, 2014, at 4:30 p.m., in the DON's office confirmed resident #13 received [MEDICATION NAME] forty-four times in error when the resident's Blood Pressure (BP) did not meet criteria to administer the medication and the resident did not receive [MEDICATION NAME] seven times when the BP parameter required administration. Further interview with the DON confirmed the facility had failed to administer the antihypertensive medication according to the parameters prescribed by the Physician 51 times in 57 days.",2017-11-01
7559,"NHC HEALTHCARE, KNOXVILLE",445098,809 EAST EMERALD AVE,KNOXVILLE,TN,37917,2014-08-06,431,E,0,1,NDS211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, medical record review, and interview, the facility failed to maintain a clean, clutter free medication room for one of one medication rooms reviewed; failed to monitor and maintain temperature logs for one of one medication refrigerators; failed to properly store topical wound and oral medications; failed to dispose of expired medications; failed to store and dispose of medications for twenty-three discharged residents; failed to reconcile the Narcotic Inventory Record Log and the Narcotic Inventory Record for four of twenty- five narcotic medications reviewed. The findings included: Review of facility policy, Medication Storage in the Facility, revealed Medications and biologicals are stored safely .properly .(c) Orally administered medications are kept separate from externally used medications .(k) Medication requiring refrigeration .between 2 degrees C (36 degrees F) and 8 degrees C ( 46 degrees F) are kept in a refrigerator .to allow temperature monitoring .(n) Medication storage areas are kept clean, well-lit and free of clutter and extreme temperatures .(o) Medication storage conditions are monitored on a monthly basis and corrective action taken if problems are identified . Review of facility policy, Disposal of Medications, Syringes, and Needles, revealed, .When medications are discontinued .resident is .discharged .the noncontrolled medications are marked as 'discontinued' and are to be destroyed . Paragraph (a) .Medications awaiting disposal are stored in a .area designated for that purpose until destroyed .(b .medications .are destroyed in accordance with the destruction policy and procedure .medications left in the facility after a resident's discharge .are destroyed . Observation of medication cart #2 on August 5, 2014, at 2:46 p.m., in the northwest hall on the 3rd floor revealed a 16 ounce bottle with approximately 14 ounces remaining of Hysept Solution 0.25% (percent) Sodium Hypochlocite Solution (used in the treatment of [REDACTED].#2 along side bottles of oral medications. Continued observation revealed a 10 ounce bottle with approximately 6 ounces remaining of Geri-Mucil, Sugar Free Fiber Laxative with a manufacturer's expiration date of April 2014 in the bottom drawer. Interview with Licensed Practical Nurse (LPN #3) on August 5, 2014, at 2:55 p.m., in the northwest hallway of the 3rd floor confirmed a 16 ounce bottle of Hysept Solution 0.25% Sodium Hypochlocite Solution was stored in the bottom drawer of medication cart #2 next to oral medications. Further interview with LPN #3 confirmed the manufacturer's expiration date was April 2014. Observation on August 5, 2014, at 3:25 p.m., in the 3rd floor medication room revealed the following: ants crawling in and on the sink; the sink drain covered with a thick, black residue; one garbage bag full of empty soda cans on the floor, and two handbags on the floor. Interview with LPN #3 on August 5, 2014 at 3:26 p.m., in the medication room with confirmed the ants in the sink, the sink was dirty, and the floor was cluttered with a garbage bag of empty soda cans and personal belongings. Observation on August 5, 2014 at 3:30 p.m., in the medication rooms revealed no temperature log on the medication refrigerator. Interview with the Assistant Director of Nursing (ADON) on August 5, 2014 at 3:32 p.m., in the medication room confirmed no temperature monitoring log on the medication refrigerator documenting daily temperatures. Observation on August 6, 2014 at 3:30 p.m., in the secured medication room revealed a clear plastic garbage bag in the cabinet under the sink, under a box of resident alarms containing 861 oral medications, as follows: 2 vials of vitamin B12 unopened, intravenous antibiotics, unopened, 28 inhalation solutions, and 1 vial of insulin improperly stored. Medications were dated from October 2013 through July 2013 for 23 discharged residents. Continued observation revealed the following classifications of the medications: [REDACTED] antiulcer; antiplatelets; antidepressants; antigout; antilipemics; antipsychotics; antirheumatic; anticonvulsants; antibiotics; anti[DIAGNOSES REDACTED]ls; anticoagulants; antiemetics; antitussives; antialzheimer; corticosteroids; diuretics; hemostatics; inotropes; iron supplements; non-steriodal antiinflammatory drugs; potassium supplements; skeletal muscle relaxants; [DIAGNOSES REDACTED]s; urinary antispasmodics; vitamins/mineral supplements. Interview with the ADON on August 5, 2014, at 3:45 p.m., in the medication room confirmed the clear plastic garbage bag of medications was improperly stored and was to be destroyed. Further interview with the ADON confirmed the medications had not been timely destroyed and .the medications should have been destroyed in thirty days . Interview with the Director of Nursing (DON) on August 6, 2014, at 3:15 p.m., in the conference room confirmed the medications for discharged residents were not destroyed in a timely manner. Observation of medication cart #1 on August 5, 2014, at 3:05 p.m., on the 3rd floor revealed four of twenty-five Narcotic Inventory Record Logs did not reconcile with the Narcotic Inventory Record for Lortab 7.5 mg, 30 tablets for resident #300; Lortab 7.5 mg, 30 tablets for resident #202; Lortab 5.0 mg, 30 tablets and Ativan 0.5 mg 30 tablets for resident #116. Continued observation revealed six of six medication carts reviewed for narcotic counts were accurate. Interview with the DON on August 6, 2014, at 1:30 p.m., in the DON's office confirmed no further Narcotic Inventory Records were found for residents #300, #202 and #116. Interview with the Pharmacist on August 6, 2014, at 2:00 p.m., in the conference room confirmed medication audits were performed monthly. Continued interview revealed the facility had a documentation and filing problem. Further interview confirmed no documentation for the destruction of the Narcotic Inventory Record's for residents #300, #202, and #116 could be found. Further interview revealed letters of inspection were sent between February 2014 through July 2014 notifying the facility of incorrect narcotic log and inaccurate documentation. Interview with the DON on August 6, 2014, at 3:15 p.m., in the conference room confirmed the Narcotic Inventory Record Logs were unable to be reconciled with the Narcotic Inventory Records for resident #300, #202, and #116.",2017-11-01
7560,"NHC HEALTHCARE, KNOXVILLE",445098,809 EAST EMERALD AVE,KNOXVILLE,TN,37917,2014-08-06,441,D,0,1,NDS211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, facility policy review, and interview, the facility failed to ensure staff washed hands after contact with residents and prior to medication administration for one of three nurses observed and failed to maintain the cleanliness of one of six geri-chairs observed. The findings included: Observation on August 4, 2014, at 6:02 a.m., in the 200 hallway revealed Registered Nurse #5 (RN) answered a personal alarm in room [ROOM NUMBER]. Continued observation revealed RN #5 repositioned the resident, stopped the alarm, and readjusted the linen on the resident's bed. Continued observation revealed RN #5 exited the room, returned to the medication cart, and resumed the medication administration for another resident without disinfecting the hands. Review of facility policy, Handwashing, revealed, .1. When to wash hands .f. Before and after caring for each patient. g. During medication pass . Interview with RN #5 on August 4, 2014, at 6:20 a.m., in the 200 hallway, confirmed the RN had not disinfected hands after direct contact with a resident, prior to resuming medication administration for another resident. Observation on August 5, 2014, at 7:55 a.m., revealed a geri-chair in the hall between rooms [ROOM NUMBERS] in the 200 hall with dust build up with stain and spill marks on the seat and on the left side of the chair, under the armrest. Interview with Licensed Practical Nurse (LPN) # 6, designated as the facility's Infection Control Nurse, in the conference room hall on August 5, 2014, at 9:37 a.m., revealed there was no policy for cleaning of the wheelchairs or geri-chairs. During interview, LPN # 6 stated, The wheelchairs and geri-chairs are cleaned thoroughly twice a year in the spring and fall and, if necessary, cleaned in the shower if soiled or on an (as needed) basis. Interview with LPN # 1 in 200 hall on August 5, 2014, at 8:07 a.m., confirmed the geri-chair in the 200 hall was used for residents and when asked when the chair would be cleaned, LPN # 1 stated before I use it. Interview continued and LPN # 1 stated, housekeeping is responsible for cleaning the chair and the person using the chair should clean it if it gets soiled before putting it back. Further interview with LPN # 1 revealed, it (the geri-chair) is really dirty. Interview with CNA # 6 in 200 hall on August 5, 2014, at 8:16 a.m., confirmed the chair is used for residents don't have their own to go to other areas in the facility. Interview continued and CNA # 6 stated it is filthy .I think that housekeeping cleans them.",2017-11-01
7561,"NHC HEALTHCARE, KNOXVILLE",445098,809 EAST EMERALD AVE,KNOXVILLE,TN,37917,2014-08-06,520,F,0,1,NDS211,"Based on review of Quality Improvement (QI) sign-in sheets and minutes, and interview, the QI Committee identified a problem and failed to develop and implement a plan of correction for controlled drug irregularities. The findings included: Review of QI sign-in sheets and concurrent interview with the Help Information Manager, on August 6, 2014, at 4:35 p.m., in the Medical Records office revealed the Pharmacist last attended the QI meeting on October 25, 2013. Further review of the October 2013 minutes revealed .controlled drug irregularities .including signed out, not documented as given. 196 doses audited, 165 doses documented as given. Plan of correction created . Continued interview revealed no further documentation of the controlled medication irregularities .it's a nursing issue . Interview with the Director of Nursing (DON), on July 6, 2014, at 5:00 p.m., in the DON's office, confirmed the facility had failed to develop a plan of correction for controlled drug irregularities.",2017-11-01
8744,"NHC HEALTHCARE, KNOXVILLE",445098,809 EAST EMERALD AVE,KNOXVILLE,TN,37917,2014-04-29,441,D,1,0,5YMP11,"**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 a dressing change in a manner to prevent the development and/or spread of infection for one resident (#4) of two residents reviewed. The findings included: Review of facility policy titled Dry, Clean Dressings most recently revised March 2005, revealed, .The purpose of this procedure is to provide guidelines for the application of dry, clean dressings .Steps in the Procedure .Tape a biohazard or plastic bag on the bedside stand or open on the bed . Continued review revealed, .Put on clean gloves. Loosen tape and remove soiled dressing .Pull glove over dressing and discard into plastic or biohazard bag .Cleanse the wound .If using gauze use a clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area (usually from the center outward) .Use dry gauze to pat the wound dry .Discard disposable items in the designated container .Reposition the bed covers . Review of facility policy titled Infectious Waste, Handling of revised April 2006, revealed, The purpose of this procedure is to provide a definition of and guidelines for the safe and appropriate handling of infectious waste. Disposable items soiled with visible blood .must be placed in red plastic bags or containers . Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed a Brief Interview for Mental Status score of 15 (0-15), the resident had a urinary tract infection within the last thirty days, and application of non-surgical dressings. Medical record review of a physician's orders [REDACTED].Pack wound with Dakin's half-strength wet to dry cover with dry gauze .secure with tape . Observation of a dressing change on April 28, 2014, at 11:15 a.m., revealed Licensed Practical Nurse (LPN) #1 washed (LPN's) hands, donned gloves, repositioned the resident's urinary catheter bag containing urine onto the bed linen. Continued observation revealed LPN #1 did not remove the gloves or wash hands, removed a blood-soaked dressing, and obtained a trash can with a clear plastic bag from the opposite side of the resident's bed. Continued observation revealed LPN #1 placed the blood-soaked dressing into the trash can lined with a clear plastic bag. Continued observation revealed LPN #1 removed gloves, washed hands, donned new gloves, moistened gauze and patted the center of the wound twice with the same gauze, and LPN #1 placed a clean dressing. Continued observation revealed LPN #1 and LPN #2 replaced the resident's bed linen. LPN #2 placed the used linen with an approximately five inch circular blood-stained area onto the resident's clean linen. Interview with LPN #1 on April 28, 2014, at 10:00 a.m., in the third floor conference room revealed LPN #1 was the facility's wound care nurse. Interview with LPN #1 on April 28, 2014, at 3:00 p.m., in the presence of the Director of Nursing, revealed dressing changes utilized clean technique unless sterile technique was ordered by a physician. Continued interview confirmed the facility failed to change the dressing according to the facility's policies in order to prevent the development and/or transmission of an infectious disease for Resident #4.",2017-04-01
9396,"NHC HEALTHCARE, KNOXVILLE",445098,809 EAST EMERALD AVE,KNOXVILLE,TN,37917,2013-12-10,323,G,1,0,NMZK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure one resident (#1) was provided two-persons to assist with a transfer, resulting in harm for one resident (#1) of five sampled residents. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Minimum Data Set, dated dated dated [DATE], revealed the resident's Brief Interview Mental Status score was 15 (intact cognition) and the resident required assistance of two persons for transfers and bed mobility. Medical record review of a care plan revealed an entry dated October 23, 2013, .ADL (Activities of Daily Living) .Req (Requires) max (maximum) assist with all adl's .mech. (mechanical) lift for all transfers - 2 staff to assist. Medical record review of a nurse's note dated November 13, 2013, revealed, 7A-7p (7 a.m. - 7 p.m.) alerted by CNA (Certified Nursing Assistant) .to come look at pt's (patient's) L (left) shoulder .my opinion was (the resident) needed an x-ray . Medical record review of an x-ray report dated November 13, 2013, revealed, .bony demineralization .Impression: non-displaced fracture lateral aspect of the humeral head. Mild widening of the left AC (Acromioclavicular) joint suggests AC separation. Observation and interview with resident #1 on December 10, 2013, at 12:22 p.m., in the resident's room, revealed the resident seated in a chair and a sling on the left upper extremity. The resident was alert and oriented. When asked about the sling on the left arm, the resident stated, I broke it. I was on a lift (mechanical device used to transfer). I'm paralyzed on the left. She (staff member/CNA #1) got it (the lift) up too high. I told her to stop and I think she got upset . Continued interview revealed the resident's son then helped and assisted with the transfer and the resident stated, .My son helped (CNA #1 ) get me in the bed straight .It (resident's arm) was burning like. I told (CNA #1) it was burning . The resident stated, .It kept hurting. They came and took x-rays and they said it was broken . Interview with CNA #1 on December 10, 2013, at 2:52 p.m., in the conference room, revealed CNA # 1 was aware the resident required the assistance of two for transfer with a mechanical lift. Continued interview revealed CNA #1 transferred the resident with a mechanical lift from a chair to over the bed without another CNA's assistance on November 12, 2013, and a second CNA usually assisted with a transfer by securing the lift pad prior to a transfer and pulling the mechanical lift to the bed. Continued interview revealed CNA #1 stepped out (of the resident's room) to look for help with the transfer, and the resident's son said he would help; the resident's son assisted with completion of the transfer. Telephone interview with the resident's physician on December 10, 2013, at 4:28 p.m., revealed, .someone with bony demineralization-fracture could have occurred during repositioning or transfer-can't say with certainty . Interview with the Director of Nursing on December 10, 2013, at 4:55 p.m., in the conference room confirmed the facility failed to provide two staff for assistance in transferring Resident #1 on November 12, 2013.",2016-12-01
9524,"NHC HEALTHCARE, KNOXVILLE",445098,809 EAST EMERALD AVE,KNOXVILLE,TN,37917,2013-07-03,279,D,0,1,8AZ411,"**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 addressing the resident's persistent refusal of care for one resident (#127) of thirty-two residents reviewed. The findings included: Resident #127 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the resident's care plan dated April 10, 2013, revealed the resident was .resistive to care at times . Medical record review of Weekly Skin Assessment Record dated April 10, 2012, revealed the resident .refuses to turn in bed .refuses to get out of bed . Medical record review of Weekly Skin Assessment Record dated June 23, 2012, revealed the resident .refuses to get out of bed or to go to shower or whirlpool . Medical record review of Weekly Skin Assessment Record dated July 10, 2012, revealed the resident .refuses meds (medications), refuses personal bath/shower except bed bath. Now refuses to get out of bed . Medical record review of a physician's letter dated June 7, 2012, revealed the resident .has declined due (to) poor nutritional status, refusing to get out of bed, and (resident) refusal to be turned while in bed . Medical record review of a physician's note dated August 20, 2012, revealed, .will d/c (discontinue) most meds as (resident) refuses greater than 90 percent of them . Interview with the resident's spouse and son on July 3, 2013, at 2:20 p.m., in the resident's room, revealed the resident has been refusing to get out of bed and refusing physical therapy and other services for at least the past year. Interview with the Director of Nursing and Assistant Director of Nursing on July 3, 2013, at 2:45 p.m., in the Director of Nursing Office, confirmed the facility was aware of the resident's refusal of care, and confirmed the facility did not develop a care plan to address the resident's refusal of care.",2016-11-01
11737,"NHC HEALTHCARE, KNOXVILLE",445098,809 EAST EMERALD AVE,KNOXVILLE,TN,37917,2011-08-31,281,D,0,1,3B3211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to check and record blood pressures as a parameter for medication administration, as ordered by the physician, for one resident (#14) of twenty-three residents reviewed. The findings included: Resident # 14 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of physician's orders [REDACTED]. (millegrams) Give 1 tablet by mouth twice daily. Hold for SBP (Systolic Blood pressure) Medical record review of the MAR (Medication Administration Record) for June 2011, revealed the [MEDICATION NAME] had been held on June 1, 10, and 30, 2011, as the systolic blood pressure had been below 100. Continued medical record review revealed the medication had been given twice a day and no blood pressure had been checked on June 6, 7, 14, 15, 23, 25, 26, 2011. Further medical record review revealed the medication had been given twice a day and the blood pressure checked only one time per day on June 2, 4, 8, 9, 11, 12, 13, 19, 22, 24, 27, 28, 29, 2011. Medical record review of the MAR for July, 2011, revealed the [MEDICATION NAME] had been held on July 2, 8, 29, 2011, as the systolic blood pressure had been below 100. Continued medical record review revealed the medication had been given twice a day and no blood pressure had been checked on July 5, 27, 30, 31, 2011. Further medical record review revealed the medication had been given twice a day and the blood pressure had been checked only one time per day on July 3, 6, 7, 15, 16, 17, 18, 19, 22, 23, 25, 2011. Medical record review of the MAR for August, 2011, revealed the [MEDICATION NAME] had been given twice a day and no blood pressure had been checked on August 9, 2011. Continued medical record review revealed the medication had been given twice a day and the blood pressure had been checked only one time per day on August 3, 5, 6, 8, 10, 13, 14, 19, 28, 2011. Observation on August 29, 2011, at 8:30 a.m., in the resident's room, revealed the resident awake, dressed, sitting in a recliner at bedside, eating breakfast. Interview with Nurse Manager #1 on August 29, 2011, at 4:30 p.m., in the second floor nurse's station, confirmed the facility had failed to follow physician orders [REDACTED].",2015-11-01
12754,"NHC HEALTHCARE, KNOXVILLE",445098,809 EAST EMERALD AVE,KNOXVILLE,TN,37917,2012-03-15,514,D,1,0,H3T211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure the medical record was complete for one (#1) of five residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had severe impairment in cognitive skills and required extensive assistance of one person physical assistance for eating. Medical record review of a laboratory report dated October 24, 2011, revealed ""...Potassium 3.0 L (low)...Reference Range...3.5-5.0..."" Medical record review of a physician's orders [REDACTED]. Medical record review of the October, 2011, Medication Administration Record [REDACTED]. Medical record review of a laboratory report dated November 29, 2011, revealed ""...Basic Metabolic Panel...Potassium 2.8...Reference Range...3.5-5.0...Magnesium 1.7...Reference Range...1.7-2.6..."" Medical record review of a physician's orders [REDACTED]. Repeat K level (after) 4th dose. Then resume KCL 20 mEq po qd..."" Medical record review of the Medication Administration Record [REDACTED] Interview on March 14, 2012, at 1:35 p.m., with the Director of Nursing (DON), in the DON's office confirmed no documentation the Potassium Chloride was administered on October 24, 2011, and November 29, 2011, at 9:00 a.m., and 3:00 p.m.",2015-07-01
13846,"NHC HEALTHCARE, KNOXVILLE",445098,809 EAST EMERALD AVE,KNOXVILLE,TN,37917,2010-09-15,281,D,1,1,62QE11,"**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 one (#22) of twenty-six residents reviewed. The findings included: Resident #22 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physicians orders dated October 1, 2009, through October 31, 2009, and November 1, 2009, through November 30, 2009, revealed, "" ...Check BP (blood pressure) daily and record on flow sheet ..."" Medical record review of the Vital Signs Record revealed no documentation blood pressure was obtained on October 1, 2, 5, 7, 12, 13, 16, 21, 22, 23, 24, 25, 26, 27, 30, and 31, 2009. Medical record review of the Vital Signs Record revealed no documentation BP was obtained on November 1, 2009, through November 7, 2009, November 10, 12, 13, 14, 16, and 17, 2009. Interview on September 14, 2010, at 10:35 a.m., with the Director of Nursing, in the conference room, confirmed no documentation the blood pressure had been obtained on the above dates as ordered by the physician. c/o #",2014-08-01
13847,"NHC HEALTHCARE, KNOXVILLE",445098,809 EAST EMERALD AVE,KNOXVILLE,TN,37917,2010-09-15,514,D,1,1,62QE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to document an assessment for one (#22) of twenty-six residents reviewed. The findings included: Resident #22 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the nurse's note dated November 19, 2009, revealed, ""...5 p Pt. leaning over in chair in room. Daughter came (and) asked this nurse to put (resident) in bed. Pt. has diarrhea-cont. on [MEDICATION NAME] cont to give fluids Q (every) 30 min. Daughter asked if we could give pt an IV (intravenous) (and) extra fluids. Notified shift supervisor, told to call (physician), paged (physician)-awaiting call back B/P 168/82 P-110 R-18 T-98.4...6:10 p called (physician) again and awaiting call back, daughter leaving (and) asked that we call when we talk to doctor...7 p Gave report to oncoming nurse (and) daughter spoke to oncoming nurse ...RN spoke (with) residents daughter...(daughter) reports concern about (resident) hydration status (and) has requested for (named resident) to be considered for IV fluids by MD this pm, RN reported that a (physician) would be notified (and) orders would be verbalized with (named daughter) via telephone...10:15 pm Resident resting in bed, alert (with) confusion noted (at) baseline, (increased) lethargy noted, vitals: 132/76 B/P, low grade temp 99.6 noted, P-86, RR-14, able to answer yes/no questions, order received from (named physician) for NS (normal saline) (at) 70 cc/hr until facility physician could eval, RN attempted to start INT x 3-no success-house sup. (supervisor) notified..."" Medical record review of the nurse ' s notes dated November 20, 2009, revealed, ""...12 A Resident remains lethargic, po (by mouth) fluids encouraged ...skin turgor poor ...loose stools x 2 this shift ...B/P 136/78, HR-82, Resp. 14, temp-98.7...1:30 A RN supervisor attempted to start INT on resident x 2 sticks-(no) success, RN called (physician)...1:50 A ...received order to D/C NS (at) 70 cc/hr until INT could be started (and) facility MD could eval..."" Medical record review of the nurse's note dated November 20, 2009, revealed, ""...6:40 a.m. Resident took AM [MEDICATION NAME] whole in pudd (pudding) this am (without) difficulty, remains lethargic (and) drowsy, is alert (without) resp. (respiratory) distress, will monitor..."" Interview on September 14, 2010, at 10:40 a.m., in the conference room, with the Director of Nursing, confirmed no documentation of an assessment of the resident from November 20, 2009, at 12:00 a.m., until November 20, 2009, at 6:40 a.m. Interview on September 14, 2010, at 3:30 p.m., by telephone, with RN #2, confirmed an assessment of the resident was done, but not documented. c/o #",2014-08-01
13848,"NHC HEALTHCARE, KNOXVILLE",445098,809 EAST EMERALD AVE,KNOXVILLE,TN,37917,2010-09-15,226,D,1,1,62QE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, and interview, the facility failed to implement the abuse policy for one resident (#14) with an allegation of abuse of twenty-six residents reviewed. The findings included: Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE] revealed the resident had short term memory problems and moderately impaired cognitive skills for decision making. Review of the statement dated August 6, 2010, and signed by Licensed Practical Nurse #1 revealed "" ...the grandson ...came into the Nurse's station and said (resident) is telling us ...'has been raped. Now (resident) has a disease' ...son ... came behind the counter and said 'my son is as delusional as (resident) ...House Supervisor notified ..."" Review of the statement dated August 7,2010 and signed by Registered Nurse #1(House Supervisor) revealed "" Friday August 6, 2010 (Licensed Practical Nurse #1) called stated that Certified Nursing Assistant #1 was talking to (resident's grandson) regarding sexual comments regarding Certified Nursing Assistant #1 ...came from 3rd floor to 2nd floor met (resident's son and grandson). The grandson spoke of [MEDICAL CONDITION] ..."" Review of the facility investigation dated August 7, 2010 revealed the resident's grandson made an accusation of sexual assault to the ER Nurse. The police and Tennessee Bureau of Investigation were notified by the ER. Upon notification August 7, 2010 the Director of Nursing suspended CNA #1 pending investigation. Review of the facility Abuse Protection and Response Policy revealed "" ... all events reported as possible abuse will be investigated ... Partners suspected of abuse will be immediately placed on administrative leave ...All alleged violations ...will be reported immediately to the Administrator or his/her designated representative ..."" Interview with Licensed Practical Nurse #1 on August 14, 2010 at 9:00 a.m., in the conference room, confirmed on August 6, 2010 the resident's grandson came abruptly to the Nurse's station reported the resident had been sexually assaulted by the man in the resident's room. Further interview confirmed the resident's son came to the Nurse's station and apologized for the grandson's behavior. Continued interview confirmed, CNA #1 was called out of the room, the resident was assessed with [REDACTED]. Interview with the resident on August 14, 2010 at 9:15 a.m., confirmed the resident denies any mistreatment by staff. Telephone with Registered Nurse #1 on August 14, 2010 at 10:00 a.m., confirmed on August 6, 2010 was called by Licensed Practical Nurse #1. The resident's grandson made a statement about a Sexual Transmitted Disease and Registered Nurse #1 talked to the family about the resident being treated for [REDACTED].#1 denies any knowledge of any allegation of sexual assault. Interview with the Director of Nursing on August 14, 2010, at 10:40 a.m., in the conference room, confirmed on August 6, 2010 an allegation of sexual abuse was made by the grandson. Continued interview confirmed the investigation was not immediately initiated and employee was not immediately placed on Administrative Leave as per the facility abuse policy. c/o TN 152",2014-08-01
13849,"NHC HEALTHCARE, KNOXVILLE",445098,809 EAST EMERALD AVE,KNOXVILLE,TN,37917,2010-09-15,315,D,0,1,62QE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to assess for a bladder training program for one (#19) resident of twenty-six residents reviewed. The findings included: Resident #19 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short term memory problems, no long term memory problems, moderately impaired cognitive skills for daily decision making, and was frequently incontinent of bowel and bladder. Medical record review of the resident assessment protocol (RAP) dated June 18, 2010, revealed, ""...Pt. (patient) has incontinence with ability to retrain based on memory recall, ability to reach toilet on time with or without assistance, adjust clothing, has social awareness and motivation..."" Review of the medical record revealed no assessment for a bladder retraining program. Interview on September 15, 2010, at 10:45 a.m., with the Assistant Director of Nursing, in the conference room, confirmed the resident had not been assessed for a bladder retraining program.",2014-08-01
13850,"NHC HEALTHCARE, KNOXVILLE",445098,809 EAST EMERALD AVE,KNOXVILLE,TN,37917,2010-09-15,224,D,0,1,62QE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to prevent misappropriation of medications for three residents (#7, # 26, # 25) of twenty-six sampled residents. The findings included: Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Narcotic Inventory Record revealed on June 6, 2010 two [MEDICATION NAME]/APAP 5 /325 mg (milligram) (pain medication) tablets were borrowed from the resident for the use of another resident. Continued review revealed no documentation the resident was credited for or reimbursed for the medication. Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Narcotic Inventory Record revealed on June 6, 2010, one 0.5 mg [MEDICATION NAME] (anxiety medication) was borrowed from the resident for the use of another resident. Continued review revealed no documentation the resident was credited for or reimbursed for the medication. Resident #26 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Narcotic Inventory Record revealed on March 27, 2010 one [MEDICATION NAME] 0.5mg was borrowed from the resident for the use of another resident. Continued review revealed no documentation the resident was credited for or reimbursed for the medication. Review of the Abuse Protection and Response Policy revealed ""...Misappropriation of Patient Property: The deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a patient's belongings or money without the patients consent..."" Interview with the Administrator on August 15, 2010 at 2:15 p.m., in the conference room confirmed, the facility had borrowed the above medications and failed to ensure the residents had been credited or reimbursed for the medications.",2014-08-01
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
3990,"NHC HEALTHCARE, ATHENS",445099,1204 FRYE ST,ATHENS,TN,37303,2016-11-30,312,D,0,1,Z4T111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure fingernails were clean and well-manicured by providing nail care for 1 resident (#52) of 25 residents reviewed. The findings included: Medical record review revealed Resident #52 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum (MDS) data set [DATE], revealed Resident #52 had severly impaired cognition, required maximum to total assistance with Activities of Daily Living (ADL) including eating and personal hygiene. Review of the resident's care plan dated 9/27/16, revealed, .Assist with personal hygiene daily and prn (as needed) .Nail care prn . Observation on 11/28/16 at 12:15 PM, in the 200 hall dining room revealed Certified Nurse Assistant (CNA) #1 was assisting Resident #52 with the lunch meal. Further observation revealed CNA #1 encouraged Resident #52 to pick up the food with the fingers to eat. Continued observation revealed Resident #52's fingernails were long, and had dark debris under the nail tips. Observation and interview with CNA #1 on 11/28/16 at 12:17 PM, in the 200 hall dining room revealed Resident #52's food was prepared in balls to assist the resident with using the fingers to feed herself. Continued interview confirmed Resident #52 had fed herself, using her fingers and there was dark debris under the nail tips. Interview with the Director of Nursing and the Registered Nurse Supervisor on 11/30/16 at 10:00 AM, in the conference room confirmed the facility failed to ensure Resident #52 had received adequate nail care.",2019-11-01
3991,"NHC HEALTHCARE, ATHENS",445099,1204 FRYE ST,ATHENS,TN,37303,2016-11-30,371,F,0,1,Z4T111,"Based on observation and interview, the facility failed to maintain the kitchen area in a clean, sanitary manner evidenced by food preparation equipment stored with dried debris; failed to store food in a safe, sanitary manner evidenced by opened and unlabeled food products stored in the freezer, and failed to serve food in a safe, sanitary manner for 68 residents receiving meals by mouth of 72 residents reviewed. The findings included: Observation and interview with the Dietary Manager (DM), during the initial tour of the dietary department on 11/28/16 from 9:30 AM to 10:15 AM, revealed 8 of 10 large cookie sheets had brown debris visible, and the mixer head had multi-colored debris also visible. Continued observation in the walk-in freezer revealed the following foods opened and undated: approximately 20 waffles; approximately 2 pounds of berries; approximately 1 pound of fried okra; 4 gallon sized bags of cooked meatloaf; 4 bratwurst; and approximately 8 pounds of chicken thighs left open to air. Interview with the DM during the tour confirmed the cookie sheets and the mixer head had debris of various colors; and the items in the freezer were opened, ready for resident use, and had not been dated after opening. Observation on 11/28/16 at 11:55 AM, of the steam table in the food serving room, revealed the DM (with the bare hands) sanitized the probe of the thermometer (not the handle) with an alcohol wipe. Continued observation revealed the DM held the unsanitized handle of the thermometer with bare hands to obtain the temperature of the soup. Continued observation revealed the DM dropped the unsanitized handle of the thermometer into the soup, and retrieved the thermometer from the soup with bare fingers. Continued observation revealed the DM continued to prepare the soup for resident consumption after dropping the thermometer into the soup. Interview with the DM on 11/28/16 at 2:45 PM, in the conference room, confirmed the facility had failed to store, serve and prepare food in a safe and sanitary manner.",2019-11-01
9397,"NHC HEALTHCARE, ATHENS",445099,1204 FRYE ST,ATHENS,TN,37303,2013-07-31,280,D,0,1,8OBR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to include two residents (#31, #79) in the resident's care plan meetings of thirty-nine residents reviewed. The findings included: Resident #31 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 an 11 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was moderately cognitively impaired. Medical record review of a Social Services note dated May 14, 2013, revealed .Care Plan mtg (meeting): SW (Social Worker) attempted to reach pt's (patient's) daughter by phone with no success . Medical record review of a Patient Care Plan Approval Form dated May 14, 2013, revealed .3. If participation is by the legal representative rather than the patient, please check reasons why the patient did not participate: .b. level of confusion . Observation and interview with the resident on July 29, 2013, at 3:40 p.m., in the resident's room revealed the resident was alert and oriented, and was able to fully participate in the Stage 1 resident interview without difficulty. Continued interview revealed the resident reported the resident had not been involved or invited to participate in care plan meetings. Interview with the Social Services Director and Social Worker #1 on July 31, 2013, at 10:38 a.m., in the Social Services Director's office revealed Social Worker #1 was responsible for inviting the resident and resident's family to participate in Care Plan meetings. Continued interview with Social Worker #1 revealed all residents are to be invited to participate in Care Plan meetings if the resident is cognitively intact and .able to make their needs known . Further interview with Social Worker #1 confirmed the resident was only moderately cognitively impaired and was able to make needs known. Continued interview confirmed the facility had failed to invite the resident to participate in Care Plan meetings. Resident #79 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the last two Minimum Data Sets (MDS) dated [DATE] and May 30, 2013, revealed the resident had scored a 15 out of 15 on the BIMS (Brief Interview for Mental Status) indicating the resident was cognitively intact. Medical record review of Social Services notes dated March 12, 2013 and May 30, 2013, revealed .pt scored 15/15 on BIMS assessment indicating cognitively intact . Medical record review of a Patient Care Plan Approval Form dated March 19, 2013 and June 6, 2013, revealed .3. If participation is by the legal representative rather than the patient, please check reasons why the patient did not participate: .b. level of confusion . Interview with the Social Services Director and Social Worker #1 on July 31, 2013, at 10:38 a.m., in the Social Services Director's office, revealed Social Worker #1 was responsible for inviting the resident and the resident's family to participate in care Plan meetings. Continued interview with Social Worker #1 revealed all residents are to be invited to participate in Care Plan meetings if the resident is cognitively intact and .able to make their needs known . Further interview with Social Worker #1 confirmed the resident was cognitively intact and was able to make needs known, and confirmed the facility had failed to invite the resident to Care Plan meetings.",2016-12-01
9398,"NHC HEALTHCARE, ATHENS",445099,1204 FRYE ST,ATHENS,TN,37303,2013-07-31,371,F,0,1,8OBR11,"Based on observation and interview, the facility failed to provide sanitary storage areas in the kitchen and failed to cover hair to prevent food contamination. The findings included: Observation and interview during the inital tour in the dietary department, on July 29, 2013, at 9:15 a.m., with the facility Chef revealed: a red tinged substance on the white shield in the ice machine; a rack of trays of juice in the juice cooler had spilled juice dried on each rack and the sides of the rack; a brown/black substance on the back wall of the juice cooler; a drawer with utensils stored next to the juice cooler had food debris on the inside bottom of the drawer; a set of four plastic drawers with utensils stored had food debris inside the bottom of the drawers; and the drip tray for the stove burners had a large amount of food debris. Interview during the inital tour with the Chef confirmed the above areas were not sanitary. Observation on July 30, 2013, at 1:10 p.m., in the kitchen on the clean side of the dishwasher, revealed dietary worker#1 had a beard, and was wearing the beard net down under the chin. Observation and interview on July 30, 2013, at 1:12 p.m., with the facility Chef in the kitchen, revealed Dietary Worker #2 had a long braid hanging down the left side of the front of the uniform. Interview with the Chef confirmed the dietary workers were required to cover the hair to prevent food contamination.",2016-12-01
11738,"NHC HEALTHCARE, ATHENS",445099,1204 FRYE ST,ATHENS,TN,37303,2012-01-25,164,D,0,1,LYOR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure privacy for one resident (#12) of nineteen residents reviewed. The findings included: Resident #12 was admitted to facility on March 25, 2010, with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS), dated [DATE], revealed the resident was severely cognitively impaired, and dependent for activities of daily living. Observation on January 24, 2012, at 8:08 a.m., in the 200 hall nursing station, revealed a laboratory technician performing a venipuncture procedure (drawing blood for lab testing) on the resident in the Activities Room adjacent to the nursing station and dining area in full view of other residents, staff, and visitors, in the dining area. Interview with the MDS Coordinator on January 24, 2012, at 8:13 a.m., at the 200 hall nursing station confirmed the facility failed to ensure privacy while performing the procedure.",2015-11-01
11739,"NHC HEALTHCARE, ATHENS",445099,1204 FRYE ST,ATHENS,TN,37303,2012-01-25,176,D,0,1,LYOR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure an assessment for self administration of medications was completed for one resident (#17) of nineteen residents reviewed. The findings included: Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medcial record review of the Minimum Data Set (MDS), dated [DATE], revealed the resident was severely cognitively impaired and dependent for activities of daily living. Medical record review of the Physician's Recapitulation Orders for January 2012, revealed [MEDICATION NAME] treatment four times daily. Observation on January 24, 2012, at 2:03 p.m., in the resident's room revealed the resident sitting upright in bed, with a nebulizer mask in the right hand lying in the resident's lap. Further observation revealed the nebulizer unit in the on position. Continued observation revealed the tubing between the mask and nebulizer unit disconnected from the nebulizer and a small amount of clear liquid in the nebulizer chamber attached to the base of the mask. Interview with Licensed Practical Nurse (LPN) #2, on January 24, 2012, at 2:08 p.m., in the residents room confirmed the LPN had started the nebulizer treatment minutes before and left the resident unattended. Continued interview confirmed the resident was unable to self administer medications and had not been assessed for self administration of medications by nebulizer.",2015-11-01
11740,"NHC HEALTHCARE, ATHENS",445099,1204 FRYE ST,ATHENS,TN,37303,2012-01-25,315,D,0,1,LYOR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to remove an indwelling bladder catheter on readmission from a hospital stay for one resident (#7) of nineteen residents reviewed. The findings included: 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 had severe cognitive impairment, required extensive assistance with all activities of daily living, and was always incontinent. Medical record review of the Admission Nursing Assessment Report dated January 20, 2012, revealed the resident was admitted to the hospital on January 3, 2012, and returned to the facility on [DATE]. Further review of the Admission Nursing Report revealed the resident returned to the facility with .indwelling bladder catheter. Medical record review of a physician's telephone order dated January 20, 2012, at 2:50 p.m., revealed .Foley Catheter 16 Fr (size of catheter). Observation on January 24, 2012, at 7:45 a.m., revealed the resident in the hall, in a wheelchair, with the catheter tubing visible and draining to gravity to the covered bag beneath the wheelchair seat. Interview with the Director of Nursing on January 24, 2012, at 2:00 p.m., in the conference room confirmed .there was no supporting [DIAGNOSES REDACTED].",2015-11-01
11741,"NHC HEALTHCARE, ATHENS",445099,1204 FRYE ST,ATHENS,TN,37303,2012-01-25,323,D,0,1,LYOR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to ensure safety equipment to prevent falls was in place for one resident (#1) of nineteen residents reviewed. The findings included: 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 had short and long term memory problems and severely impaired cognitive skills for daily decision making. Further medcial record review of the MDS revealed the resident required extensive assistance with most activities of daily living, needed staff to provide weight-bearing support, and was totally dependent for all transfers. Medical record review of the Care Plan, dated May 3, 2011, and updated through August 15, 2011, revealed the resident had all four side rails up with full padding and a bed sensor alarm when in bed and a clip alarm when in the wheelchair to alert staff of unassisted transfers. Medical record review of the nurse's notes dated December 15, 2011, through December 19, 2011, revealed the resident had fallen on December 15, 2011, and had no injuries. Medical record review of the Post Falls Nursing assessment dated [DATE], at 12:00 p.m., revealed the resident's family came into the resident's room to visit and found the resident on the floor. The resident was assessed, no injury found, the physician was notified, and no new orders were given. Interview on January 24, 2012, at 7:50 a.m., with the Licensed Practical Nurse #2 (LPN) asssigned to the resident on December 15, 2011, in the resident's room, confirmed the resident was found on the floor on December 15, 2011, around lunch time. Continued interview confirmed the side rail pad was on the floor and the bed sensor alarm had not sounded. Continued interview with LPN #2 revealed the resident had been placed in the wrong bed and the alarm was not in place. Housekeeping had cleaned the room earlier that week and removed both beds from the room. When the housekeepers returned the beds to the resident room, the beds were put on the wrong sides of the room, and the resident was given the roommates bed, with no sensor alarm. Interview with the Assistant Director of Nursing on January 24, 2012, at 3:00 p.m., in the conference room, confirmed the beds and furniture were cleaned and removed from the room, put back on the wrong sides of the room, and Resident #1 was in the bed without the safety devices when the fall occurred. C/O #",2015-11-01
11742,"NHC HEALTHCARE, ATHENS",445099,1204 FRYE ST,ATHENS,TN,37303,2012-01-25,332,D,0,1,LYOR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and interview, the facility failed to prevent medication errors less than five percent resulting in three errors within fifty-one opportunities to equal an error rate of five percent. Observations revealed errors occurred with one (LPN (Licensed Practical Nurse) #1) of six LPNs, one (Section One, Long Hall Medication Cart) of four medication carts, one (7 a.m., to 3 p.m., shift) of three shifts, and two (#10, #11) of eleven residents observed. The findings included: Medication Error #1 Observation on January 23, 2012, at 9:50 a.m., at the Station One, Long Hall Medication Cart, revealed LPN #1 administered the following medications: [REDACTED]. Medical record review of the Physician's Quarterly Recapitulation Orders for January 1, 2012 to April 1, 2012, for Resident #10 revealed an order for [REDACTED].>Interview with LPN #1 on January 23, 2012, at 11:15 a.m., at the Station One Nursing Station confirmed the failure to administer the dose of Therapeutic Vitamins with Minerals tablet to Resident #10. Further interview revealed the medication was in stock and the reply to the question by LPN #1 Would you (LPN #1) have given the medication at a later time during the day? was no. Medication Error #2 Observation on January 23, 2012, at 9:50 a.m., at the Station One, Long Hall Medication Cart, revealed LPN #1 administered the following medications: [REDACTED]. Medical record review of the Physician's Quarterly Recapitulation Orders for January 1, 2012 to April 1, 2012, for Resident #10 revealed an order for [REDACTED].>Interview with LPN #1 on January 23, 2012, at 11:15 a.m., at the Station One Nursing Station confirmed the failure to administer the dose of Refresh Tears to each eye to Resident #10. Further interview revealed the medication was in stock and the reply by LPN #1 to the question Would you (LPN #1) have given the medication at a later time during the day? was no. Medication Error #3 Observation on January 23, 2012, at 10:00 a.m., at the Station One, Long Hall Medication Cart, revealed LPN #1 administered the following medications: [REDACTED]#11. Medical record review of the Physician's Quarterly Recapitulation Orders for January 1, 2012 through April 1, 2012, for Resident #11 revealed an order for [REDACTED].>Interview with LPN #1 on January 23, 2012, at 11:20 a.m., at the Station One Nursing Station confirmed the failure to administer the dose of Therapeutic Vitamins with Minerals to Resident #11. Further interview revealed the medication was in stock and the reply by LPN #1 to the question Would you (LPN #1) have given the medication at a later time during the day? was no.",2015-11-01
11743,"NHC HEALTHCARE, ATHENS",445099,1204 FRYE ST,ATHENS,TN,37303,2012-01-25,428,D,0,1,LYOR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to notify the physician timely of pharmacy consultant reports for one resident (#16) of nineteen residents reviewed. The findings included: Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Pharmacy Consultant Recommendation to the Physician dated September 23, 2011, revealed .consider changing administration times of Renvela (medication used to reduce phosphorus levels, for people on dialysis) so that is given with meals so that it can bind to dietary phosphorus. Continued review of the Pharmacy Recommendation revealed the Physician was not notified until October 15, 2011. Further review revealed the Physician agreed with the recommendation on October 15, 2011. Medical record review of the Medication Administration Record [REDACTED]. Interview and medical record review with the Director of Nursing and the Assistant Director of Nursing in the Director's office on January 25, 2012, at 9:00 a.m., confirmed the facility failed to ensure that Pharmacy Recommendations were acted upon timely.",2015-11-01
11912,"NHC HEALTHCARE, ATHENS",445099,1204 FRYE ST,ATHENS,TN,37303,2012-10-24,280,D,1,0,YWUS11,"**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 for use of a mechanical lift for one resident (#2) of five sampled residents. The findings included: Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Minimum Data Set (MDS) dated [DATE], revealed the resident was severely impaired with decision-making skills, totally dependent on staff on all activities of daily living, and had skin tears. Medical record review of a facility care plan effective through December 20, 2012, revealed, .Skin integrity.Assist of two for transfers.Dermasavers (skin protectors) to BLE (bilateral lower extremities).9-27-12 wedge cushion under bil (bilateral) legs when up in gerichair. Medical record review of a nurse's note dated September 20, 2012, revealed, .bruises in various stages of healing to BLE. Medical record review of a Hospice Aide Visit Note dated September 26, 2012, revealed, .2 person A (assist) with max (maximum) assist.Pt had bruises on L and R (left and right) leg after using sit to stand lift.bruises.were larger. Observation with the Director of Nursing (DON) and the Assistant Director of Nursing on October 24, 2012, at 12:45 p.m., revealed the resident seated in a geri-chair, a wedge cushion was under the resident's legs, and Dermasvers were on both legs. Interview with the Director of Nursing on October 24, 2012, at 12:45 p.m., in the Activity Room, revealed the resident's plan of care did not include use of a mechanical lift and confirmed the facility failed to update the care plan for Resident #2 on September 26, 2012. C/O: #",2015-10-01
11913,"NHC HEALTHCARE, ATHENS",445099,1204 FRYE ST,ATHENS,TN,37303,2012-10-24,323,D,1,0,YWUS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility investigation, observation, and interview, the facility failed to supervise to prevent accidental bruising during the use of a mechanical lift for one resident (#2) of five sampled residents. The findings included: Medical record review revealed resident (#2) was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of an H&P dated July 19, 2011, revealed, .thin wasted frail.plan of care hospice. Medical record review revealed the resident had a history of [REDACTED]. Medical record review revealed care plan interventions included padded siderails, assist of two for repositioning and transfers, Dermasavers to the extremities (the Dermasavers could be removed for hygiene/bathing). Medical record review of a nurse's note dated August 27, 2012, revealed, resisting care.hitting kicking. SR covers were in place res knocked them off. Medical record review of a social service note dated September 5, 2012, revealed, .appears fidgety. Medical record review of a nurse's note dated September 20, 2012, revealed, .bruising in various stages of healing. Medical record review of a hospice aide's note dated September 26, 2012, revealed, .2 person assist with max assist.bruises on L and R leg after sit to stand lift bruises on L and R leg were larger. Review of facility investigation dated September 27, 2012, revealed the bruises resulted from use of the lift during a transfer. Interview with the DON on October 24, 2012, confirmed the facility failed to ensure the resident was supervised to prevent injury (bruises) during the use of the lift. C/O #",2015-10-01
12372,"NHC HEALTHCARE, ATHENS",445099,1204 FRYE ST,ATHENS,TN,37303,2012-05-23,164,D,1,0,HI5611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide confidentiality of clinical records for one resident (#1) of seven residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident scored fifteen of fifteen on the Brief Interview for Mental Status (BIMS) with intact cognitive skills, no memory impairment, and no behaviors. Medical record review revealed resident #1 was transferred from the facility and admitted to the hospital on April 11, 2012, with [DIAGNOSES REDACTED]. The resident was discharged back to the facility on [DATE], following a three day hospital stay. Medical record review of a Discharge Planner note, from the local hospital, dated April 13, 2012, at 5:40 p.m., revealed ""...verbal permission from pts (patients) daughter via phone call...first choice NHC (National Health Care of Athens)..."" Interview with the Administrator on May 22, 2012, at 12:05 p.m., in the Administrator's office, confirmed when the resident went to the hospital in April, 2012, the resident's family member did not want the resident admitted to another nursing home facility following the hospital stay, but the facility had previously been in contact with another nursing home facility regarding possible placement at the other facility. Interview with the Social Service Director on May 22, 2012, at 4:45 p.m., in the Social Service office, confirmed the resident's clinical information had been faxed to another local nursing home on April 13, 2012, for possible placement in the other facility, and neither the resident nor family had not requested or given permission for clinical information to be sent. C/O #",2015-08-01
12373,"NHC HEALTHCARE, ATHENS",445099,1204 FRYE ST,ATHENS,TN,37303,2012-05-23,205,D,1,0,HI5611,"**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 provide written notice of the bed-hold policy within twenty-four hours of a transfer for one resident (#1) of seven residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident scored fifteen of fifteen on the Brief Interview for Mental Status (BIMS) with intact cognitive skills, no memory impairment, and no behaviors. Medical record review revealed resident #1 was transferred from the facility and admitted to the hospital on April 11, 2012, with [DIAGNOSES REDACTED]. The resident was discharged back to the facility on [DATE], following a three day hospital stay. Medical record review and review of facility documentation revealed no documentation the resident or the resident's representative had been given written notice of the facility's bed-hold policy within 24 hours of admission to the hospital. Interviews with the Social Service Director on May 22, 2012, at 4:15 p.m., and 4:45 p.m., in the Social Service office, confirmed a family member of the resident was notified verbally by the Administrator the resident had no bed hold days, after the resident was admitted to the hospital. Interview with the Administrator on May 23, 2012, at 12:05 p.m., in the Administrator's office, confirmed the facility failed to provide a written notice within twenty-four hours of transfer to the hospital of the bed hold policy. C/O #",2015-08-01
12374,"NHC HEALTHCARE, ATHENS",445099,1204 FRYE ST,ATHENS,TN,37303,2012-05-23,246,D,1,0,HI5611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to accommodate individual needs for one resident (#1) of seven residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident scored fifteen of fifteen on the Brief Interview for Mental Status (BIMS) with intact cognitive skills, no memory impairment, and no behaviors. Continued review of the MDS revealed the resident required total staff assistance for all transfers, eating, and activities of daily living (ADLS). Medical record review of an Interdisciplinary Care Plan, dated May 10, 2012, revealed ""...dependent on staff for ADLS r/t (related to) [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] will have all daily needs for ADL, met by staff...two person transfer w/ (with) total body lift to electric w/c (wheelchair) with chin control for mobility, tv (television) controls and computer access...total assist of two persons for toileting and position changes in bed and w/c...staff to totally assist with meals daily...reposition frequently as pt (patient) is unable to make even slight changes unassisted...residents needs and wants will be met daily without excess demands..."" Interview with the resident on May 22, 2012, at 9:10 a.m., and 3:40 p.m., in the resident's room, revealed the Maxi Lift (mechanical lift resident needed to be moved from bed to chair and chair to bed) had broken on May 12, 2012, and had not been repaired until May 17, 2012. Further interview revealed the resident's electric chair would recline for sleeping and the resident stayed in the electric wheelchair from May 12, through May 17, 2012. Further interview revealed the resident did not use a facility supplied bed or mattress; the height of the resident's personal bed did not adjust and the Arjo lift (the facility's other mechanical lift) did not go up high enough to place the resident in the resident's bed. Further interview revealed the Administrator offered on the third or fourth day to change the resident's bed to a facility supplied bed, and the resident requested the resident's mattress be placed on the facility bed, but staff never changed the bed. Further interview confirmed the resident had not been offered another alternative. Interview with Certified Nurse Assistant (CNA) #1 on May 22, 2012, at 2:45 p.m., in the Nurse's Station, revealed the resident had been in the electric wheelchair from May 12, 2012, through May 17, 2012, and had not been placed in the resident's bed at night due to the Arjo Lift would not raise the resident high enough to place the resident on the resident's bed. Continued interview revealed the Arjo Lift would allow the staff to provide all ADLS the only change in routine care from May 12, 2012, through May 17, 2012, was the resident was not able to lie down on the resident's bed. Interview with Licensed Practical Nurse (LPN) #1 on May 22, 2012, at 3:15 p.m., in the Activity Room, confirmed the Maxi Lift broke on May 12, 2012, at 3:00 p.m., and was not operational until May 17, 2012, sometime in the morning. Further interview revealed the facility attempted to contact the Administrator and the Maintenance Director regarding the broken Maxi Lift and did not receive a return call on May 12 or May 13, 2012. Further interview confirmed the broken mechanical lift was the lift required to put resident #1 to bed, the resident was not offered any alternatives (manual lift or bed options) over the weekend and the resident stayed up in the electric wheelchair from May 12 through May 17, 2012. Interview with CNA #2 on May 23, 2012, at 9:15 a.m., in the Conference Room, revealed the Maxi Lift was broken when the CNA arrived at work on May 14, 2012, staff reported to the CNA the Maxi Lift had been broken since May 12, 2012, and the resident had been in the chair since May 12, 2012. Continued interview revealed the Arjo Lift had been in place, staff had been using the Arjo Lift to provide routine care, and the Arjo Lift would not raise the resident high enough to place the resident on the resident's bed. Further interview confirmed, on May 15, 2012, the Administrator offered to change the resident's bed to a facility bed so the resident could lie down, and the resident requested own personal mattress be placed on the facility bed, but nothing had been changed. Interview with CNA #3 on May 22, 2012, at 3:05 p.m., in the Activity Room, confirmed the resident required total care, while the Maxi Lift was broken the resident stayed in the electric chair all day, staff repositioned the resident, staff performed routine care with the Arjo Lift, but staff had not been able to lie the resident down in bed. Interview with the Administrator on May 22, 2012, at 11:30 a.m., in the Administrator's office, confirmed the mechanical lift was broken May 12, through 17, 2012, the resident had stayed in the chair without going to bed from May 12, 2012, through May 17, 2012, and the facility did not accommodate the resident's needs for five days. C/O #",2015-08-01
12375,"NHC HEALTHCARE, ATHENS",445099,1204 FRYE ST,ATHENS,TN,37303,2012-05-23,250,D,1,0,HI5611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, interview, and review of facility investigation, the facility failed to provide Social Services adequate to meet the needs of two (#1, #5) residents of seven residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident scored fifteen of fifteen on the Brief Interview for Mental Status (BIMS) with intact cognitive skills, no memory impairment, and no behaviors. Continued review of the MDS revealed the resident required total staff assistance for all transfers, eating, and activities of daily living (ADLS). Medical record review of an Interdisciplinary Care Plan, dated May 10, 2012, revealed ""...dependent on staff for ADLS r/t (related to) quadriplegia secondary to Multiple Sclerosis...resident will have all daily needs for ADL, met by staff...provide oral care...two person transfer w/ (with) total body lift to electric w/c (wheelchair) with chin control for mobility, tv (television) controls and computer access...total assist of two persons for toileting and position changes in bed and w/c...unable to utilize hand toggle switch independently...staff to totally assist with meals daily...reposition frequently as pt (patient) is unable to make even slight changes unassisted...residents needs and wants will be met daily without excess demands...meet residents needs and wants as much as possible but set limits...tell (resident)...how many minutes may be spent before beginning, that you may return later if needed, whether care can be done as (resident) requests...Inappropriate Behavior AEB (as exemplified by) attempted manipulation and control of staff and family, demanding and impatient, verbally sharp w/ caregivers...Anxiety AEB easily frustrated, repetitive health complaints, anxious concerns, insomnia, unpleasant mood in the mornings, social isolation..."" Medical record review revealed no Social Services Notes from January 2012, through May 22, 2012, related to any concerns, meetings, or needs. Observation of the resident on May 22, 2012, at 9:10 a.m., in the resident's room, revealed the resident in an electric wheelchair, with chin control for television control, call light, remote fan, computer with whisper software, and head piece for volume. Interview with the resident, at this time, confirmed the resident had expressed concerns and had meetings with the facility Administration related to personal care not being provided and the facility not meeting the resident's needs or addressing the resident's concerns. Continued interview confirmed the Social Worker of the facility had not visited with the resident or attended any meetings discussing the resident's concerns related to personal care and concerns. Interview with the Social Service Director on May 22, 2012, at 4:45 p.m., in the Social Service office, confirmed the Social Worker had been aware of the facility meetings with the resident regarding the resident and family concerns related to the resident's care; the facility informing the resident and the resident's family the facility was recommending discharge home or other placement; and the facility's refusal to take the resident back after a transfer to the hospital. Continued interview at this time confirmed the Social Worker had not had any contact with the resident or provided any services to the resident, ""Administrator had handled the situation."" Interview with the Administrator and the Senior Regional Vice President on May 23, 2012, at 10:00 a.m., in the conference room, confirmed the resident had concerns and issues the facility was attempting to resolve, and the resident had psychosocial issues and could benefit from social services interventions, but no social services consult or interventions had been completed. Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a facility investigation dated May 16, 2012, revealed an allegation of physical abuse had occurred in the facility on May 15, 2012, at 6:00 p.m., in which resident #5 was being fed by a family member. It was alleged the family member ""...slapped (the resident) in the face..."" in an attempt to wake the resident, so the family member could feed the resident the evening meal. Interview with the Social Worker on May 23, 2012, at 10:00 a.m., outside the Social Worker's office, confirmed the incident had been investigated by the Administrator and the Social Worker had not been involved with the investigation and had not contacted the resident or the resident's family related to the allegation of physical abuse to assess for any psychosocial needs or interventions that could be beneficial. Interview with the Administrator on May 23, 2012, at 10:15 a.m., in the conference room, confirmed the facility failed to initiate a Social Services consultation/case review for the resident related to the allegation of physical abuse to assess the resident and offer any psychosocial interventions. C/O # C/O #",2015-08-01
12376,"NHC HEALTHCARE, ATHENS",445099,1204 FRYE ST,ATHENS,TN,37303,2012-05-23,312,D,1,0,HI5611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide oral hygiene for one resident (#1) of seven residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident scored fifteen of fifteen on the Brief Interview for Mental Status (BIMS) with intact cognitive skills, no memory impairment, and no behaviors. Continued review of the MDS revealed the resident required total staff assistance for all transfers, eating, and activities of daily living (ADLS). Medical record review of an Interdisciplinary Care Plan, dated May 10, 2012, revealed ""...dependent on staff for ADLS r/t (related to) [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] will have all daily needs for ADL, met by staff...provide oral care...residents needs and wants will be met daily without excess demands...meet residents needs and wants as much as possible but set limits...tell (resident)...how many minutes may be spent before beginning, that you may return later if needed, whether care can be done as (resident) requests..."" Interviews with the resident on May 22, 2012, at 9:10 a.m., and 3:30 p.m., in the resident's room, revealed the the resident stated ""...staff do not brush my teeth everyday...they run out of time..."" Further interviews confirmed the resident's teeth were brushed on May 22, 2012, by Certified Nursing Assistant (CNA) #2 and a student, but there were days when the resident's teeth did not get brushed because the CNAs did not have time. Interviews with CNA #1 on May 22, 2012, at 2:45 p.m., at the nurse's station, with CNA #4 on May 22, 2012, at 3:05 p.m., at the nurse's station, and with Licensed Practical Nurse #1 on May 22, 2012, at 3:15 p.m., at the nurse's station, confirmed the resident's personal care took longer to perform than other residents and staff frequently had to limit the amount of time spent performing the resident's care in order to complete other tasks and care for other residents. Interview with CNA #2 on May 23, 2012, at 9:15 a.m., in the conference room, confirmed the resident's personal care took longer to perform than other residents and the resident's teeth did not get brushed daily. Interview with the Regional Vice President on May 23, 2012, at 10:00 a.m., in the conference room, confirmed expectations of the staff would be to brush the resident's teeth at a minimum once daily. C/O #",2015-08-01
12377,"NHC HEALTHCARE, ATHENS",445099,1204 FRYE ST,ATHENS,TN,37303,2012-05-23,456,D,1,0,HI5611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure equipment required to transfer a resident was maintained in working condition for one resident (#1) of seven residents reviewed. The findings included: Resident #1 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident scored fifteen of fifteen on the Brief Interview for Mental Status (BIMS) with intact cognitive skills, no memory impairment, and no behaviors. Continued review of the MDS revealed the resident required total staff assistance for all transfers, eating, and activities of daily living (ADLS). Medical record review of an Interdisciplinary Care Plan, dated May 10, 2012, revealed ""...dependent on staff for ADLS r/t (related to) [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] will have all daily needs for ADL, met by staff...two person transfer w/ (with) total body lift to electric w/c (wheelchair)...total assist of two persons for toileting and position changes in bed and w/c...reposition frequently as pt (patient) is unable to make even slight changes unassisted...residents needs and wants will be met daily without excess demands..."" Interview with the resident on May 22, 2012, at 9:10 a.m., and 3:40 p.m., in the resident's room, revealed the Maxi Lift (mechanical lift resident needed to be moved from bed to chair and chair to bed) had broken on May 12, 2012, and had not been repaired until May 17, 2012. Further interview revealed the resident's electric chair would recline for sleeping and the resident stayed in the electric wheelchair from May 12, through May 17, 2012. Further interview revealed the resident did not use a facility supplied bed or mattress; the height of the resident's personal bed did not adjust and the Arjo lift (the facility's other mechanical lift) did not go up high enough to place the resident in the resident's bed. Interview with the Maintenance Director on May 22, 2012, at 11:00 a.m., in the maintenance office, confirmed a verbal request to repair the Maxi Lift, which had been broken, was received by the Maintenance Director on one day (unknown which day) and the lift had been fixed the next day. Further interview confirmed no written order had been completed by the staff and no purchase order had been completed by the Maintenance Director. Interview with Certified Nurse Assistant (CNA) #1 on May 22, 2012, at 2:45 p.m., in the Nurse's Station, revealed the resident had been in the electric wheelchair from May 12, 2012, through May 17, 2012, and had not been placed in the resident's bed at night due to the Arjo Lift would not raise the resident high enough to place the resident on the resident's bed. Continued interview revealed the Arjo Lift would allow the staff to provide all ADLS the only change in routine care from May 12, 2012, through May 17, 2012, was the resident was not able to lie down on the resident's bed. Further interview confirmed three other residents did not receive their normal care due to the lift being broken. Interview with Licensed Practical Nurse (LPN) #1 on May 22, 2012, at 3:15 p.m., in the Activity Room, confirmed the Maxi Lift broke on May 12, 2012, at 3:00 p.m., and was not operational until May 17, 2012, sometime in the morning. Further interview revealed the facility attempted to contact the Administrator and the Maintenance Director regarding the broken Maxi Lift and did not receive a return call on May 12 or May 13, 2012. Further interview confirmed the broken mechanical lift was the lift required to put resident #1 to bed, the resident was not offered any alternatives (manual lift or bed options) over the weekend and the resident stayed up in the electric wheelchair from May 12, 2012 through May 17, 2012. Interview with CNA #2 on May 23, 2012, at 9:15 a.m., in the Conference Room, revealed the Maxi Lift was broken when the CNA arrived at work on May 14, 2012, staff reported to the CNA the Maxi Lift had been broken since May 12, 2012, and the resident had been in the chair since May 12, 2012. Continued interview revealed the Arjo Lift had been in place, staff had been using the Arjo Lift to provide routine care, and the Arjo Lift would not raise the resident high enough to place the resident on the resident's bed. Interview with CNA #3 on May 22, 2012, at 3:05 p.m., in the Activity Room, confirmed the resident required total care, when the Maxi Lift was broken the resident stayed in the electric chair all day, staff repositioned the resident, staff performed routine care with the Arjo Lift, but staff had not been able to lie the resident down in bed. Interview with the Administrator on May 22, 2012, at 11:30 a.m., in the Administrator's office, confirmed the mechanical lift was broken May 12, through 17, 2012, two residents in the facility required use of the broken lift, and all equipment in need of repair was to be reported immediately to the Maintenance Director for repair. C/O #",2015-08-01
13765,"NHC HEALTHCARE, ATHENS",445099,1204 FRYE ST,ATHENS,TN,37303,2011-01-20,159,D,0,1,2IG611,"Based on review of patient trust accounts, facility policy review, and interview, the facility failed to notify the resident or the resident's responsible party when the balance in the resident trust account was within $200.00 of the SSI (Social Security Income) resource limit ($2,000.00) for one resident (#5) of thirty resident trust account balances reviewed. The findings included: Review of resident #5's trust fund statement dated November 1, 2010, through January 19, 2011, revealed a balance of $1,875.30 on December 10, 2010, and a balance of $1,918.70 on January 7, 2011. Review of the facility's policy Patient Trust Balance Review revealed ""...Federal regulations require that patients or their responsible party be notified when balances in their Patient Trust account are within $200.00 of the state maximum asset balance..."" Interview on January 19, 2010, at 10:50 a.m., with the Assistant Bookkeeper, in the conference room, confirmed resident #5 or resident #5's responsible party had not been notified the resident's trust fund balance was within $200.00 of the SSI income limit.",2014-09-01
13766,"NHC HEALTHCARE, ATHENS",445099,1204 FRYE ST,ATHENS,TN,37303,2011-01-20,441,D,0,1,2IG611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, observation, and interview, the facility failed to ensure staff washed hands and wore gloves to maintain infection control for one (#15) of nineteen residents reviewed. The findings included: Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the facility policy, Handwashing/Hand Hygiene, revealed, "" ...Employees must wash their hands for ten (10) to fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions:...Before and after direct contact with residents...If hands are not visibly soiled, use an alcohol-based hand rub...before and after direct contact with residents..."" Observation on January 19, 2011, at 8:15 a.m. revealed the LPN (Licensed Practical Nurse) #1 placed medication into a medication cup; locked the medication cart; picked up the medication cup and insulin syringe from the medication cart; entered the resident's room and without washing the hands or applying gloves, administered the insulin and medication to the resident. Interview on January 19, 2011, at 8:25 a.m., in the hall, with LPN #1, confirmed hands were not washed prior to administration of the insulin and gloves were not worn to administer the insulin. Interview on January 19, 2011, at 12:00 noon, in the hall, with the Director of Nursing, confirmed hands are to be washed prior to administration of an injection and gloves are to be worn to administer an injection.",2014-09-01
13767,"NHC HEALTHCARE, ATHENS",445099,1204 FRYE ST,ATHENS,TN,37303,2011-01-20,315,D,0,1,2IG611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, facility policy review, and interview, the facility failed to develop a bladder retraining/toileting program for one (#15) of nineteen residents reviewed. The findings included: Resident #15 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 able to make needs known, able to understand what was said, and was frequently incontinent of bladder. Medical record review of the urinary incontinence Care Area Assessment (CAA), for the MDS dated [DATE], revealed the resident was able to recognize the need to urinate. Medical record review of the Urinary Incontinence Assessment & Evaluation revealed ""...Can the resident comprehend & follow through on education & instructions? Yes. Can the resident identify urinary urge sensation? Yes...If the answers to the above questions are 'YES,' or conditions are reversible such that the resident can comprehend & learn, proceed with the retraining program as appropriate to the resident..."" Medical record review of a toileting grid, for resident #15, revealed the resident had twenty-eight episodes of urinary incontinence documented from January 3-13, 2011. Observation and interview on January 19, 2011, at 4:00 p.m., revealed the resident lying on the bed, and stated was aware of toileting needs, and incontinence briefs were utilized. Review of the facility's policy Toileting Plans for Urinary Incontinence revealed ""The purpose of this procedure is to provide guidelines for the initiation and monitoring of behavioral interventions and/or a toileting plan for the resident with urinary incontinence...Monitor, record and evaluate information about the resident's bladder habits, and continence or incontinence, including: Voiding patterns (frequency, volume, time, quality of stream, etc...Assess the resident for appropriateness of behavioral programs which promote urinary continence. The resident must possess some essential skills to be successful with specific interventions attempted. Staff must identify whether the resident can: Comprehend educational efforts and follow-through with instructions; Identify the urge to urinate..."" Interview on January 19, 2011, at 3:40 p.m., with Registered Nurse #1, at the nursing station, revealed the staff was to toilet the resident every two hours, and confirmed a bladder retraining/toileting plan had not been developed for the resident.",2014-09-01
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
4239,"NHC HEALTHCARE, PULASKI",445101,993 E COLLEGE ST,PULASKI,TN,38478,2016-09-29,282,D,0,1,O8O911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to follow care plan interventions for nutrition, carrot splints, and finger separators for 2 of 20 (Residents #60 and #125) sampled residents of the 36 residents included in the stage 2 review. The findings included: 1. Medical record review revealed Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] and the quarterly MDS dated [DATE] revealed Resident #60 was cognitively intact, had no weight loss of 5 percent (%) or more in the last month or weight loss of 10% or more in the last 6 months, and that Resident #60 received a mechanically altered diet. The care plan dated 8/18/16 documented, Problem Altered food/fluid needs related to .Wounds .Mechanically altered diet .Risk for weight variance .Offer Hs (hour of sleep) snacks .Nsg (nursing) to offer Promod TID (three times a day) .Offer Readyshakes at lunch and supper . Review of Resident #60's Meal% (percent) Tracking Sheet, dated (MONTH) (YEAR) revealed no documentation that the HS Snack was provided. The physician's orders [REDACTED].PROMOD LIQUID PROTEIN (SUPPLEMENT) .30ML (milliliters) BY MOUTH THREE TIMES DAILY . Review of the Medication, Treatment and Task Administration Record Report (MAR) for (MONTH) (YEAR) revealed that Resident #60 refused the Promod Liquid Protein Supplement on the following dates: 7/1/16, 7/3/16, 7/5/16 - 7/8/16, 7/10/16, 7/15/16 - 7/17/16, 7/19/16 - 7/24/16, 7/27/16 - 7/29/16. Review of the MAR for (MONTH) (YEAR) revealed that Resident #60 refused the Promod Liquid Protein Supplement on the following dates: 8/2/16 - 8/5/16, 8/7/16 - 8/10/16, 8/12/16 - 8/31/16. Review of the MAR for (MONTH) (YEAR) revealed that Resident #60 refused the Promod Liquid Protein Supplement 9/1/16 - 9/27/16. Review of Resident #60's meal tray card for the lunch meal on 9/28/16 at 1:02 PM revealed that Resident #60 was to receive a READYSHAKE. Observations in the resident's room at 9/28/16 at 1:03 PM, revealed Resident #60 received a pureed lunch meal. Resident #60 did not receive a Readyshake on her lunch tray. Interview with the Registered Dietitian (RD) on 9/28/16 at 2:19 PM, in the Conference Room, the RD was asked how do you ensure your recommendations are effective. The RD stated, .interview of resident, staff and CNA's (certified nursing assistant) .it is not a check list or anything . The RD was asked when she would look at Resident #60's weight again. The RD stated, .if she has significant weight loss . Interview with Registered Nurse (RN) #1 on 9/28/16 at 2:45 PM, in the south hall, RN #1 was asked if the care plan was followed for providing the Readyshake to Resident #60 at lunch. RN #1 stated, No . Interview with the RD on 9/28/16 at 3:35 PM, in the Conference Room, the RD was asked if there was a policy on nutrition and weight loss. The RD stated, I don't have a set policy . Interview with the Director of Nursing (DON) on 9/28/16 at 2:02 PM, in the DON's office, the DON was asked if a resident is ordered a readyshake how is it documented. The DON stated .we don't document . Interview with Registered Nurse (RN) #2 on 2/28/16 at 2:40 PM, in her office, RN #2 was asked how do you expect the care plan to be implemented. RN #2 stated, .if its in the care plan we alert the nurses . Interview with RN #1 on 9/28/16 at 2:45 PM, in the south hall, RN #1 was asked if the care plan was followed for providing the Readyshake to Resident #60 at lunch. RN #1 stated, No . Interview with the Director of Nursing (DON) on 9/29/16 at 9:54 AM, by telephone, the DON was asked how the physician is notified when a resident refuses a supplement. The DON stated, (Named physician) looks at the MAR's every 2 weeks .we print them off for him and the nurse practitioner looks at them every week . When asked if there was evidence that the physician or nurse practitioner had reviewed Resident #60's MAR, the DON stated, They don't sign it (the MAR) and we don't keep them. When asked if the nurses document that the physician or nurse practitioner was informed that Resident #60 was refusing the Promod, the DON stated, Not that I'm aware of. The facility was unable to provide documentation that the physician was notified of Resident #60 refusing Promod. 2. Medical record review revealed Resident #125 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS dated [DATE] and the quarterly MDS dated [DATE] revealed Resident #125 was severely cognitively impaired and totally dependent in functional status. The resident's care plan dated 8/23/16, documented, .Apply carrot splints and finger separators to bilateral hands at 10 am remove at 3 pm q (every) day . Observations in Resident #125's room on 9/26/16 at 12:54 PM, revealed the resident lying in bed and finger separators not applied. Observations in Resident #125's room on 9/27/16 at 11:18 AM, revealed resident lying in bed, carrot splints and finger separators not applied. Interview with CNA #1 on 9/27/16 at 12:03 PM, at the South Nursing Station, CNA #1 was asked if Resident #125's carrot splints and finger separators were in place as ordered. CNA #1 stated, No Ma'am they weren't . Interview with the DON on 9/28/16 at 10:15 AM, in the DON's office, the DON was asked if it is appropriate for the carrot splints and finger separators to not be applied as ordered. The DON answered, No.",2019-10-01
4240,"NHC HEALTHCARE, PULASKI",445101,993 E COLLEGE ST,PULASKI,TN,38478,2016-09-29,318,D,0,1,O8O911,"**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 carrot splints and finger separators for 1 of 3 (Resident #125) sampled residents of the 15 residents with contractures in the stage 2 review. The findings included: 1. Medical record review revealed Resident #125 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] and the quarterly MDS dated [DATE] revealed Resident #125 was severely cognitively impaired and totally dependent in functional status. Review of the physician's order dated 5/4/16 documented, .APPLY CARROT SPLINTS AND FINGER SEPARATORS TO BOTH HANDS AT 10AM, REMOVE AT 3PM Q (every) DAY . The resident's care plan dated 8/23/16, documented, .Apply carrot splints and finger separators to bilateral hands at 10 am remove at 3 pm q day . Observations in Resident #125's room on 9/26/16 at 12:54 PM, revealed the resident lying in bed and finger separators not applied. Observations in Resident #125's room on 9/27/16 at 11:18 AM, revealed resident lying in bed, carrot splints and finger separators not applied. Interview with CNA #1 on 9/27/16 at 12:03 PM, at the South Nursing Station, CNA #1 was asked if Resident #125's carrot splints and finger separators were in place as ordered. CNA #1 stated, No Ma'am they weren't . Interview with the Director of Nursing (DON) on 9/28/16 at 10:15 AM, in the DON's office, the DON was asked if it is appropriate for the splints finger separators to not be applied as ordered. The DON answered, No .I think if they are ordered they are ordered for a reason .",2019-10-01
4241,"NHC HEALTHCARE, PULASKI",445101,993 E COLLEGE ST,PULASKI,TN,38478,2016-09-29,325,D,0,1,O8O911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, meal tray card review, observation, and interview, the facility failed to provide nutritional supplements and bedtime snacks as ordered and recommended for 1 of 5 (Resident #60) sampled residents of the 11 residents with nutritional issues included in the stage 2 review. The findings included: Medical record review revealed Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] and the quarterly MDS dated [DATE] revealed Resident #60 was cognitively intact, had no weight loss of 5 percent (%) or more in the last month or weight loss of 10% or more in the last 6 months and that Resident #60 received a mechanically altered diet. The Vitals Report revealed Resident #60's weight on 8/1/16 was 153 pounds and on 9/1/16 her weight was 149 pounds, which is a 2.6% loss in a month. The Registered Dietitian's (RD) note dated 8/12/16 documented, .She receives promod 30ml (milliliters) BID (twice daily) providing 20g (grams) of protein and 200 calories .has inadequate protein/calorie intake r/t (related to) poor intake, increased needs for wound healing as evidence by leaves 50+ (50 percent (%) or more) uneaten at lunch and supper. Will add readyshake at lunch and supper and increase promod to 30ml TID all providing 700 calories, 42g protein. She is at nutritional risk . The care plan dated 8/18/16 documented, Problem Altered food/fluid needs related to .Wounds .Mechanically altered diet .Risk for weight variance .Offer Hs (hour of sleep) snacks .Nsg (nursing) to offer Promod TID (three times a day) .Offer Readyshakes at lunch and supper . Review of Resident #60's Meal% Tracking Sheet dated (MONTH) (YEAR), revealed no documentation that the HS Snack was provided as ordered. The physician's orders [REDACTED].PROMOD LIQUID PROTEIN (SUPPLEMENT) .30ML (milliliters) BY MOUTH THREE TIMES DAILY . Review of the Medication, Treatment and Task Administration Record Report (MAR) for (MONTH) (YEAR) revealed that Resident #60 refused the Promod Liquid Protein Supplement on the following dates: 7/1/16, 7/3/16, 7/5/16 - 7/8/16, 7/10/16, 7/15/16 - 7/17/16, 7/19/16 - 7/24/16, 7/27/16 - 7/29/16. Review of the MAR for (MONTH) (YEAR) revealed that Resident #60 refused the Promod Liquid Protein Supplement on the following dates: 8/2/16 - 8/5/16, 8/7/16 - 8/10/16, 8/12/16 - 8/31/16. Review of the MAR for (MONTH) (YEAR) revealed that Resident #60 refused the Promod Liquid Protein Supplement 9/1/16 - 9/27/16. Review of Resident #60's meal tray card for the lunch meal on 9/28/16 at 1:02 PM revealed that Resident #60 was to receive a Readyshake. Observations in the resident's room at 9/28/16 at 1:03 PM, revealed Resident #60 received a pureed lunch meal. Resident #60 did not receive a Readyshake on her lunch tray. Interview with the Director of Nursing (DON) on 9/28/16 at 2:02 PM, in the DON's office, the DON was asked if a resident is ordered a readyshake, how it is documented. The DON stated .we don't document .the dietitian keeps up with the weight loss . Interview with the Registered Dietitian (RD) on 9/28/16 at 2:19 PM, in the Conference Room, the RD was asked how do you ensure your recommendations are effective. The RD stated, .interview of resident, staff and CNA's (certified nursing assistant) .it is not a check list or anything . The RD was asked when she would look at Resident #60's weight again. The RD stated, .if she has significant weight loss . Interview with Registered Nurse (RN) #1 on 9/28/16 at 2:45 PM, in the south hall, RN #1 was asked if the care plan was followed for providing the Readyshake to Resident #60 at lunch. RN #1 stated, No . Interview with the RD on 9/28/16 at 3:35 PM, in the Conference Room, the RD was asked if there was a policy on nutrition and weight loss. The RD stated, I don't have a set policy . Interview with the Director of Nursing (DON) on 9/29/16 at 9:54 AM, by telephone, the DON was asked how the physician is notified when a resident refuses a supplement. The DON stated, (Named physician) looks at the MAR's every 2 weeks .we print them off for him and the nurse practitioner looks at them every week . When asked if there was evidence that the physician or nurse practitioner had reviewed Resident #60's MAR, the DON stated, They don't sign it (the MAR) and we don't keep them. When asked if the nurses document that the physician or nurse practitioner was informed that Resident #60 was refusing the Promod, the DON stated, Not that I'm aware of. The facility was unable to provide documentation that the physician was notified of Resident #60 refusing Promod.",2019-10-01
4242,"NHC HEALTHCARE, PULASKI",445101,993 E COLLEGE ST,PULASKI,TN,38478,2016-09-29,371,F,0,1,O8O911,"Based on policy review, observation and interview, the facility failed to ensure food was prepared and served under sanitary conditions as evidenced by carbon build-up and grease on pots and pans, grease buildup on the floor under the stove and deep fryer, can opener with brown sticky build-up around the blade, cookware and serving trays stacked and stored while wet, grease traps on the floor with dark brown build-up, kitchen staff with hair not completely covered, and dirty steam tables during 2 of 2 (9/26 and 9/27/16) days of observations. The facility had a census of 89, with 89 of those residents receiving a meal tray from the kitchen. The findings included: 1. The WEEKLY CLEANING schedule documented, .Monday, and Friday Decarbon pots and pans . Observations in the kitchen on 9/26/16 at 11:10 AM, and on 9/27/16 at 8:10 AM, revealed carbon build-up and grease on pots and pans. Interview with the Corporate Dietitian (CD) on 9/26/16 at 11:20 AM, in the kitchen, the CD was asked if it was acceptable to have carbon and grease build-up on pots and pans. The CD stated, No. 2. The facility's FLOORS policy documented, .Using short handle broom, sweep under all equipment, around legs, and in corners, etc. Use push broom to sweep remaining floor to remove all loose soil/debris. Use short handled broom to sweep debris into dustpan .Apply floor cleaner/degreaser/sanitizer evenly over floors with deck brushes or mops . Observations in the kitchen on 9/26/16 at 11:10 AM, and on 9/27/16 at 8:10 AM, revealed grease build-up on the floor under the stove and deep fryer. Interview with the CD on 9/27/16 at 11:20 AM, in the kitchen, the CD was asked if it was acceptable to have grease build-up under the stove and fryer. The CD stated, No. 3. The WEEKLY CLEANING schedule documented, . on Wednesday can openers inc (including) base . Observations in the kitchen on 9/26/16 at 11:10 AM, revealed a can opener with brown, sticky build-up around the blade. Interview with the CD on 9/26/16 at 11:10 AM, in the kitchen, the CD was asked if it was acceptable to have brown sticky build-up around the blade. The CD stated, No. 4. The facility's MANUAL WAREWASHING policy documented, .Air-dry items. Make sure all items are completely dry before stacking to prevent wet-nesting . Observations in the kitchen on 9/26/16 at 11:10 AM, revealed 6 wet sheet pans stacked under the prep table, and 4 wet half pans on the clean rack. Interview with the CD on 9/26/16 at 11:10 AM, in the kitchen, the CD was asked if it was acceptable to have stacks of wet cookware. The CD stated, No. Observations in the kitchen on 9/27/16 at 11:20 AM, revealed 10 wet serving trays stacked on the serving line. Interview with the CD on 9/27/16 at 11:20 AM, in the kitchen, the CD was asked if it was acceptable to have stacks of wet trays on the serving line. The CD stated, No. 5. The facility's WASTE MANAGEMENT policy documented, .Grease traps, if used shall be located to be easily accessible for cleaning . Observations in the kitchen on 9/26/16 at 11:10 AM, and on 9/27/16 at 8:10 AM, revealed two floor grease traps with large amounts of dark brown build-up. Interview with the CD on 9/27/16 at 11:10 AM, in the kitchen, the CD was asked if it was acceptable to have the dark brown build-up in the grease traps. The CD stated, No. 6. The facility's HYGIENIC & SAFETY PRACTICES policy documented, .Dietary Partners .shall wear hair restraints .to effectively keep their hair from contacting exposed food . Observations in the kitchen on 9/26/16 at 11:00 AM, revealed the CD, Dietary Staff (DS) #1, DS #2, DS #3, and DS #4 with their hair not completely covered. Observations in the kitchen on 9/27/16 at 8: 15 AM, revealed DS #5, DS #6, and maintenance staff #1 with their hair not completely covered. Interview with the CD on 9/27/16 at 11:00 AM, in the kitchen, the CD was asked if it was acceptable for staff to be in the kitchen with their hair not completely covered. The CD stated, No. 7. Observations in the day room on the 100 hall on 9/26/16 at 11:30 AM, and 9/27/16 at 8:30 AM, revealed the steam table with dry white substance around the steam table, and dark substance inside of the steam table. Interview with the CD on 9/27/16 at 11:25 AM, in the day room, the CD was asked if it was acceptable to have dry white substance and dark particles on and inside of the steam table. The CD stated, No. Observations in the dining room on the south hall on 9/27/16 at 11:00 AM revealed the steam table in the south hall dining room noted with a dark substance inside the steam table. Interview with DS #7 on 9/27/16 at 2:07 PM, in the south dining room, DS #7 was asked who is responsible for cleaning the steam table. DS #7 stated, .we all are . DS #7 was shown the steam table and was asked what the dark substance was inside the steam table. DS #7 stated, .dried food . DS #7 was asked should the steam table look like this. DS #7 stated, .no .",2019-10-01
4243,"NHC HEALTHCARE, PULASKI",445101,993 E COLLEGE ST,PULASKI,TN,38478,2016-09-29,441,E,0,1,O8O911,"Based on policy review, observation and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 2 of 4 (Licensed Practical Nurse (LPN) #1and 2) nurses failed to use a barrier or to clean the over-the-bed tables prior to placing reuseable resident equipment on the tables during medication (med) administration. The Findings included: The facility's SPECIFIC MEDICATION ADMINISTRATION PR[NAME]EDURES policy documented, .Use a barrier (e.g., clean disposable tray or plastic cup) to carry medication containers into the resident's room .This will serve as a barrier between the supplies and the over-the-bed table or other surface on which the supplies are placed while the medication is administered . Observations in Resident #125's room on 9/27/16 at 8:05 AM, revealed LPN #2 removed the plunger from the 60 cc (cubic centimeters) syringe and laid it on the over-the-bed table with no barrier on the table, and without cleaning the surface of the table. Observations on 9/27/16 at 8:11 AM, in Resident #125's room, revealed LPN #2 used a gloved finger to stir the diluted crushed meds in the 4 med cups. Observation on 9/27/16 at 3:47 PM, in Resident #1's room, revealed LPN #1 removed the plunger from the 60 cc (cubic centimeters) syringe and laid it on the over-the-bed table without placing a barrier, or cleaning the surface of the table. Interview with the Director of Nursing (DON) on 9/28/16 at 3:50 PM in the DON's office was asked, what should nurses do with the plunger when it is removed from the syringe while administering Percutaneous Endoscopic Gastrostomy (PEG) medications. The DON stated, Hold it in your hand or place it on the over-the-bed table on a barrier. The DON was asked if a nurse should stir the diluted medications in the med cups with a gloved finger. The DON stated, .no .",2019-10-01
5718,"NHC HEALTHCARE, PULASKI",445101,993 E COLLEGE ST,PULASKI,TN,38478,2015-09-01,253,D,0,1,IE2Y11,"Based on policy review, observation, and interview, the facility failed to provide effective housekeeping services to maintain a sanitary, orderly and comfortable environment as evidenced by holes in the ceiling, stains on the wall, peeling wallpaper, holes in a door, missing caulking and black substance to base of a commode, scuffed walls and doors, peeling paint to a window sill, missing paint to walls and door facings, black substance to a resident's room shower, peeling paint to doors, and odors in a room in 7 of 57 (Rooms 107, 109, 110, 115, 124, 218, and 320) resident rooms. The findings included: 1. The facility's daily cleaning schedule documented, .Group #1 Cleans all of East Hall . on South Hall . and patients rooms 203 and 205 . Group #2 Cleans all of West Hall . Group #3 Cleans all of Richland Hall . Group #4 Cleans all of Rehab Hall . Group #5 Cleans all 204, 206, 207, 208, 209, 211, 213, 215, 216, 217, 218 . 2. Observations in room 107 on 8/31/15 at 9:59 AM, revealed a small hole in the ceiling above B bed, the wall under B side's television had stains and splatters noted. 3. Observations in room 109 on 8/30/15 at 10:50 AM, revealed peeling wallpaper below the window with a black substance underneath the peeling wallpaper. 4. Observations in room room 110 on 8/31/15 at 9:52 AM, revealed a small hole in the ceiling above the B bed, the bathroom door with 2 small holes to the outside of the door, in the bathroom, the commode was missing caulking, and a thick black substance around the base of the commode. 5. Observations in room 115 on 8/31/15 at 10:09 AM, revealed the bathroom walls scuffed, and the wall gouged under the paper towel holder. 6. Observations in room 124 on 8/30/15 at 12:17 PM, revealed paint peeling in the window sill in the room, the bathroom walls in front of the commode were scuffed and missing paint, missing paint to the door facings scuffed, and the wooden doors scuffed and scratched (doors to the bathroom and closets). 7. Observations in room 218 on 8/31/15 at 8:06 AM, revealed the shower in the bathroom noted with black, slimy substance along edges of tile against the wall, and inside of the door of the bathroom with peeling paint and scuffed. 8. Observations in room 320's bathroom on 8/30/15 at 10:35 AM, 12:58 PM and 4:06 PM, and on 8/31/15 at 8:17 AM, revealed a clothes hamper had dirty clothes running over with the presence of a strong odor. Interview with the Director of Environmental Services (DES) on at 8/31/15 at 5:24 PM, at the East/West nurses station, the DES was asked to discuss the process for resident's dirty clothes being placed in the hampers in the bathrooms and how they get laundered. The DES stated, The tech (technician) places the clothes in it and the families come to get them and wash them, if the family does their laundry. The DES was asked about the process if the hamper in the residents bathroom was overflowing. The DES stated, If it is overflowing, we contact the family to see if they need us to do the laundry for them. The DES was asked what the process was if the laundry was soiled. The DES stated, If they are heavy soiled, then they go to laundry. The DES was asked what if the clothing was soiled with an odor. The DES stated,They should send them straight to laundry. Interview with the DES on 8/31/2015 at 5:31 PM, the DES was asked to walk with surveyor to room 320 and look at the laundry in the hamper in the bathroom. The DES entered the bathroom in room 320 and stated, Usually the CNAs (Certified Nursing Assistants) tell me if a resident's laundry is running over as she picked up clothes hamper to take it out of room. The DES was then asked if a resident's laundry should be left in this condition. The DES stated, This should not be this way, and it should not be smelling like this. 9. Interview with the DES and the Director of Maintenance (DOM) while touring the building with the environmental concerns on 9/1/15 beginning at 9:45 AM, the DOM was asked about the hole in the ceiling of room 107. The DOM stated, There is fire caulk in it, will have to sheetrock mud it, and go over it, think was a cable in it at one time, have had to fix several of these. Need to regrout the shower. The DES stated, The bathrooms and rooms are cleaned on a daily basis, and there is a monthly deep cleaning schedule also. The DES and DOM confirmed the environmental issues with rooms 107, 109, 110, 115, 124, 218, and 320.",2018-12-01
5719,"NHC HEALTHCARE, PULASKI",445101,993 E COLLEGE ST,PULASKI,TN,38478,2015-09-01,323,D,0,1,IE2Y11,"Based on observation and interview, the facility failed to ensure safe storage of toxic chemicals as evidenced by unsecured cleaning chemicals in 1 of 3 (West shower room) shower rooms. The findings included: Observations in the west shower room on 8/30/15 at 10:55 AM, and 12:55 PM, and on 8/31/15 at 8:20 AM, 11:40 AM and 2:17 PM, revealed an environmental services cart was stored with 2 full bottles of (named brand) Urine Remover and 1 full bottle of (named brand) Disinfectant on the cart. The shower room door was not locked, and could be accessible to residents. Interview with the Director of Nursing (DON) on 8/31/15 at 2:25 PM, in the west shower room, the DON was asked if an environmental services cart with unsecured chemicals should be accessible to the residents. The DON stated, No. The DON was asked how she would keep the residents from gaining access to the cart with the unsecured chemicals. The DON stated, Well we couldn't. There is no way to lock the door. I don't know why it (environmental services cart) is in here. I'm going to tell them to get it out of here right now.",2018-12-01
5720,"NHC HEALTHCARE, PULASKI",445101,993 E COLLEGE ST,PULASKI,TN,38478,2015-09-01,371,F,0,1,IE2Y11,"Based on review of the United States Department of Agriculture (USDA) food keeper guidelines, policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by expired food, opened unlabeled and undated food in the walk in refrigerator, and a dirty microwave oven in 1 of 2 (South hall pantry) nourishment areas. The facility had a census of 96, with 95 of those residents receiving a meal tray from the kitchen. The findings included: 1. The USDA, food keeper guidelines documented, .The Food Keeper contains valuable storage advice to help you maintain the freshness and quality of foods . Refrigerate food to preserve freshness. However, over time, even chilled food begins to go bad. The Food Keeper charts indicate refrigerator storage times for a wide variety of food items . Cooked meats (after home cooking) . 3- (to) 4 days . deli foods . Salads containing meat, fish, poultry or eggs . 3-4 days . Canned goods . such as . stew, soups . 3-4 days . 2. The facility's safety and sanitation best practice guidelines for refrigerators and freezer storage policy documented, .Foods will be stored in their original container or . approved container . Clearly labeled with the contents and the use by date . b) Once food is cooked, such perishable items must be labeled with the discard date before placing in the refrigerator . Leftovers will be placed in . approved containers, covered, labeled, dated, and stored in refrigerator . The designated partner will check leftovers on a daily basis and plan for their use . Refrigerated leftovers not used within time frame .will be discarded . 3. Observations in the kitchen on 8/31/15 at 10:42 AM, revealed the following items in the walk in refrigerator: a. A container labeled pulled pork dated 8/26/15. b. A container labeled tuna salad dated 8/25/15. c. An opened container labeled Cream of Chicken soup dated 8/25/15. d. An opened container labeled Chicken soup dated 8/24/15. e. An opened 1/2 gallon container of Fat Free Milk with an expiration date of 8/4/15. f. An unopened container of French onion dip with an expiration date of 8/20/15. g. An unopened 1/2 gallon container Half and (&) Half with an expiration date of 8/24/15. h. An opened package of deli turkey with a sell by date of 6/9/12. i. Two unlabeled and undated bowls containing cottage cheese with fruit. j. An opened, unlabeled and undated package of sliced roast beef. k. An opened, unlabeled and undated package of hot dogs. l. An opened, unlabeled and undated package of sliced deli ham. m. An opened, unlabeled and undated package of cooked ham. n. Three unlabeled and undated plates of salad. The facility did not follow their policy of labeling cooked foods with a discard date before placing it in the refrigerator. Interview with the Certified Dietary Manager (CDM) on 8/30/15 at 11:00 AM, in the walk in refrigerator, the CDM was asked how long they keep opened food items in the refrigerator. The CDM stated, 7 days. I usually check everything on Mondays and Thursdays. The CDM was asked if opened food items should be labeled and dated. The CDM stated, Yes. 4. Observations in the walk in refrigerator on 8/31/15 at 9:12 AM, revealed an unopened carton of French Onion Dip with an expiration date of 8/20/15. Interview with the CDM on 8/31/15 at 9:17 AM, in the kitchen, the CDM verified the French Onion dip was expired. 5. Observations in the south hall pantry on 8/31/15 at 9:30 AM, revealed a dirty microwave with a build up of food particles inside. Interview with the CDM on 8/31/15 at 9:31 AM, in the south hall pantry, the CDM was asked if the microwave was clean. The CDM stated, No. The CDM was asked who is responsible for cleaning the microwave in the nourishment room. The CDM stated, Housekeeping. I'll get her on it right now. Interview with the CDM on 9/1/15 at 9:25 AM, in the conference room, the CDM stated, Housekeeping said they are supposed to clean the microwaves everyday.",2018-12-01
5721,"NHC HEALTHCARE, PULASKI",445101,993 E COLLEGE ST,PULASKI,TN,38478,2015-09-01,441,D,0,1,IE2Y11,"Based on observation and interview, the facility failed to ensure infection control practices were maintained to prevent the potential spread of infections as evidenced by an ice cart stored in 1 of 3 (South shower room) shower rooms. The findings included: Observations in the south hall shower room on 8/30/15 at 10:35 AM, on 8/30/15 at 3:50 PM, and on 8/31/15 at 11:49 AM, revealed a metal ice cart with ice. Interview with Licensed Practical Nurse (LPN) #1 on 8/31/15 at 12:08 PM, in the south hall shower room, LPN #1 was asked if the ice cart was always stored in the shower room. LPN #1 stated, They leave the ice cart in the shower room to drain. Interview with the Director of Nursing (DON) on 8/31/15 at 12:10 PM, in the south hall shower room, the DON was asked if the ice cart should be stored in the shower room. The DON stated, No, it should not be in here.",2018-12-01
5722,"NHC HEALTHCARE, PULASKI",445101,993 E COLLEGE ST,PULASKI,TN,38478,2015-09-01,465,E,0,1,IE2Y11,"Based on policy review, observation, and interview, the facility failed to ensure 1 of 3 (South shower room) shower rooms was clean and sanitary and failed to ensure 2 of 5 (East and West hall exit doors) exit doors were maintained. The findings included: 1. The facility's daily cleaning schedule documented, .Group #1 Cleans all of East Hall . east shower room . Group #2 Cleans all of West Hall . west shower room . Group #3 Cleans all of Richland Hall . Group #4 Cleans all of Rehab Hall . Group #5 Cleans . south shower room . 2. Observations in the south hall shower room on 8/30/15 at 10:35 AM and 3:50 PM and on 8/31/15 at 11:49 AM, revealed white paint chips on the floor and an offensive odor. There were several brown areas on the floor of the shower stall. Interview with Student Nursing Assistant (SNA) #1 on 8/31/15 at 12:03 PM, at the south nurses station, SNA #1 was asked if she saw the brown substance on the floor. SNA #1 stated, I did not notice that (brown substance) on the floor. Interview with Licensed Practical Nurse (LPN) #1 on 8/31/15 at 12:08 PM, in the south hall shower room, LPN #1 was asked if she saw the brown substance on the floor this morning when a shower was given. LPN #1 stated, I did not notice that on the floor this morning. Interview with the Director of Nursing (DON) on 8/31/15 at 12:10 PM, in the south hall shower room, the DON was asked what was her expectation of housekeeping regarding the cleaning the shower room. The DON stated, It should be cleaned every day. 3. Observations on 8/30/15 at 11:00 AM, in the west hall at the exit door across from room 122, revealed a large amount black/scuffed/scratches to the doors. Interview with the Director of Maintenance (DOM) in front of the exit door across from room 122 on 9/1/15 at 9:55 AM, the DOM confirmed this door was very scuffed and stated, This is where we get deliveries. Observations in the west hall at the exit door beside room 126 on 9/1/15 at 9:00 AM, revealed the exit door with peeling paint at the bottom of the doors. 4. Observations in the east hall at the exit doors beside room 107 on 9/1/15 at 9:00 AM, revealed these doors were scuffed and brown stains were noted to the bottom of the door. Interview with the Director of Environmental Services (DES) and the DOM in front of the exit doors on 9/1/15 beginning at 10:00 AM, they confirmed these doors were scuffed and had stains. The DES was asked about the doors cleaned. The DES stated, Daily with the rooms The DOM stated, The doors are a never ending job, we paint them, and they get scuffed almost immediately again.",2018-12-01
9399,"NHC HEALTHCARE, PULASKI",445101,993 E COLLEGE ST,PULASKI,TN,38478,2013-04-10,280,D,0,1,CC0411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to revise the care plan for falls for 2 of 21 (Residents #46 and 85) sampled residents of the 29 residents included in the stage 2 review. The findings included: 1. Medical record review for Resident #46 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Post Falls Nursing Assessment documented, .4/3/13 12:00 PM . FOUND ON FLOOR BESIDE BED . Were orders received? YES RESPERDAL 0.5 MG (milligram) TID (three times a day) FOR INCREASED ANXIETY . Review of the physician's orders [REDACTED].[MEDICATION NAME] 0.5 MG TABLET . ONE (1) PO (by mouth) TID ANXIETY . Review of the care plan dated 1/29/13 documented, .PROBLEM . At risk for falls related to . The intervention for the fall on 4/3/13 was not documented on the care plan. During an interview in the Director of Nursing's (DON) office on 4/9/13 at 5:45 PM, the DON was asked should a new intervention for a fall be added to the care plan. The DON stated, Yes. 2. Medical record review for Resident #85 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Post Falls Nursing Assessment dated 3/13/13 documented, .THIS NURSE HEARD NOISE FROM HALL WAY. PT (patient) WAS FOUND ON KNEES WITH WALKER, FACING THE WALL Describe task patient attempting at time of fall: Exiting commode while unattended . Location of incident: PATIENT'S BATHROOM . What immediate interventions were identified to prevent future falls? 01 Attend while toileting . Review of the nurses' notes dated 3/13/13 documented, .0 (no) apparent injury from the fall this AM (morning) . Review of the care plan dated 12/25/12 and 3/21/13 documented, .PROBLEM . At risk for falls related to . There was no new intervention on the care plan for the fall on 3/13/13. During an interview in the DON's office on 4/10/13 at 7:40 AM, the DON was asked if she would expect the new intervention to be brought forward to the care plan. The DON stated, I would.",2016-12-01
9400,"NHC HEALTHCARE, PULASKI",445101,993 E COLLEGE ST,PULASKI,TN,38478,2013-04-10,322,D,0,1,CC0411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, it was determined the facility failed to ensure that placement of a percutaneous endoscopy gastrostomy (PEG) tube was verified prior to administering medications for 1 of 2 (Resident #204) residents observed receiving medications via a PEG tube. The findings included: Review of the facility's Medication Administration via (by) Gastrostomy Tube policy documented, .4. Check placement by auscultation and/or aspiration . Medical record review for Resident #204 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] documented, .B. Feeding tube while a resident (checked) . Observations in Resident #204's room on 4/9/13 at 2:06 PM, revealed Nurse #1 injected air into the PEG tube, poured the medication into the syringe and administered the medication without listening with a stethoscope while injecting the air or aspirating. Nurse #1 did not check for tube placement prior to administering the medication. During an interview in the Director of Nursing's (DON) office on 4/10/13 at 11:50 AM, the DON was asked how would she expect a nurse to check PEG tube placement prior to medication administration. The DON stated, .either by auscultation or aspiration . listening with a stethoscope while injecting air or aspirating with a syringe .",2016-12-01
11744,"NHC HEALTHCARE, PULASKI",445101,993 E COLLEGE ST,PULASKI,TN,38478,2012-01-11,441,D,0,1,EW0411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, observation, and interview, it was determined 1 of 1 treatment nurse (Nurse #1) failed to ensure infection control practices were used to prevent cross contamination when gloves and the wound were contaminated during two dressing changes. The findings included: Review of the facility's CLEANING OF SHARED MEDICAL EQUIPMENT CONTAMINATED WITH INFECTIOUS FLUIDS OR OTHER POTENTIALLY INFECTIOUS MATTER policy documented, EQUIPMENT/SUPPLIES: Sodium Hypochlorite Solution 1: (to) 10. 2. Clean shared medical equipment with sodium hypochlorite solution 1:10. Medical record review for Resident #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's telephone order dated 12/16/11 documented, .Clean skin tear L (left) lower arm with NS (normal saline), apply [MEDICATION NAME] and allevyn q (every) 3 days and prn (as needed).' Observations in the locker room on 1/10/12 at 8:18 AM, Nurse #1 placed his clean gloves and dressing supplies on top of the dressing cart without cleaning or using a barrier. The dressing cart had dirty particles and brown colored circles on it. Nurse #1 continued to Resident #1's room where the wound was cleaned and [MEDICATION NAME] applied. Resident #1 touched the clean area to his gown prior to the outer dressing being applied. This contaminated the wound. Medical record review for Resident #12 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a telephone order dated 12/21/11 documented, .Clean R ^ (upper) back with NS (Normal Saline) (lesion) pat dry, apply [MEDICATION NAME] AG and alleyn q d (day). Observations in the locker room on 1/10/12 at 8:40 AM, Nurse #1 placed his clean gloves and dressing supplies on top of a dressing cart cleaning or placing a barrier on it. Nurse #1 continued to Resident #12's room and placed the gloves on the part of the overbed table which was not cleaned or covered with a barrier. After cleaning the wound, the Certified Nursing Assistant (CNA) #1 let the resident's shirt drop over the wound area before Nurse #1 had applied the dressing, which contaminated the wound. During an interview in the locker room on 1/10/12 at 9:05 AM, Nurse #1 was asked when the treatment cart was cleaned and if it was dirty. Nurse #1 stated, (Cleaned) A few days. I'm only here 2 days a week. Nurse #1 was asked about the treatment cart being dirty. Nurse #1 stated, Yes (indicating the cart was dirty). During an interview in the locker room on 1/10/12 at 9:10 AM, the Director of Nursing (DON) brought in a wet rag and wiped the treatment cart. The DON was asked what she was cleaning the cart with. The DON stated, .Just water. cause it (treatment cart) never leaves this room.",2015-11-01
13851,"NHC HEALTHCARE, PULASKI",445101,993 E COLLEGE ST,PULASKI,TN,38478,2010-10-20,332,D,0,1,Y41H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, it was determined the facility failed to ensure 3 of 9 (Nurses #2, 4 and 5) nurses administered medications without a medication error of less than 5 percent (%) for 3 of 5 (Residents #6, 14 and 15) sampled residents and for 1 of 6 Random Residents (RR #2). A total of 5 errors were observed out of 40 opportunities for error, resulting in a medication error rate of 12.5%. The findings included: 1. Review of the facility's""HUMALOG/[MEDICATION NAME] INSULIN ORDERED AC (before meals) ADMINISTRATION"" policy documented, ""PURPOSE: To ensure that designated partner administers Humalog/[MEDICATION NAME] Insulin ordered ac according to the standard in reference to meal time OBJECTIVE: 1. Administration of Humalog/[MEDICATION NAME] Insulin is within 15 minutes of meal... PROCEDURE... 2. Administer Humalog/[MEDICATION NAME] Insulin within 15 minutes of the projected meal delivery time 3. If meal delivery is delayed, administer a protein snack and a carton of milk or juice..."" a. Medical record review for Resident #6 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].= (amount of insulin to be administered) 2 UNITS, 201-250=4 UNITS..."" Review of a physician's orders [REDACTED]."" Observations in Resident #6's room on 10/18/10 at 4:35 PM, revealed Nurse #2 administered Humalog insulin 6 units and [MEDICATION NAME]4 units to Resident #6. Resident #6 did not receive his meal tray until 5:22 PM. The administration of the Humalog and [MEDICATION NAME] insulins more than 15 minutes before Resident #6 received his meal tray resulted in medication error #1 and #2. During an interview at the South nurse's station on 10/19/10 at 2:30 PM, the Director of Nursing stated, ""They (nurses) know if trays aren't on the hall they better not be giving the insulin. They (nurses) know that."" b. Medical record review for Resident #15 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].[MEDICATION NAME] 100 u (units) / (per) ml (milliliter) vial 22 units sq (subcutaneous) before lunch..."" Observations in Resident #15's room on 10/19/10 at 11:35 AM, revealed Nurse #4 administered 22 units of [MEDICATION NAME]to Resident #15. Resident #15 did not receive her meal tray until 12:21 PM. The administration of the [MEDICATION NAME]more than 15 minutes before Resident #15 received her meal tray resulted in medication error #3. 2. Medical record review for Resident #14 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Observations in Resident #14's room on 10/19/10 at 9:37 AM, revealed Nurse #5 administered one inhalation of the [MEDICATION NAME] Handihaler to Resident #14. The failure to administer two inhalations resulted in medication error #4. 3. Medical record review for RR #2 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Observations in the South dining room on 10/18/10 at 4:40 PM, revealed Nurse #2 administered 10 ml of Miracle Mouth wash to RR #2. Nurse #2 had RR#2 to swallow the mouth wash. The swallowing of the mouth wash instead of rinsing resulted in medication error #5.",2014-08-01
13852,"NHC HEALTHCARE, PULASKI",445101,993 E COLLEGE ST,PULASKI,TN,38478,2010-10-20,431,D,0,1,Y41H11,"Based on policy review, observation and interview, it was determined the facility failed to ensure medications were in locked compartments at all times in 1 of 7 (West hall) medication storage areas. The findings included: Review of the facility's ""Medication Storage"" policy documented, ""...Medication rooms, carts and treatment carts or trays shall be kept locked when it is not in a nurse's immediate view..."" Observations on the west hall on 10/20/10 at 6:25 AM, revealed the west hall medication cart was left unlocked, unattended and out of the nurse's view. During an interview on the west hall on 10/20/10 at 6:30 AM, Nurse #8 verified that the medication cart was left unlocked.",2014-08-01
13853,"NHC HEALTHCARE, PULASKI",445101,993 E COLLEGE ST,PULASKI,TN,38478,2010-10-20,502,D,0,1,Y41H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to ensure laboratory services were completed as ordered by the physician for 2 of 19 (Residents #1 and 9) sampled residents. The finding included: 1. Medical record review for Resident #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders dated 7/21/10 documented ""...Repeat UA (Urinalysis) c (with) C&S (Culture and Sensitivity) 7/30/10."" The facility was unable to provide documentation that the UA with C&S was done on 7/30/10 as ordered. During an interview in the copy room on 10/19/10 at 4:00 PM, Nurse #9 was asked to provide laboratory results for 7/30/10. Nurse #9 stated, ""UA and C&S was not done."" 2. Medical record review for Resident #9 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the lab values for 10/5/10 documented ""...faxed to (physician) 10-5-10 ... new orders 10-5-10..."" Review of the physician's orders dated 10/5/10 revealed no physician's order for that date. During an interview at the South nurses station on 10/19/10 at 10:40 AM, Nurse #9 stated, ""I took the order for [MEDICATION NAME] and to recheck the it ([MEDICATION NAME] and international ratio (pt/inr)) 10/12/10. I wrote the increase in [MEDICATION NAME] on the log and on the MAR (medication administration record), but I forgot to write the order and order the pt/inr for the 12 th..."" The pt/inr was not done on 10/12/10 as ordered by the physician.",2014-08-01
13854,"NHC HEALTHCARE, PULASKI",445101,993 E COLLEGE ST,PULASKI,TN,38478,2010-10-20,309,D,0,1,Y41H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, it was determined the facility failed to follow physician's orders for no sliding scale coverage at hour of sleep and [MEDICAL CONDITION] disease (TED) hose for 2 of 19 (Residents #6 and 9) sampled residents. The findings included: 1. Medical record review for Resident #6 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's order dated 9/27/10 documented ""...FSBS (fingerstick sugar blood sugar) ac (before meals) meals c (with) [MEDICATION NAME]per SS (sliding scale) as follows ...FSBS @ (at) HS (hour of sleep) (0 SS coverage)..."" Resident #6's diabetic monitoring log for October 2010 revealed [MEDICATION NAME] sliding scale insulin was given at 10:00 PM as followed: 10/6/10 - 8 units and 10/14/10 - 2 units. During an interview in the Assistant Director of Nursing's (ADON) office on 10/20/10 at 12:50 PM, the ADON was asked about the insulin documented a being given at 10:00 PM. The ADON stated, ""...it insulin) should not have happened (been given)."" 2. Medical record review for Resident #9 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #9's physician's order dated 10/9/10 documented ""...TED Hose..."" Observations in Resident #9's room on 10/18/10 at 10:00 AM, 2:45 PM and 2:50 PM, revealed Resident #9 was not wearing TED hose as ordered. During an interview in the Resident #9's room on 10/19/10 at 2:50 PM Nurse #10 stated, the TED hose should be on, they (TED hose) are ordered.""",2014-08-01
13855,"NHC HEALTHCARE, PULASKI",445101,993 E COLLEGE ST,PULASKI,TN,38478,2010-10-20,333,D,0,1,Y41H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, it was determined the facility failed to ensure residents were free of significant medication errors when 2 of 9 (Nurses #2 and 4) nurses failed to ensure insulin was administered correctly in correlation with meals. The findings included: 1. Review of the facility's""HUMALOG/[MEDICATION NAME] INSULIN ORDERED AC (before meals) ADMINISTRATION"" policy documented, ""PURPOSE: To ensure that designated partner administers Humalog/[MEDICATION NAME] Insulin ordered ac according to the standard in reference to meal time OBJECTIVE: 1. Administration of Humalog/[MEDICATION NAME] Insulin is within 15 minutes of meal... PROCEDURE... 2. Administer Humalog/[MEDICATION NAME] Insulin within 15 minutes of the projected meal delivery time 3. If meal delivery is delayed, administer a protein snack and a carton of milk or juice..."" 2. Medical record review for Resident #6 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].= (amount of insulin to be administered) 2 UNITS, 201-250=4 UNITS..."" Review of a physician's orders [REDACTED]."" Observations in Resident #6's room on 10/18/10 at 4:35 PM, revealed Nurse #2 administered Humalog insulin 6 units and [MEDICATION NAME]4 units to Resident #6. Resident #6 did not receive his meal tray until 5:22 PM. The administration of the Humalog and [MEDICATION NAME] insulins more than 15 minutes before Resident #6 received his meal tray resulted in significant medication errors. 3. Medical record review for Resident #15 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].[MEDICATION NAME] 100 u (units) / (per) ml (milliliter) vial 22 units sq (subcutaneous) before lunch..."" Observations in Resident #15's room on 10/19/10 at 11:35 AM, revealed Nurse #4 administered 22 units of [MEDICATION NAME]to Resident #15. Resident #15 did not receive her meal tray until 12:21 PM. The administration of the [MEDICATION NAME]more than 15 minutes before Resident #15 received her meal tray resulted in a significant medication error. 4. During an interview at the South nurse's station on 10/19/10 at 2:30 PM, the Director of Nursing stated, ""They (nurses) know if trays aren't on the hall they better not be giving the insulin. They (nurses) know that.""",2014-08-01
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
3749,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2016-12-07,241,D,0,1,K5ZX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation, and interview, the facility failed to maintain and enhance the dignity of 2 residents (#149, #190) of 7 residents observed by speaking in a loud, derogatory manner during meal service in 1 of 4 dining rooms observed. The findings included: Review of the facility policy Resident Rights & (and) Dignity, undated, revealed .we promote .environment that maintains or enhances each resident's dignity and respect .independence and dignity in dining .aides not yelling .speaking respectfully .addressing the resident with a name of the resident's choice . Medical record review revealed Resident #149 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) of 7 indicating severe cognitive impairment and a functional eating status of limited assistance. Medical record review revealed Resident #190 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed a BIMS of 9 indicating moderately impaired cognition and a functional eating status of supervision. Observation on 12/7/16 from 1:00 PM to 1:30 PM of the lunch meal service in the fifth floor dining room revealed 2 Certified Nursing Assistants (CNA) (#2, #4) were feeding 3 female residents, and 2 male residents at another table. Continued observation revealed a third table with 2 (#149, #190) female residents eating their meals. Observation of CNA #2 on 12/7/16 at 1:10 PM, in the fifth floor dining room revealed CNA #2 feeding a resident, yelled out to Resident #190 at another table, What is taking you so long to eat .hey, southern belle, do you need something else to eat . Further observation revealed Resident #190 responded to CNA #2 .why are you rushing me . Observation of CNA #2 on 12/7/16 at 1:13 PM, in the fifth floor dining room revealed CNA #2 while feeding a resident, CNA #2 yelled out to Resident #149 at another table, . (a variation of resident's name) .what do you need . Interview with Resident #190 on 12/7/16 at 1:30 PM, in the fifth floor dining room confirmed CNA #2 addressed her as a southern belle; it was .okay .; and she had not asked the facility to address her in that manner. Interview with Resident #149 on 12/7/16 at 1:30 PM, in the fifth floor dining room confirmed CNA #2 called her (a variation of her name); it was .okay . ; and she had not asked the facility to address her in that manner. Interview with CNA #2, CNA #4, and the fifth floor Registered Nurse Supervisor on 12/7/16 at 1:35 PM, in the fifth floor Care Plan office, confirmed CNA #2 had yelled across the dining room and addressed the residents (#149, #190) using derogatory names. Interview with the Director of Nursing (DON) on 12/7/16 at 1:40 PM, in the DON office, confirmed the facility failed to respect the dignity of Residents #149 and #190 by speaking loudly, disrespectfully, and addressing the residents in a derogatory manner.",2020-02-01
3750,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2016-12-07,323,D,0,1,K5ZX11,"**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 and monitor interventions in order to reduce the risk of elopement for 1 resident (#178) of 2 resident reviewed for wandering of 32 residents reviewed. The findings included: Review of the facility policy, Elopement Policy and Procedure, last revised 8/10/16, revealed it is the policy of this facility that every effort will be implemented to provide a safe environment for our residents while preventing elopements from occurring .Notify the nursing supervisor and staff .The staff should monitor the resident closely and it should be passed on in report of the elopement attempt .The MDS (Minimum Data Set) will address the elopement risk and interventions put in place . Medical record review revealed Resident #178 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Nurses Notes dated 10/5/16, revealed the resident was noted with increased disorientation, calling out for persons not in the room, and the resident was placed on MD (Medical Doctor) board for review and treatment. Medical record review of the Nurses Notes dated 10/8/16, revealed the resident made several attempts to get on the elevator to go to the 15th floor and was easily redirected and frequently requested to call his son. Medical record review of the Nurses Notes dated 10/10/16, revealed Call received from first floor that res (resident) on first floor. Went to bring res back up to fifth floor. Res using electric wheelchair with cane, walker, and small box of belongings. Asked res where he was going. Res replied, I just got back from Chicago. I don't like riding the trains. Res back to room. Medical record review of Resident #178'S Care Plan dated 10/10/16, revealed, Wandering/ Elopement Risk related to confusion .Resident will not successfully elope the facility and will be monitored of their whereabouts on an ongoing basis x (times) 90 days .Exit seeking behaviors will be reduced to Medical record review of the Resident Elopement Assessment Form, dated 10/8/16, revealed Resident #178 scored an 11, at risk for elopement. Medical record review of the Resident Elopement Assessment Form, dated 10/10/16, revealed Resident #178 scored 14, indicating the resident is at risk for elopement, with a history of 1-2 episodes, and intermittent confusion. Medical record review of the MDS, dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating the resident had moderately impaired cognition, was self-ambulatory in a wheelchair, with 1-3 episodes of wandering, and the resident was at risk of potentially wandering to a dangerous place. Observation on 12/6/16 at 3:38 PM, on the 5th floor, revealed Resident #178 was in a wheelchair in front of the elevator with no staff present. Interview with Certified Nursing Assistant (CNA) #1, on 12/6/16 at 11:15 AM, on the 5th floor hallway, revealed CNA #1 was unaware of any resident who was at risk for elopement and stated residents on the 5th floor were able to go as far as outside of the building to include the parking lot. Interview with Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #1, on 12/6/16 at 3:45 PM , at the 5th floor Nursing Station, revealed RN #1 and LPN #1 were unaware of Resident #178 risk for elopement. Continued interview with LPN #1 revealed residents who were at risk for elopement were usually communicated through shift reports. Continued interview with RN #1 revealed, Zero are at elopement risk . If they have eloped before, (or stated) I want to go home, I want to go home, that would be an elopement risk. Continued interview confirmed, the 5th floor residents were not at risk for elopement because the 3rd floor was where the residents at risk for elopement were placed. Interview with RN #2, on 12/7/16 at 8:23 AM, on the 5th floor hallway, revealed she was unaware of Resident #178's risk of elopement. Interview with CNA #2, on 12/7/16 8:25 AM, on the 5th floor hallway, confirmed the facility failed to communicate Resident #178's risk for elopement and stated the nurse would have to tell CNA's of an elopement/wandering risk and, they haven't told me so. Interview with CNA #3, on 12/7/16 at 8:31 AM, on the 5th floor hallway, revealed she was unaware of Resident #178's risk for elopement. Interview with the Director of Nursing (DON) on 12/7/16 at 10:30 AM, in the DON office, revealed the facility process was to be aware of which residents were at risk for elopement/wandering. Continued interview revealed the charge nurse and supervisors were to communicate with the staff which residents were at risk for elopement/wandering. Further interview confirmed facility policy had not been followed, and the facility failed to inform staff of Resident #178's risk for elopement/wandering, stating they should have followed the process in place.",2020-02-01
3751,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2016-12-07,441,D,0,1,K5ZX11,"Based on review of facility policy, observation, and interview, the facility failed to maintain safe and sanitary shower rooms for 2 of 6 shower rooms observed of 8 shower rooms available for resident use. The findings included: Review of the facility policy Infection Control Shower and Whirlpools revised 6/1/00 revealed .after each shower .the bathing area will be cleaned .to prevent the spread of infection . Observation with the fifth floor Registered Nurse (RN)/Supervisor on 12/6/16 at 8:50 AM, in the fifth floor West Shower room, revealed a portable toilet with brown debris on the sides and rim of the removable bowl, a formed brown bowel movement in the toilet as identified by the RN/Supervisor, and a wet, dripping washcloth on the shower grab bar in the 1 of 2 shower stalls. Further observation revealed a covered, dirty linen basket available for use. Observation with the fifth floor RN/Supervisor on 12/6/16 at 9:05 AM, in the second floor West Shower room, revealed 2 brown debris forms identified by the RN/Supervisor as stool (feces) on the floor of 1 of 2 shower floors. Interview with the fifth floor RN/Supervisor on 12/6/16 at 9:10 AM, in the second floor West Shower room, confirmed the facility failed to maintain the fifth and second floor West Shower rooms in a sanitary manner for the residents.",2020-02-01
7429,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2014-09-17,241,D,0,1,K05811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, facility policy review, and interview, the facility failed to ensure dignity was maintained for one resident (#53) of one wing of eight wings observed during the initial tour. The findings included: Resident #53 was admitted to facility on November 12, 2009, with [DIAGNOSES REDACTED]. Medical record review of Annual Minimum Data Set (MDS) dated [DATE], revealed the resident was severely cognitively impaired and required extensive to total dependence on all Activities of Daily Living (ADLs). Observation on September 15, 2014 at 8:49 a.m., on the third floor East hall, revealed resident #53 being transported by Certified Nursing Assistant (CNA #1) in a shower chair in the hallway. Continued observation revealed resident #53 had a blue blanket draped around the shoulders, covering the upper body, leaving the thighs and buttocks covered with fecal material, exposed and the right upper chest exposed. Review of facility policy, Bath (Shower), undated revealed .screen and drape resident for maximum privacy . Review of facility policy, Patient's Rights, undated revealed .each patient in this nursing facility has .the right to .be treated courteously, fairly, and with the fullest measure of dignity . Interview with CNA #1 on September 15, 2014 at 8:50 a.m., in the third floor East shower room, confirmed the resident was not fully covered and the thighs, buttocks and legs were exposed. Interview with the Assistant Director of Nursing on September 17, 2014, at 4:42 p.m., in the conference room confirmed the facility had failed to maintain dignity for resident #53 while being transported in the shower chair.",2017-12-01
7430,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2014-09-17,309,D,0,1,K05811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #30 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Departmental Note dated July 15, 2014, revealed .Readmission note: Resident arrived back at (facility) from (named hospital) by ambulance . Medical record review of the hospital physician's orders [REDACTED].follow up (with) psy (psychiatric) services (at) the facility . Medical record review of a Departmental Note dated July 31, 2014, revealed .Pt (patient) was verbal toward a pt .at the DR (dining room) table. Pt was rude (and) used curse words .Pt unable to re-direct. Pt offered to have lunch in (resident's) room . Medical record review of the Departmental Notes dated August 4, 2014, revealed .2 CNA's (Certified Nursing Assistants) reported to this nurse that the resident has been using foul language to the staff and to other residents . Medical record review of the Departmental Note dated August 8, 2014, revealed .Resident had inappropriate behavior during lunch time in the dining room today, upset and yelling at staff because (resident) was advised not to give food to another resident . Observation on September 17, 2014, at 9:25 a.m., revealed the resident lying on a low bed. Interview on September 17, 2014, at 4:30 p.m., with the Assistant Director of Nursing, in the conference room confirmed the physician's orders [REDACTED]. C/O # Based on medical record review, review of facility policy, and interview, the facility failed to follow the procedures for administration of medication for one resident (#257) and failed to follow physician orders [REDACTED].#30) of forty-one residents reviewed. The findings included: Resident #257 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #257 was discharged on [DATE]. Medical record review of Departmental Notes, dated April 7, 2014, at 12:33 p.m., revealed .swallows meds (medicines) crushed c (with) pudding s (without) diff (difficulty) given per (spouse) . Further review revealed electronic signature of Licenced Practical Nurse (LPN #1). Review of facility policy, Medication, Given by Licensed Personnel Only, (undated) revealed .the resident must take the medication in your presence. Never leave it with the resident (or sitter) . Review of facility policy, Self-Administration, (undated) revealed .Shannondale policy prohibits the administration of medications by family members . Interview with LPN #1, on September 17, 2014, at 1:34 p.m., in the conference room confirmed the medications for Resident #257 were crushed, mixed with pudding or yogurt, taken into Resident #257's room, and the medications left with the spouse to be administered .at least twice .",2017-12-01
7431,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2014-09-17,329,D,0,1,K05811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of Psychoactive and Sedative/Hypnotic Utilization, review of Summary of Pharmacy Recommendations, and interview, the facility failed to attempt a gradual dose reduction and tapering of psychoactive medications for one resident (#19) of five residents reviewed for unnecessary medications. The findings included: Resident #19 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 was severely cognitively impaired and required extensive to total dependence on all Activities of Daily Living (ADLs). Medical record review of Physician order [REDACTED].[MEDICATION NAME] 0.5 mg (milligram) tablet (an antipsychotic medication) .every twelve hours .[MEDICATION NAME] 20 mg tablet (an antidepressant medication) .daily . Medical record review of Psychiatric Progress Notes revealed the resident was last seen by psychiatric services on August 19, 2013, with recommendation .consider decrease [MEDICATION NAME] to be 0.5 mg q (every) 12 hours . Medical record review of physician's orders [REDACTED]. Review of Psychoactive and Sedative/Hypnotic Utilization by Resident reports prepared by consultant pharmacist and dated August 2013 to August 2014 revealed the Consultant Pharmacist reviewed the resident's psychoactive medications every month. Continued review revealed the last recommendation for gradual dose reduction for the resident's antipsychotic medication ([MEDICATION NAME]) was August 2013. Continued review revealed no recommendations related to the resident's antidepressant medication ([MEDICATION NAME]). Review of Summary of Pharmacy Recommendations July 2013 to August 2014 prepared by the consultant pharmacist revealed, .6/23/14 to MD (Medical Doctor) .Resident is getting both [MEDICATION NAME] (an antipsychotic medication) and [MEDICATION NAME] with doses of both given at 9 p.m. Last reduction of the [MEDICATION NAME] was 8/13 .Please document if necessary to continue on both antipsychotics at the current doses . Continued review revealed no recommendations for the antidepressant medication. Interview with the resident's Physician on September 17, 2014, at 2:00 p.m., by telephone, revealed the Physician relies on the Consultant Pharmacist and psychiatric services to alert the Physician for the need of gradual dose reductions. Interview with the Assistant Director of Nursing on September 17, 2014, at 4:13 p.m., in the Conference Room confirmed the facility had failed to attempt a gradual dose reduction/tapering of the resident's antipsychotic and antidepressant medication.",2017-12-01
7432,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2014-09-17,431,D,0,1,K05811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility policy, review of manufacturer's recommendation, and interview, the facility failed to date an open vial of Tubersol (a Tuberculin Purified Protein, used for tuberculin skin testing) to ensure it was used or discarded within thirty days after opening in one of three medication storage refrigerators, failed to ensure eight expired UA (urine) preservative tubes were not available for use in one of three medications storage rooms reviewed, failed to lock medication cabinets in resident rooms, and to label, date, and discard an expired medication for three cabinets of twenty-four cabinets reviewed. The findings included: Observation and interview with Licensed Practical Nurse (LPN) #1 on [DATE], at 7:40 a.m., at the second floor medication storage room refrigerator revealed one opened, partially used, undated, vial of Tubersol. Interview with LPN #1 confirmed the vial was opened and undated and available for resident use. Observation and interview with LPN #1 on, [DATE], at 7:50 a.m., in the second floor medication storage room, revealed a plasic storage box containing laboratory specimen collection tubes. Continued observation revealed eight red and yellow top UA preservative tubes each with an expiration date of [DATE]. Interview with LPN #1 confirmed the UA tubes had expired and were available for resident use. Review of the manufacturer's recommendation for the Tubersol revealed, .a vial of Tubersol which has been entered and in use for thirty days should be discarded . Observation on [DATE], at 12:15 p.m., in resident rooms on the fourth floor (rooms 1, 2, 3) revealed unlocked cabinets containing the following: room [ROOM NUMBER]: one jar of mineral cream, one 500ml (milliliter) sterile water nebulizer, Aloe Vesta (skin cleanser) spray, Antifungal cream, Mupirocin (antibiotic) ointment 2% (percent), Vasolex (vasoline barrier) ointment. Continued review revealed the Mineral Cream, Aloe Vesta, Antifungal, Mupirocin and Vasolex were all opened, unlabeled, and undated. room [ROOM NUMBER]: Wound Cleanser (antimicrobial), Perox a Mint (oral debriding agent), Nystatin (antifungal antibiotic) powder, Mineral cream, four tubes of Vasolex ointment, and Proctozone-HC 2.5 %( anti-itch rectal) ointment. Continued review revealed the Wound Cleanser, Perox a Mint, Nystatin, Mineral Cream, Vasolex ointment and Proctozone- HC 2.5% were opened, unlabeled, and undated with two tubes of the Vasolex missing caps and the Nystatin with an expiration date of [DATE]. room [ROOM NUMBER]: Wound Cleanser, opened, undated, unlabeled. Review of facility policy, Medication Given by Licensed Personnel Only, (undated) revealed .ointments, ect. for treatments .Do Not leave in the resident's room (unless in locked cabinet) . Review of facility memo, Preventative Skin Care Program, dated [DATE] revealed .the Anti-Fungal Cream .requires an order and must be applied by a nurse . Interview with LPN #2, on [DATE], at 12:35 p.m., at the second floor nursing station confirmed the cabinet drawer with a lock in the resident rooms are for wound care and oxygen supplies and must be locked. Further interview in rooms [ROOM NUMBER], confirmed the facility had failed to ensure medication cabinets were locked, opened medications were dated and labeled, and to replace the expired Nystatin powder. C/O #",2017-12-01
9401,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2013-08-21,164,D,0,1,DKDH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide visual privacy during care for one resident (#207) of thirty-one residents reviewed. The findings included: Resident #207 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set, dated dated dated [DATE], revealed the resident had moderately impaired cognitive skills, required extensive assistance of two persons with transfers, and extensive assistance of one person with dressing and personal hygiene. Observation on July 20, 2013, at 10:30 a.m., revealed the resident seated on a shower chair in the resident's room. Continued observation revealed the resident had an incontinence brief in place with the pants below the knees, with the upper thighs exposed, and Certified Nursing Assistant (CNA) #2 was assisting the resident. Continued observation revealed the resident's roommate was in the room and the privacy curtain was not in use. Interview on July 21, 2013, at 3:30 p.m., with the Director of Nursing (DON), in the DON's office, confirmed the privacy curtain was to be pulled to provide visual privacy when care/treatments were provided and confirmed the resident's privacy was not maintained.",2016-12-01
9402,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2013-08-21,315,D,0,1,DKDH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, facility policy review, and interview, the facility failed to implement a bladder retraining program for one resident (#215) of thirty-one residents reviewed. The findings included: Resident #215 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the significant change of status Minimum Data Set (MDS) dated [DATE], revealed the resident was frequently incontinent of bladder. Medical record review of the quarterly MDS dated [DATE], revealed the resident was always incontinent of bladder. Medical record review of the Urinary Incontinence Management Evaluation form dated February 3, 2013, March 18, 2013, and June 18, 2013, revealed the following: The resident understands-clear comprehension; makes self understood-both verbal and non-verbal expression; was aware when needs to void; had social awareness concerning incontinence; and was motivated/desires to be continent of urine. Continued review of the Urinary Incontinence Management Evaluation form revealed the resident scored a six indicating the resident was likely to benefit from a bladder training program. Medical record review of the Care Plan reviewed on June 28, 2013, revealed .Potential for skin breakdown associated with decreased mobility and freq (frequently) incont (incontinent) .provide pericare as needed with each incontinent episode . Medical record review revealed no documentation a bladder retraining program had been developed for the resident. Observation on August 21, 2013, at 11:00 a.m., revealed the resident lying on a low bed sleeping. Review of facility policy, Urinary Incontinence Management Program, revealed .To assess and determine upon admission and with any change of status that a resident who is incontinent of bladder receives appropriate treatment and services. To restore the optimum level of bladder function possible related to each individual resident's cognitive and functional abilities as well as medical condition .residents scoring 6 - 9 points on the Evaluation may likely benefit from a bladder retraining program . Interview on August 21, 2013, at 8:30 a.m., with the Assistant Director of Nursing (ADON), in the ADON's office confirmed a bladder retraining program had not been developed for the resident.",2016-12-01
9403,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2013-08-21,323,D,0,1,DKDH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a facility investigation, observation, and interview, the facility failed to ensure a safety device was in place for one resident (#207) of thirty-one residents reviewed. The findings included: Resident #207 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set, dated dated dated [DATE], revealed the resident had short and long term memory problems, moderately impaired cognitive skills, balance during surface-to surface transfers was not steady, and was only able to stabilize with human assistance. Medical record review of a Fall Risk assessment dated [DATE], revealed the resident was at risk for falls. Medical record review of a Nurse's Note dated July 7, 2013, at 12:24 p.m., revealed resident was sitting in TV room and fell asleep, noted several resident yelled at the same time, finding that resident was found sitting on the floor leaned up against another resident on the left. All that witnessed incident stated that .was sleeping and just slipped out of .chair .no injury noted . Review of facility documentation revealed the resident had fallen from a wheelchair on July 7, 2013, and after the fall the resident was to be placed in a geri chair (chair able to be reclined). Medical record review of a Nurse's Note dated August 12, 2013, revealed Late entry for 4:15 p.m., resident observed out in loby (lobby) lieing (lying) face down in front of wheelchair with pommel cushion in wheelchair and locked .abrasion and hematoma to left side for head .cut to lower lip .rom (range of motion) adq (adequate) assist up to wheel chair, assist to bed supervisor checked resident out .neuro checks good answer question with nod of head correctly, denies pain. Medical record review of the Care Plan reviewed on June 18, 2013, revealed .At risk for falls r/t (related to) CVA, weakness, unsteady gait, vision impairment .no slip socks as ordered, pressure sensitive alarm to bed, pressure sensitive alarm to chair, assist with all ambulation/transfer attempts prn (as needed) .ensure that resident has and wears properly-fitting non-skid soled shoes for ambulation .pommel cushion as ordered .(7/7/13 geri chair as ordered) (8/12/13-neuro checks per protocol, apply ice to hematoma as ordered) Observation and interview with Registered Nurse (RN) #1 on August 21, 2013, at 2:30 p.m., revealed the resident seated in a wheelchair with a pommel cushion and a safety alarm in place in the common area, and confirmed the resident was not placed in a geri chair. Continued interview revealed the geri chair was to be used for safety. Interview on August 21, 2013, at 2:40 p.m., with the Assistant Director of Nursing (ADON), in the conference room, confirmed the resident was not seated in a geri chair at the time of the resident's fall on August 12, 2013.",2016-12-01
9404,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2013-08-21,371,F,0,1,DKDH11,"Based on observation and interview, the facility failed to provide sanitary storage of food and equipment. The findings included: Observation of the dietary department on August 19, 2013, from 6:00 a.m. until 6:30 a.m., revealed: 1. All bowls stored face up on shelving and available for use; 2. Stand up coolers times two with noticeable food debris present on floor of coolers and tray holding racks and available for use; 3. Divided plates stored face up with debris noted in compartments and available for use; 4. Thickened apple juice in reach in cooler opened, undated, and available for use; 5. Thickened iced tea in reach in cooler opened, undated, and available for use; 6. Thickened cranberry juice in reach in cooler opened, undated, and available for use; 7. Employee 20 ounce bottle of soft drink in reach in cooler; 8. One gallon of Italian Dressing in walk in cooler opened, undated, and available for use; 9. One gallon of Mayonnaise in walk in cooler opened, undated, and available for use; 10.One gallon of Sweet Pickle Relish in walk in cooler opened, undated, and available for use; 11.One gallon of Hamburger Dill Pickles in walk in cooler opened, undated, and available for use. Interview with the Dietary Manager on August 19, 2013, at 6:30 a.m., in the dietary department confirmed all bowls and divided plates were to be stored clean with the opening facing down, the standup coolers were dirty, the thickened apple juice, ice tea, and cranberry juice were not dated when opened, employee food and drinks were not to be stored in the kitchen coolers, and the Italian Dressing, Mayonnaise, Sweet Pickle Relish, and Hamburger Dill Pickles were not dated when opened. Continued observation of the dietary department on August 19, 2013, at 9:00 a.m. to 9:30 a.m. revealed: 1. Food processor was stored wet and available for use; 2. Ham in walk in cooler was not wrapped or dated and available for use; 3. Sliced corned beef in walk in cooler was not wrapped or dated and available for use; 4. Bowl from large standup mixer was stored wet with standing water in the bottom of the bowl and available for use; 5. Seven one-half pans were stored wet on the wire rack shelving and available for use; 6. Twelve one-half bananas were in the dry storage area in plastic bags undated and available for use; 7. Twelve individual repackaged servings of peanut butter were in the dry storage area undated and available for use; 8. 32 ounce bottle of green food coloring in the walk in cooler opened, undated, and available for use; 9. 32 ounce bottle of yellow food coloring in the walk in cooler opened, undated, and available for use; 10. 32 ounce bottle of red food coloring in the walk in cooler opened, undated, and available for use; 11. One gallon of corn oil under prep table opened, undated, and available for use; 12. Five gallon plastic container of oil under prep table was unlabeled, undated, and available for use; 13. One gallon of pancake and waffle syrup on prep table opened, undated, and available for use. Interview with the Dietary Manager on August 19, 2013, at 9:30 a.m., in the dietary department, confirmed the food processor was stored wet, ham and sliced corned beef were not wrapped or dated in the walk in in cooler, large stand up mixer was stored wet with water standing in the bottom of the bowl, seven half pans were stored wet, twelve half bananas and twelve individual peanut butter containers were stored in the dry storage room, bottles of green, yellow, and red food coloring were stored in the walk in cooler undated, and gallon containers of oil and pancake syrup were stored undated. Continued observation of the dietary department on August 19, 2013, from 10:30 a.m. to 10:45 a.m., revealed: 1. One bucket of cleaning solution with rags inside them stored on a food prep table while food was being prepared; 2. Two buckets of cleaning solution with rags inside them stored under another food prep table with clean cook ware next to them. Interview with the Dietary Manager on August 19, 2013, at 10:45 a.m., in the dietary department confirmed the buckets with cleaning solution were not to be stored on food preparation tables or with clean cook ware.",2016-12-01
9405,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2013-08-21,441,D,0,1,DKDH11,"Based on observation, review of facility policy, and interview, the facility failed to ensure hands were washed appropiately. The findings included: Observation on August 19, 2013, at 9:00 a.m., in the resident's third floor dining room, revealed Certified Nursing Assistant (CNA #1), serving breakfast trays, touching the resident's trays and CNA #1's face without wearing gloves or washing hands. Continued observation revealed this occurred for two of two residents observed. Review of facility policy, Standard Precautions, last revised June 1, 2000, revealed .washing hands .before/after touching a resident .after contact with any body fluid .after touching any item used by or for the resident . Interview with the Licensed Practical Nurse (LPN #1), on August 19, 2013, at 9:10 a.m., in the 300 hallway, confirmed hands must be washed prior to touching a resident's food or food tray, after touching of the face, and when contact had occurred with the resident. Continued interview with LPN #1 confirmed the facility policy had not been followed.",2016-12-01
11436,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2013-01-03,366,D,1,0,NFEK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure one (#1) of five sampled residents received a substitute after refusing food served. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed the resident is currently on the Hospice Benefit and has a recent history of significant weight loss. Observation on January 3, 2012, from 12:30 p.m. until 1:30 p.m., in the dining room, revealed the resident was provided a pureed lunch. Continued observation revealed CNA #1 (Certified Nursing Assistant) attempted to feed the resident, and the resident spit the food out. Observation on January 3, 2012, at 12:50 p.m., revealed CNA #1 requested licensed nurse #1 order a pimento cheese or something soft. Continued observation revealed the pimento cheese sandwich (not pureed) was delivered to the resident at 1:06 p.m. Observation and interview on January 3, 2012, at 1:10 p.m., in the dining room, with the charge nurse (licensed nurse #2) revealed the resident currently had a physician's orders [REDACTED].#1 about the pimento cheese sandwich, and the CNA stated the sandwich was soft, and the CNA thought a soft food was allowable on the resident's pureed diet. Observation on January 3, 2012, at 1:11 p.m., in the dining room, revealed the charge nurse removed the resident from the dining room, and placed the resident (seated in the wheelchair) in the second floor day room. Continued observation from 1:11 p.m. to 1:35 p.m., in the second floor day room, revealed the resident remained in the second floor day room without being offered a pureed substitute. Interview on January 3, 2012, at 3:00 p.m., in the Director of Nursing office, with the charge nurse and the Assistant Director of Nursing, confirmed the resident was not offered a pureed substitute. c/o#",2016-01-01
11593,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2012-01-31,157,D,0,1,C4G311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to notify the family and physician timely of an injury during a transfer for one resident (#29) of thirty-one residents reviewed. The findings included: Resident #29 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].Res (resident) c/o (complaint of) pn (pain) and swelling L (left) knee. Daughter request x-ray .obtained . Medical record review of a Radiology Report dated December 18, 2010, revealed .left knee shows diffuse severe osteopenia .there is a displaced fracture involving the metaphyseal level of the left distal femur . Interview by telephone on January 30, 2012, at 2:28 p.m., with Certified Nursing Aid (CNA) #2, who provided the resident care on December 17, 2010, prior to the resident's complaint of pain, revealed the CNA was transferring the resident to bed with (name) lift when the resident's knee hit the bed. Interview on January 30, 2012, at 2:37 p.m., in the facility activity room, with Licensed Practical Nurse (LPN) #7, the LPN who investigated the potential cause of the fracture on December 20, 2010, revealed CNA #2 had reported to the LPN during the investigation .may have hit the resident's knee on the bed during a tansfer .didn't tell anyone at that time . Interview with the Assistant Director of Nursing (ADON) on January 30, 2012, at 2:00 p.m., in the facility risk management office, revealed the resident's fracture was investigated as an injury of unknown origin. Continued interview revealed the potential cause was not determined until December 20, 2010. Interview with the resident's Physician on January 31, 2012, at 8:05 a.m., confirmed the x-ray report dated December 18, 2010, showed severe osteopenia and the fracture could have occurred during the transfer. Interview with the Director of Nursing (DON) on January 31, 2012, at 7:55 a.m., in the Director's office, confirmed the physician was not notified until December 18, 2010, of a change after the resident started complaining of pain and a order for the x-ray was obtained. C/O #",2015-12-01
11594,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2012-01-31,279,D,0,1,C4G311,"**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 history of chest pain, stroke, and pacemaker for one resident (#10) of thirty-one residents reviewed. The findings included: Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Progress Note from a discharging facility dated November 16, 2011, revealed .Chief complaint .Chest pain .Location .at pacemaker .will follow protocol for [MEDICAL CONDITION] . Interview and medical record review with the Director of Nursing, in the Director's Office on January 29, 2012, at 2:29 p.m., confirmed the care plan did not address the history of chest pain, stroke, and pacemaker.",2015-12-01
11595,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2012-01-31,280,D,0,1,C4G311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to update a care plan related to falls risk, for one resident (#27) of thirty-one residents reviewed. The findings included: Resident #27 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].d/c (discontinue) PSA (patient safety alarm) . Medical record review of an Interdisciplinary Care Plan dated September 11, 2011, revealed .PSA to bed . Interview with the facility Risk Manager, on January 30, 2012, at 3:55 p.m., in the Activities Conference Room, confirmed the physician's orders [REDACTED]. [REDACTED].>C/O #",2015-12-01
11596,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2012-01-31,323,D,0,1,C4G311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, and interview the facility failed to complete quarterly reviews of fall assessments to accurately reflect the fall risk of one resident (#29) of thirty-one residents reviewed. The findings included: Resident #29 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the facility Fall Risk assessment dated [DATE], through January 25, 2010, revealed a review date of July 27, 2009, and .during the last 90 days the resident has had no falls . Continued medical record review of a Fall Risk assessment dated [DATE], revealed .during the last 90 days the resident has had no falls . Further medical record review of a Fall Risk assessment dated [DATE], revealed .during the last 90 days the resident has had no falls . Facility policy review of the Fall Management Policy and Procedure revealed, .Fall risk assessments are to be completed with the MDS (Minimum Data Set) quarterly . Interview and review of the facility fall investigations with the facility Risk Manager, on January 30, 2012, at 10:15 a.m., revealed the resident had falls on June 21, 2009, July 11, 2010, July 18, 2010, August 3, 2010, September 25, 2010, and November 16, 2010. Continued interview and medical record review of the facility Fall Risk Assessments, confirmed the facility failed to complete the Fall Risk Assessment to accurately reflect the resident's fall risk. Interview and policy review with the Director of Nursing (DON) in the facility activity room on January 30, 2012, at 8:08 a.m., confirmed the facility Fall Management Policy was not followed. C/O #",2015-12-01
11597,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2012-01-31,371,F,0,1,C4G311,"Based on observation, review of facility policy, and interview, the facility failed to ensure cleanliness of the can opener, proper storage of canned goods, food was not available beyond the expiration date, and cleanliness of the fans in the walk-in cooler in the Dietary Department; failed to ensure food was labeled in the refrigerator for one of three Nourishment rooms observed; failed to ensure the ice machine was clean for one of three Nourishment rooms observed; and failed to ensure the ice cooler was clean for one of three ice coolers observed. The findings included: Observation of the Dietary Department on January 29, 2012, from 9:45 a.m., until 10:45 a.m., revealed the following: 1. The can opener had dried food build-up on the base of the can opener and around the operating mechanism. 2. In the dry storage, stacked with the stocked canned food items were the following cans of food, with dents present in the cans: (1) 4 pounds (lbs) can chunk light tuna, (1) 6 lbs 9 ounces (oz) can pineapple tidbits, (1) 112 oz can oven baked apples, (2) 6 lbs 6 oz cans French style beans, (1) 108 oz can applesauce, and (1) 104 oz can peeled apples. 3. In the salad cooler was a pan of ham salad with a date of December 23, 2011. 4. In the walk-in freezer, one box of 4 oz beef liver layer pack with a date of October 29, 2010. 5. In the walk-in cooler, two of two fans had dust, lint, and debris on the fans. Review of the facility's policy Food Storage dated 2008, revealed, .Leftover food is used within 3 days or discarded . Interviews with the Morning Supervisor and the Dietary Manager on January 29, 2012, between 9:45 a.m., and 10:45 a.m., in the Dietary Department, confirmed the can opener and fans in the walk-in cooler were in need of cleaning, dented cans were to be stored separately from food stock and returned to the distributor, and the ham salad and beef liver pack was available for use beyond the expiration date. Observation of the Nourishment Room on the fourth floor on January 29, 2012, at 4:00 p.m., revealed the refrigerator contained one covered bowl of carrots, one covered bowl of peas, and one wrapped turkey sandwich, all with one resident's name or room number, but no date of preparation or expiration. Further observation of the refrigerator revealed a small individual carton of chocolate milk, opened, with no name and no date when opened. Continued observation of the Nourishment Room, revealed in the ice machine, dust and debris were covering the metal strip under the lid. Review of the facility's policy Food Storage dated 2008, revealed, .Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before refrigerated. Leftover food is used within 3 days or discarded .Refrigeration .All foods should be covered, labeled and dated . Review of the Ice Machine Cleaning Schedule revealed the ice machine was cleaned on January 11, 2012. Interview with Licensed Practical Nurse #5, on January 29, 2012, at 4:00 p.m., in the fourth floor Nourishment Room, confirmed the food items were not dated, open individual cartons of milk were to be discarded and not placed in the refrigerator, and the ice machine was in need of cleaning. Observation on January 30, 2012, at 3:30 p.m., in the 200 floor nourishment station revealed, a blue, 20 quart plastic cooler sitting on the hydration cart. Further observation revealed the cooler to be half filled with ice cubes on which there were two quarter sized areas of black debris. Interview with Licensed Practical Nurse #1 on January 30, 2012, at 3:32 p.m., in the 200 hall nourishment station, confirmed the ice was readied for resident use, and the presence of the debris.",2015-12-01
11598,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2012-01-31,425,D,0,1,C4G311,"Based on observation, interview, and review of facility policy, the facility failed to ensure medications were not prepared until time of administration for one of three nurses observed during medication pass. The findings included: Observation of Licensed Practical Nurse (LPN) #2 on January 29, 2012, between 4:15 p.m., and 4:33 p.m., during a medication pass on the third floor, revealed the LPN placed a clear, plastic medication cup, containing one pill in the top drawer of the cart. Continued observation revealed the medication cup was labeled with a room number, and did not indicate the name of the medication. Continued observation revealed the nurse, between 4:15 p.m., and 4:33 p.m., administered medications to four different residents in three different resident rooms with the medication remaining in the top drawer of the cart. Interview with LPN #2 on January 29, 2012, at 4:33 p.m., on the third floor hallway, confirmed the pill in the medication cup was a Percocet (schedule II narcotic) for resident #22 the LPN had dispensed prior to starting the medication pass. Continued interview confirmed the medication was stored in the medication cup in the top drawer of the cart to be administered later. Review of the facility's policy, Drug Administration (no date), revealed .Drugs are given as soon as possible after doses prepared . Medical record review of the Medication Administration Record [REDACTED]#2 dispensed the medication). Interview with the Director of Nursing (DON) on January 30, 2012, at 2:15 p.m., in the Activities Room, confirmed the nurses were not to dispense medications until the time of administration, and it was not according to facility policy to dispense a schedule II narcotic over an hour before administering and leaving in a top drawer of an unlocked cart.",2015-12-01
11599,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2012-01-31,431,E,0,1,C4G311,"Based on observation, interview, and review of facility policy, the facility failed to secure medications in the drug cart during medication pass, including a schedule II narcotic, for two of two carts observed; failed to ensure medications were properly labeled for three of three medication carts observed; failed to ensure biologicals were not available for use beyond the expiration date for one of two Medication Preparation rooms observed; and failed to ensure schedule II narcotics were secured behind two locks for one of three medication carts and one of two Medication Prep aration rooms observed. The findings included: Observation of Licensed Practical Nurse (LPN) #2 on January 29, 2012, between 4:15 p.m., and 4:33 p.m., during a medication pass on the third floor, revealed the LPN placed a clear, plastic medication cup, containing one pill in the top drawer of the cart. Continued observation revealed the medication cup was labeled with a room number, and did not indicate the name of the medication. Continued observation revealed the nurse, between 4:15 p.m., and 4:33 p.m., administered medications to four different residents in three different resident rooms with the medication remaining in the top drawer of the cart. Continued observation revealed the LPN went to the first resident room, and without locking the medication cart, administered medications to the resident with the back turned to the cart and the cart out of line of sight. Continued observation revealed the nurse went to the second room, without locking the medication cart, pulled the cart into the resident's room, administered medications to two residents, and entered the bathroom to wash the hands with the door of the bathroom blocking eye contact with the unlocked medication cart. Continued observation revealed the LPN went to the third resident room, and without locking the cart, entered the resident's room, checked a finger stick blood sugar, and administered an insulin injection, with the LPN's back turned to the medication cart and the unlocked cart out of line of sight. Interview with LPN #2 on January 29, 2012, at 4:33 p.m., on the third floor hallway, confirmed the pill in the medication cup was a Percocet (schedule II narcotic) for resident #22 the LPN had dispensed prior to starting the medication pass. Continued interview confirmed the medication was stored in the medication cup in the top drawer of the cart to be administered later; the medication cart had not been locked during the medication administration; and the cart was not in the line of sight when entering the bathroom to wash the hands. Observation of LPN #3 on January 30, 2012, at 8:10 a.m., on the fifth floor, during a medication pass, revealed the LPN dispensed medications for a resident, and without locking the medication cart, entered the resident's room, turned the LPN's back to the cart in the doorway out of line of sight, and assisted the resident to take medications. Observation of the cart, while the LPN was in the resident room with the back turned, revealed a plastic piece of the cart was missing with pills visible in the cart from the hallway. Review of facility policy, Pharmacy Utilization of Services (no date), revealed .Narcotics on the floors are under double lock and key . Interview with the Director of Nursing (DON) on January 30, 2012, at 2:15 p.m., in the Activities Room, confirmed nurses were to keep the medication cart either locked or in direct line of sight at all times. Further interview confirmed turning a back to the cart would not have the medication cart in direct line of sight. Observation of a medication cart on the third floor on January 29, 2012, at 4:35 p.m., revealed the top drawer contained two packages of Metoprolol 50 milligrams (mg) with no prescription label and no resident's name. Interview with LPN #2 on January 29, 2012, at 4:35 p.m., on the third floor hallway, confirmed the medications were loose and the LPN did not know who the medications were for. Observation of a medication cart in the fifth floor medication room, on January 30, 2012, at 2:30 p.m., revealed a top drawer contained one bottle of Azelastine Nasal Spray with no prescription label and no label to indicate the resident's name. Interview with LPN #3 on January 30, 2012, at 2:30 p.m., in the fifth floor medication room, confirmed nasal sprays were individual use and the nasal spray had no label to indicate the resident's name or prescription instructions. Observation of a medication cart on January 31, 2012, at 8:15 a.m., in the third floor medication room, with LPN #6 revealed one open partially used tube of Triamcinolone Acetonide Cream (topical steroid) with a faded illegible resident label on the outside of the tube, and one open partially used tube of Terbinafine Hydrochloride Cream (antifungal) with a faded illegible resident label on the outside of the tube. Interview with LPN #6 on January 31, 2012, at 8:15 a.m., in the third floor medication room confirmed that medications are to be thrown away when there is no name on it or you can't read label. Observation of the Medication Preparation room on the third floor on January 31, 2012, at 8:15 a.m., revealed a box with supplies to obtain blood for laboratory tests contained three purple top vaccutainers with an expiration date of April 2011 and two Urine C&S (culture and sensitivity) tubes with an expiration date of September 2010. Interview with LPN #6 on January 31, 2012, at 8:15 a.m., in the third floor Medication Preparation Room confirmed the laboratory tubes were available for use beyond the expiration date. Observation of the second floor Medication Preparation Room on January 31, 2012, at 10:10 a.m., revealed the door to the room was locked. Further observation revealed setting on a countertop in a plastic bin was a medication sheet with 22 pills of Opana (schedule II narcotic) ER (extended release) 10 mg tablets. Interview with LPN #4 on January 31, 2012, at 10:10 a.m., in the second floor Medication Preparation Room confirmed the nurses place medications from discharged residents in the bin for pick up by the pharmacy every day. Further interview confirmed the pills of Opana were secured by only one lock and not two double locks. Review of facility policy, Pharmacy Utilization of Services (no date), revealed .Narcotics on the floors are under double lock and key . Interview with the Pharmacist on January 31, 2012, at 10:30 a.m., in the pharmacy, confirmed schedule II narcotics were to be secured behind two locks and placing the medications in the bin secured only by the door lock would not meet requirements of two locks.",2015-12-01
11600,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2012-01-31,441,D,0,1,C4G311,"Based on observation, interview, and review of facility policy, the facility failed to follow policy related to infection control during the ice pass for one of three observations; failed to ensure sharps containers were not used beyond safety recommendations for one of three medication carts observed; and failed to ensure nurses wore gloves during invasive procedures for one of three nurses observed during medication pass. The findings included: Observation on January 29, 2012, at 2:10 p.m., on the Fifth floor hallway, revealed Certified Nurse Assistant (CNA) #1 filling ice water pitchers with ice outside three separate resident rooms. Further observation revealed CNA #1 went into each resident's room, took each resident's water pitcher outside the room, filled the pitcher with ice, returned the pitchers into the room and exited without sanitizing the hands between residents. Further observation at 2:15 p.m., revealed the CNA exiting a resident's room with a dirty lunch tray, took the tray out into the hallway to the cart in the dining room, and reentered the resident's room and then exited the room without washing or sanitizing the hands. Interview with CNA #1, on January 29, 2012, at 2:20 p.m., on the Fifth floor hallway, confirmed the pitchers had been used by residents and the hands had not been sanitized between residents. Review of facility policy, Hand Hygiene, revealed .when hands are visibly dirty or contaminated with proteinaceous material .perform hand hygiene with either a non-antimicrobial soap and water or an antimicrobial soap and water .if hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all clinical situations other than those listed under handwashing above . Interview with the Director of Nursing (DON), on January 29, 2012, at 3:00 p.m., in the DON's office, confirmed the CNA failed to sanitize the hands between resident rooms and failed to follow standard infection control practice. Observation of a medication cart during medication pass on January 29, 2012, between 4:15 p.m., and 4:33 p.m., on the third floor, revealed the sharps container full of needles and syringes above the line marked ? full. Further observation revealed two syringes protruded through the opening in the top of the container. Further observation revealed the instructions on the box indicated the container was to be closed, locked, and disposed of when full to the ? line marking on the container. Review of facility policy, Infectious Waste Management dated 2007, revealed .Sharps containers will not be overfilled. They should be replaced when ? full. When full, the Charge Nurse or designated staff member will be responsible to see that the containers are removed from the use area . Review of facility policy, Handling and/or Disposing of Used Needles, dated 2007, revealed .Safety Precautions .When the sharps container is ? filled, the container must be stored until picked up by a licensed vendor for proper disposal . Interview with Licensed Practical Nurse (LPN) #2 on January 29, 2012, at 4:33 p.m., on the third floor hallway, confirmed the sharps container was beyond the ? mark and needed to be removed from the medication cart. Observation of LPN #2 on January 29, 2012, between 4:25 p.m., and 4:33 p.m., during a medication pass on the third floor, revealed the LPN entered resident #31's room, and without donning gloves, used a lancet to prick the resident's finger and obtained blood from the finger, applied blood to an applicator for obtaining blood sugar values, and pressed an alcohol pad to the resident's finger with the LPN's two fingers behind the alcohol pad. Further observation revealed, without donning gloves, LPN #2 administered an insulin injection to the resident's abdomen. Review of facility policy, Blood Glucose Monitoring Policy and Procedure, updated April 18, 2011, revealed .Infection Control Guidelines .Wear gloves during procedure .Wash hands and put on gloves .select puncture site and clean with alcohol pad. Puncture site with lancet .Touch the blood drop to the white area at the end of the test strip .Briefly apply pressure to the puncture site until bleeding stops .Remove and discard gloves . Interview with LPN #2 on January 29, 2012, at 4:33 p.m., outside resident #31's room, confirmed the LPN did not wear gloves while obtaining a blood sample to check the resident's blood sugar or while giving an insulin injection. C/O #",2015-12-01
11601,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2012-01-31,465,D,0,1,C4G311,"Based on observation, policy review, and interview, the facility failed to maintain a sanitary environment. The findings included: Observations, on January 29, 2012, at 10:25 a.m., of the East Bath room, on the fifth floor, revealed a portable commode chair with urine colored liquid in the receptacle and yellow stains on the seat. Review of facility policy, Commode Chair, Care and Cleaning of, revealed .After each use of the Commode Chair .Empty commode receptacle in the adjacent toilet and rinse well .use brush and disinfectant solution to clean . Interview with the Nursing Supervisor, in the Fifth Floor East Bath, on January 29, 2012, at 10:35 a.m., confirmed the commode chair receptacle contained urine, and should have been cleaned after use and before being stored in the Bath Room. C/O #",2015-12-01
13697,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2010-11-03,505,E,0,1,135711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to promptly notify the physician of the laboratory results for four (#3, #23, #24, and #25) of thirty residents reviewed. The findings included: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Continued medical record review of the physician's orders [REDACTED]. Medical record review of a wound culture dated October 22, 2010, revealed ""...Final report...Result 1 Escherichia coli...Result 2 Proteus mirabilis...Result 3 Staphylococcus aureus [MEDICAL CONDITION] resistant (MRSA)..."" Medical record review revealed no documentation the physician or Nurse Practitioner was notified of the final report of the positive wound culture dated October 22, 2010, until the Nurse Practitioner initialed the report on October 25, 2010. Interview on November 2, 2010, at 9:40 a.m., with the physician and the Director of Nursing, in the conference room, revealed positive wound cultures were to be reported to the physician when the facility obtained the report and confirmed there was a delay in notifying the physician or Nurse Practitioner of the positive wound culture. Resident #23 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Medical record review of a progress note, written on the physician's progress notes, dated July 2, 2010, revealed ""Resident having pain, pressure & c/o (complains of) frequency when vding (voiding)."" Medical record review of a laboratory report dated July 4, 2010, revealed a positive urine culture with the causative organism [DIAGNOSES REDACTED] pneumoniae. Medical record review revealed no documentation the Nurse Practitioner or physician was notified until July 6, 2010, when an order was obtained to [MEDICATION NAME](antibiotic) 500 mg twice a day for five days. Interview on November 3, 2010, at 10:10 a.m., with the Director of Nursing, in the conference room, confirmed the delay in notifying the Nurse Practitioner or Physician of the positive urine culture. Resident #24 was admitted to the facility October 3, 2008, with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Medical record review of a nurse's note dated October 25, 2010, revealed ""...urine for urinalysis...obtained."" Medical record review of a laboratory report dated October 25, 2010, revealed the resident's urine was positive for Escherichia coli. Further medical record review of the laboratory report revealed the organism was sensitive to [MEDICATION NAME]. Medical record review of a nurse's note dated October 27, 2010, revealed ""...UA C&S report called to...NP (nurse practitioner). Resistant to most antibiotics, NP will f/u in am..."" Continued medical record review of a physician's orders [REDACTED]. (milligrams) PO (by mouth) x 10 days."" Interview with the Director of Nursing, on November 3, 2010, at 10:10 a.m., in the conference room, confirmed the facility failed to notify the nurse practitioner of the positive urine culture on October 25, 2010, when the lab results were received from the laboratory until October 27, 2010, (two days later) . Resident #25 was admitted to the facility June 22, 2007, with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Medical record review of the laboratory report dated August 20, 2010, revealed the Resident's urine was positive for Escherichia coli. Further medical record review of the laboratory report revealed the organism was sensitive to [MEDICATION NAME] ([MEDICATION NAME]). Continued medical record review of a physician's orders [REDACTED]. Interview with the Director of Nursing, November 3, 2010, at 10:10 a.m., in the conference room, confirmed the facility failed to notify the physician of the positive urine culture on August 20, 2010, when the lab results were received from the laboratory, until August 23, 2010 (three days later).",2014-10-01
13698,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2010-11-03,280,D,0,1,135711,"**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 two residents (#14, #17) of thirty residents reviewed. The findings included: Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had no memory or cognitive impairment, required extensive assistance with transfers, personal hygiene, dressing, and had exhibited socially inappropriate behaviors. Medical record review of the resident's care plan dated September 2, 2010, revealed no documentation the resident's behaviors had been addressed. Observation on November 1, 2010, at 11:10 a.m., revealed the resident seated in a wheelchair in the resident's room reading a book. Continued observation revealed the resident was dressed, well-groomed, and able to carry on conversation appropriately. Interview with the Charge Nurse/LPN (Licensed Practical Nurse) #2 on November 3, 2010, at 10:30 a.m., at the 3rd floor nurses station, confirmed the resident had exhibited sexually inappropriate behaviors with the staff. Continued interview with LPN #2 confirmed the resident's care plan had not been revised to address the behaviors. Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the October 2010 physician's recapitulation orders revealed ""...Heel protectors when in bed..."" Medical record review of the care plan reviewed on October 19, 2010, revealed no documentation the care plan had been revised to reflect the heel protectors while in bed. Observation on November 2, 2010, at 10:25 a.m., revealed the resident lying on the bed without the heel protectors in place. Interview on November 2, 2010, at 12:30 p.m., with Licensed Practical Nurse #1, in the conference room, confirmed the care plan reviewed on October 19, 2010, had not been revised to reflect the heel protectors.",2014-10-01
13699,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2010-11-03,312,D,0,1,135711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to provide nail care for two residents (#21, #27) of thirty residents reviewed. The findings included: Resident #21 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], and February 25, 2010, revealed the resident was totally dependent on staff for personal hygiene. Observation of the resident, in the resident's room, on November 1, 2010, at 9:00 a.m., November 2, 2010, at 2:00 p.m., and November 3, 2010, at 8:45 a.m., revealed a dark substance under the fingernails. Further observation revealed the fingernails to be overgrown with rough edges. Observation and interview in the resident's room with the Assistant Director of Nursing (ADON) on November 3, 2010, at 9:00 a.m., confirmed the fingernails needed to be cleaned and trimmed. Resident #27 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE], revealed ""extensive assistance with personal hygiene."" Medical record review of the Comprehensive Care Plan dated March 20, 2010, revealed ""extensive assist of one with all ADL's (activities of daily living)."" Observation of the resident, in the resident's room on November 1, 2010, at 9:00 a.m., November 2, 2010, at 2:45 p.m., and November 3, 2010, at 8:30 a.m., near the nurse's station on third floor revealed discolored overgrown finger nails. Interview on November 3, 2010, at 9:00 a.m., with the ADON in the third floor activity area, confirmed the resident's fingernails needed to be trimmed.",2014-10-01
13700,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2010-11-03,514,D,0,1,135711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to accurately document the enteral feeding flow rate for one resident (#22) of thirty residents reviewed. The findings included: Resident #22 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Medical record review of the nurse's notes dated July 25th and 26th, 2010, August 1st, 2nd, 8th, and 15th, 2010, and September 5th and 6th, 2010, revealed the resident received the tube feeding at 50 ml /hour. Review of the facility's ""Completed Care Tasks"" document (an electronic document) revealed the resident received the tube feeding at 55 ml/hr. on July 25th and 26th, 2010, August 1st, 2nd, 8th, and 15th, 2010, and September 5th and 6th, 2010. Interview with the Director of Nursing on November 3, 2010, at 2:41 p.m., in the conference room confirmed the medical record was not accurate.",2014-10-01
13701,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2010-11-03,502,D,0,1,135711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical recod review and interview the facility failed to provide timely laboratory services for one resident (#24) of thirty residents reviewed. The findings included: Resident #24 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Medical record review of a nurse's note dated October 25, 2010, revealed ""...urine for urinalysis ...obtained."" Further medical record review of the nurse's notes dated October 20-30, 2010, revealed no documentation of any attempts to collect a urine specimen as ordered on October 22, 2010. Interview with the Director of Nursing, November 3, 2010, at 10:10 a.m., in the conference room, confirmed the urine specimen was not collected until October 25, 2010 (3 days later).",2014-10-01
13702,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2010-11-03,441,D,0,1,135711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, facility policy review, and interview, the facility failed to appropriately clean equipment after use, the staff failed to wash the hands after providing care for one resident (#3) of thirty residents reviewed, and failed to administer a medication in a sanitary manner during a medication pass. The findings included: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a preliminary wound culture report dated October 21, 2010, revealed ""...Result 1 Gram negative rods...Result 2 Proteus mirabilis..."" Continued medical record review of the preliminary wound culture report revealed the gram negative rods and Proteus mirabilis were susceptible to [MEDICATION NAME] (antibiotic). Medical record review of a physician's orders [REDACTED]. Medical record review of a wound culture dated October 22, 2010, revealed ""...Final report...Result 1 Escherichia coli...Result 2 Proteus mirabilis...Result 3 Staphylococcus aureus Methicillin resistant (MRSA)..."" Continued medical record review of the wound culture dated October 22, 2010, revealed the MRSA was not susceptible to the [MEDICATION NAME]. Continued medical record review of the wound culture dated October 22, 2010, revealed the Nurse Practitioner had initialed the laboratory report as reviewed on October 25, 2010. Medical record review revealed no documentation an antibiotic was ordered to treat the MRSA. Observation on November 2, 2010, at 10:00 a.m., with Registered Nurse (RN) #1, revealed the resident lying on the bed, on the left side, exposing a dressing covering the wound on the sacrum. Continued observation revealed RN #1 removed the dressing from the wound and described the wound as a Stage II ulcer measuring 2.1 cm (centimeters) by 1.0 cm with an approximate depth of 0.2 cm., with a small amount of serous drainage. Interview on November 1, 2010, with RN #2, in the conference room, revealed RN #2 was unaware the wound culture dated October 22, 2010, was positive for MRSA. Continued interview revealed RN #2 would contact the Nurse Practitioner. Medical record review of a Nurse Practitioner's order dated November 1, 2010, revealed ""[MEDICATION NAME] (antibiotic) 500 mg po (by mouth) TID (three times a day) X (times) 7 days..."" Medical record review of a note written on the physician's progress notes dated November 1, 2010, revealed ""Wound culture MRSA...(sensitive to) [MEDICATION NAME]"" Observation on November 1, 2010, at 11:15 a.m., revealed Certified Nursing Assistant (CNA #1) transported the resident from the shower room, located across the hall from the resident's room, in a wheeled shower chair. Continued observation revealed the resident was covered with a sheet and the bare buttocks were on the shower chair seat. Observation on November 1, 2010, at 11:30 a.m., revealed RN #1 and CNA#1 were providing care to the resident. Observation revealed while RN #1 was providing wound care to the resident, CNA #1 exited the room to return the shower chair to the shower room. Continued observation revealed CNA #1 returned to the resident's room, and after RN #1 completed the wound care and exited the room, CNA #1 continued to provide care to the resident. Continued observation revealed CNA #1, with gloved hands, applied an incontinence brief and clothing to the resident. Continued observation revealed CNA #1 rolled the resident side to side in order to position the resident's pants and to place a mechanical lift sling under the resident. Continued observation revealed CNA #1 removed the gloves and without washing the hands or using hand sanitizer, exited the room and obtained a mechanical lift from the hallway. Continued observation revealed CNA #1 returned to the resident's room, hooked the sling to the mechanical lift, transferred the resident to a chair, and returned the mechanical lift to the hallway. Continued observation revealed CNA #1 returned to the resident's room and without washing the hands or using hand sanitizer, applied gloves, brushed the resident's hair, removed the gloves and without washing the hands or using hand sanitizer, checked and applied a safety alarm, placed pillows behind the resident's head and legs, applied a throw over the resident's legs, and placed the soiled linen into the soiled linen cart located in the hallway. Continued observation revealed CNA #1 returned to the resident's room and applied hand sanitizer to the hands. Review of the facility's policy Cleaning and Disinfection of Shower Chairs/Shower Beds revealed ""Purpose: To provide supplies and equipment that are adequately cleaned or disinfected...Shower chairs/beds will be cleaned immediately after each use. Cleaning may be done in the shower room using disinfectant wipes..."" Review of the facility's policy When to Wash Hands revealed ""Before touching a patient, After touching a patient...After touching any item used by or for a patient..."" Interview on November 1, 2010, at 12:10 p.m., with CNA #1, in the lobby, revealed CNA #1 had cleaned the shower chair with soap and water, after returning the shower chair to the shower room, and confirmed the disinfectant wipes were not used to clean the shower chair. Interview on November 2, 2010, with RN #1/Infection Control Coordinator, in RN #1's office, revealed the hands were to be washed after each time the gloves were removed, and confirmed appropriate hand hygiene was not completed. Observation on November 2, 2010, at 8:25 a.m., during medication administration revealed LPN #2 dropped a pill on the top of the medication cart, picked it up with bare fingers, placed it in the medication cup, and administered it to the resident. Interview with LPN #2 on November 2, 2010, at 8:25 a.m., confirmed the medication had not been administered in a sanitary manner.",2014-10-01
13703,SHANNONDALE HEALTH CARE CENTER,445105,7424 MIDDLEBROOK PIKE,KNOXVILLE,TN,37909,2010-11-03,431,D,0,1,135711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure medications designated for emergency use were safe for administration in one emergency box of three medication preparation rooms observed. The findings included: Observation on [DATE], at 10:40 a.m., revealed the contents list on the top of the emergency medication box stored in the third floor medication preparation room had ""Dextrose 50%"" (intravenous medication) (IV) with an expiration date of [DATE]. Observation at this time revealed LPN #2 unlocked the emergency box and revealed two packages of the 50% Dextrose product with expiration dates of [DATE], stored inside the emergency box. Interview on [DATE], at 10:40 a.m., in the medication preparation room on the third floor with Licensed Practical Nurse #2 confirmed the IV medication had expired.",2014-10-01
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
5468,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2015-12-02,328,D,0,1,9CP211,"Based on observation and interview, the facility failed to secure oxygen cylinders in 2 of 25 rooms observed. The findings included: Observation on 11/30/15 at 8:10 AM, on the first floor, revealed 1 full oxygen 300 E cylinder, free standing beside a dresser in a resident's room. Observation on 11/30/15 at 8:17 AM, on the first floor, revealed 1 free standing oxygen 300 E cylinder, 1/2 full, beside a dresser in a resident's room. Interview with Registered Nurse (RN) #1 on 11/30/15 at 8:20 AM, on the 100 hallway, confirmed the oxygen cylinders were not secured. Interview with the Administrator on 12/2/15 at 10:20 AM, in the conference room, revealed the facility did not have a written policy for securing oxygen tanks.",2019-02-01
5469,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2015-12-02,441,D,0,1,9CP211,"Based on facility policy review, observation, and interview, the facility failed to ensure 2 of 5 Certified Nurse Aides (CNA) observed sanitized hands after caring for residents. The findings included: Review of the facility policy titled, Infection Control Manual, revised 10/1/08, Handwashing revealed, .Wash Hands before and after contact with each patient . Observation of CNA #1 on 11/30/15 at 3:05 PM, on the 100 hallway revealed the CNA was obtaining the residents' vital signs. Continued observation revealed CNA #1 entered and exited 3 residents' rooms without sanitizing the hands. Interview with CNA #1 on 11/30/15 at 3:15 PM, at the first floor nursing station, revealed, .everything on the machine is disposable . During the interview, when asked about the facility's handwashing policy, the CNA replied, I suppose I could have washed my hands . Observation of CNA #3 on 11/30/15 at 2:00 PM, in the long hallway of the second floor, revealed the CNA exited a resident room holding a dirty linen bag, disposed of the bag in a dirty linen closet, and entered another resident room without sanitizing the hands. Interview with CNA #3, on 11/30/15 at 2:05 PM, on the 200 hallway, confirmed the CNA did not sanitize the hands after contact with dirty linen, and entered another resident room with contaminated hands. Interview with two CNAs ( #1 and #2) on 11/30/15 at 3:30 PM, at the second floor nursing station, revealed CNA #1 stated handwashing was required after direct contact with a resident. Further interview revealed CNA #2 stated handwashing was always required when exiting a resident room. Interview with the Infection Control Nurse on 12/2/15 at 9:00 AM, in the conference room, revealed the facility's infection control program did not include strategies to track compliance with handwashing by the resident care staff.",2019-02-01
7245,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2014-10-01,157,D,0,1,BCK011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to notify a physician of a significant change in behaviors for one resident (#30) of twenty-nine residents reviewed. The findings included: Resident #30 was admitted to the facility on [DATE], for [DIAGNOSES REDACTED]. Medical record review of a Social Services note date January 24, 2014, at 3:00 p.m., revealed .an anti-anxiety medication has been prescribed this month .staff is monitoring for any further problems with agitation or wandering . Medical record review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #30 had short and long term memory loss. Continued review of the MDS revealed .Staff Assessment of Resident Mood .Being short-tempered, easily annoyed .no . Medical record review of the quarterly MDS dated [DATE], revealed Resident #30 had short and long term memory loss. Continued review of the MDS revealed .Staff Assessment of Resident Mood .Being short-tempered, easily annoyed .yes .symptom frequency .2-6 days (several days) . Medical record review of a Social Services note dated July 8, 2014, at 1:10 p.m., revealed symptoms of minimal depression. Nursing reports (Resident #30) has had a few episodes of agitation-short tempered . Medical record review of the care plan last reviewed on July 14, 2014, revealed .[MEDICAL CONDITION] medication monitoring .behavior history: restless, anxious, obsessive compulsive, agitation .resident's behaviors will be monitored as evideced (evidenced) by less noted episodes through: behavior monitoring nursing staff observe behaviors and reports to MD (Medical Doctor)/NP (Nurse Practitioner) any changes as indicated .current behaviors: 9/25/14: resident continues to have episodes of anxiety and obsessive behaviors .becomes occasionally agitated . Medical record review of a Nurse's Note dated August 6, 2014, at 11:00 p.m., revealed .infrequent periods of brief agitation noted . Medical record review of a Nurse's Note dated August 7, 2014, at 10:00 p.m., revealed .(increased) agitation and anxiety noted, yelling at other pt (patient) at times, threw full cup of coffee while arguing with other pt . Medical record review of a Nurse's Note dated August 13, 2014, revealed .behavior has increased .more agitated. Frequent arguments c (with) res (resident) (increased) anxiety noted . Medical record review of a Nurse's Note dated August 20, 2014, at 4:00 p.m., revealed .Pt (patient) requires constant redirection d/t (due to) obsessive/compulsive movements .Pt can become easily upset and threatening to staff & (and) fell ow pts . Medical record review of a Nurse's Note dated August 26, 2014, at 3:00 p.m., revealed .redirection is consistently necessary d/t obsessive compulsive behavior . Review of a Physician's recapitulation order dated September 1, 2014, revealed .01/14/2014 [MEDICATION NAME] 15mg (milligram) tablet .give 1/2 (one-half) tablet (7.5 mg) by mouth twice daily-Diagnosis: [REDACTED]. Medical record review of a Nurse's Note dated September 10, 2014, at 3:00 p.m., revealed .confusion is noted at times and becomes agitated . Interview with Certified Nursing Assistant (CNA) #1 on October 1, 2014, at 8:45 a.m., outside room [ROOM NUMBER], revealed .can become irritated .I usually talk to (Resident #30) when upset and ask what is wrong .usually calms down in a couple of minutes . Interview with Licensed Practical Nurse (LPN) #2 on October 1, 2014, at 8:49 a.m., outside room [ROOM NUMBER], revealed .(Resident #30) likes to clean, has some poor decision making some times .gets upset with finances and getting a paycheck .I have seen .throw a rag randomly but not at anyone .I just talk to .ask what's wrong .takes just a few minutes to calm down .have heard .uses some bad words .not directed at anyone . Interview with LPN #1 on October 1, 2014, at 8:58 a.m., outside room [ROOM NUMBER], revealed .can get agitated .throws rags .can use cuss words when frustrated .usually redirect .takes a few minutes . Interview with LPN #3 on October 1, 2014, at 9:06 a.m., at the third floor nurses station, revealed .likes coffee and if (Resident #30) is told (Resident #30) had enough .will say I will knock the hell out of you .(Resident #30) has an issue with (Resident #37) .calls (Resident #37) a witch and other names .friendly with all other residents .(Resident #37) will sit in front of the coffee so (Resident #30) can't get to it .tell (Resident #30) can't talk like that and redirect (Resident #30) .that is all it takes . Interview with the Nurse Practitioner (NP) on October 1, 2014, at 9:15 a.m., in the unit manager's office, revealed the NP is in the facility each week on Monday, Wednesday, and Friday. Further interview revealed .there is a memo board at the nurses station that the nurses will leave me a note about anyone I need to see .the nurses list any concerns or issues regarding residents since I was here last .a little while back (Resident #30) had a UTI (urinary tract infection) and started acting odd .that was in August .that is the last behaviors I am aware of .I am not aware of increasing behaviors .psych (psychiatric) is not seeing the resident .but needs to be . Interview with Registered Nurse (RN) #1 and the NP on October 1, 2014, at 9:25 a.m., in the unit manager's office, confirmed the NP was not aware of the change in behaviors for Resident #30.",2018-02-01
7246,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2014-10-01,514,D,0,1,BCK011,"**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 provide accurate documentation for range of motion (ROM) services for one resident, (#51) of three residents reviewed receiving ROM services of twenty nine residents reviewed. The findings included: Resident #51 was admitted [DATE], with [DIAGNOSES REDACTED]. [MEDICAL CONDITION], and Anxiety. 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) assessment indicating the resident was cognitively intact. Medical record review revealed an electronic physicians order dated April 30, 2014, for maintenance ROM three times weekly. Medical record review of the Restorative Flow Sheet Report revealed the resident received ROM services nine times in the month of June, 2014, seven times in the month of July, 2014, and six times in the month of August, 2014. Medical record review of the Restorative Narrative Notes dated June 27, 2014, July 28, 2014, and August 28, 2014, revealed the resident received maintenance ROM three times a week. Observation of resident #51 on September 29, 2014, at 10:00 a.m., in the resident's room revealed bilateral hand contractures. The 3rd, 4th, and 5th digits were flexed tightly into the palms bilaterally. The index fingers were in extension. A therapeutic soft carrot was laying on the over the bed table for the resident to place in the hands several times daily. Review of the facility policy Range of Motion Exercises revised June 1997, revealed .documentation of range of motion exercise program occurs in .graphic record and basic care sheet .clinical notes . Interview with the Assistant Director of Nursing (ADON) on October 1, 2014, at 10:35 a.m., in the conference room confirmed the Restorative Narrative Notes were the monthly documentation for ROM services. Further interview confirmed that the Restorative Flow Sheet Report for August 2014, documented the resident received ROM 6 times during the month of August and the Restorative Narrative Notes dated August 28, 2014, stated the resident received ROM 3 times a week in the month of August and the documentation did not match.",2018-02-01
9250,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2013-08-28,441,D,0,1,ZN3U11,"Based on observation, facility policy review, and interview, the facility failed to ensure infection control was maintained for one resident (#17) of twenty-nine residents reviewed. The findings included: Observation on August 26, 2013, at 4:00 p.m., with Licensed Practical Nurse (LPN) #1 revealed LPN #1 obtained a fingerstick from resident # 17, returned to the medication cart, drew up the resident's insulin and obtained other medications for the resident, returned to the resident's room and administered the insulin without washing the hands or applying gloves. Review of the facility policy, Alcohol Based Handrub, revealed .wash hands with appropriate soap and water if hands are visibly soiled or contaminated with blood or body fluids. Alcohol-Based Handrubs may be used for the following routine cleaning: .Before having direct contact with patients . Review of the facility policy, Subcutaneous Injections, revealed .The following equipment and supplies will be necessary when performing this procedure .Personal protective equipment ( .gloves .) . Interview with Licensed Practical Nurse (LPN) #1, on the hall , at 4:05 p.m., confirmed LPN #1 did not wash the hands or apply gloves prior to administering the insulin. Interview on August 28, 2013, at 8:00 a.m., with the Director of Nursing (DON), in the DON's office, confirmed gloves are to be worn when administering an injection .",2017-01-01
11602,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2012-02-08,312,D,0,1,X9TW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide personal hygiene in a timely manner for one resident (#17) of twenty-five resident reviewed. The findings included: Resident #17 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 physical assistance of one person for toilet use and cleansing self after bladder/bowel elimination. Observation of resident #17 on February 6, 2012, at 9:35 a.m., revealed the resident lying in bed; interview with the resident at time of observation revealed the resident stated had called for assistance to be cleaned up. Continued interview revealed the resident had called for assistance three times and no staff had come to the resident's aide. Further interview revealed the resident was laying in bowel movement; resident stated had been asking for assistance since between 7:30 a.m. and 8:00 a.m. The surveyor encouraged the resident to call for assistance again, the resident was hesitant due to afraid of making the staff upset. The resident called for assistance at 9:35 a.m., the nurses' station answered call and informed resident staff would be right there. Staff entered to provide assistance at 9:55 a.m. (20 minutes later). Interview with Licensed Practical Nurse #5 (LPN) on February 7, 2012, at 2:30 p.m., at the nurses' station, verified would expect some staff person to help/assist the resident within 5-10 minutes of a request. Interview with Charge Nurse #1 (CN) on February 7, 2012, at 2:35 p.m., at the nurses' station, verified would expect a staff person to help/assist a resident within 5-10 minutes. Interview with the House Supervisor on February 7, 2012, at 3:25 p.m., at the nurses' station, confirmed expects the staff to help any resident who asks for assistance within 5-10 minutes.",2015-12-01
11603,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2012-02-08,431,D,0,1,X9TW11,"Based on observation and interview, the facility failed to properly separate topical and oral medications for two of six medication carts and failed to ensure medications were not available for use beyond the expiration date on one of six medication carts. The findings included: Observation of the third floor long hall medication cart on February 7, 2012, at 1:34 p.m., revealed one bottle of Chloraseptic spray (throat analgesic) with no prescription label and an expiration date of July 2011. Interview with Licensed Practical Nurse (LPN) #3 on February 7, 2012, at 1:34 p.m., at the third floor nurses station, confirmed the medication was available for use beyond the expiration date. Observation of the second floor short hall medication cart on February 7, 2012, at 1:59 p.m., revealed Nystatin Cream (antifungal) and Paxil (antidepressant) 40 milligram tablets were located within the same compartment in the medication cart. Interview with LPN #2 on February 7, 2012, at 1:59 p.m., at the second floor nurses station, confirmed topical ointments and oral medications were not to be stored in the same medication compartment. Observation of the first floor short hall medication cart on February 7, 2012, at 2:20 p.m., revealed Saline Nasal Spray and two tubes of Bactroban (antibacterial) ointment were located within the same compartment in the medication cart. Interview with LPN #4 on February 7, 2012, at 2:20 p.m., at the first floor nurses station, confirmed internal and external medications were not to be stored in the same medication compartment.",2015-12-01
11604,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2012-02-08,441,E,0,1,X9TW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, facility policy review, and interview, the facility failed to maintain infection control for the treatment cart during dressing change for one resident (#1); failed to ensure staff washed hands after providing direct resident care for one resident (#17); failed to ensure hand washing during a dressing change for one resident (#25) of twenty-five residents reviewed; and failed to wash the hands during medication administration and to clean injection ports of insulin bottles prior to withdrawing insulin for three of three insulin administrations observed. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review revealed the resident started receiving Hospice Care on November 18, 2011. Observation on February 6, 2012, at 3:15 p.m., revealed a Hospice Nurse was doing a dressing change. Continued observation revealed the Hospice Nurse took the treatment cart into the resident's room, and stationed the cart next to the resident's bed. Interview with the Hospice Nurse on February 6, 2012, at 3:30 p.m., in the hallway, confirmed always took the treatment cart into the resident's room. Observation of the treatment cart on February 7, 2012, at 8:10 a.m., with LPN #5 revealed the cart contained individual containers of normal saline, different sizes of gauze, disinfectant wipes, hand sanitizer, tape, alcohol pads, individual medications, moisturizing creams, zinc creams, foam gauze pads. Interview with LPN #5 at the time of observation revealed the treatment cart was to stay in hallway due to infection control. Interview with the Assistant Director of Nursing on February 7, 2012, at 12:05 p.m., in the hallway, confirmed the treatment cart was not to be taken into resident's rooms due to infection control. Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation on February 6, 2012, at 10:00 a.m., in the resident's room, revealed Certified Nursing Assistant #1 (CNA) was wearing gloves providing incontinence care of a bowel movement. Continued observation revealed after the CNA provided the care the CNA removed the soiled brief and pad and placed in a plastic bag. Continued observation revealed the CNA did not remove the soiled gloves/wash the hands; placed a clean gown on the resident, pulled the privacy curtain, retrieved the shower chair stationed in the foyer of the room, moved the over bed table, moved the plastic container of the disposable wipes, assisted the resident to the shower chair, placed a clean blanket around the resident, using the same gloves to provide the incontinence care. Review of the facility's policy Handwashing dated October 1, 2008, revealed .wash hands before and after contact with each patient . Interview with the Director of Nursing on February 8, 2012, at 8:10 a.m., in the hallway, confirmed gloves are to be removed and hands washed after providing incontinence care. Resident #25 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Weekly Wound Assessment Record updated January 31, 2012, revealed the resident had a surgical wound to the left proximal (upper buttocks/lower back area) buttocks measuring 2.7 centimeters (cm) by 12.6 cm with a depth of 2.3 cm, and undermining of 8.9 cm; a surgical wound to the right ischial (lower buttocks area) measuring 1.4 cm by 2.1 cm with a depth of 0.3 cm; and a surgical wound to the left ischial measuring 1.0 cm by 0.6 cm, with a depth of 0.3 cm. Observation of a dressing change on February 7, 2012, from 9:45 a.m., until 10:20 a.m., in the resident's room, revealed Licensed Practical Nurse #5, without washing or sanitizing the hands, entered the resident's room with supplies to change three dressings on the resident's buttocks. Further observation revealed the LPN, without washing or sanitizing the hands, prepared an over bed table with the supplies for the dressing changes. Further observation revealed, without washing or sanitizing the hands, the LPN donned gloves, removed the old dressings from the left proximal buttocks and the left ischial, pulled soiled gauze packing from the pocket of the left proximal buttocks wound, and without washing or sanitizing the hands, changed gloves, cleaned the wound by irrigating it with a 60 milliliter syringe of normal saline, packed the wound pocket with wet gauze, opened two packages of dry gauze, covered the wound with the dry gauze, removed the soiled gloves and, with ungloved hands, secured the dressing with tape. Further observation revealed, without washing or sanitizing the hands, the LPN cleaned the over bed table, prepared supplies for the next dressing, donned clean gloves, and cleaned the left ischial wound. Further observation revealed, without washing or sanitizing the hands, the LPN changed gloves, covered the left ischial wound with wet gauze, then dry gauze, and secured with tape. Further observation revealed the LPN removed the soiled gloves, without washing or sanitizing the hands, donned clean gloves, changed the resident's draw sheet, rolled the resident to the left side, moved the over bed table to the opposite side of the bed, opened new supplies, and removed the gloves. Further observation revealed the LPN, without washing or sanitizing the hands, prepared the supplies for the next dressing change, donned clean gloves, removed old linen from the resident's bed, removed the dressing from the right ischial wound, and removed the soiled gloves. Further observation revealed, without washing or sanitizing the hands, the LPN donned clean gloves, cleaned the wound, covered the wound with wet gauze, then covered the wound with dry gauze, removed the soiled gloves, and, with ungloved hands, secured the dressing with tape. Further observation revealed the LPN, without washing or sanitizing the hands, donned clean gloves, positioned the resident in bed, and gathered up trash from the room. Observation revealed the LPN washed the hands before leaving the resident's room. Review of the facility's policy, Dressing-Clean Technique, revised June, 1997, revealed, .Wash hands before and after procedure and wear gloves . Review of the facility's policy, Handwashing, revised October 1, 2008, revealed, .Wash hands before and after contact with each patient .and before and after removal of gloves . Interview with LPN #5 on February 7, 2012, at 10:23 a.m., outside the resident's room, confirmed the LPN did not wash or sanitize the hands before beginning the dressing change, did not wash or sanitize the hands after removing the soiled dressings, before applying clean dressings, and did not wash or sanitize the hands between dressing changes for multiple, separate wounds. Interview with the Director of Nursing (DON) on February 7, 2012, at 10:45 a.m., in the DON'S office, confirmed nursing staff were trained to wash or sanitize the hands prior to beginning a dressing change, between removing soiled dressings and applying clean dressings, and in between dressing changes for multiple separate wounds. Observation of Licensed Practical Nurse (LPN) #1 on February 6, 2012, at 4:30 p.m., on the first floor, revealed the LPN donned gloves before checking a finger stick blood sugar (FSBS), completed the FSBS, removed the gloves, and without washing the hands, obtained an insulin syringe. Continued observation revealed the LPN obtained the insulin bottle previously opened, and did not clean the injection port prior to withdrawing the insulin. Interview with LPN #1 on February 6, 2012, at 4:45 p.m., on the first floor long hall, confirmed the hands were not washed before drawing up insulin for administration and the insulin bottle injection port was not cleaned prior to withdrawing insulin. Review of the facility's Handwashing policy dated October 1, 2008, revealed, .wash hands before and after contact with each patient .and before and after removal of gloves . Observation of LPN #2 on February 7, 2012, at 7:37 a.m., at the second floor nurses' station, revealed LPN #2 drew up insulin in a syringe for administration for one resident. Further observation revealed the insulin bottle had been setting in the medication cart, previously opened, and the injection port was not cleaned prior to withdrawing insulin. Further observation of LPN #2 on February 7, 2012, at 7:44 a.m. at the second floor nurses' station, revealed LPN #2 drew up insulin in a syringe for administration to a second resident. Further observation revealed the insulin bottle had been setting in the medication cart, previously opened, and the injection port was not cleaned prior to withdrawing the insulin. Interview with LPN #2 on February 7, 2012, at 7:44 a.m., at the second floor short hall, confirmed the insulin bottles were not cleaned prior to withdrawing insulin. Interview with the Director of Nursing (DON) on February 7, 2012, at 10:45 a.m., in the DON office, confirmed the expectation is that insulin vials will be cleaned by alcohol if already opened. C/O #",2015-12-01
11605,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2012-02-08,514,D,0,1,X9TW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to assure the medical record reflected administration of a house supplement for one resident (#2) of twenty-five residents reviewed. The findings included: Resident #2 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Physician's Telephone Order dated November 18, 2011, revealed .house supplement TID (three times a day) with meals . Interview and medical record review with Resident Care Coordinator #1, on February 7, 2012, at 9:00 a.m., revealed the December, January and February Medication Administration records (MAR) did not document the administration of the house supplement. Interview with the Director of Nursing on February 8, 2012, at 9:05 a.m., in the Director's office confirmed the MAR's did not document administration of the house supplement for December, January, and February.",2015-12-01
13165,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2011-12-07,323,G,1,0,FVDY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide supervision to prevent multiple injuries including fractures (Actual Harm) for one resident (#1) of five residents reviewed. The findings included: Resident #1 was admitted to the facility from an acute care hospital on June 21, 2011, with [DIAGNOSES REDACTED]. Medical record review of the Interim Care Plan completed on admitted d June 21, 2011, revealed "" ...At risk for falls related h/o (history of) falls, unsteady gait, poor safety awareness, confusion ...Goal: to prevent injury related to falls ...orient the resident to room, bed controls, light and call-light ...grab bars in bathroom ...instruct and remind the resident to use the call light to ask for assist ...keep path around the bed and to the bathroom clear from clutter ...clip alarm on admission ..."" Medical record review of a Post Falls Nursing assessment dated [DATE], at 1:15 a.m., revealed "" ...Alarm sounded, staff was immediately in the room and resident was already on the floor on ...knees with arms on bed ...fell from bed ...mats placed by bed on floor ..."" Medical record review of a Post Falls Nursing assessment dated [DATE], at 1:00 a.m., revealed "" ...CNA (certified nursing assistant) went into room and found resident on floor beside bed on knees ...clip alarm found lying in bed with string clip off of resident gown ...alarm not sounding ...Describe task patient attempting at time of fall: Exiting bed over siderail ...clip alarm reapplied to resident gown ...placed floor mat beside bed and bed pressure alarm ..."" Medical record review of a nurse's note dated August 5, 2011, at 2:15 p.m., revealed "" ...Alert charting: fall ...fall precautions in place ..."" Medical record review of a nurse's note dated August 9, 2011, revealed ""late entry for August 5, 2011 ...falls f/u (follow up) ...resident found in floor beside bed ...resident was attempting to ambulate alone ...fell from w/c (wheelchair) ...resident with known attempts to txf (transfer from bed) / bed to w/c however no demonstration of self txf /w/c to bed ...assessed found to have no injuries ...currently with safety precautions in bed (secondary) to attempts as noted above ...will (change) clip alarm f/ bed (in bed) to all times (secondary) to poor safety awareness ..."" Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had short and long term memory problems, severe cognitive impairment, and required extensive assistance with most activities of daily living, one person assist with mobility and two person assist with transfers. Continued medical record review of the MDS revealed the resident's balance was unsteady, and had been unable to stabilize without assistance when moving from sit to stand, walking, when moving on and off a toilet seat, and when transferring from surface to surface (bed to chair or wheelchair). Medical record review of a Post Falls Nursing assessment dated [DATE], at 1:35 p.m., revealed "" ...Loud noise came from bathroom while therapist waited outside bathroom door with door cracked open ...exiting commode while unattended ...intervention ...attend while toileting ..."" Medical record review of a Nurse's note dated October 11, 2011, at 12:30 p.m., revealed "" ...hematoma noted to back of head ...bruised area noted to right area below temple ...small bruised area noted to (L) (left) hip ...c/o (complained of) mild pain with movement of (L) leg..MD (physician) notified with n/o (new order) received ...to x-ray left hip..."" Medical record review of the x-ray report revealed no fracture. Medical record review of a nurse's note dated October 13, 2011, at 12:00 p.m., revealed "" ...up in w/c early this shift after several attempts to get OOB (out of bed) without assistance ...Pt. (patient) bathed, toileted, and dressed @ (at) this time ...some c/o lower back pain ...relieved by PRN (as needed) pain meds ...no further injury noted ...hematoma to back of head has decreased in size ...neuro checks within normal limits ...all safety measures in place ..."" Medical record review of a nurse's note dated October 20, 2011, at 3:30 p.m., revealed "" ...Extensive assist required for toileting, transfers, and bed mobility..safety precautions in use ..."" Medical record review of a nurse's note dated October 26, 2011, at 2:30 p.m., revealed "" ...resident moved to room (#) to be closer to nurse's station ...resident with attempts to get OOB several times ...safety precautions in place ..."" Medical record review of a nurse's note dated November 7, 2011, at 9:30 a.m., revealed "" ...Bruises noted on Rt (right) shoulder...Rt knee swollen...RLE (right lower extremity) shortening with internal rotation...new order to x-ray."" Medical record review of a nurse's note dated November 7, 2011, (no time) revealed "" ...per FNP (Family Nurse Practitioner) after further assessment...RLE's, knee and shoulder painful upon movement ...Hydrocodone 5/325 (milligrams) given and Ativan 0.5 mg given for pain and agitation/anxiety...x-rays cancelled with (name of company) ...will send pt. by (ambulance) to (named hospital)...pain medication is effective...pt. (patient) is calm..."" Medical record review of the hospital Emergency Department record dated November 7, 2011, at 5:30 p.m., revealed ""...Brought in from nursing home (name)...Pt. found internal rotation of (R) leg, bruising (R) shoulder, bruising & (and) swelling (R) knee..."" Medical record review of Radiology reports dated November 7, 2011, revealed ""...Left Parietal scalp soft tissue swelling/hematoma (no fracture)...Comminuted (splintered or crushed) and displaced right subtrochanteric femoral fracture of the right proximal femur...Comminuted and displaced distal right clavicular fracture...Medial knee soft tissue injury...no fracture or subluxation..."" Medical record review of the hospital discharge record dated November 14, 2011, revealed the resident was admitted to the hospital for surgical repair of the right femoral fracture. Review of a facility investigation dated November 7, 2011, revealed the resident had been found in bed at 8:30 a.m., with a swollen right knee, a shortened and rotated right leg, right shoulder bruising, and pain with movement. Further review of the facility investigation revealed staff working the prior evening, and night shifts, on November 6 and 7, 2011, had been interviewed by the Director of Nursing (DON) and none were aware of any alarms sounding or of any abnormal events occurring with the resident on either shift. Medical record review revealed the resident was readmitted to the facility on [DATE]. Medical record review of a nurse's note dated November 18, 2011, at 11:00 a.m., revealed ""...Event f/u (follow-up)...resident with recent Right clavicle fracture and right hip fracture per hospital admission 11/7/11...per staff interview, resident with fracture of unknown origin noted November 7, 2011...no noted attempts to get OOB per night shift interviews...resident with H/O (history of) falls in past with safety alarms in place ...no reported events of alarms sounding prior to event to indicate/believe attempts to get OOB ...will continue with safety precautions of pressure alarm to bed, safety mats beside bed, & clip alarm at all times secondary to h/o falls..."" Interview with CNA #1 on December 2, 2011, at 1:15 p.m., in the Social Services office, confirmed CNA #1 delivered the breakfast tray to the resident's room on Monday, November 7, 2011, at approximately 8:00 a.m. CNA #1 stated the resident took only juice for breakfast and when CNA #1 attempted to reposition the resident in preparation for a shower, the resident screamed. The CNA immediately called the nurse and then noticed the right knee ""...swelling and kinda blue..."" Licensed Practical Nurse #1 (LPN) arrived at the resident's beside and both CNA #1 and LPN #1 noted more bruising in the resident's right hip area. Interview with LPN #1 on December 5, 2011, at 7:00 a.m., in the 2nd floor office, confirmed LPN #1 had been assigned to care for resident #1 on day shift, 7:00 a.m. to 3:00 p.m., on November 7, 2011. Continued interview revealed LPN #1 stated ""I knew the resident had fallen several times in the past ...I arrived at 7 a.m...from the time I came on until the time we noticed the bruises, nothing happened, no alarms sounded, and the resident was in the bed as far as I knew."" Interview with the Charge Nurse, on December 5, 2011, at 7:35 a.m., in the 2nd floor office, confirmed on November 7, 2011, the resident was in bed ""...when I was called to the room, I went into the room between 8:30 a.m. and 9:00 a.m. that morning. I looked at the right knee, it was swollen, I moved it a little and the resident screamed. I looked at the other places next, saw a bruised shoulder, bruised hip, and one foot shorter than the other, and ordered x-ray immediately. The Nurse Practitioner was here, assessed the resident right away, said cancel the x-ray and send to the hospital."" Interview with LPN #3, on December 5, 2011, at 7:10 a.m., in the 2nd floor office, confirmed LPN #3 worked on November 7, 2011, on the 7a.m., to 3 p.m., shift. LPN #3 stated ""...(Charge Nurse) came and got me to come look at the resident... pulled back the sheet, the right shoulder and under arm were bruised but not like someone pulled the resident up by the arm, horrible, dark, purple bruising...I don't see the resident much, I work the short hall usually (other end of floor, around the corner from the nurse's station) ...I heard no alarms that morning."" Interview with LPN #2 on December 5, 2011, at 6:05 a.m., in the 2nd floor office, confirmed LPN #2 worked on November 6, 2011, on the 11 p.m. to 7 a.m. shift, (night shift prior to the discovery of the injuries on November 7, 2011), and was assigned as the resident's nurse. LPN #2 stated ""(Resident #1)...doesn't move a whole lot when in bed but can move...don't know if...can take off clip alarm...no one said anything about anything...saw no signs of pain, heard no alarms, no moaning."" Interview with CNA #3 on December 5, 2011, at 6:20 a.m., in the 2nd floor office, confirmed CNA #3 worked on November 6, 2011, from 11 p.m. to 7 a.m., (night shift prior to discovery of the injuries on November 7, 2011), and was assigned to resident #1. CNA #3 stated Resident #1 was asleep throughout the night and not wet until the last rounding at 5:30 a.m., on November 7, 2011. CNA #4 was with CNA #3 when they changed the resident's pad on the last round and the resident woke up. CNA #3 stated they did not notice any injury. Interview with CNA #4 on December 5, 2011, at 6:05 a.m., in the 2nd floor office, confirmed CNA #4 worked on November 6, 2011, from 11:00 p.m. to 7:00 a.m., (night shift prior to discoveryof the injuries on November 7, 2011). CNA #4 confirmed completing the last round together with CNA #3 on that shift. CNA #4 confirmed they did not note any injury for Resident #1. Interview with CNA #7 on December 4, 2011, at 4:10 p.m., confirmed CNA #7 worked from 3 p.m. to 11:00 p.m., on November 6, 2011, (the day before the discovery of the injuries) and was assigned to care for resident #1. CNA #7 stated ""I put (resident #1) to bed...just do a transfer...can stand real good, stand and pivot to the bed, put gown on, clip alarm, pressure pad alarm on bed, check to make sure the alarms are working...I did final round at 10:00 p.m., ...(resident) dry and asleep, did not wake up...clip alarm still on."" Interview with LPN #4 on December 2, 2011, at 3:35 p.m., in the 2nd floor office, confirmed LPN #4 worked on November 6, 2011, from 7:00 a.m. to 11:00 p.m., (day before discovery) and was assigned to resident #1. LPN #4 confirmed resident #1 had been up most of the day and was sleeping in the bed at 9:00 p.m. LPN #4 stated the CNAs did not report anything abnormal. ""Nobody said anything that night and (resident) did not call out."" Interview by telephone on December 7, 2011, at 9:25 a.m., with the resident's Physician, (related to the injuries discovered on November 7, 2011) confirmed, ""I can't find specifics for that many injuries...(resident) had to have fallen or been dropped to have gotten that many injuries."" Interview and review of Radiology reports dated November 7, 2011, by telephone on December 8, 2011, at 10:15 a.m., with the Radiologist who provided the consultation confirmed the type of fractures the resident had ""could not have been...spontaneous...had to have been some type of trauma..."" Interview and medical record review of nurse's notes and post fall assessments, with the Assistant Director of Nursing (ADON) on December 1, 2011 at 2:30 p.m., in the Medical Records office, confirmed the resident had fallen several times since admission: June 28, 2011, at 1:15 a.m., from the bed with alarm sounding; July 9, 2011, at 1:00 a.m., ""exiting from bed over side rail"", clip alarm found on bed, not sounding; August 5, 2011, at 2:15 (no other notation) fell from the wheelchair while attempting to transfer unassisted; and on October 10, 2011, at 1:35 p.m., from the commode ""exiting commode while unattended"" in the Physical Therapy suite bathroom. Interview with the ADON, by phone on December 5, 2011, at 2:45 p.m., confirmed the resident experienced an unwitnessed event, discovered on November 7, 2011, which resulted in fractures, hematoma, and numerous bruises and required hospitialization and surgical intervention. C/O #",2015-04-01
13704,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2010-10-20,431,D,0,1,SKCQ11,"Based on observation and interview, the facility failed to store and maintain an accurate record of medication disposition for one medication cart of four observed. The findings included: Observation of a medication cart at the second floor nursing station on October 20, 2010, from 1:15 p.m. until 1:30 p.m., revealed the cart had six drawers which contained residents' medications in cardboard blister-pack sheets (individual pills pushed through a foil cover on the back of the sheet). Further observation revealed each drawer contained medications for multiple residents based on the room number. Further observation on October 20, 2010, from 1:15 p.m., until 1:30 p.m., revealed the first drawer had three loose pills in the bottom of the drawer; the second drawer had four loose pills in the bottom of the drawer; the third drawer had two loose pills in the bottom of the drawer; the fourth drawer had six loose pills in the bottom of the drawer; the fifth drawer had four loose pills in the bottom of the drawer; and the sixth drawer had six loose pills in the bottom of the drawer. Interviews with the second floor nurse manager and Licensed Practical Nurse #1 on October 20, 2010, from 1:15 p.m., until 1:30 p.m., at the second floor nursing station, confirmed there were multiple pills loose in the bottoms of the medication drawers, and the pills could not be identified as to what medication or which resident. Further interviews confirmed the medications were not properly stored and accounted for.",2014-10-01
13705,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2010-10-20,281,D,0,1,SKCQ11,"**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 resident's pain and obtain an order before administering medications for one resident, (#13), of twenty-four residents reviewed. The findings included: Resident #13 was admitted to the facility October 28, 2009 with [DIAGNOSES REDACTED]., and Gait Disturbance. Medical record review of the physician's orders [REDACTED]. Medical record review of the nurse's note dated April 17, 2010 at 2 a.m., revealed "" ...c/o (complaint of) Rt. Hip, groin, leg pain...PRN (as needed) given at 12:45 a.m..."" Medical record review of the Narcotic Inventory Record dated April 17, 2010, revealed the resident received one [MEDICATION NAME]/APAP 5/325 mg (milligrams - pain medication) at 12:45 a.m. Medical record review of the facility Narcotic Inventory Record for Resident #13 revealed an additional dose of [MEDICATION NAME]/apap 5/325 milligrams (mg) was signed out by LPN #2 at 6:45 a.m. April 17, 2010. Medical record review of the nurse's notes revealed no documentation the physician was notified on April 17, 2010, at 12:45 a.m., or 6:45 a.m., of the resident's pain or for a request from the nurse to the doctor for an order for [REDACTED]. Interview with the DON on October 20, 2010 at 2:10 p.m., in the conference room, confirmed the third shift nurse, LPN#2, failed to report the resident's new onset of pain to the physician and failed to get an order for [REDACTED].",2014-10-01
13706,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2010-10-20,425,D,0,1,SKCQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure the safe administration of medication for one resident of twenty-four residents reviewed. The findings included: Resident # 13 was admitted to the facility October 28, 2009 with [DIAGNOSES REDACTED]., and Gait Disturbance. Medical record review of the physician's orders [REDACTED]. Medical record review of the nurse's note dated April 17, 2010 at 2 a.m. revealed ""...PRN (as needed) given at 12:45 a.m."" Medical record review of the Narcotic Inventory Record dated April 17, 2010, revealed the resident received one Hydrocodone/APAP 5/325 mg (milligrams - pain medication) at 12:45 a.m. Medical record review of the facility Narcotic Inventory Record for Resident #13, dated December 3, 2009, revealed the medication, (hyrocodone/apap 5/325 mg) was still available to dispense and LPN #2 had signed out a dose of one tablet April 17, 2010 at 12:45 a.m. and another tablet at 6:45 a.m. April 17, 2010. Medical record review of the facility Medication Administration Record [REDACTED]., was marked "" ...d/c 4-5-10"" and no documentation, front or back, by LPN #2 that the medication was given twice on April 17, 2010. Interview with the Director of Nursing (DON) at 2:10 p.m. October 20, 2010 in the conference room, confirmed LPN #2 administered two doses of hydrocodone /apap without a physician's orders [REDACTED].",2014-10-01
13707,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2010-10-20,221,D,0,1,SKCQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to assess for use of a physical restraint for one resident (#12) of twenty-four residents reviewed. The findings included: Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had impaired long and short term memory; severely impaired cognitive skills; required total assistance for all activities of daily living; had not experienced any fall in the last 180 days; and did not use any devices or restraints. Medical record review of the Care Plan dated April 14, 2010, and updated September 9, 2010, revealed the resident was at risk for falls; was to have a clip alarm on at all times; and the bed was to be against the wall with safety mats on the open side. Medical record review of the Side Rail Assessment completed September 3, 2010, revealed, ""Patient requires assist with bed mobility and transfers. Upper Side Rails do not restrict current physical capabilities and are not a restraint. Lower Rails are not elevated."" Medical record review of the High-Risk Patient Selection Form dated September 3, 2010, revealed, ""H/O (history of) falls - End Stage Alzheimers (with) disorientation @ (at) all times. Risk for falls. Clip alarm/Bed against wall for fall prevention."" Observations of the resident on October 18, 2010, at 8:00 a.m., 10:45 a.m., and 4:10 p.m., revealed the resident in bed, with the bed against the wall; upper and lower side rails raised on the side of the bed away from the wall; and a wedge cushion, underneath the fitted sheet, filling the space between the upper and lower side rails. Observation of the resident on October 19, 2010, at 8:00 a.m., and 8:20 a.m., revealed the resident in bed, with the bed against the wall; upper and lower side rails raised on the side of the bed away from the wall; and a wedge cushion, partially underneath the fitted sheet, filling the space between the upper and lower side rails. Interview with CNA (certified nurse aide) #1 on October 19, 2010, at 8:10 a.m., in the resident's room, confirmed both upper and lower side rails were raised, and a wedge cushion was placed in the space between the side rails because the resident would hang the legs over the side of the bed, between the rails, and was at risk for falling out of the bed. Interview with the LPN/MDS (licensed practical nurse) Careplans staff member on October 19, 2010, at 8:20 a.m., in the resident's room, confirmed the resident would attempt to swing legs between the side rails and sit on the side of the bed, placing the resident at risk for falling. Continued interview confirmed the resident did not have any safety awareness and was not able to understand or retain instructions from staff. Continued interview confirmed the wedge between the raised side rails prevented the resident from sitting on the side of the bed, which was a restraint, and the resident had not been assessed for the use of restraints. Interview with the MDS Coordinator on October 19, 2010, at 10:05 a.m., in the resident's room, confirmed the resident was assessed for the upper side rail to be raised, not the lower side rail, and the resident was capable of removing the wedge. Interview with the Second Floor Nurse Manager on October 20, 2010, at 8:45 a.m., in the resident's room, confirmed the resident had not been assessed for the lower side rail being raised, and confirmed the resident was not capable of removing the wedge when placed underneath the fitted sheet, which was a restraint for the resident.",2014-10-01
13856,"NHC HEALTHCARE, FT SANDERS",445107,2120 HIGHLAND AVE,KNOXVILLE,TN,37916,2011-04-12,333,D,1,0,96TD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure one resident (#4) was free of a significant medication error of five residents reviewed. The findings included: Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had moderate impairment of decision-making skills and required extensive assistance with all activities of daily living. Medical record review of a nurse's note dated February 10, 2011, at 7:45 a.m., revealed, ""...appeared lethargic...Talking to staff but appeared drowsy..."" Medical record review of a nurse's note dated February 10, 2011, at 9:00 a.m., revealed, ""(Blood Pressure) 95/63...felt diaphoretic...from wheelchair to bed. Elevated feet. Pt's (Patient)skin returned to normal. Felt warm & (and) dry..."" Medical record review of a nurse's note dated February 10, 2011, at 11:10 a.m., revealed, ""...Respirations 5-BP (Blood Pressure) 112/64...Going to (hospital)...staring up at ceiling with eyes open. Still responding to name."" Review of an emergency room report dated February 10, 2011, revealed [MEDICATION NAME] (medication to reverse the effects of narcotic overdose) was administered to reverse the effects of the narcotic which had been administered to resident #4. Medical record review of a nurse's note dated February 10, 2011, at 6:00 p.m., revealed, ""Returns to facility...Alert & responsive...Resp. (respirations) even and unlabored."" Interview on April 11, 2011, at 11:25 a.m., with the Director of Nursing confirmed resident #4 was given resident #5's 6:00 a.m., [MEDICATION NAME] (narcotic [MEDICATION NAME]) on February 10, 2011. Medical record review of the physician's orders [REDACTED]. Telephone interview on April 11, 2011, at 3:30 p.m., with the Registered Nurse (RN) on duty on day shift on February 10, 2011, confirmed resident #5 reported ""...did not get [MEDICATION NAME] (6:00 a.m.)...is well aware and can tell us this."" Continued interview with the RN confirmed resident #4 was ""making comments and laughing-not like (resident)"", and confirmed the resident's respirations ""begun to get lower and lower. We thought we better send...out...called hospital and they said they had gotten...respirations back up and were sending...back..."" Telephone interview on April 11, 2011, at 3:45 p.m., with the Licensed Practical Nurse (LPN) who was assigned to the resident on night shift on February 9-10, 2011, confirmed the LPN went into the room to administer the 6:00 a.m., [MEDICATION NAME] to resident #5 when a Certified Nursing Assistant requested assistance from the LPN. Continued interview confirmed the LPN ""got confused"" and administered [MEDICATION NAME] 40 mg, belonging to resident #5, to resident #4. The LPN stated, ""I got my wires crossed and gave it to the resident in B bed instead of A bed."" C/O #",2014-08-01
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
3628,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2016-11-02,371,F,0,1,CHYD11,"Based on facility policy review, observation, and interview, the facility failed to properly store dry stock and frozen food items in a sanitary manner; failed to serve food in a sanitary manner; failed to ensure kitchen equipment, walk in cooler, and non-food contact surfaces were clean; and failed to properly air dry steam table pans in 5 of 5 stacked steam table pans observed, affecting 149 of 157 residents. The findings included: Review of the facility policy, Safety & Sanitation Best Practice Guidelines Sanitation Dry Storage, dated revised 1/2011 revealed .All non-potentially hazardous foods shall be stored in a clean and dry location not exposed to dust or other contamination .If opened, packages should be closed securely to protect product . Review of the facility policy, Safety & Sanitation Best Practice Guidelines Sanitation Refrigerator and Freezer Storage, dated revised 1/2011 revealed .Foods will be stored in their original container or an approved container or wrapped tightly .Clearly labeled with the contents and the use by date . Review of the facility policy, Safety & Sanitation Best Practice Guidelines Cleaning Equipment, dated revised 1/2011 revealed .Equipment must be cleaned and/or sanitized after each use .The physical facilities shall be cleaned as often as necessary to keep clean . Review of the facility policy, Safety & Sanitation Best Practice Guidelines Sanitation Manual[NAME]Washing, dated revised 1/2011 revealed .Air Dry all items. Make sure all items are completely dry before stacking . Review of the facility policy, Safety & Sanitation Best Practice Guidelines Personnel Glove Use, dated revised 1/2011 revealed .there should be NO bare hand contact with ready-to-eat foods . Observation on 10/31/16 at 10:00 AM, in the Dish room, revealed 2 of 2 two inch steam table pans and 3 of 3 six inch steam table pans stored wet. Observation on 10/31/16 at 10:05 AM, with the Dietary Manager (DM) in kitchen, revealed 4 of 4 work tables with dried food debris on the table top and bottom shelves. Continued observation revealed a food warmer with dried thick debris on the sides, door, and bottom. Further observation revealed the tray line conveyor with dried debris on the rollers, sides, and bottom and multiple condiment packets on the bottom. Continued observation revealed the can opener with dried food debris on the blade. Further observation revealed the convection oven with thick burnt debris on the sides, front and doors. Observation with the DM on 10/31/16 at 10:15 AM, in the kitchen, revealed two food storage bins one for flour and one for sugar with dried sticky debris on the lids and food particles in the bottoms of the bins. Observation with the DM on 10/31/16 at 10:20 AM, in the kitchen of a dry stock room, revealed the following available for resident consumption: six bags of dry cereal with no label or use by date 3 of 6 were open to air. Continued observation revealed dry cereal and other food particles on the stock room floor. Observation with the DM on 10/31/16 at 10:25 AM, in the kitchen, of the walk-in freezer revealed the following foods with no label, use by date, and not tightly wrapped all items available for resident consumption: a). 9 Hamburger patties b). 3 Chicken tenders c.) a ten pound box approximately 3/4 full of cubed pork patties open to air d.) a two pound bag of Crab meat approximately 3/4 full Observation on 10/31/16 between 11:35 AM, and 11:50 AM of Dining Service in the [NAME] Dining room, revealed Certified Nursing Aide CNA #3 cutting a resident's sandwich, touching the bread, picking up a slice of tomato and placing it on the sandwich with her bare hands. Continued observation revealed the Speech Pathologist cutting a resident's sandwich touching the bread with her bare hands. Interview with the DM on 10/31/16 at 10:25 AM, in the kitchen, confirmed the facility failed to properly store dry stock and frozen food items in a sanitary manner; failed to ensure kitchen equipment, walk in cooler, and non-food contact surfaces were clean; and failed to properly air dry steam table pans. Interview on 10/31/16 at 11:35 AM with CNA #3 in the [NAME] Dining room, confirmed she did touch the resident's sandwich and a slice of tomato with her bare hands. Interview on 10/31/16 at 11:40 AM, with the Speech Language Pathologist (SLP) in the [NAME] Dining room, confirmed she did touch the resident's sandwich with her bare hands. Continued interview revealed she was unsure if touching the ready-to-eat food was an acceptable practice. Interview on 11/1/16 at 4:05 PM, in the conference room, with the Director of Nursing confirmed ready-to-eat foods are not to be touched with bare hands and the facility failed to follow their policy.",2020-04-01
3629,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2016-11-02,469,F,0,1,CHYD11,"Based on facility policy review, observation, and interview, the facility failed to eliminate the present of insects; failed to eliminate sources of food; and failed to routinely clean to eliminate harborage conditions in the Dietary Department effecting 149 of 157 residents. The findings included: Review of the facility policy, Safety & Sanitation Best Practice Guidelines Safety Pest Control, revealed .eliminating sources of food and shelter .the presence of insects and other pests shall be controlled to eliminate their presence .Premises should be routinely cleaned to eliminate harborage conditions . Review of a Pest Control Customer Service Report, dated 10/3/16 revealed .Kitchen area-interior-hole/gap noted on wall behind microwave .seal to prevent pest entry or harborage .Receiving dock-exterior-exit door doesn't close/seal properly exclusion measures here will reduce the number of pests entering the area, found door not completely sealed closed . Observation with the Dietary Manager (DM) on 10/31/16 at 10:20 AM, in the kitchen of a dry stock room, revealed a metal storage rack containing three bags of dry cereal open to air. Continued observation revealed dry cereal and other food particles on the stock room floor. Continued observation revealed one insect crawling on the floor, and one insect crawling on the wall behind the rack. Interview with the DM on 10/31/16 at 10:20 AM, in the kitchen confirmed the facility failed to ensure the kitchen was free of insects.",2020-04-01
5345,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2015-10-28,371,F,0,1,N9R211,"Based on review of facility policy, observation, and interview, the facility dietary department failed to follow facility policy for hair covering, to store dishes under sanitary conditions, to store foods under sanitary conditions, to maintain sanitary food production equipment. The findings included: Review of facility policy, Personnel, Personal Hygiene, revised 1/2011 revealed .Dietary partners shall wear hair restraints .to effectively keep their hair from contacting exposed food . Review of facility policy, Sanitation, Machine Warewashing, revised 1/2011 revealed .Make sure all items are completely dry before stacking to prevent wet-nesting . Review of facility policy, Safety & Sanitation Best Practice Guidelines, Cleaning Procedures, Deep Fryer, revealed .After each use: 1. Clean outside surfaces. 2. Clean and filter grease . Observation of the dietary employees on 10/26/15 at 9:42 AM, in the kitchen revealed 3 of 9 employee's hair was not fully covered. Interview with the Food Service Director on 10/26/15 at 11:17 AM, in the kitchen confirmed the facility policy was not being followed. Observation of cleaned stacked dishes on 10/26/15 at 10:25 AM, in the kitchen revealed 14 large trays and 4 bowls nesting wet. Interview with the Food Service Director on 10/26/15 at 10:25 AM, in the kitchen confirmed dishes were not stored per facility policy. Observation of the walk-in cooler on 10/26/15 at 9:55 AM, revealed a bag of English muffins dated 10/17/15, a plastic bag containing 5 bread bowls lying on the floor and a container of two dozen eggs with 7 eggs broken and still in the tray. Interview with the Food Service Director on 10/26/15 at 10:25 AM, confirmed the English muffins were to be disposed of within 7 days (10/24/15), the plastic bag of bread bowls were not to be on the floor of the cooler, and broken eggs were to be removed immediately. Observation of the deep fryers on 10/26/15 at 10:26 AM revealed 1 of 2 deep fryer had food debris floating in the grease and along the sides of the fryer. Interview with the Food Service Director on 10/26/15 at 10:26 AM confirmed the deep fryer was not clean.",2019-03-01
7005,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2014-08-12,252,D,0,1,FK2C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility policy, review of facility Housekeeping checklists and calenders and interview, the facility failed to provide an odor free environment and an odor free sanitary mattress for one resident (#102) of five residents reviewed for incontinence of forty-two residents reviewed. The findings included: Observation on [DATE], at 3:05 p.m., in the room of resident #102, revealed resident #102 and the roommate seated in chairs, the beds had been made, and a very strong urine odor was present. Observation on [DATE], at 7:57 a.m., in the room of resident #102 revealed no residents present, resident #102's bed had been made, a safety mat was on the floor beside the bed, and a very strong urine odor was present. Observation on [DATE], at 7:45 a.m., in the room of resident #102 revealed the roommate of resident #102 sitting in a wheelchair. Further observation revealed both beds were made, and a very strong urine odor was present. Review of the facility policy titled Housekeeping Cleaning Schedule-Daily revealed, .wet mop patient room .review Housekeeping Checklist (Housekeeping Report/Room Readiness checklist) to assure maximum cleanliness . Review of the July and [DATE], Housekeeping Report/Room Readiness checklist, and the July and [DATE], calendar revealed deep cleaning of the bed frame and mattress had been scheduled for the room of resident #102 on [DATE], and [DATE]. Further review of the calendar revealed the [DATE], and [DATE], were not initialed. Interview and observation with Certified Nurse Assistant, (CNA) #1 on [DATE], at 7:50 a.m., in the room of resident #102 confirmed a very strong urine odor present. Continued interview with CNA #1 revealed housekeeping says the urine is in the floor, and they can't get it gone. Observation revealed resident #102's bed was made and a comforter was on top of the clean linens. Further observation revealed CNA #1 placed the bed comforter to the nose and stated yeah, it smells like urine. Further observation revealed when CNA #1 removed the bed linens, the mattress had a white powdery substance on it, and smelled of urine. Further interview with CNA #1 confirmed the strong urine odor was coming from the mattress of resident #102. Further interview with CNA #1 confirmed the room of resident #102 had been cleaned by housekeeping, and the bed linens had been changed that morning, but was unsure of who had changed the linens, or placed the white powdery substance on the mattress. Interview with housekeeper #1 on [DATE], at 8:00 a.m., at the 2 west nurses station, revealed the mattresses were cleaned when notified by the CNA's, upon a residents discharge, or when a resident changed rooms. Further interview with housekeeper #1 revealed the mattresses were cleaned with a disinfectant and not a white powdery substance. Further interview confirmed housekeeper #1 had already cleaned the room of resident #102 that morning and had noticed a urine odor in the room. Interview and observation with housekeeper #2 on [DATE], at 8:20 a.m., in the room of resident #102, confirmed the mattress of resident #102, had a hole in it, and the foam had been saturated with urine. Further interview with housekeeper #2 revealed the mattress with a hole had been placed in the dumpster. Observation revealed another mattress was present, and the strong urine odor was now only slightly noticeable. Further interview with housekeeper #2 revealed that mattresses were routinely changed when a resident was discharged , changed rooms, or died . Further interview revealed the mattress's were not otherwise changed unless housekeeper # 2, or the maintenance supervisor were notified. Further interview revealed, the bed rails, headboards and mattresses were routinely cleaned monthly, with Oxyfect, the same disinfectant used for daily cleaning of the resident rooms. Further interview and observation with housekeeper #2 revealed a copy of the July and [DATE], deep cleaning schedule and calendar schedule was posted in the 2 west housekeeping closet. Further interview revealed mattresses were changed on a as needed basis. Further interview revealed the calendar would be initialed when deep cleaning was completed. Further interview confirmed the calendar was not initialed on [DATE] or [DATE], indicating the deep cleaning for the room of resident #102 had not been completed. Further interview confirmed a break-down in communication between housekeeping and nursing staff to housekeeper #2 or the maintenance supervisor regarding the need for a new mattress for resident #102. Interview with the Administrator on [DATE], at 4:00 p.m., in the east hallway on the 1st floor confirmed the mattress for resident #102 had a hole in it, and was saturated with urine and the facility failed to provide an odor free environment and an odor free sanitary mattress for resident #102.",2018-03-01
7006,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2014-08-12,356,C,0,1,FK2C11,"Based on observation and interview, the facility failed to post the nurse staffing data. The findings included: Observation on August 10, 2014, at 11:00 a.m. and at 11:30 a.m., in the hallway outside the Administrator's office, revealed the nurse staffing data was not posted. Interview with the Administrator, on August 10, 2014, at 11:30 a.m., at the nurse staffing posting site, revealed .we know the staff posting is missing, we're still working on it . Interview with the Director of Nursing (DON) and the Staffing Coordinator, on August 10, 2014, at 2:53 p.m., in the DON's office, confirmed the nurse staffing data had not been posted Saturday, August 9, 2014, or Sunday, August 10, 2014. Further interview revealed it was the responsibility of the Staffing Coordinator to prepare the posting.",2018-03-01
7007,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2014-08-12,364,D,0,1,FK2C11,"Based on observation and interview, the facility failed to ensure expired milk was not accessible for resident consumption in one of three refrigeration units, of five dining rooms reviewed. The findings included: Observation on August 10, 2014, at 11:00 a.m., in the refrigration unit in the rehabilitation dining room, revealed two unopened 8-ounce cartons of buttermilk with an expiration date of August 3, 2014. Continued observation at 11:30 a.m., revealed residents in the rehabilitation dining room, lunch being served and the buttermilk remained in the refrigerator. Interview and observation with assistant cook #1 on August 10, 2014, at 11:36 a.m., in the rehabilitation dining room, confirmed two unopened 8-ounce cartons of buttermilk, with an expiration date of August 3, 2014, were in the refrigerator and were available for resident use.",2018-03-01
7008,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2014-08-12,441,D,0,1,FK2C11,"Based on observation and interview, the facility failed to provide a sanitary humidifier bottle for oxygen delivery for one resident (#171) of eleven residents reviewed who received oxygen therapy of forty-two residents reviewed. The findings included: Observation on August 10, 2014, at 10:15 a.m., in resident #171's room revealed the resident was receiving oxygen from an oxygen concentrator, the humidifier bottle that humidified the oxygen was empty and dated June 11, 2014. Observation on August 11, 2014, at 3:30 p.m., in resident #171's room revealed the resident was receiving oxygen from the oxygen concentrator and the humidifier bottle was approximately 1/2 full and dated June 11, 2014. Observation with LPN #1 on August 12, 2014, at 12:32 p.m., in resident #171's room revealed the resident was receiving oxygen from the oxygen concentrator, the humidifier bottle was approximately 1/2 full, and was dated June 11, 2014. Interview with LPN #1 on August 12, 2014, at 12:32 p.m., in resident #171's room revealed the humidifier bottles were changed every month on the second Wednesday. Continued interview confirmed the date on the water bottle was June 11, 2014, and the bottle should have been changed on July 9, 2014, the second Wednesday in July.",2018-03-01
8613,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2014-05-14,226,D,1,0,Y4F911,"Based on employee record review, facility policy review and interview, the facility failed to follow their Abuse policy by not having obtained an abuse registry check at hire for two Licensed Practical Nurse (LPN) #6 and LPN #7, of five employee records reviewed. The findings included: Review of the employee record for LPN #6 revealed the hire date of March 25, 2013. Further review of the record revealed no documentation of an abuse registry check. Review of the employee record for LPN #7 revealed the hire date of November 7, 2005, and the re-hire date of August 14, 2008. Further review of the record revealed no documentation of an abuse registry check upon re-hire in August 2008. Review of the facility policy, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect and Misappropriation of Property, last revised on August 1, 2011, revealed .The center will not employ individuals who .Are currently listed on .any other State employee screening or disqualification list for Abuse . Further review of the policy revealed the center would .check all appropriate .registry . Interview with the Director of Nursing, in the conference room on April 6, 2014, at 12:45 p.m., confirmed the the facility failed to follow their policy by not having obtained an Abuse registry check for LPN #6 and LPN #7.",2017-05-01
8614,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2014-05-14,441,D,1,0,Y4F911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain an environment to prevent cross contamination. The findings included: Observation during a facility tour on March 25, 2014, at 10:40 a.m., with the Director of Housekeeping present, revealed the resident was not in room [ROOM NUMBER] and a housekeeper was sweeping a pile of debris from the sweeping on the floor in the resident's room. Further observation revealed the oxygen concentrator was in operation and the nasal cannula was stored on the seat of the recliner, and the CPAP (Continuous Positive Air Pressure) mask was stored on a table surface. Interview with Certified Nurse Aide #6, during the observation in the resident's room, on March 25, 2014, confirmed the mask was to be stored in bag and placed in the drawer. Observation and interview during a facility tour on March 25, 2014, at 11:08 a.m., with the Director of Housekeeping present, confirmed in room [ROOM NUMBER], by the B bed, a CPAP mask was stored on the CPAP machine. Observation and interview, with the Director of Housekeeping, during a facility tour on March 25, 2014, at 11:10 a.m., confirmed resident #4 was in the room and the nebulizer mask was stored on top of the nebulizer machine. Interview with nurse in room revealed the nebulizer treatment was completed 30 minutes prior to observation and the mask should be stored in a bag after use. Observation on March 26, 2014, at 10:35 a.m., revealed resident #4 in the room and the nebulizer mask was stored on the nebulizer machine. Interview with Registered Nurse #3, in the room during the observation, confirmed the mask should be in a bag for storage when not in use.",2017-05-01
8615,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2014-05-14,514,D,1,0,Y4F911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review and interview, the facility failed to accurately transcribe a medication order and failed to document as needed medication administration and effectiveness on the Medication Administration Record as per policy for one resident (#2), of eighteen residents reviewed. The findings included: Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Further review revealed the resident was discharged from the facility to the hospital, for shortness of breath, on October 26, 2013, and readmitted to the facility on [DATE]. Further review revealed the resident was discharged to the hospital on December 20, 2013, and did not return to the facility. Medical record review of the hospital physician note dated October 18, 2013, revealed the primary [DIAGNOSES REDACTED]. Medical record review of the hospital Discharge Mediation Reconciliation dated October 18, 2013, revealed .[MEDICATION NAME] (antibiotic to treat [MEDICAL CONDITION]) 125 mg (millegrams )po QID through October 28, 2013 . Medical record review of the facility admission physician orders [REDACTED].[MEDICATION NAME] 125 mcg (micrograms) po q day . Further review revealed the facility made a transcription error when compared to hospital Discharge Mediation Reconciliation. Medical record review of the October 2013 Mediation Administration Record (MAR) revealed .[MEDICATION NAME] oral solution give 2.5 milliliters (ml) (125 mg) by mouth four times a day for 10 days . Interview with the Director of Nursing (DON) on May 14, 2014, at 10:35 a.m., in the conference room, confirmed the facility failed to accurately transcribe the [MEDICATION NAME] order from the hospital discharge medication reconciliation to the facility admission medication recapitulation dated October 18, 2013. Medical record review of the hospital Discharge Medication Reconciliation Record dated October 28, 2013, revealed .[MEDICATION NAME]-[MEDICATION NAME] (medication for pain ) 7.5 mg-325 mg/15 ml oral [MEDICATION NAME] give 15 ml by mouth every (po q) 4 hours, as needed (PRN ) for pain . Medical record review of the Nurse's Notes dated November 13, 2013, at 1734 (5:34 p.m.) revealed .PRN pain meds (medication) given x 1 (times one) with positive effects . Medical record review of the Nurse's Notes dated November 14, 2013, at 0300 (3:00 a.m.) revealed .Denies any pain or discomfort at all, refuses pain [MEDICATION NAME] despite daughter's urging it be administered . Review of the Pain Assessment Tool dated October 18, 2013, October 25, 2013, November 4, 3013, November 11, 2013, and November 22, 2013, revealed resident #2 replied No to Do you have pain now?, and Yes to Is your pain being managed at acceptable level? Review of the October, November, and December 2013, Medication Administration Records revealed the [MEDICATION NAME]-[MEDICATION NAME] PRN had not been administered. Review of the policy Documentation Guidelines Mediation and Treatments, dated January 1, 2010, revealed .PRN Medication: The reason for giving and its effect must be recorded each time the PRN medication is given. Record notes on the PRN record or in the Nurses Notes if prn records are not used . Interview with the Director of Nursing, on May 14, 2014, at 9:45 a.m., in the conference room, confirmed the facility nurses were to document PRN medication administration and effectiveness on the MAR. Further interview confirmed the nurses failed to document PRN medication administration on the front of the MAR and the reason and effectiveness of the PRN medication on the back of the MAR per facility policy.",2017-05-01
9525,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2013-07-03,246,D,0,1,HY6I11,"Based on observation and interview, the facility failed to maintain a call light within reach for one (#99) of thirty-nine residents reviewed. The findings included: Observation on July 1, 2013, at 2:37 p.m., revealed resident #99 on the bed with bilateral quarter side rails in the up position at the head of the bed. Further observation revealed the call light was on the chair next to the head of the bed and was not within reach of the resident. Interview on July 1, 2013, at 2:40 p.m., in the resident's room, with Certified Nurse Aide #2 revealed the resident was capable of activating the call light. Further interview confirmed the call light was not within the reach of the resident.",2016-11-01
9526,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2013-07-03,279,D,0,1,HY6I11,"**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 for one resident (#79) of thirty-nine residents reviewed. The findings included: Resident #79 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed the resident had a [MEDICAL TREATMENT] access in the right upper arm and received [MEDICAL TREATMENT] three days a week at an outpatient clinic. Medical record review of the care plan updated March 31, 2013, revealed the [MEDICAL TREATMENT] acess was not care planned to address the care of [MEDICAL TREATMENT] access located in the right upper arm. Further review revealed the care plan did not address the practice which requires no needle sticks or blood pressure checks in the arm of the access. Observation and interview on July 2, 2013, at 12:30 pm, revealed the resident was sitting in the recliner in the room, with a gauze bandage on the right upper arm. Resident stated had just got back from [MEDICAL TREATMENT]. Interview with Registered Nurse Supervisor #1, on July 2, 2013, at 2:30 p.m., at the nurses' station, confirmed the care plan did not address the care of the resident's [MEDICAL TREATMENT] access in the right upper arm.",2016-11-01
9527,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2013-07-03,315,D,0,1,HY6I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to assess a resident's bladder status and implement a bladder training program to maintain/improve bladder function for one (#86) of thirty-nine residents reviewed. The findings included: Resident #86 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of nursing care plan dated January 9, 2013, revealed bladder incontinence was not addressed as a problem in itself but was noted as an intervention for altered skin integrity - to keep dry and do pericare after incontinence. Review of the Occupational Therapy (OT) consult dated January 10, 2013, revealed .review of this patient's chart does not reveal a condition that would require intervention by an OT . Continued review of the consult revealed .intervention would not produce any significant changes until the underlying medical condition is addressed . Review of the Urinary Incontinence and Indwelling Catheter assessment from the 5 day Minimum Data Set, dated dated [DATE], revealed modifiable factors contributing to transient urinary incontinence were pain and medications. Continued review of the form revealed sections on other factors contributing to incontinence, laboratory tests, diseases and conditions, type of incontinence were not completed. Further review of the form revealed a section on analysis of findings: review indicators and supporting documentation, and draw conclusions, description of problem, causes and contributing factors, and risk factors related to care area revealed documentation including PT/OT (Physical Therapy/Occupational Therapy) notes, MAR (Medication Administration Record), risks. Further review of the form revealed a section entitled referral to another discipline with PT/OT to increase independence written under the statement. Continued review of the form revealed a section entitled document reason(s) care plan will/will not be developed and documentation included .@ (at) risk for unwanted SE (side effects) of meds, UTI (urinary tract infection), ADL (activities of daily living) deficit, and falls . Further review of the form revealed no documentation as to whether a care plan would or would not be developed. Interview with the Director of Nursing (DON) on July 2, 2013, at 4:10 p.m., in the conference room, confirmed a bladder training program had not been developed for this resident. Continued interview with the DON on July 3, 2013, at 7:53 a.m., in the conference room, confirmed the resident did not have a 72 hour bladder assessment/voiding pattern completed. Further interview with the DON confirmed the only bladder assessment available was the 5 day MDS (Minimum Data Set). Continued interview with the DON confirmed the care plan did not address improving bladder function and/or restoring as much normal bladder function as possible.",2016-11-01
9528,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2013-07-03,431,D,0,1,HY6I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, interview, and facility policy review, the facility failed to label an intravenous (IV) bag for one (#99) of thirty-nine residents reviewed. The findings included: Resident # 99 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician phone order dated June 27, 2013, revealed .3) Ertepenem (antibiotic medication) 1 gm (gram) IV Q day x (Intravenously every day for) 7 days . UTI (Urinary Tract Infection) . Observation on July 1, 2013, at 2:37 p.m., in the resident's room, revealed an IV medication bag on an IV pole with the pharmacy label dated June 29, 2013, of .INVANZ (antibiotic Ertepenem) 1gm (gram) .100 ml (milliliters) infuse contents of bag 1gm over 60 min (minutes) every day for 7 days . Further observation revealed no facility label addressing the date and time of the administration, and no initials of the nurse administering the medication. Interview on July 1, 2013, at approximately 2:45 p.m., with Licensed Practical Nurse #2 and Licensed Practical Nurse #4 in the resident's room, confirmed the IV bag failed to have the administration date, time and initials of the nurse. Review of the facility policy entitled IV Therapy revealed .IV solutions are to be changed and labeled every 24 hours . Interview with the Director of Nursing, in the conference room, on July 2, 2013, at 1:50 p.m., confirmed the IV bag was to be labeled with the administration date, time and nurse's initials.",2016-11-01
9529,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2013-07-03,441,D,0,1,HY6I11,"Based on observation and interview, the facility failed to maintain fans in a sanitary manner for two (#8, #99) of thirty-nine residents reviewed. The findings included: Observation on July 1, 2013, at 2:00 p.m., in the room of resident #8 revealed the resident was on the bed with a box fan in operation directed at the resident. Further observation revealed the fan guard and blades had a heavy accumulation of debris. Interview on July 1, 2013, at 2:00 p.m., with Certified Nurse Aide #3 and Licensed Practical Nurse #3, confirmed the fan guard and blades were heavy with debris and blowing in the direction of the resident. Observation on July 1, 2013, at 2:37 p.m., in the room of resident #99 revealed the resident on the bed, with a nasal cannula in place, and a box fan in operation directed at the resident. Further observation revealed the fan guard and blades had a heavy accumulation of debris. Interview in the resident's room, on July 1, 2013, at 2:42 p.m., with Housekeeper #1, confirmed the fan had debris on the guard and blades and was directed at the resident in the bed. Interview on July 1, 2013, at 2:45 p.m., with Licensed Practical Nurse #4 confirmed the fan grate and blades were dirty and the fan was directed at the resident.",2016-11-01
9530,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2013-07-03,463,D,0,1,HY6I11,"Based on observation and interview the facility failed to ensure that a emergency bathroom light was functional in one of four common shower rooms. The findings included: Observation and interview with Maintenance employee #1 on July 2, 2013, at 4:36 p.m., in the 2 east shower room, confirmed the bathroom emergency call light was non functional.",2016-11-01
11606,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2012-12-14,224,J,1,0,ZJ7C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, facility investigation review, observation, and interview the facility neglected to provide the necessary care to prevent an avoidable pressure sore for one (#3) of twenty-two residents reviewed. The facility's failure resulted in an Immediate Jeopardy (a situation in which a provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death) for resident #3 who developed a stage IV (4) pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle accompanied by tunneling) to the sacrum. The Senior Vice President and Administrator were notified of the Immediate Jeopardy on December 12, 2012 at 1:40 p.m. in the conference room. F-224 represents Substandard Quality of Care. The findings included: Review of the facility policy entitled Skin Integrity Prevention and Management: Assessment and Treatment Guidelines: Pressure Ulcer Assessment and Treatment Guidelines for all Patients with Pressure Ulcers revealed the .turn schedule and positioning will be individualized to the patient. Patient/family involvement in the development of plan of care. Education to ensure support and compliance with treatment plan . Review of the facility policy entitled Skin Integrity Prevention and Management: Interventions/Positioning revealed .Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief. Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. If the resident refuses care, an evaluation of the basis for refusal, and the identification and evaluation of potential alternatives is indicated . Medical record review revealed resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].) Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 14 (13-15 equals cognitively intact); had no behavior issues; required extensive assistance with bathing, grooming and dressing; had a [MEDICAL CONDITION] and indwelling urinary catheter to prevent irritation of skin; had no pressure ulcers; and used a sliding board for transfer from the bed to the chair. Medical record review revealed the resident was being treated weekly at a wound care clinic at the hospital for [MEDICAL CONDITION] to the lower legs. On August 7, 2012 the resident had an appointment at the wound care clinic (was seen at clinic at approximatley 1:30 p.m.). Medical record review revealed, prior to the transfer to the wound care clinic, Certified Nursing Assistant (CNA) #1 assisted the resident from the bed to the wheelchair using the transfer board. When the resident returned from the wound clinic on August 7, 2012 the sliding board was missing. Medical record review revealed on August 15, 2012 (9 days later) the sliding board was found on the resident's bed between the bottom sheet and the mattress. Interview with CNA #3 on December 11, 2012 at 7:55 a.m. in the 2 East Nursing Station revealed CNA #3 went into the resident's room (on August 15, 2012) to get .up for an appointment. Continued interview revealed the CNA turned the resident to change .and something hard was under the resident which turned out to be the sliding board. Further interview revealed .I looked at .back end and I was horrified. I called the nurse who then called the Wound Care Nurse. The wound was grapefruit size, open, very red, and looked as if it had been there awhile. It covered most of one cheek and part of the other . Continued interview revealed the CNA was unaware the resident's sliding board had been missing. Interview with the Wound Care Nurse (WCN) on December 10, 1012 at 1:50 p.m. in the conference room revealed the nurse called to say a wound was found and the nurse needed the WCN to assist. Continued interview revealed when the resident was turned over completely, the WCN's knuckles hit something hard. Interview revealed the resident's sliding board was found between the fitted sheet and the mattress. Continued interview with the WCN revealed a purple area with fluid under it on the resident's sacrum with one side peeling. Continued interview with the WCN confirmed a Stage IV pressure ulcer to the sacrum. Medical record review of the Weekly Wound Assessment Record dated August 15, 2012 (not timed) revealed an unstageaable pressure ulcer on the sacrum measuring 8.5 centimeters (cm) by 17.5 cm. Continued review of the Wound Assessment revealed exudate (oozing fluid) was present and the wound bed was moist. Medical record review of the Weekly Wound Care Assessment Progress Notes dated August 15, 2012 at 1:00 p.m. revealed .Noted pressure site unstageable sacrum. Mod (Moderate) amt (amount) clear serous exudates (oozing fluids). Rt.(right) buttock area purplish in color with peeling skin. Lt.(left) buttocks green skin peeling blister like. Physician notified with new orders for Allevyn (foam dressing used for partial to full thickness wounds) daily until healed . Review of the Physician Progress/Procedure Note from the Wound Care Center, dated August 22, 2012 revealed .(patient) has developed sacral decubitus ulcer after lying on sliding board for 9 days. Patient will likely need several debridements of sacral wound. Clinitron bed. Sacral wound has dark necrotic eschar . Medical record review of a nurse's note dated August 22, 2012 at 4:30 p.m. revealed .Pt. (Patient) pale, warm diaphoretic (sweating) with rapid shallow resp (respirations) BP (blood pressure) 160/88, pulse 140. Pt. Voiced c/o (complaints of) SOB (shortness of breath). Pt. Assisted back to room and nurse updated on pt. condition . Medical record review of a nurse's note dated August 22, 2012 at 5:30 p.m. revealed .Pt. assessed D/T (due to) diaphoresis, increased BP, pulse, and respirations. Pt. SOB with talking/minimal exertion. Attempt to contact WCC (Wound Care Center) for report upon pt return from visit today. NP (Nurse Practitioner) notified with order to transfer pt to ER (emergency room ) for evaluation . Medical record review of the Emergency Department visit dated August 22, 2012 at 6:18 p.m. revealed resident .had wound debridement today and felt weak, flushed, SOB, and has been [MEDICAL CONDITION] (rapid pulse) . Continued review of the Emergency Department notes revealed the resident was admitted to the hospital on August 22, 2012. Medical record review of the Hospital History and Physical dated August 22, 2012 revealed .pt recently had trouble with increasing odor from the wound on the sacrum. It is a stage IV decubitus. The patient is noted to have a very bad odor from the wound. Patient has minimal sensation from about the couple of inches below the rib cage down . Medical record review of a Hospital Consultation by the Infectious Diseases physician dated August 26, 2012 revealed .patient was started on triple antibiotic coverage [MEDICAL CONDITION] ([MEDICAL CONDITION] Resistant Staphlococcus Aureus) and Pseudomonas in right lower leg as well as multi drug resistant Pseudomonas UTI (urinary tract infection). Patient will likely need debridement of the sacral wound but will refer back to Wound Care Clinic . Medical record review of the Hospital Discharge Summary dated August 29, 2012 revealed the patient requested and was transferred from the hospital to a different long-term care facility. Observation of and interview with resident #3 at the new facility on December 7, 2012 at 12:00 p.m. revealed the resident had a white plastic sliding board which was used to transfer from the bed to the chair. The resident reported the transfer board was missing for nine days. Continued interview with the resident revealed the resident experienced a big sore to his buttock. The resident reported having a sore to the buttocks before which had healed, but the sore had reopened after laying on the transfer board for nine days. The resident reported if the facility had changed the bed, the transfer board would have been found under the bottom sheet. The resident further reported not being bathed or showered from August 7 through 15, 2012 and was only turned on the night shift and that was for placement of a wedge behind the back. Review of an undated facility investigation revealed resident #3 reported the transfer sliding board missing. Staff were questioned and a search began. The resident had stated the last time the board was used was the day the resident went to the wound clinic on August 7, 2012. The resident also stated the last person to assist to and from the bed using the sliding board was Certified Nursing Assistant (CNA) #1. Review revealed on Wednesday, August 15, 2012 the unit manager nurse who completed the investigation was called to the resident's room by a CNA to report a bad place on .bottom. The unit manager nurse and another Licensed Practical Nurse (LPN) and a CNA entered the room and when they assisted the resident to turn over they noticed a large possible stage IV area to the sacrum. Due to the loss of sensation the resident was unaware of the area. The nurse immediately contacted the facility wound care coordinator who came and evaluated and dressed the wound. During turning and repositioning the patient, the wound care coordinator felt something hard in the bed and discovered the patient's sliding board between the sheet and the bed mattress. The unit manager nurse and the Director of Nursing (DON) began an investigation as to how and when this transfer sliding board could have been left between the sheet and the mattress. Interview with Licensed Practical Nurse (LPN) #1 on December 11, 2012 at 7:40 a.m. in the 2 East Nursing Station confirmed bed linens were changed at the time a bath was given. Further interview with LPN #1 confirmed the CNAs completed a skin assessment daily on all residents. Further interview confirmed the CNA was to report any changes including bruises and was expected to turn the resident over to view the coccyx and back. Continued interview with the LPN revealed resident #3 did not go to the shower but would usually ask for a bath when an appointment was scheduled the next day. Interview on December 11, 2012 at 8:25 a.m. in the conference room with the nurse completing the facility investigation, revealed the nurse was the unit Manager on the floor where the resident resided at the time of the incident. Continued interview revealed, as part of the investigation, staff were questioned; the resident was interviewed; and staff were inserviced on turning and positioning as well as skin assessment. Further interview confirmed no one on the staff was aware the board was under the resident for nine days or how it got under the fitted sheet. Continued interview with the nurse revealed the CNAs completed an inspection of the resident's skin from head to toe when vital signs were taken. Further interview revealed vital signs were taken once a day and were divided up so each shift did some vital signs so the skin inspections were divided up so some were completed on each shift. Continued interview revealed linens were changed at the time of the bath as the resident permited. Further interview with this nurse confirmed no one knew how the sliding board got there or who left it on the bed. Telephone interview with the resident's physician on December 11, 2012 at 8:55 a.m. revealed the physician also became the facility's Medical Director on December 1, 2012. Continued interview with the physician revealed the Wound Care Nurse called on August 15, 2012 to report the area on the sacrum which could break open and finding the board under the resident, both of which were concerning. Continued interview revealed since the area had been open in the past the resident was at increased risk of the area breaking down again. Further interview confirmed with daily skin assessments, turning and positioning, and linen changes, the staff should have found the sliding board much earlier. Continued interview confirmed staff .careless in not doing what they are supposed to be doing. It is concerning. The skin could discolor in a couple of days but would take longer to break open . Further interview revealed the physician did not recall if the resident was examined by the physician after the pressure ulcer was identified. Interview with LPN #2 on December 12, 2012 at 7:20 a.m. in the 2 East Nursing station revealed LPN #2 performed some skin assessments on resident #3 and would look over the resident while giving medications. Continued interview revealed the LPN would ask the resident if there were any problems or pain. Further interview revealed it was hard to get the resident to roll but the resident would hold onto the half rail and pull self over. Continued interview revealed the LPN could observe the resident's back from the waist upward but was unable to see the resident's buttocks on any skin assessment. Further interview with LPN #2 revealed .did not know about the sliding board being under the resident until everything broke . Continued interview revealed if the sheets were dirty the resident would ask for them to be changed, but the resident did own [MEDICAL CONDITION] care. Interview with LPN #2 confirmed the resident needed help turning to get all the way over but preferred to remain on the back to eat and watch TV. Continued interview revealed the LPN was not sure if the risks of not turning and staying on the back for long periods of time were discussed with the resident. Further interview revealed the resident .wouldn't allow us to do certain things for .and wanted to self turn but probably was not capable of repositioning self . Further interview with LPN #2 confirmed the Weekly Skin Assessment was completed on August 9, 2012 without observing the resident's buttocks. Interview with the Interim Director of Nursing (DON) on December 12, 2012 at 12:20 p.m. in the conference room confirmed an area was noticed on the resident's bottom; several people were called to assess the area; and the Wound Care Nurse found the sliding board under the resident. Further interview with the DON revealed staff were asked how the board got there but no one knew how. The DON stated staff were in-serviced on turning and providing skin care. Continued interview revealed the DON was unable to remember knowing the board was missing but the resident reported the board missing to the Administrator. Review of the nursing care plan dated May 24, 2012 revealed the resident was at times non-compliant with turning and repositioning in the bed and chair. Staff were to encourage the resident to turn and reposition. The care plan noted the resident had a history of [REDACTED]. Continued review revealed the care plan was not updated to address the stage IV pressure sore to the sacrum, the treatment of [REDACTED]. Interview with the Interim DON on December 13, 2012 at 3:00 p.m. in the conference room confirmed the nursing care plan did not address the resident's refusal of baths and turning as problems or interventions to be taken other than encourage the resident to turn and reposition. Further interview with the DON confirmed the stage IV pressure sore and the sliding board had not been care planned as a problem. The DON confirmed no documentation from the physician and/or Nurse Practitioner following the discovery of the stage IV pressure ulcer on the sacrum of resident #3 to indicate the resident was seen and examined by medical personnel. In Summary: The facility failed to follow facility policies for Skin Integrity Prevention and Management and Pressure Ulcer Assessment and Treatment which resulted in resident #3 developing an avoidable pressure ulcer which was not discovered until it was a stage IV open wound. The Immediate Jeopardy was effective from August 7, 2012 through December 13, 2012. An acceptable Allegation of Compliance, which removed the Immediate Jeopardy, was received and corrective actions were validated by the survey team through medical record review; review of inservice education records; review of assessments; and interview. The survey team verified the Allegation of Compliance through: 1. Review of inservice records from education on revised process for CNAs to complete and document daily skin assessments of residents. 2. Review of Weekly Skin Assessment records for all residents in the facility which were completed on December 12, 2012. 3. Review of revised CNA skin inspection form and documentation for 55 residents completed on December 12 and 13, 2012. 4. Review of twenty-five records to ensure the nursing care plan had been updated appropriately to reflect changes in the resident's status. 5. Review of inservice records from education on completion and update of nursing care plan to reflect changes in resident status. 6. Review of inservice records from education on Incidents of Abuse & Neglect. 7. Interview with CNAs and nurses regarding their understanding of completion of CNA Inspection Report, Weekly Skin Assessment, completion/updating care plan and recognition and reporting residents who may be the victim of abuse and/or neglect. 8. Interview with the Senior Vice President to ensure those staff who were not present for the inservices would receive the information before being allowed to care for residents. Noncompliance continues at a D level for monitoring corrective actions. The facility is required to submit a plan of correction.",2015-12-01
11607,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2012-12-14,279,J,1,0,ZJ7C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to revise and update the Plan of Care to address refusal of care and failed to develop interventions for a Stage IV pressure ulcer for one (#3) of twenty-two residents reviewed. The facility's failure resulted in an Immediate Jeopardy (a situation in which a provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death) for resident #3 who developed a stage IV (4) pressure sore to the sacrum. The Senior Vice President and Administrator were informed of the Immediate Jeopardy on December 12, 2012 at 1:40 p.m. in the conference room. A partial extended survey was conducted on December 14, 2012. The findings included: Medical record review revealed resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 14 (13 -15 equals cognitively intact); had no behavioral issues; required extensive assistance with bed mobility; required extensive assistance with bathing, grooming, and dressing; required limited assistance with eating; had a [MEDICAL CONDITION] and indwelling foley catheter to prevent irritation of skin; did not have one or more unhealed pressure ulcers at Stage I or higher; had no mood issues; and used a sliding board to transfer from the bed to the chair. Medical record review of the Weekly Wound Care Assessment Progress Notes dated August 15, 2012 at 1:00 p.m. revealed .Noted pressure site unstageable sacrum. Mod (moderate) amt (amount) clear serous exudate (oozing fluids). Rt (right) buttock area purplish in color with peeling skin. Lt (left) buttocks green skin peeling blister like. Physician notified with new orders for Allevyn daily until healed . Medical record review of the Wound Care Assessment Progress Notes dated August 22, 2012 at 12:20 p.m. revealed .pressure area to sacrum remains unstageable with moderate amt serous exudate noted with slough in wound bed . Review of the Physician Progress/Procedure Note dated August 22, 2012 revealed .pt (patient) has developed sacral decubitus ulcer after lying on sliding board for 9 days. Patient will likely need several debridements of sacral wound. Clinitron bed. Sacral wound has dark necrotic eschar . Interview with the Wound Care Nurse (WCN) on December 10, 2012 at 1:50 p.m. in the conference room, revealed the nurse called to say a wound was found and the nurse needed the WCN to assist. Continued interview with the WCN revealed when the resident was turned over completely, the WCN's knuckles hit something hard. Continued interview with the WCN confirmed the resident's sliding board was found between the fitted sheet and the mattress. Continued interview with the WCN revealed a purple area with fluid under it on the resident's sacrum with one side peeling. Continued interview with the WCN confirmed a Stage IV pressure ulcer to the sacrum. Interview with the Interim Director of Nursing (DON) on December 12, 2012 at 12:20 p.m. in the conference room revealed if a resident refused care it would be reflected in the care plan as well as documented in the monthly summary completed by the nurse. Continued interview with the DON revealed documentation should be entered in the care plan that refusal of care was the resident's usual behavior. Continued interview revealed Social Services and nursing document in the nursing care plan regarding care given to the resident or refusal of care. Review of the nursing care plan dated May 24, 2012 revealed the resident was at times non-compliant with turning and repostioning in the bed and chair. Staff were to encourage the resident to turn and repostion. The care plan noted the resident had a history of [REDACTED]. Continued review of the nursing care plan revealed no entry for behavior issues to include refusal to turn. Continued review revealed the plan was not updated to address the stage IV pressure sore to the sacrum, the treatment of [REDACTED]. Interview with the Interim DON on December 13, 2012 at 3:00 p.m. in the conference room, confirmed the nursing care plan did not address the resident's refusal of baths and turning as problems or interventions to be taken. Continued interview with the DON confirmed the stage IV pressure sore and the sliding board had not been care planned as a problem with planned interventions. The Immediate Jeopardy was effective from August 7, 2012 through December 13, 2012. An acceptable Allegation of Compliance, which removed the Immediate Jeopardy, was received and corrective actions were validated by the survey team through medical record review; review of inservice education records; review of assessments; and interview. The survey team verified the Allegation of Compliance through: 1. Review of inservice records from education on revised process for CNAs to complete and document daily skin assessments of residents. 2. Review of Weekly Skin Assessment records for all residents in the facility which were completed on December 12, 2012. 3. Review of revised CNA skin inspection form and documentation for 55 residents completed on December 12 and 13, 2012. 4. Review of twenty-five records to ensure the nursing care plan had been updated appropriately to reflect changes in the resident's status. 5. Review of inservice records from education on completion and update of nursing care plan to reflect changes in resident status. 6. Review of inservice records from education on Incidents of Abuse & Neglect. 7. Interview with CNAs and nurses regarding their understanding of completion of CNA Inspection Report, Weekly Skin Assessment, completion/updating care plan and recognition and reporting residents who may be the victim of abuse and/or neglect. 8. Interview with the Senior Vice President to ensure those staff who were not present for the inservices would receive the information before being allowed to care for residents. Noncompliance continues at a D level for monitoring corrective actions. The facility is required to submit a plan of correction.",2015-12-01
11608,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2012-12-14,314,J,1,0,ZJ7C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, facility investigation review, observation, and interview the facility failed to provide the necessary care to prevent an avoidable pressure sore for one (#3) of twenty-two residents reviewed. The facility's failure resulted in an Immediate Jeopardy (a situation in which a provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death) for resident #3 who developed a stage IV (4) pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle accompanied by tunneling) to the sacrum. The Senior Vice President and Administrator were notified of the Immediate Jeopardy on December 12, 2012 at 1:40 p.m. in the conference room. F-314 represents Substandard Qualtiy of Care. The findings included: Review of the facility policy entitled Skin Integrity Prevention and Management: Assessment and Treatment Guidelines: Pressure Ulcer Assessment and Treatment Guidelines for all Patients with Pressure Ulcers revealed the .turn schedule and positioning will be individualized to the patient. Patient/family involvement in the development of plan of care. Education to ensure support and compliance with treatment plan . Review of the facility policy entitled Skin Integrity Prevention and Management: Interventions/Positioning revealed .Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief. Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. If the resident refuses care, an evaluation of the basis for refusal, and the identification and evaluation of potential alternatives is indicated . Medical record review revealed resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].) Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 14 (13-15 equals cognitively intact); had no behavior issues; required extensive assistance with bathing, grooming and dressing; had a [MEDICAL CONDITION] and indwelling urinary catheter to prevent irritation of skin; had no pressure ulcers; and used a sliding board for transfer from the bed to the chair. Medical record review revealed the resident was being treated weekly at a wound care clinic at the hospital for [MEDICAL CONDITION] to the lower legs. On August 7, 2012 the resident had an appointment at the wound care clinic (was seen at clinic at approximatley 1:30 p.m.). Medical record review revealed, prior to the transfer to the wound care clinic, Certified Nursing Assistant (CNA) #1 assisted the resident from the bed to the wheelchair using the transfer board. When the resident returned from the wound clinic on August 7, 2012 the sliding board was missing. Medical record review revealed on August 15, 2012 (9 days later) the sliding board was found on the resident's bed between the bottom sheet and the mattress. Interview with CNA #3 on December 11, 2012 at 7:55 a.m. in the 2 East Nursing Station revealed CNA #3 went into the resident's room (on August 15, 2012) to get .up for an appointment. Continued interview revealed the CNA turned the resident to change .and something hard was under the resident which turned out to be the sliding board. Further interview revealed .I looked at .back end and I was horrified. I called the nurse who then called the Wound Care Nurse. The wound was grapefruit size, open, very red, and looked as if it had been there awhile. It covered most of one cheek and part of the other . Continued interview revealed the CNA was unaware the resident's sliding board had been missing. Interview with the Wound Care Nurse (WCN) on December 10, 1012 at 1:50 p.m. in the conference room revealed the nurse called to say a wound was found and the nurse needed the WCN to assist. Continued interview revealed when the resident was turned over completely, the WCN's knuckles hit something hard. Interview revealed the resident's sliding board was found between the fitted sheet and the mattress. Continued interview with the WCN revealed a purple area with fluid under it on the resident's sacrum with one side peeling. Continued interview with the WCN confirmed a Stage IV pressure ulcer to the sacrum. Medical record review of the Weekly Wound Assessment Record dated August 15, 2012 (not timed) revealed an unstageaable pressure ulcer on the sacrum measuring 8.5 centimeters (cm) by 17.5 cm. Continued review of the Wound Assessment revealed exudate (oozing fluid) was present and the wound bed was moist. Medical record review of the Weekly Wound Care Assessment Progress Notes dated August 15, 2012 at 1:00 p.m. revealed .Noted pressure site unstageable sacrum. Mod (Moderate) amt (amount) clear serous exudates (oozing fluids). Rt.(right) buttock area purplish in color with peeling skin. Lt.(left) buttocks green skin peeling blister like. Physician notified with new orders for Allevyn (foam dressing used for partial to full thickness wounds) daily until healed . Review of the Physician Progress/Procedure Note from the Wound Care Center, dated August 22, 2012 revealed .(patient) has developed sacral decubitus ulcer after lying on sliding board for 9 days. Patient will likely need several debridements of sacral wound. Clinitron bed. Sacral wound has dark necrotic eschar . Medical record review of a nurse's note dated August 22, 2012 at 4:30 p.m. revealed .Pt. (Patient) pale, warm diaphoretic (sweating) with rapid shallow resp (respirations) BP (blood pressure) 160/88, pulse 140. Pt. Voiced c/o (complaints of) SOB (shortness of breath). Pt. Assisted back to room and nurse updated on pt. condition . Medical record review of a nurse's note dated August 22, 2012 at 5:30 p.m. revealed .Pt. assessed D/T (due to) diaphoresis, increased BP, pulse, and respirations. Pt. SOB with talking/minimal exertion. Attempt to contact WCC (Wound Care Center) for report upon pt return from visit today. NP (Nurse Practitioner) notified with order to transfer pt to ER (emergency room ) for evaluation . Medical record review of the Emergency Department visit dated August 22, 2012 at 6:18 p.m. revealed resident .had wound debridement today and felt weak, flushed, SOB, and has been [MEDICAL CONDITION] (rapid pulse) . Continued review of the Emergency Department notes revealed the resident was admitted to the hospital on August 22, 2012. Medical record review of the Hospital History and Physical dated August 22, 2012 revealed .pt recently had trouble with increasing odor from the wound on the sacrum. It is a stage IV decubitus. The patient is noted to have a very bad odor from the wound. Patient has minimal sensation from about the couple of inches below the rib cage down . Medical record review of a Hospital Consultation by the Infectious Diseases physician dated August 26, 2012 revealed .patient was started on triple antibiotic coverage [MEDICAL CONDITION] ([MEDICAL CONDITION] Resistant Staphlococcus Aureus) and Pseudomonas in right lower leg as well as multi drug resistant Pseudomonas UTI (urinary tract infection). Patient will likely need debridement of the sacral wound but will refer back to Wound Care Clinic . Medical record review of the Hospital Discharge Summary dated August 29, 2012 revealed the patient requested and was transferred from the hospital to a different long-term care facility. Observation of and interview with resident #3 at the new facility on December 7, 2012 at 12:00 p.m. revealed the resident had a white plastic sliding board which was used to transfer from the bed to the chair. The resident reported the transfer board was missing for nine days. Continued interview with the resident revealed the resident experienced a big sore to his buttock. The resident reported having a sore to the buttocks before which had healed, but the sore had reopened after laying on the transfer board for nine days. The resident reported if the facility had changed the bed, the transfer board would have been found under the bottom sheet. The resident further reported not being bathed or showered from August 7 through 15, 2012 and was only turned on the night shift and that was for placement of a wedge behind the back. Review of an undated facility investigation revealed resident #3 reported the transfer sliding board missing. Staff were questioned and a search began. The resident had stated the last time the board was used was the day the resident went to the wound clinic on August 7, 2012. The resident also stated the last person to assist to and from the bed using the sliding board was Certified Nursing Assistant (CNA) #1. Review revealed on Wednesday, August 15, 2012 the unit manager nurse who completed the investigation was called to the resident's room by a CNA to report a bad place on .bottom. The unit manager nurse and another Licensed Practical Nurse (LPN) and a CNA entered the room and when they assisted the resident to turn over they noticed a large possible stage IV area to the sacrum. Due to the loss of sensation the resident was unaware of the area. The nurse immediately contacted the facility wound care coordinator who came and evaluated and dressed the wound. During turning and repositioning the patient, the wound care coordinator felt something hard in the bed and discovered the patient's sliding board between the sheet and the bed mattress. The unit manager nurse and the Director of Nursing (DON) began an investigation as to how and when this transfer sliding board could have been left between the sheet and the mattress. Interview with Licensed Practical Nurse (LPN) #1 on December 11, 2012 at 7:40 a.m. in the 2 East Nursing Station confirmed bed linens were changed at the time a bath was given. Further interview with LPN #1 confirmed the CNAs completed a skin assessment daily on all residents. Further interview confirmed the CNA was to report any changes including bruises and was expected to turn the resident over to view the coccyx and back. Continued interview with the LPN revealed resident #3 did not go to the shower but would usually ask for a bath when an appointment was scheduled the next day. Interview on December 11, 2012 at 8:25 a.m. in the conference room with the nurse completing the facility investigation, revealed the nurse was the unit Manager on the floor where the resident resided at the time of the incident. Continued interview revealed, as part of the investigation, staff were questioned; the resident was interviewed; and staff were inserviced on turning and positioning as well as skin assessment. Further interview confirmed no one on the staff was aware the board was under the resident for nine days or how it got under the fitted sheet. Continued interview with the nurse revealed the CNAs completed an inspection of the resident's skin from head to toe when vital signs were taken. Further interview revealed vital signs were taken once a day and were divided up so each shift did some vital signs so the skin inspections were divided up so some were completed on each shift. Continued interview revealed linens were changed at the time of the bath as the resident permited. Further interview with this nurse confirmed no one knew how the sliding board got there or who left it on the bed. Telephone interview with the resident's physician on December 11, 2012 at 8:55 a.m. revealed the physician also became the facility's Medical Director on December 1, 2012. Continued interview with the physician revealed the Wound Care Nurse called on August 15, 2012 to report the area on the sacrum which could break open and finding the board under the resident, both of which were concerning. Continued interview revealed since the area had been open in the past the resident was at increased risk of the area breaking down again. Further interview confirmed with daily skin assessments, turning and positioning, and linen changes, the staff should have found the sliding board much earlier. Continued interview confirmed staff .careless in not doing what they are supposed to be doing. It is concerning. The skin could discolor in a couple of days but would take longer to break open . Further interview revealed the physician did not recall if the resident was examined by the physician after the pressure ulcer was identified. Interview with LPN #2 on December 12, 2012 at 7:20 a.m. in the 2 East Nursing station revealed LPN #2 performed some skin assessments on resident #3 and would look over the resident while giving medications. Continued interview revealed the LPN would ask the resident if there were any problems or pain. Further interview revealed it was hard to get the resident to roll but the resident would hold onto the half rail and pull self over. Continued interview revealed the LPN could observe the resident's back from the waist upward but was unable to see the resident's buttocks on any skin assessment. Further interview with LPN #2 revealed .did not know about the sliding board being under the resident until everything broke . Continued interview revealed if the sheets were dirty the resident would ask for them to be changed, but the resident did own [MEDICAL CONDITION] care. Interview with LPN #2 confirmed the resident needed help turning to get all the way over but preferred to remain on the back to eat and watch TV. Continued interview revealed the LPN was not sure if the risks of not turning and staying on the back for long periods of time were discussed with the resident. Further interview revealed the resident .wouldn't allow us to do certain things for .and wanted to self turn but probably was not capable of repositioning self . Further interview with LPN #2 confirmed the Weekly Skin Assessment was completed on August 9, 2012 without observing the resident's buttocks. Interview with the Interim Director of Nursing (DON) on December 12, 2012 at 12:20 p.m. in the conference room confirmed an area was noticed on the resident's bottom; several people were called to assess the area; and the Wound Care Nurse found the sliding board under the resident. Further interview with the DON revealed staff were asked how the board got there but no one knew how. The DON stated staff were in-serviced on turning and providing skin care. Continued interview revealed the DON was unable to remember knowing the board was missing but the resident reported the board missing to the Administrator. Review of the nursing care plan dated May 24, 2012 revealed the resident was at times non-compliant with turning and repositioning in the bed and chair. Staff were to encourage the resident to turn and reposition. The care plan noted the resident had a history of [REDACTED]. Continued review revealed the care plan was not updated to address the stage IV pressure sore to the sacrum, the treatment of [REDACTED]. Interview with the Interim DON on December 13, 2012 at 3:00 p.m. in the conference room confirmed the nursing care plan did not address the resident's refusal of baths and turning as problems or interventions to be taken other than encourage the resident to turn and reposition. Further interview with the DON confirmed the stage IV pressure sore and the sliding board had not been care planned as a problem. The DON confirmed no documentation from the physician and/or Nurse Practitioner following the discovery of the stage IV pressure ulcer on the sacrum of resident #3 to indicate the resident was seen and examined by medical personnel. In Summary: The facility failed to develop a care plan with interventions and failed to provide care for resident #3 who was at risk for pressure sores and who developed an avoidable stage IV pressure sore. The Immediate Jeopardy was effective from August 7, 2012 through December 13, 2012. An acceptable Allegation of Compliance, which removed the Immediate Jeopardy, was received and corrective actions were validated by the survey team through medical record review; review of inservice education records; review of assessments; and interview. The survey team verified the Allegation of Compliance through: 1. Review of inservice records from education on revised process for CNAs to complete and document daily skin assessments of residents. 2. Review of Weekly Skin Assessment records for all residents in the facility which were completed on December 12, 2012. 3. Review of revised CNA skin inspection form and documentation for 55 residents completed on December 12 and 13, 2012. 4. Review of twenty-five records to ensure the nursing care plan had been updated appropriately to reflect changes in the resident's status. 5. Review of inservice records from education on completion and update of nursing care plan to reflect changes in resident status. 6. Review of inservice records from education on Incidents of Abuse & Neglect. 7. Interview with CNAs and nurses regarding their understanding of completion of CNA Inspection Report, Weekly Skin Assessment, completion/updating care plan and recognition and reporting residents who may be the victim of abuse and/or neglect. 8. Interview with the Senior Vice President to ensure those staff who were not present for the inservices would receive the information before being allowed to care for residents. Noncompliance continues at a D level for monitoring corrective actions. The facility is required to submit a plan of correction.",2015-12-01
11609,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2012-12-14,490,J,1,0,ZJ7C11,"br>Based on medical record review, facility documentation review, facility policy review, interview, and observation, the facility failed to be administered in a manner to monitor and ensure turning and positioning of residents; to update careplans and develop interventions regarding a resident's refusal of care; to investigate the disappearance of a sliding board; and to provide the necessary care to prevent the development of a Stage IV (4) pressure ulcer. The facility's failure placed resident #3 in Immediate Jeopardy (a situation in which a provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death) for development of a stage IV decubitus ulcer. The Senior Vice President and the Administrator were informed of the Immediate Jeopardy on December 12, 2012 at 1:40 p.m. in the Conference Room. The findings included: Interview with the Administrator on December 6, 2012 at 4:00 p.m. and December 11, 2012 at 7: 40 a.m., in the Conference Room confirmed the facility did not have an effective system in place to ensure the completion and monitoring of skin inspections; turning/positioning; or bathing of residents. Refer to F224 for neglecting to provide the necessary care to prevent a Stage IV pressure ulcer. Refer to F279 for failure to update and develop the Care Plan Refer to F314 for failure to provide the necessary care to prevent a stage IV pressure sore The Immediate Jeopardy was effective from August 7, 2012 through December 13, 2012. An acceptable Allegation of Compliance, which removed the Immediate Jeopardy, was received and corrective actions were validated by the survey team through medical record review, review of inservice education records; review of assessments; and interview. The survey team verified the Allegation of Compliance through: 1. Review of inservice records from education on revised process for CNAs to complete and document daily skin assessments of residents. 2. Review of Weekly Skin Assessment records for all residents in the facility which were completed on December 12, 2012. 3. Review of revised CNA skin inspection form and documentation for 55 residents completed on December 12 and 13, 2012. 4. Review of twenty-five records to ensure the nursing care plan had been updated appropriately to reflect changes in the resident's status. 5. Review of inservice records from education on completion and update of nursing care plan to reflect changes in resident status. 6. Review of inservice records from education on Incidents of Abuse & Neglect. 7. Interview with CNAs and nurses regarding their understanding of completion of CNA Inspection Report, Weekly Skin Assessment, completion/updating care plan and recognition and reporting residents who may be the victim of abuse and/or neglect. 8. Interview with the Senior Vice President to ensure those staff who were not present for the inservices would receive the information before being allowed to care for residents. Noncompliance continues at a D level for monitoring corrective actions. The facility is required to submit a plan of correction.",2015-12-01
11745,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2011-09-14,241,D,0,1,IGV111,"**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 timely respecting the dignity of one (#12) of twenty-six residents reviewed. The findings included: Resident #12 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident required assistance with all activities of daily living. Observation and interview on September 14, 2011, at 8:18 a.m., in the resident's room, revealed the resident in bed, the resident's breakfast tray on the over bed table, with none of the containers opened. Interview with resident #12 revealed the resident did not want the food tray set up because the resident was waiting for staff to return to the room and cleanup the resident I have a dirty diaper, they said they would get help and be right back to clean me up, but no one has come back Observation on September 14, 2011, from 8:20 a.m. to 8:45 a.m., (25 minutes) at the rehab nurse's desk observing the resident's doorway, revealed three Certified Nurse Assistants (CNA) and four nurse's passed the resident's door and none of the staff entered the room to assist the resident Interview on September 14, 2011, at 8:45 a.m., with CNA #4 at the rehab nurse's desk revealed CNA #1 had delivered resident #12's breakfast tray to the room. Observation on September 14, 2011, at 8:47 a.m., revealed CNA #2 and CNA #3 entered resident #12's room and provided incontinence care for liquid feces. Continued observation revealed CNA #4 went to the facility kitchen and got a hot breakfast tray for the resident. Interview on September 14, 2011, at 9:05 a.m., with resident #12 with CNA #2 and CNA #3 present in the resident's room, .I waited over an hour for help, they said they would be right back, I watched the clock, this is too long to wait!. Interview on September 14, 2011, at 10:44 a.m., near room [ROOM NUMBER] with CNA #1 confirmed CNA #1 delivered resident #12's breakfast tray that morning and the resident had requested assistance with incontinence care due to having liquid feces. Continued interview revealed CNA #1 looked for another staff member to assist cleaning up the resident but no one was in the hallway and the CNA continued to deliver breakfast trays. Continued interview confirmed the resident waited for 25-60 minutes for staff to return when the resident was soiled with feces did not respect the resident's dignity.",2015-11-01
11746,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2011-09-14,279,D,0,1,IGV111,"**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 for two residents (#1, #17) of twenty-six residents reviewed. The findings included: Resident # 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the resident care plan revised July 5, 2011, revealed .Problem.overall decline in condition.Approaches.tilt back wheelchair for positioning. Continued medical record review of the current care plan dated July 20, 2011, revealed no documentation of the positioning devise. Interview with the Minimum Data Set Coordinator (MDS) #1 on September 13, 2011, at 10:30 a.m., at the west wing nurse's station, confirmed the facility failed to revise the care plan to address the positioning device. Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS (Minimum Data Set) dated August 21, 2011, revealed the resident scored 15 of 15 on the BIMS (brief interview for mental status), and received [MEDICAL TREATMENT]. Interview with the resident on September 13, 2011, at 3:40 p.m., in the resident's room, revealed the resident received [MEDICAL TREATMENT] at a local clinic three days per week. Continued interview revealed the resident received treatment via a [MEDICATION NAME] catheter located in the right chest area. Medical record review of the care plan updated August 14, 2011, did not reflect the [MEDICATION NAME] catheter, including the type of care or precautions. Interview with the Director of Nursing (DON) on September 14, 2011, at 8:00 a.m., in the DON's office, confirmed the care plan did not address the resident's [MEDICATION NAME] catheter for [MEDICAL TREATMENT].",2015-11-01
11747,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2011-09-14,309,D,0,1,IGV111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and observation the facility failed to ensure communication with The End Stage [MEDICAL TREATMENT] Clinic ([MEDICAL CONDITION]) for one resident (#17) of twenty-six residents reviewed. The findings included: Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident scored 15 of 15 on the BIMS (brief interview for mental status), and received [MEDICAL TREATMENT]. Interview with the resident on September 13, 2011, at 3:40 p.m., in the resident's room, revealed the resident received [MEDICAL TREATMENT] at a local clinic three days per week. Continued interview revealed the resident received [MEDICAL TREATMENT] treatment via a [MEDICATION NAME] catheter located in the right chest area. Medical record review revealed no documentaion of any communication with or from the [MEDICAL TREATMENT] clinic on the care or precautions of the [MEDICATION NAME] catheter. Interview with the Director of Nursing on September 14, 2011, at 8:00 a.m., at the nurses' station, confirmed the medical record contained no documentation of communication with the [MEDICAL TREATMENT] clinic regarding the [MEDICATION NAME] catheter.",2015-11-01
11748,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2011-09-14,315,D,0,1,IGV111,"**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 correctly to prevent urinary tract infections for one (#12) of twenty-six residents reviewed. The findings included: Resident #12 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident required assistance with all activities of daily living. Observation on September 12, 2011, at 8:50 a.m., in resident #12's room revealed Certified Nurse Assistant (CNA) #2 and CNA #3 assisted the resident with incontinence care for liquid feces and indwelling urinary catheter care. Continued observation revealed while the resident laid on the back, CNA #2 held the resident's indwelling urinary catheter drainage bag approximately ten to twelve inches above the resident (allows the urine to run back into the bladder), while CNA #3 used a wet towel to wipe the liquid feces from the resident's inner thighs. Continued observation revealed after the resident was assisted to lie on the right side CNA #2 using a disposable wipe, washed from the resident's anus to the perineum (area between the vagina and the anus) to remove the liquid feces; while CNA #3 held the resident's indwelling urinary catheter drainage bag approximately twelve inches above the resident. Continued observation revealed as CNA #2 assisted the resident to a comfortable position CNA #3 held the resident's indwelling urinary catheter drainage bag approximately twelve inches above the resident. Interview on September 14, 2011, at 9:10 a.m., at the rehab nurse's desk with Unit Manager #1 confirmed washing from a resident's anus towards the perineum and holding an indwelling urinary catheter drainage bag above the resident could cause a urinary tract infection and was not the correct procedure to complete incontinence care.",2015-11-01
11749,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2011-09-14,371,F,0,1,IGV111,"Based on observation and interview, the facility dietary department failed to maintain equipment in a sanitary manner and failed to remove an expired food product. The findings included: Observation on September 12, 2011, beginning at 10:00 a.m., with the Registered Dietitian present, revealed the following: 1.) Numerous one-half steam table pans and one-third steam table pans were stacked and stored wet on the storage rack. 2.) The underside of the muffin tins had a heavy accumulation of blackened debris. 3.) The mid-sized table top mixer had dried white and tan splatters on the underside of the beater arm. 4.) The six burner range top back splash and spill pan had a heavy accumulation of blackened debris. 5.) The can opener had metal shavings present on the base of the can opener. Observation on September 12, 2011, beginning at 10:18 a.m., with the Registered Dietitian and Dietary Manager present, revealed the following: 1.) In the walk-in refrigerator was a container labeled Pimiento Cheese dated 9/3 (September 3). Interview with the Registered Dietitian on September 12, 2011, present during the observations beginning at 10:00 a.m., in the dietary department, confirmed the pans on the rack were stacked and stored wet. Further interview confirmed the underside of the muffin tins had blackened debris present. Further interview confirmed the mixer had not been used since last night and the underside of the beater arm had dried tan and white splatters present. Further interview confirmed the range top back splash and spill pan had an accumulation of blackened debris. Further interview confirmed the can opener had metal shavings present. Continued interview confirmed the pimiento cheese was out of date and was to have been discarded.",2015-11-01
11750,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2011-09-14,441,D,0,1,IGV111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, facility policy review, and interview, the facility failed to follow the facility's policy for Infection Control for two residents (# 2, #20) with clostridium difficle of twenty-six residents reviewed. The findings included: Resident # 2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a laboratory result dated August 30, 2011, revealed .C (clostridium) Difficile (bacterium that causes diarrhea) positive. Resident # 20 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a laboratory result dated August 24, 2011, revealed .C (clostridium) Difficile positive. Observation of resident #2, and #20 (roomates) in the residents room on September 13, 2011, at 8:02 a.m., revealed both residents were in contact isolation. Continued observation of the resident's room at this time revealed a red biohazard bag partially filled with linens, in the floor in front of resident # 2's bed, not in a container. Review of the facility's policy for Clostridium Difficile Guidelines revealed .contact isolation:.all trash and linen containers will be lined with red biohazard bags. Observation and interview with the unit manager #2 on September 13, 2011, at 8:12 a.m., in the resident's room confirmed the red biohazard bag should be placed in a container. Interview with the Director of Nursing on September 13, 2011, at 8:15 a.m., at the west unit nurse's desk confirmed that the facility's failed to maintain infection control for residents with clostridium difficle.",2015-11-01
11751,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2011-09-14,456,D,0,1,IGV111,"Based on observation and interview, the facility failed to maintain the tilt skillet in the dietary department and failed to maintain the temperature control mechanism for one of three steam tables observed. The findings included: Observation on September 12, 2011, at 10:17 a.m., in the dietary department with the dietary manager present, revealed a missing vent cover on the lid of the tilt skillet. Further observation revealed the tilt skillet was in use at the time of the observation. Interview with the dietary manager on September 12, 2011, at 10:17 a.m. in the dietary department, confirmed the skillet vent was to be covered. Observation on September 13, 2011 at 8:09 a.m., of the two west dining room tray line in operation, with the dietary manager present, revealed the temperature control knobs on the right hand side of the steam table were missing. Interview with the dietary manager at 8:25 a.m., on September 13, 2011, in the two west dining room, confirmed that temperature control knobs were to be in place.",2015-11-01
11752,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2011-09-14,514,D,0,1,IGV111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to maintain a complete medical record for one (#13) of twenty-six residents reviewed. The findings included: Resident #13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician's admission orders [REDACTED] Medical record review of the resident's August 2011, Medication Administration Record [REDACTED] Medical record review of the resident's September 2011, MAR indicated [REDACTED] Observation on September 13, 2011, at 8:00 a.m., 9:40 a.m., 11:05 a.m., in the resident's room revealed a pitcher filled with ice water, on the over bed table, and within the resident's reach. Interview on September 13, 2011, 1:15 p.m., with Certified Nurse Assistant (CNA) #4 in the resident's room revealed the CNA had refilled the resident's water pitcher two times since 10:00 a.m., that morning. Continued interview and review of the resident's September 2011, Rehab Patient Group Worksheet with CNA #4 revealed the resident had a fluid restriction of 1200 ml/day. Interview on September 13, 2011, at 3:47 p.m., in the one west hallway with the Director of Nursing (DON) revealed on August 31, 2011, the physician discontinued the order dated August 30, 2011, for resident #13 to have fluids restricted to 1200 ml/day, and was unaware if the physician's orders [REDACTED]. Interview on September 14, 2011, at 10:00 a.m., in the one west hallway with the DON confirmed the physician's orders [REDACTED].#13's fluid restriction of 1200 ml/day was not in the resident's medical record, and the medical record was not complete.",2015-11-01
13293,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2011-10-26,514,D,1,0,WFBG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the faciity failed to maintain a complete and accurate medical record by documenting bowel movements and the effectiveness of medications administered for constipation for one (#3) of six reisdents reviewed. The findings included: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15/15 indicating the resident as alert and oriented; required assistance with transfers and activities of daily living; was incontinent of bowel and bladder; was on a low sodium 2000 ml (milliliters) per day fluid restriction; and used a wheelchair for ambulation. Medical record review revealed no documentation of the resident's bowel movements either on the Intake-Output Record or in the nursing notes. Review of the Medication Admission Record (MAR) dated August 22, 2011 through August 31, 2011, revealed the resident received [MEDICATION NAME] tablets 5 mg (milligrams on August 29, 2011. Continued review of the MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. Medical record review revealed no documentation of the effectiveness of the [MEDICATION NAME]. Further medical record review revealed an x-ray of the kidneys/ureters/bladder was performed on September 12, 2011, and showed evidence of fecal impaction. Review of physician's orders [REDACTED]. Interview with the DON on October 26, 2011, at 1:15 p.m., in the conference room, revealed the CNA (Certified Nursing Assistants) have a paper that they write down when residents have a bowel movement. Continued interview revealed this form is kept for five days usually then is shredded. Continued interview revealed there is no actual documentation in the resident's record of date, time, size, or quality of bowel movement. C/O #",2015-02-01
13768,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2010-08-11,281,D,0,1,FH1311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to follow the physician's orders for one (#12) of thirty-three residents reviewed. The findings included: Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's order dated July 7, 2010, revealed the resident was to receive [MEDICATION NAME] (medication to treat [MEDICAL CONDITION]) 40,000 units subcutaneously every three weeks, and to hold or not administer the medication if the hemoglobin was greater than 12 or the hematocrit was greater than 32. Medical record review of a physician's order dated July 19, 2010, revealed the hemoglobin and hematocrit were to be checked every month. Medical record review of a laboratory report dated July 6, 2010, revealed the hemoglobin was 9.3 (reference range 11.5-15.5) and the hematocrit was 27.9 (reference range 36.0-45.0). Medical record review of the July 2010, Medication Record revealed the [MEDICATION NAME] was administered on July 8, 2010, and a box on the Medication Record indicated the [MEDICATION NAME] was also to be administered on July 29, 2010. Continued review of the July 2010, Medication Record revealed the [MEDICATION NAME] was not initialed as administered on July 29, 2010. Observation on August 9, 2010, at 1:30 p.m., revealed the resident lying on a low bed, with bilateral floor mats in place. Interview on August 9, 2010, at 2:35 p.m., with Licensed Practical Nurse (LPN) #1, (nurse responsible for the administration of the [MEDICATION NAME] on July 29, 2010), in the nursing station, confirmed the [MEDICATION NAME] was not administered as ordered on July 29, 2010.",2014-09-01
13769,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2010-08-11,425,D,0,1,FH1311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and observation, the facility failed to ensure a medication was available for one (#12) of thirty-three residents reviewed. The findings included: Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the July 2010, physician's recapitulation orders revealed the resident was to receive Patanol (medication to treat allergic conjunctivitis) 0.1% ophthalmic solution one drop to each eye twice a day. Medical record review of the July 2010, Medication Record revealed the Patanol was circled as not administered on July 12, 13, and 14, 2010. Medical record review of the reverse side of the July 2010, Medication Record revealed on July 13, 2010, ""Patanol gtts (drops) not available-ordered from pharmacy."" Interview on August 10, 2010, at 7:10 a.m., with Licensed Practical Nurse (LPN) #3 (nurse responsible for the administration of the Patanol on July 12, 13, and 14, 2010), at the nursing station, confirmed the Patanol was not available on July 12, 13, and 14, 2010.",2014-09-01
13770,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2010-08-11,514,D,0,1,FH1311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to maintain a complete medical record for one (#12) of thirty-three residents reviewed. The findings included: Medical record review of resident #12's July 2010, physician's recapitulation orders revealed the resident was to receive [MEDICATION NAME] (medication to treat allergic [MEDICAL CONDITION]) 0.1% ophthalmic solution one drop to each eye twice a day. Medical record review of the July 2010, Medication Record revealed the [MEDICATION NAME] was circled as not administered on July 12, and 14, 2010. Medical record review of the Nurses's Medication Notes, located on the reverse side of the July 2010, Medication Record revealed no documentation why the [MEDICATION NAME] was not administered on July 12 and 14, 2010. Interview on August 9, 2010, at 2:50 p.m., with the Director of Nursing (DON), in the conference room, revealed when a medication was circled as not administered, the reason for not administering the medication was to be documented on the reverse side of the Medication Record. Interview on August 10, 2010, at 7:10 a.m., with Licensed Practical Nurse (LPN) #3 (nurse responsible for the administration of the [MEDICATION NAME] on July 12, and 14, 2010), at the nursing station, confirmed the reason for not administering the [MEDICATION NAME] was not documented on July 12, and 14, 2010.",2014-09-01
13771,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2010-08-11,246,D,0,1,FH1311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview, the facility failed to provide insure a call light was within reach for one (#31) of thirty three residents reviewed. The findings included: Resident #31 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had difficulty with long and short term memory, moderate difficulty with decision making skills, and required assistance with all activities of daily living. Observation on August 11, 2010, at 9:10 a.m., revealed the resident lying in the bed, and requesting a bed pan. Continued observation at the same time, revealed the call light had been placed on the bed side table out of the resident's reach. Interview with Certified Nursing Assistant (CNA #5) on August 11, 2010, at 9:10 a.m., in the resident's room, confirmed the resident needed to use the bed pan and the call light was not in the resident's reach.",2014-09-01
13772,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2010-08-11,176,D,0,1,FH1311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to assess for self-administration of medications for one (#8) of thirty-three residents reviewed. The findings included: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident was comatose and dependent for all activities of daily living. Medical record review of the June 2010, physician's recapitulation orders, signed by the physician on July 14, 2010, revealed the resident was to receive Atrovent ([MEDICATION NAME][MEDICATION NAME]) unit dose and [MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME]) 0.63 mg by a nebulizer treatment. Medical record review revealed no documentation the resident had been assessed for self-administration of medications. Observation on August 9, 2010, at 3:05 p.m., revealed the resident sitting in an electric wheelchair, unattended, receiving a nebulizer treatment. Continued observation revealed the bottom of the nebulizer mask was located in the resident's mouth. Observation and interview on August 9, 2010, at 3:10 p.m., with Licensed Practical Nurse (LPN) #2, revealed the resident sitting in the electric wheelchair, with the bottom of the nebulizer mask located in the resident's mouth. Interview with LPN #2, at the time of the observation, revealed the nebulizer mask had been placed on the resident approximately 30 minutes prior to the observation. Continued interview with LPN #2 confirmed the resident had not been assessed for self-administration of medications.",2014-09-01
13773,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2010-08-11,371,F,0,1,FH1311,"Based on observation, review of manufacturer's instructions, and interview, the facility failed to maintain the dietary department in a clean and sanitary manner. The findings included: Observation of the dietary department on August 9, 2010, at 9:30 a.m., with the Dietary Manager and the Registered Dietitian (RD), revealed the dishwasher failed to reach temperatures recommended by the manufacturer, of 160 degrees F. during the wash cycle. Continued observation revealed the wash temperature reached 155 degrees F. Continued observation on August 9, 2010, at 10:35 a.m., revealed the dishwasher temperature reached 150 degrees F. Observation of the metal plate on the side of the dishwasher indicated the wash temperature should reach 160 degrees F. Continued observation on August 9, 2010, at 9:45 a.m., with the Dietary Manager and the R.D., revealed twenty-seven pans, of various sizes, were stacked and stored wet. Continued observation on August 9, 2010, at 9: 50 a.m., revealed an eight foot, two compartment sink table had food, moisture, and debris built up around the table legs, and along the front edge of the lower shelf. Interview with the Registered Dietitian and Dietary Manager on August 9, 2010, at 10:40 a.m., in the kitchen, confirmed the dishwasher, hot temps, did not reach the manufacturer's recommendations; twenty-seven pans were stacked and stored wet, and the table had food, moisture, and debris built up on the second (lower) shelf. Observation of the hot food temperatures on August 10, 2010, at 11:50 a.m., with the Dietary Manager and the Registered Dietitian, of the front tray line, revealed the temperatures of the Pork Chops and Hamburger Patties were below the recommended hot food temperatures of 140 degrees F. or above. Continued observation of the Front Tray Line, revealed the Pork chops were 130 degrees F. and the Hamburger Patties were 120 degrees F. Both the Pork Chops and the Hamburger Patties were pulled and reheated. Interview with the Registered Dietitian on August 10, 2010, at 12:15 p.m., in the dietary department, confirmed the food temperatures were below 140 degrees F. Interview with the RD on August 11, 2010, at 9:00 a.m., in the dietary department, confirmed approximately 5 - 7 trays were served prior to rechecking the food temperatures.",2014-09-01
13774,"NHC HEALTHCARE, MURFREESBORO",445108,420 N UNIVERSITY ST,MURFREESBORO,TN,37130,2010-08-11,441,D,0,1,FH1311,"Based on observation, facility policy review, and interview, the facility staff failed to wash the hands after providing incontinence care for one (#1) of thirty-three residents reviewed. The findings included: Observation on August 11, 2010, at 10:20 a.m., revealed Certified Nursing Assistant (CNA) #1 providing incontinence care to resident #1, after an episode of fecal incontinence. Continued observation revealed after providing incontinence care to the resident, CNA #1 removed the gloves and without washing the hands, obtained clean linen from a linen cart located in the hallway. Continued observation revealed CNA #1 returned to the resident's room and placed the clean linen on the resident's bed. Continued observation revealed CNA #1 again exited the resident's room without washing the hands and opened the door to a linen closet, to obtain a pillow. Continued observation revealed there were no pillows located in the linen closet and CNA #1 proceeded to the elevator and pushed the button to go to the laundry to obtain a pillow. Review of the facility's policy Handwashing revealed ""...Hands must be washed with soap and water when...Before and after assisting resident with meals or toileting..."" Interview on August 11, 2010, at 10:35 a.m., with the Director of Nursing, in the nursing station, confirmed the hands are to be washed after providing incontinence care, and confirmed proper hand hygiene was not completed.",2014-09-01
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
3906,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2017-02-08,278,D,0,1,7T7F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to accurately assess the [MEDICAL TREATMENT] status for 1 Resident (#26) of 2 residents reviewed for [MEDICAL TREATMENT]. The findings included: Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the facility failed to accurately assess the [MEDICAL TREATMENT] services provided. Medical record review of a Physicians Order dated 3/5/15 revealed [MEDICAL TREATMENT] at (named) [MEDICAL TREATMENT] clinic. Interview with the MDS Coordinator responsible for the accuracy of the MDS assessment,on 2/8/17 at 2:00 PM at the AB nurses station confirmed the facility failed to accurately address the [MEDICAL TREATMENT] status for the resident on the 11/11/16 Quarterly MDS. Interview with the Director of Nursing (DON) on 2/8/17 at 2:25 PM at the AB nurses station confirmed the facility failed to accurately address the [MEDICAL TREATMENT] status of Resident #26.",2020-01-01
3907,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2017-02-08,282,D,0,1,7T7F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to provide the treatment as ordered for an unstageable pressure ulcer to the coccyx of 1 Resident (#156) of 5 residents reviewed with pressure ulcers. The findings included: Medical record review revealed Resident #156 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident was admitted to the facility with 9 unstageable pressure ulcers and 3 suspected deep tissue injury wounds. Treatment included pressure ulcer care, application of ointment/medications, and non surgical dressings. Medical record review of the Care Plan dated 1/3/17 revealed a problem of Skin related to multiple pressure wounds. Approaches included, .Provide wound care per orders to following wounds: Coccyx-unstageable wound . Medical record review of the physician's orders [REDACTED].Clean unstageable wound to Coccyx with normal saline pat dry apply [MEDICATION NAME] (foam dressing that gels on contact) and cover dsg (dressing) qod (every other day) . Observation of wound care with the Wound Care Nurse with the MDS nurse present, on 2/8/17 at 10:40 AM in Resident #156's room revealed the Wound Care Nurse was providing pressure ulcer treatment to the resident's coccyx. Continued observation revealed the Wound Care Nurse applied Santyl (an enzyme prescription ointment used to clean wounds to aid in healing) to the resident's coccyx before placing a dressing over the pressure ulcer. Interview with the Wound Care Nurse on 2/8/17 at 11:30 AM at the AB Nurse Station confirmed she applied Santyl ointment instead of [MEDICATION NAME] to the resident's coccyx during wound care. Continued interview confirmed the Wound Care Nurse failed to follow the care plan for treatment of [REDACTED].#156. Interview with the Director of Nursing (DON) on 2/8/17 at 4:00 PM in the DON's office confirmed the facility failed to follow the care plan for treatment of [REDACTED].#156.",2020-01-01
3908,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2017-02-08,314,D,0,1,7T7F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility protocol review, medical record review, observation and interview, the facility failed to provide the treatment as ordered for an unstageable pressure ulcer to the coccyx of 1 Resident (#156) of 5 residents reviewed for pressure ulcers. The findings included: Review of facility policy How to Perform a Dressing Change, undated revealed, .Review the physician's orders [REDACTED]. Review of facility Documentation Guidelines revealed, Routine .Treatments are given only on orders of a physician . Medical record review revealed Resident #156 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident was admitted to the facility with 9 unstageable pressure ulcers and 3 suspected deep tissue injury wounds. Treatment included pressure ulcer care,application of ointment/medications and non surgical dressings. Medical record review of the physician's orders [REDACTED].Clean unstageable wound to Coccyx with normal saline pat dry apply [MEDICATION NAME] (foam dressing that gels on contact) and cover dsg (dressing) qod (every other day) . Observation of wound care with the Wound Care Nurse with the MDS nurse present, on 2/8/17 at 10:40 AM in Resident #156's room, revealed the Wound Care Nurse was providing pressure ulcer treatment to the resident's coccyx. Continued observation revealed the Wound Care Nurse applied Santyl (an enzyme prescription ointment used to clean wounds to aid in healing) to the resident's coccyx before placing a dressing over the pressure ulcer. Interview with the Wound Care Nurse on 2/8/17 at 11:30 AM at the AB Nurse Station confirmed she applied Santyl ointment instead of [MEDICATION NAME] to the resident's coccyx during wound care treatment. Continued interview confirmed the Wound Care Nurse failed to apply the correct treatment for [REDACTED]. Interview with the Director of Nursing (DON) on 2/8/17 at 4:00 PM in the DON's office confirmed the facility failed to provide the ordered treatment for [REDACTED].#156.",2020-01-01
3909,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2017-02-08,356,C,0,1,7T7F11,"Based on observation and interview, the facility failed to post the nurse staffing information on a daily basis for 2/4/17 and 2/5/17. The findings included: Observation on 2/6/17 at 9:05 AM in the front lobby of the facility, during the initial tour, revealed the facility failed to post the nurse staffing information for 2/6/17. Interview with Licensed Practical Nurse (LPN) #1 on 2/6/17 at 9:20 AM at the AB nurse's station confirmed the nurse staffing information was not posted for 2/4/17 and 2/5/17. Continued interview with LPN #1 confirmed the daily nurse staffing information for 2/6/17 was posted by 10:00 AM. Interview with the Director of Nursing (DON) on 2/7/17 at 1:30 PM in the classroom confirmed the facility failed to post the nurse staffing information for 2/4/17 and 2/5/17.",2020-01-01
3910,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2017-02-08,364,F,0,1,7T7F11,"Based on facility policy review, observation and interview, the facility dietary department failed to serve hot food at or above 135 degrees Fahrenheit (F) and cold food at or less than 41 degrees F. The findings included: Review of facility policy, Safety & (and) Sanitation Best Practice Guidelines, revised 1/2011 revealed .Time and Temperature Control .Hot food will be held at 135 degrees F or above .Cold food will be held at 41 degrees F or lower . Observation on 2/6/17 beginning at 11:25 AM in the dietary department of the resident mid-day meal trayline service, revealed 1 tray delivery cart including 2 pureed texture meals had left the dietary department for tray distribution to the residents. Continued observation revealed milk cartons stacked in a container of ice with no ice in contact with the 3 cartons of milk on the upper layer. Further observation revealed the Dietary Manger obtained a temperature of 116.5 degrees F for the pureed pork loin stored in the steamtable and 47 degrees F for milk in the upper layer not in contact with the ice. Observation on 2/7/17 at 7:20 AM in the dietary department of the resident morning meal trayline service revealed milk cartons stacked in a container of ice with no ice in contact with the 5 cartons of milk on the upper layer. Further observation revealed the Registered Dietitian obtained a temperture of 46 degrees F for the milk on the upper layer not in contact with the ice. Interview with the Dietary Manager and the Registered Dietitian on 2/6/17 at 11:35 AM and the Registered Dietitian on 2/7/17 at 7:30 AM in the dietary department confirmed the facility failed to maintain the pureed pork loin at or above 135 (140) degrees F and the milk at or less than 41 (45) degrees F. Interview with the Dietary Manager on 2/8/17 at 4:39 PM in the classroom confirmed the facility failed to follow the facility policy to maintain hot food at or greater than 135 degrees F and maintain cold food at or less than 41 degrees F.",2020-01-01
5346,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2016-02-04,157,D,0,1,GY8E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, 1 of 7 nurses (Registered Nurse (RN) #1) failed to notify the physician of elevated blood sugar results. The findings included: Medical record review revealed Resident #127 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Humalog 100 units/ml (milliliter) vial . Administer SSI (sliding scale insulin) Sub-Q (subcutaneous) AC (before meals) & (and) HS (at bedtime) as follows: 401- (to) 450= (amount of insulin to be administered) 12 units and call MD (medical doctor) . Observations in Resident #127's room on 2/1/16 beginning at 5:00 PM, revealed RN #1 performed an accucheck with a blood glucose of 402. RN #1 waited until trays arrived before administering insulin to this resident. At 5:58 PM, RN #1 performed another accucheck on this resident because it had been more than 30 minutes since the previous accucheck, with a result of 442. RN #1 did not notify the physician of the elevated blood sugar. Interview with RN #1 on 2/3/16 at 4:35 PM, at the AB nurses' station, RN #1 was asked if she had called the physician about Resident #127's elevated blood sugars on 2/1/16. RN #1 stated, No ma'am, his is over 450 that we call, want me to show you (went to computer and revealed Resident #127's Medication Administration Record [REDACTED]. No I did not (notify the MD).",2019-03-01
5347,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2016-02-04,242,E,0,1,GY8E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to honor residents' choices for 4 of 15 (Residents #8, 24, 32 and 42) sampled residents interviewed regarding choices. The findings included: 1. Review of the facility's BATH, SHOWER policy documented, Designated partner will perform shower on a regular basis . 2. Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan dated 12/26/15 documented a problem of Activities of Daily Living (ADL) with approaches that included staff to assist with all bathing, dressing and hygiene needs daily. An annual Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 13, which indicated no cognitive impairment, with a daily preference for choosing between a tub bath, shower, bed bath or sponge bath as very important to Resident #8. Interview with Resident #8 on 2/3/16 at 6:30 PM, in her room, Resident #8 was asked how many showers she usually got in a week. Resident #8 stated, Some weeks I don't get any, and some weeks I get 1. 3. Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 60 day MDS assessment dated [DATE] documented a BIMS score of 13, which indicated no cognitive impairment. Resident #24 required physical help in part of bathing activity and one person physical assist. Interview with Resident #24 on 2/1/16 at 4:06 PM, in his room, Resident #24 was asked do you choose how many times a week you take a bath or shower. Resident #24 stated, No. I got a shower on Saturday and if I ask during the week they say, 'I don't have time or will have to wait until another day'. Resident #24 was asked whether you choose to take a shower, tub, or bed bath. Resident #24 stated, No, would like a shower 2 or 3 times a week. Interview with Certified Nursing Assistant (CNA) #3 on 2/3/15 at 2:25 PM, at the nurses' station, CNA #3 was asked if Resident #24 gets a shower. CNA #3 stated, Yes. CNA #3 was asked on what days. CNA #3 stated, Wednesday and Sunday. Interview with the Unit Manager (UM) on 2/3/15 at 2:32 PM, at the nurses' station, the UM was asked who was assigned to Resident #24 today. The UM stated, (Named CNA #4). The UM was asked if she had any documentation that resident #24 had a shower today. The UM stated, No. The UM was asked if there was any documentation that a shower had been offered. The UM stated, No, ma'am. Interview with Licensed Practical Nurse (LPN) #2 on 2/3/15 at 3:05 PM, at the nurses station, LPN #2 was asked if Resident # 24 received a shower today. LPN #2 stated, I don't think so. Interview with Resident #24 on 2/3/15 at 3:15 PM, in his room, Resident #24 was asked if he received a shower today. Resident #24 stated, No,ma'am. Resident #24 was asked if he was offered a shower today. Resident #24 stated, No, ma'am. Interview with the UM on 2/3/16 at 4:30 PM, in the Social Service's office, the UM was asked if this is the sheet (the daily CNA assignment sheet given to the surveyor earlier) used for residents in regards to baths and showers. The UM stated, This is the sheet. The UM verified Resident #24's shower days are Wednesday and Saturday. Interview with CNA #4 on 2/3/16 at 5:25 PM, in the conference room, CNA #4 was asked how often Resident #24 received a shower. CNA #4 stated, Showers on Wednesday and Saturday. CNA #4 was asked if Resident #24 received a shower today (Wednesday). CNA #4 stated, No, he didn't. CNA #4 was asked if he offered Resident #24 a shower today. CNA #4 stated, No, I didn't. 4. Medical record review revealed Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan dated 1/7/16 revealed a problem of cognitive deficits with a goal that Resident #32 will be out of her room interacting with others such as care givers, family, peers, on a daily basis to encourage cognitive stimulation through approaches to include assist to and from group functions of choice. An annual MDS dated [DATE] revealed a BIMS score of 14, which indicated no cognitive impairment, with a daily preference for for activities as somewhat important to do things with groups of people. Interview with Resident #32 on 2/2/16 at 9:21 AM, in her room, Resident #32 she was asked if she can choose when to get up in the mornings. Resident #32 stated, Not this morning. Today, I wanted to go to exercise (group activity) and I told her (CNA) that I wanted to get up and go to exercise, but she didn't get me up in time. It starts at 10. She (CNA) never came back to get me up. Interview with CNA #2 on 2/2/16 at 9:40 AM, on the D hall, CNA #2 was asked if Resident #32 asked her to get up and go to exercise. CNA #2 stated, Yes, but I had an emergency with another resident and she had a BM (bowel movement) and I had to clean her up. Observations in the dining room TV area on 2/2/16 at 10:45 AM, revealed Resident #32 sitting in her wheelchair with a small group of residents. Music was playing. Interview with Resident #32 on 2/2/16 at 5:35 PM, Resident #32 was asked if she went to activities this morning. Resident #32 stated, They (staff) got me to activities about 10:30 AM, but I missed the exercise (class). It's from 10 to 10:30. The CNA came in and told me that she had to clean another lady up that had a BM (didn't go to exercise class). 5. Medical record review revealed Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan dated 1/27/16 documented a problem of ADL with approaches to include staff to assist with bathing, dressing, grooming. Interview with Resident #42 (Resident Council member) on 2/3/16 at 3:45 PM, in Resident #42's room, Resident #42 stated, Also, I am lucky if I get 1 shower a week. I asked the tech (CNA) today if I could get a shower. She said, 'I will go and check to see if it's your shower day today' but she never came back to me. So, I assumed it must not have been my shower day today. 6. Interview with the Director of Nursing (DON) on 2/3/16 at 5:12 PM, in the conference room, the DON was asked what prompted the new shower trial schedule. The DON stated, The department heads do weekly rounds, and I noticed people weren't going down there (to the shower) as often as they should. No one told me, I just noticed it. This is just a trial. I am doing it on this side (halls C and D) first to see if it helps. The DON was asked if she expected the staff to give residents showers on their shower days. The DON stated, Yes, they should. The DON was asked if a resident asked to have a shower on a day that is not their scheduled shower day, does she expect the staff to give them a shower. The DON stated, Yes, they should get a shower when they ask for one.",2019-03-01
5348,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2016-02-04,278,D,0,1,GY8E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record and interview, the facility failed to accurately assess 1 of 20 (Resident #53) sampled residents for medications of the 32 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #53 was admitted to the facility on [DATE] with admitting [DIAGNOSES REDACTED]. Pathological Fracture. The significant change Minimum Data Set ((MDS) dated [DATE] documented Resident #53 received Antipsychotic, Antianxiety and Antidepressant medications 7 of 7 days and Antibiotic medications 0 of the 7 days. The Medication and Treatment Administration Records for (MONTH) (YEAR) documented: a. Ziprasidone (Antipsychotic) was documented as administered on 1/9/16, 1/11/16, 1/12/16, 1/13/16, 1/14/16, and 1/15/16 (6 of 7 days). b. [MEDICATION NAME] (Antianxiety) was documented as administered 1/9/16 (1 of 7 days). c. [MEDICATION NAME] (Antidepressant) was documented as administered on 1/9/16, 1/11/16, 1/12/16, 1/13/16, 1/14/16, and 1/15/16 (6 of 7 days). d. [MEDICATION NAME] (Antibiotic) was documented as administered on 1/15/16 (1 of 7 days). Interview with the MDS Coordinator on 2/3/16 at 9:20 AM, in the MDS office, the MDS Coordinator was asked if the significant change MDS dated [DATE] should be coded as antipsychotic 6 days, antianxiety 1 day, antidepressant 6 days, and antibiotic 1 day. he MDS Coordinator stated, Yes ma'am. I will modify it. It has already been transmitted.",2019-03-01
5349,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2016-02-04,282,D,0,1,GY8E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to follow care plan interventions for nutrition for 1 of 19 (Resident #72) sampled residents of the 32 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #72 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 12/25/15 documented, .PROBLEM . Nutrition/hydration: (Named Resident #72) is at risk for alteration in nutrition . Serve food quickly - pt (patient) may leave the dining room if not served . Observations in the dining room on 2/3/16 beginning at 5:20 PM, revealed 24 residents were being served. Residents had been served trays, while Resident #72 was wheeling himself about in the dining room. Resident #72 wheeled himself out of the dining room, and down the A hall. There were dependent diners (residents who need assistance eating) seated at a separate table in the rear of the dining room. As Certified Nursing Assistant (CNA) #1 retrieved a tray from the cart to serve to one of the dependent residents, CNA 1 stated, Where did (Named Resident #72) go to? As Licensed Practical Nurse (LPN) #1 retrieved Resident #72's tray from the cart. LPN #1 stated, Where is (Named Resident #72)? CNA #1 stated, I will go get him. At that time, Resident #72 was at the edge of the A hall. CNA #1 stated, Well there you are. CNA #1 served Resident #72's tray with the other dependent diners. Resident #72 was the 23rd resident served of the 24 residents in the dining room. The staff did not serve Resident #72's tray quickly, as care planned. Interview with the Director of Nursing (DON) on 2/3/16 at 6:35 PM, in front of the C/D nurses' station, the DON was asked how the staff would know what the care plan interventions are. The DON stated, They have care approach cards in their closets, and they (staff) should be reporting off to each other. The DON was told the situation in the dining room, and she confirmed Resident #72 should have been served timely.",2019-03-01
5350,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2016-02-04,314,D,0,1,GY8E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the National Pressure Ulcer Advisory Panel (NPUAP) Pressure Ulcer Prevention and Treatment quick reference guide, policy review, medical record review and interview, the facility failed to conduct a weekly pressure ulcer assessment for 1 of 3 (Resident #22) sampled residents reviewed of the 5 residents with a pressure ulcer. The findings included: The NPUAP Prevention and treatment of [REDACTED].Pressure Ulcer Assessment 1. Assess the pressure ulcer initially and re-assess it at least weekly . Document the results of all wound assessments . The facility's pressure ulcer management documented, .3. Weekly a. Wound assessments are documented using the Pressure Ulcer Progress Note . Medical record review revealed Resident #22 was admitted with [DIAGNOSES REDACTED]. A weekly wound assessment record revealed the following: a. Wound #1 - Stage 3 - Right Ischium/Buttocks - admitted with. b. Wound #2 - Stage 3 - Left Ischium/Buttocks - admitted with. c. Wound #3 - Unstageable - Sacrum - admitted with. d. Wound #4 - Stage 3 - Lower Right Ischium/Buttocks - admitted with (same as Wound #1 and became a separate wound on 12/15/15) There were no weekly pressure ulcer assessments documented on wounds #1, 2, 3 or 4 for the week of 1/24/16 through 1/30/16. Interview with the Director of Nursing (DON) on 2/3/16 at 9:55 AM, in the conference room, the DON stated, Wound #1 and 4 used to be 1 wound but they separated into 2 back in December. Interview with the DON on 2/3/16 at 3:01 PM, in the conference room, the DON was asked if she expected her staff to do weekly wound assessments on Resident #22. The DON stated, Yes, it's expected.",2019-03-01
5351,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2016-02-04,371,F,0,1,GY8E11,"Based on policy review, observation, and interview, the facility failed to ensure food was prepared and served in a sanitary manner as evidenced by 6 of 8 dietary staff members (Dietary staff members (DSM) #1, 2, 3, 4, 5, and 6) had exposed hair from a hair restraints, expired food items, opened, unlabeled and undated food items, scoops in bins, dirty shelves, and a dented can. The facility had a census of 85, with 83 of those residents receiving a meal tray from the kitchen. The findings included: 1. The facility's .HYGIENIC & (and) SAFETY PRACTICES . policy documented, .Hair Restraints for Dietary Partners . shall wear hair restraints . worn to . keep their hair from contacting exposed food . a. Observations in the kitchen on 2/1/16 beginning at 10:30 AM, revealed DSM #1 and 2 wore a hair restraint, but their hair was not completely covered. b. Observations in the kitchen on 2/2/16 at 4:55 PM, revealed DSM #3, 4 and 5 wore a hair restraint, but their hair was not completely restrained. c. Observations in the kitchen on 2/4/16 at 11:22 AM, revealed DSM #1 wore a hair restraint, but her hair was not completely restrained. d. Observations in the dining room on 2/3/16 at 11:32 AM, revealed DSM #6 wore a hair restraint while serving behind the buffet line and her hair was not completely covered. Interview with the Certified Dietary Manager (CDM) and Registered Dietician (RD) on 2/4/16 at 11:50 AM, in the large conference room, the CDM was asked if hair should be completely covered by hair restraints. The CDM stated, Right. 2. The facility's .Safety & Sanitation Best Practice Guidelines . policy documented, .Cooked Meats . Storage Time 7 days . Special Instructions . covered securely, date with use by date . Canned Fruits, opened . covered securely, date with use by date . Commercially prepared Meat . Salads . chicken . Special Instructions . covered securely; date with use by date . A. Observations in the kitchen on 2/1/16 beginning at 10:30 AM, revealed the following: a. Nine cartons of expired fat free chocolate milk, dated 1/31 and 1 carton of expired fat free chocolate milk, dated 1/24 in the reach-in cooler. b. Eight cartons of expired fat free chocolate milk, dated 1/31 in the walker-in cooler. c. A container of expired tomato sauce, not labeled and dated 1/22/16 in the walk-in cooler. d. A container of a white powder substance sitting on a shelf that was not labeled or dated. e. Three large plastic bins: 1 bin labeled corn meal with a scoop in it, 1 bin labeled sugar, with a scoop in it, and 1 bin labeled oatmeal and none of these were dated. f. An opened bag of chicken tenders, not labeled or dated in the reach-in freezer. g. An opened bag of french fries with 2 sides torn, not sealed, labeled or dated in the reach-in freezer. h. An opened bag of tater tots, not labeled or dated in the reach-in freezer. i. An opened package of bacon, not labeled or dated in the reach-in freezer. j. An opened bag of spicy fries, not labeled or dated in the reach in-freezer. k. Five clear plastic containers on the wall labeled Raisin Bran, Frosted Flakes, Cheerios, Rice Krispies, and Corn Flakes not dated. l. A container of food with a lid not secured, not labeled, in the walk-in cooler. The CD identified the food as chicken salad. m. A plastic container of fruit with a lid not secured and not labeled in the walking - cooler. The CD identified the fruit as as pineapple. Interview with the Clinical Dietician (CD) on 2/1/16 at 10:33 AM, in the kitchen, the CD was asked if the containers should be labeled. The CD stated, Uh-huh. The CD confirmed the milk and tomato sauce were expired. Interview with DSM #7 on 2/1/16 at 10:34 AM, in the kitchen, DSM #7 was asked what was in the container. DSM #7 stated, Flour. DSM #7 was asked if it should be labeled and dated. DSM #7 stated, Supposed to be. B. Observations in the kitchen on 2/2/16 beginning at 4:55 PM, revealed the following: a. Three large plastic bins: 1 bin labeled corn meal with a scoop in it, 1 bin labeled sugar, with a scoop in it, and 1 bin labeled oatmeal and none were dated. b. A bag of french fries opened, not labeled or dated in the reach-freezer. c. A carton of no sugar ice cream opened and not dated in the reach-in freezer. d. A bag of sweet potato fries opened, not sealed and not labeled or dated in the reach-in freezer. e. An opened bag of tater tots with 3 open areas on the bag, not sealed, labeled or dated in the reach-in freezer. f. An opened box of bratwurst not sealed, labeled or dated in the reach-in freezer. g. Two glasses of milk with an A on the lid, not labeled or dated in the reach-in cooler. h. Seven glasses of thickened milk, not labeled or dated in the reach-in cooler. i. Four glasses of thickened tea, not labeled or dated in the reach-in cooler. j. Seven glasses of thickened orange juice, not labeled or dated in the reach-in cooler. k. A tray of jello, not labeled in the reach-in cooler. l. Two metal containers of cooked sausage and bacon mixed together, not labeled in the reach-in cooler. m. A metal pan of expired tomato sauce not labeled and dated 1/20/16 in the reach-in cooler. n. A metal pan with gravy, not labeled in the reach-in cooler. o. Six trays of bacon, a tray of sausage and a half (1/2) tray of biscuits, not labeled or dated in the reach-in cooler. p. Four bowls with lids on them in the kitchen, not dated or labeled. The CDM was unsure of the contents. q. Five clear plastic containers on the wall labeled Raisin Bran, Frosted Flakes, Cheerios, Rice Krispies, and Corn Flakes not dated. r. A container of expired tomato sauce not labeled and dated 1/22/16 in the walk-in cooler. s. A container of pineapple, not labeled and unable to read the date in the walk-in cooler. t. A container of chicken salad with an unsecured lid, not labeled in the walk-in cooler. u. The milk cooler had dirty shelves with a dried substance on the shelves. The CDM took her fingernail and scratched a flaky substance off the shelf. Interview with the CDM on 2/2/16 at 4:58 PM, in the kitchen, the CDM was asked if the shelves were dirty in the milk cooler. The CDM stated, Yeah, I can clean them. Interview with the CDM and RD on 2/4/16 at 11:50 AM, in the large conference room, they were asked if food should be labeled according to the policy. The RD shook her head yes. The CDM was asked would you expect bins to have scoops in them. The CDM stated, Not have scoops in them. 3. Observations in the kitchen on 2/2/16 at 5:30 PM, revealed a dented can of Ensure in the walk-in cooler. Interview with the CDM on 2/2/16 at 5:30 PM, in the walk-in cooler, the CDM was asked if there was a dent in the can. The CDM stated Yes. The CDM was asked if it needed to be in the cooler. The CDM stated, No, (should be) in a box in my office.",2019-03-01
6882,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2014-12-10,371,F,0,1,0T2D11,"Based on policy review, observation and interview, it was determined the facility failed to ensure food was protected from physical contaminates and other sources of contamination as evidenced by 8 of 8 unauthorized persons (Environmental Services Director, Nurse #1, Maintenance Director, Certified Nursing Assistant (CNA) #1, 2, 3, Recreational Assistant #1, and Physical Therapy (PT) Director) entered the kitchen without a hair net and/or beard covering which could have affected 86 of the 89 residents in the building. The facility had 2 residents currently under isolation precautions. The findings included: 1. Review of the facility's HYGIENIC & (and) SAFETY PRACTICES policy documented, .Effective personal hygienic and safety practices are essential in preventing food contamination. All Dietary partners must have an understanding of sanitation guidelines and put into practice those guidelines in order to provide a safe product for all customers . GUIDELINES . 3. Hair Restraints for Dietary Partners . Dietary partners shall wear hair restraints such hats, hair coverings, or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles . 2. Observations in the kitchen on 12/8/14 at 11:10 AM, revealed the Environmental Services Director obtained 2 cartons of milks from the kitchen serving area, as Nurse #1 was leaving the serving area. Each of these employees did not have a hair restraint on. There was a sign in the service hall at the door prior to entering the kitchen at the serving line stating, Entering Service Area No Hair Restraint Required, then a sign in the kitchen at the walking area just prior to entering the area on the other side of the tray line stating, Entering Production Area Hair Restraints are Required Beyond This Point. This sign also was at the doorway to dish room in the service hall stating, Entering Production Area Hair Restraints are Required Beyond This Point. 3. Observations in the kitchen on 12/8/14 at 12:24 PM, revealed the Maintenance Director standing in the kitchen at the serving line without a hair restraint on, conversing with the cook, as CNA #1 entered this area without a hair restraint on. 4. Observations in the kitchen on 12/9/14 at 12:34 PM, revealed CNA #2 and CNA #3 were standing in the kitchen at the serving line obtaining a tray without hair restraints on. 5. Observations in the kitchen on 12/9/14 at 5:25 PM, revealed Recreational Assistant #1 entered the kitchen at the serving line to obtain a tray, and was not wearing a hair restraint. 6. Observations in the kitchen on 12/10/14 at 7:55 AM, revealed the PT Director standing in the kitchen in front of the serving line without a hair restraint on. 7. During an interview in the kitchen on 12/10/14 at 8:10 AM, the Dietary Manager (DM) was asked about the staff entering the kitchen without hair restraints. The DM stated, I know, have changed their policy and have it separated between production area and service area. I know has been a problem in the past. The DM confirmed the staff entered the kitchen without hair restraints on.",2018-04-01
6883,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2014-12-10,441,D,0,1,0T2D11,"Based on policy review, personnel record review, observation and interview, it was determined the facility failed to ensure 1 of 5 (Nurse #1) nurses observed during medication administration performed hand hygiene before and after the removal of gloves and 1 of 5 (New Employee #1) newly hired employees was free of communicable diseases. The findings included: 1. Review of the facility's infection control manual documented, .Section 702 . HANDWASHING . PR(NAME)EDURE Wash hands . before and after removal of gloves . Observation of administration of medication via an enteral tube on D hall on 12/9/14 at 5:42 PM, revealed Nurse #1 spilled water from a syringe onto Resident #112's abdomen and onto the nurse's gloves while checking placement of the enteral tube. Nurse #1 moved to the foot of the bed, removed and discarded the wet gloves into the garbage can, put on new gloves and continued the medication administration. Nurse #1 did not wash her hands or use an alcohol based hand gel between changing gloves. During an interview at the medication cart on D hall on 12/9/14 at 5:50 PM, Nurse #1 verified she did not wash her hands when she changed gloves. 2. Review of the facility's infection control manual documented, .Section 402 . PURPOSE . An annual health screen is completed, reviewed, and filed annually in the partner health record . Review of the personnel record for New Employee #1 did not contain a completed health screen that had been reviewed and signed by a physician indicating that she was free of communicable diseases. During an interview in the business office on 12/10/14 at 3:55 PM, the Assistant Director of Nursing (ADON) was asked if she had proof that New Employee #1 with a hire date of 8/11/14 was free of communicable diseases. The ADON stated, I can't. I don't know why she was missed.",2018-04-01
8908,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2013-07-12,225,D,0,1,5JNA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, it was determined the facility failed to implement the abuse prevention policy and procedure to perform a complete and thorough investigation of an injury of unknown origin or report the incident to the state survey agency within 5 working days of the injury for 1 of 2 (Resident #66) residents with injuries of the 31 sampled residents included in the stage 2 review. The findings included: Review of the facility's Abuse Protection & (and) Response Policy-Tennessee Only documented, .Injuries of Unknown Source: An injury should be classified as an injury of unknown source when both of the following are met: The source of the injury was not observed by any person or the source of the injury could not be explained by the patient. The injury is suspicious because of the extent of the injury or the location of the injury . Review of the facility's INCIDENT AND ACCIDENT PROCESS policy documented, .An incident or accident is defined as any occurrence that is outside the norms or any happening that is not consistent with the routine operation of the center or care of a particular patient . Some examples of incidents/accidents are: .Unexplained bruising . Document all known facts, results of assessment including a complete description of injuries, treatment, notification of physician and family . Occurrences of an unusual nature will be reported as required by . and State Law . Medical record review for Resident #66 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/13/12 revealed section C1200 was coded as 2, indicating moderately impaired cognitive skills for decision making. Review of the MDS with an ARD of 5/14/13 revealed section C1200 was coded as 3, indicating severely impaired cognitive skills for decision making. Review of a nurses' note dated 6/16/13 documented, Daughter here feeding pt (patient) lunch, notified this nurse of bruising (R) (right) side of face @ (at) corner of eye (symbol for zero) nonverbal s/s (signs and symptoms) pain- (symbol for zero indicating no) grimacing or moaning when touched. Pt frequently pulls self to bedrail. Unable to determine cause. Pads placed on siderails . Review of the Incident Investigation dated 6/15/13 documented, .Type of incident Bruise of unknown origin . Incident: Noted Bruise to corner of (R) eye & (and) small bruise lower lip. Family & MD (Medical Doctor) notified . Investigation: Bruise not there Sat (Saturday) but noted Sun (Sunday) morning. Interviewed CNA's (certified nursing assistants) & Nurses states Pt. (patient) frequently pulls self to SR (siderail) & moves continuously in Bed. Pt on ASA (Aspirin) daily. SR padded for safety . Result: Pt attempts to get OOB (out of bed). SR's padded. Spoke c (with) Daughter. Bruise unknown origin. Daughter request SR padded . During an interview in the Director of Nursing's (DON) office on 7/10/13 at 10:10 AM, the DON was asked about the bruise on Resident #66 face. The DON stated, Know had whelp corner of eye, next day dark place on eye had been thrashing around in bed thought may have hit siderail. Interviewed CNAs and they didn't know how it happened other than thrashing around in bed. There was a blue place on inner lip not really a bruise, looks like she bit her lip. Took statements, no written statement. I didn't have them write a statement just took them and documented it . During an interview in the DON's office on 7/11/13 at 4:31 PM, the DON was asked if the incident had been reported to the state. The DON stated, No because we didn't suspect abuse . The DON was then asked if they had determined for sure what caused the bruise and area inside Resident #66's lower lip. The DON stated, No, can't say for sure . The facility was unable to provide documentation of a description of the bruise to Resident #66's face and lower lip. The facility failed to thoroughly investigate or report this injury of unknown origin to the state survey certification agency within 5 workig days of the injury.",2017-03-01
8909,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2013-07-12,226,D,0,1,5JNA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, it was determined the faility failed to implement the abuse prevention policy and procedure for performing a complete and thorough investigation of an injury of unknown origin for 1 of 2 (Resident #66) residents with injuries of the 31 sampled residents included in the stage 2 review. The findings included: Review of the facility's Abuse Protection & (and) Response Policy-Tennessee Only documented, .Injuries of Unknown Source: An injury should be classified as an injury of unknown source when both of the following are met: The source of the injury was not observed by any person or the source of the injury could not be explained by the patient. The injury is suspicious because of the extent of the injury or the location of the injury . Review of the facility's INCIDENT AND ACCIDENT PROCESS policy documented, .An incident or accident is defined as any occurence that is outside the norms or any happening that is not consistent with the routine operation of the center or care of a particular patient . Some examples of incidents/accidents are: .Unexplained brusing . Document all known facts, results of assessment including a complete description of injuries, treatment, notification of physician and family . Occurences of an unusual nature will be reported as required by . and State Law . Medical record review for Resident #66 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minumum Data Set (MDS) with an assessment reference date (ARD) of 11/13/12 revealed section C1200 was coded as 2, indicating the resident is moderately impaired cognitive skills for decision making. Review of and the MDS with an ARD of 5/14/13 revealed section C1200 was coded as 3, indicating the resident is severely impaired cognitive skills for decision making. Review of a nurse's note dated 6/16/13 documented, Daughter here feeding pt (patient) lunch, notified this nurse of bruising (R) (right) side of face @ (at) corner of eye (symbol for zero) nonverbal s/s (signs and symptoms) pain- (symbol for zero indicating no) grimacing or moaning when touched. Pt frequently pulls self to bedrail. Unable to determine cause. Pads placed on siderails . Review of the facility's Incident Investigation dated 6/15/13 documented, .Type of incident Bruise of unknown origin . Incident: Noted Bruise to corner of (R) eye & (and) small bruise lower lip. Family & MD (Medical Doctor) notified . Investigation: Bruise not there Sat (Saturday) but noted Sun (Sunday) morning. Interviewed CNA's (certified nursing sssistants) & Nurses states Pt. frequently pulls self to SR (siderail) & moves continuously in Bed. Pt on ASA (aspirin) daily. SR padded for safety . Result: Pt attempts to get OOB (out of bed). SR's padded. Spoke c (with) Daughter. Bruise unknown origin. Daughter request SR padded . During an interview in the Director of Nursing's (DON) office on 7/10/13 at 10:10 AM, the DON was asked about the bruise on Resident #66's face. The DON stated, Know had whelp corner of eye, next day dark place on eye had been thrashing around in bed thought may have hit siderail. Interviewed CNAs and they didn't know how it happened other than thrashing around in bed. There was a blue place on inner lip not really a bruise, looks like she bit her lip. Took statements, no written statement. I didn't have them write a statement just took them and documented it . During an interview in the DON's office on 7/10/13 at 10:20 AM, CNA #1 was asked about the bruise on the resident's face. CNA #1 stated, I fed her (Resident #66) breakfast and didn't see it (bruise). When lunch came around daughter asked what happened to her face. Someday she moves some, but she doesn't always. She was anxious that day, scratching, had seen bruises on her hand but never on face and scratches on her leg . During an interview in the DON's office on 7/11/13 at 4:31 PM, the DON was asked if the incident had been reported to the state. The DON stated, No because we didn't suspect abuse . The DON was then asked if they had determined for sure what caused the bruise and area inside Resident #66's lower lip. The DON stated, No, can't say for sure . The facility was unable to provide documentation of the description of the bruise on Resident #66's face or inner lower lip. The facility failed to implement their abuse prevention policy and procedure for performing a complete and thorough investigation of an injury of unknown origin.",2017-03-01
8910,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2013-07-12,280,D,0,1,5JNA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to ensure the care plan was complete for behaviors for 1 of 2 (Resident #119) residents of the 31 sampled residents included in the stage 2 review. The findings included: Medical record review for Resident #119 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Nurses' notes documented the following: a. 12/28/12 - 1a (AM) Pt. (patient) found wandering the hallways . b. 12/30/12 - 10p (PM) .wandering hallways trying to go in other pts rooms . c. 1/1/13 - 10p .Pt. wandering the halls. redirect multiple times from pts rooms . d. 1/9/13 - 10:30p .Pt conts to wander hallways into other patients rooms slight agitation when redirected by staff . e. 1/17/13 - 2a .Pt wandering halls into patient room. found attempting to remove a painting from the wall & (and) almost dropping painting on himself & techs (technicians) . 1/17/13 - 7AM .Pt was flipping over dining room tables and chairs. Pt got stuck in one of the chair . Pt got combative Took 4 staff members to get pt out of chair . Social service notified of pts agitation. f. 2/8/13 - 10p .Pt. wanders into other pts rooms c (with) redirection x (times) 4 . g. 2/11/13 - 10:40 p .pt wandering and pacing halls multiple attempts to redirect also attempted to urinate on wall in hallway and going in other patients rooms . h. 2/12/13 - 730-Pt wandering into other pts room Inappropriate behavior (trying to get in a bed in another room) noted, staff intervened. Social services notified . The 14 day Minimum Data Set ((MDS) dated [DATE] and the 30 day MDS dated [DATE] documented the resident with severe impaired cognition with behaviors. A Physician's facility follow-up dated 2/15/13 documented, Assessment / Plan: [MEDICAL CONDITION]. He was put on [MEDICATION NAME] 10 mg (milligrams) q. (every) day . During an interview in the conference room on 7/11/13 at 8:00 AM, the Social Worker (SW) stated, I monitor behaviors. On (named Resident #119) I called the caregiver . The SW was asked about the inappropriate incident of the resident trying to get in a bed in another room. The SW stated, I called the Behavior Health Clinic to come and evaluate him . I would document what I did in social services notes. No, I can't find anything in chart . During an interview in the conference room on 7/11/13 at 8:25 AM, the Director of Nursing (DON) was asked about the inappropriate behavior situation. The DON stated, Yes, it should have been documented. The social worker was brand new and we told her to document it . Yes, it should be in the notes. (Named Resident #119) was one that wandered worse at night . he would go in other resident rooms especially at night he had to be watched closely . The comprehensive care plan did not address [MEDICAL CONDITION] or combativeness and did not include any interventions provided by the Social Worker.",2017-03-01
8911,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2013-07-12,282,D,0,1,5JNA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, it was determined the facility failed to follow the care plan interventions for padded siderails and assistance of staff with toileting for 2 of 21 (Residents #66 and 161) residents of the 31 sampled residents included in the stage 2 review. The findings included: 1. Medical record review for Resident #66 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an assessment preference date (ARD) of 11/13/12 revealed section C1200 was coded as 2, indicating the resident is moderately impaired for cognitive skills for decision making. Review of the MDS with an ARD of 5/14/13 revealed section C1200 was coded as 3, indicating the resident is severely impaired for cognitive skills for decision making. A nurse's note dated 6/16/13 documented, Daughter here feeding pt (patient) lunch, notified this nurse of bruising (R) (right) side of face @ (at) corner of eye (symbol for zero) nonverbal s/s (signs and symptoms) pain- (symbol for zero indicating no) grimacing or moaning when touched. Pt frequently pulls self to bedrail. Unable to determine cause. Pads placed on siderails . Review of the care plan dated 5/25/13 and updated 6/16/13 documented, Pad SR (siderails) R/T (related to) pt moving in Bed . Observations in Resident #66's room on 7/9/13 at 7:22 AM, 4:04 PM and 4:50 PM, revealed Resident #66 lying in bed with siderails not padded. During an interview in the Director of Nurse's (DON) office on 7/10/13 at 10:30 AM, the DON was asked about padded siderails for Resident #66. The DON stated, When in bed the siderails should be padded. The DON verified Resident #66's siderails were not padded on 7/9/13 at 4:04 PM, and 4:50 PM. 2. Medical record review for Resident #161 documented an admission date of [DATE] with [DIAGNOSES REDACTED]., [MEDICAL CONDITION], Dysphagia, Gastro [MEDICAL CONDITION] Reflux Disease and History of [MEDICAL CONDITIONS]. The admission MDS dated [DATE] documented the resident with a brief interview memory status (BIMS) of moderate impaired cognition, requiring extensive assistance with Activities of Daily Living, at risk for falls and receiving antidepressants and antibiotics. The comprehensive care plan dated 6/17/13 documented, .(Resident #161's name) requires assistance with adls (activities of daily living) with the approach of Bed mobility, transfers, and ambulation with asst. (assistance) of staff as requires asst. per staff for in room BRP (bathroom privileges) qd (every day) . A post falls nursing assessment dated [DATE] at 11:20 AM documented, CNA (certified nursing assistant) heard patient call out. She (CNA) went to room and found patient lying on floor inside bedroom entrance door with bathroom door up against outer door . exiting commode while unattended . patient stated got up from toilet and lost my balance . Resident #161's 6/22/13 fall resulted in a fractured right hip injury and a hematoma to the head. There was no documentation of the asst per staff for in room BRP (bathroom privileges) per care plan. The facility failed to follow the comprehensive care plan for assistance with toileting. During an interview in the conference room on 7/11/13 at 9:20 AM, CNA #4 was asked about care provided for Resident #161. CNA #4 stated, I help with his bath. He is independent, have to talk with him. I walk him to the bathroom, dress him, walk him to his wheelchair . on the day (Resident #161) fell he had taken himself to the bathroom, he told us that .",2017-03-01
8912,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2013-07-12,323,J,0,1,5JNA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the fall prevention program, medical record review, observation and interview, it was determined the facility failed to ensure the environment was safe and free of accident hazards, failed to ensure assessment of each resident was complete and accurate and failed to implement appropriate and measurable interventions to prevent potential injuries for 3 of 6 (Residents #161, 146 and 66) residents with falls or injury of unknown origin of the 31 residents included in the stage 2 review. The facility failed to accurately and completely assess residents with falls, implement appropriate interventions and provide supervision to ensure the environment was safe and free of accident hazards which placed Resident #161 and Resident #146 in immediate jeopardy. In the conference room on 7/11/13 at 7:10 PM, the Administrator, the Director of Nursing (DON), and the Regional Nurse Consultant were informed of the immediate jeopardy (IJ). This IJ was removed on 7/12/13. The findings included: 1. Review of the facility's fall prevention program documented, .Falls can have serious consequences for both the resident and the facility . Injuries caused by falls increase the resident's risk of death, decrease the resident's ability to function, and reduce quality of life. Even falls that do not cause injuries lead to fear of falling, which may cause the resident to become less active. In turn, this inactivity hastens the decline of frail residents . Poor safety practices also increase fall risk . These include . unsafe transfer and mobility . The program goal was to reduce falls in nursing homes . Step 5 is to identify those residents at high risk of falling who will be included in the program . Step 6 is to conduct the program assessments for high-risk residents. These assessments are designed to identify problems and guide you to solutions . Unsafe behavior. Some residents fall because of unsafe behavior related to dementia . To manage residents with unsafe behavior, it is important to learn about the behavior pattern . know what triggers the behavior . Prescribed drugs should be reviewed . The resident's medical status should be evaluated . for medical condition may be contributing to the behavioral symptoms. Each resident should also be assessed to determine what specific strategies would reduce fall risk . The safety and appropriateness of all equipment and restraint, including alarms, barriers, siderails and seating items should be reevaluated . The Fall Prevention Nurse will use Section 1 of the High-Risk Resident Selection Form to decide whether or not to enroll the resident in the program . There are four possible assessments from which to choose of each high-risk resident in the program . They are the Walking Assessment, Wheelchair Assessment, Benzodiazepine Assessment, and Behavior Assessment . For unsafe behavior, check if the resident had any of the following unsafe behaviors two or more times in the past month: a. Tried to stand, transfer, or walk alone unsafely; b. climbed over bed rails or tried to get out of the bed alone unsafely; c. Walked or paced when too tired to be safe or d. Propelled a wheelchair or walked alone in unsafe areas such as outdoors on rough pavement or in a parking lot . The Behavior Assessment will help you manage unsafe behaviors that often increase fall risk . First, you are asked to describe the unsafe behavior in as much detail as possible, including time of day, location, frequency, equipment present and what appears to precipitate the behavior . Second, you will need to read the chart and talk with staff to determine what the current behavior management plan is and whether it is effective. You are asked to record the approaches and their effectiveness. Third, you are asked to look at a list of suggestions and to check each task you think may improve the resident's safety. These tasks, as well as any current approaches which are effective, will be added to the resident's care plan . When the assessments for a high-risk resident are finished, the Fall Prevention Nurse must ensure that the tasks that were identified to improve the resident's safety are carried out in an organized way . 1. Review the assessments. 2. Write the nursing tasks on the Action List of the High-Risk Resident Follow-Up Form and review the list with staff. 3. Follow-up with unit staff to ensure that tasks on the Action List are being carried out and revise them as necessary. 4. Inform other staff of their tasks, complete your tasks, and follow-up to ensure that all tasks are completed 5. Review resident falls using the Fall Record of the High-Risk Resident Follow-up Form and revise the Action List as necessary . 2. Medical record review for Resident #161 documented an admission date of [DATE] with [DIAGNOSES REDACTED]., Osteoarthritis, Dysphagia, Gastro Esophageal Reflux Disease and History od Clostridium Difficile (C-diff). The admission Minimum Data Set ((MDS) dated [DATE] documented the resident with a brief interview memory status (BIMS) of moderate impaired cognition, requiring extensive assistance with Activities of Daily Living, at risk for falls and receiving antidepressants and antibiotics. The high risk patient selection form (facility fall risk assessment) dated 5/28/13 documented assessment type as admission . resident had a fall in past 30 days . had taken antidepressant Remeron in past 7 days . and proceed with section 2 . Section 2 of the high risk patient selection form dated 6/17/13 documented, All patients in the program will need a transfer and mobility assessment, unless they are always assisted or bed bound . always asst (assist) care plan decision to proceed and DX (diagnosis): L (left) Hip Fx (fracture) R/T (related to) Fall dx Alzheimer's dementia . There was no documentation on the unsafe behavior area of the assessment form. There was no behavior assessment completed per the facility's fall prevention program. A restorative nursing screening form dated 6/17/13 late entry for 6/1/13 documented .requires ext (extensive) asst (assistance) x (times) 2 w (with) / toileting needs- 2 (secondary to) L Hip Fx- Bed mobility ext asst x 2, transfers ext asst x 2, ambulation w/RW (rolling walker) min (minimum) - max (maximum) asst 1- (to) 2 in corridor & (and) room . (Initiate Fall program-High Risk). The interim plan of care dated 5/28/13 documented, Identified Problems / Needs of . assess for unsteady gait, dizziness & intervene as needed, verbally remind patient not to ambulate alone, Fall Risk Assessment, Low bed . The admission MDS dated [DATE] documented the resident with a BIMS of moderate impaired cognition. This is not an appropriate intervention for a cognitively impaired resident. The interim plan of care was updated on 6/3/13 and documented, Personal alarms as needed Prime Snap (name of a personal body alarm) 6/3. The interim plan of care was updated on 6/4/13 and documented, Fall 6/4/13-6/4 Monitor & Assist frequently r/t (related to) diarrhea. The comprehensive care plan dated 6/17/13 documented, .(Resident #161's name) requires assistance with adls (activities of daily living) with the approach of Bed mobility, transfers, and ambulation with asst. of staff as requires asst. per staff for in room BRP (bathroom privileges) qd (every day) . The facility failed to follow the comprehensive care plan for assistance with toileting. The certified nursing assistant (CNA) care card documented, .Ambulation/ Transferring/ bed mobility assistance x 2 . Fall Risk hip precautions . A post falls nursing assessment dated [DATE] at 4:30 PM documented, Pt (patient) was found in (on) the floor after having an incontinent episode . safety device in use Alarm . Description of injury Abrasion to Right Elbow . What immediate interventions were initiated to prevent future falls? The facility staff documented, .Patient was assisted with toileting and frequently monitored due to diarrhea. A falls meeting agenda dated 6/5/13 documented, .(listed room number) - 6/4- 4:30pm- found on floor Pt had incontinent episode and slipped, Alarm sounding. Moved closer to NSG (nursing) station 6-5-13 Now in (listed a different room). There was no documentation of a post falls investigation or a high risk resident follow-up form provided by the facility for this fall. There was no documentation of the always asst intervention documented on the admission high risk patient selection form. The resident sustained [REDACTED]. A post falls nursing assessment dated [DATE] at 11:20 AM documented, CNA heard patient (Resident #161) call out. She (CNA) went to room and found patient lying on floor inside bedroom entrance door with bathroom door up against outer door . exiting commode while unattended . patient stated got up from toilet and lost my balance . safety devices in use low bed alarm . description of injury . Site 1 Patient c/o (complained of) severe right hip pain external left leg rotation . site 2 knot w/redness top of head . what immediate interventions were initiated to prevent future falls? The staff documented, .attend while toileting . The post falls investigation dated 6/26/13 documented, .Fall investigation 6/22/13 11:20 AM type of injury bone fracture hip hematoma head . exiting commode while unattended . needed care plan changes: Do not leave alone in bathroom . A nurse's note dated 6/22/13 at 2:50 PM documented, Pt. admitted to (name of local hospital) . to have surgery. A nurses note dated 6/25/13 at 8:10 PM documented, .Pt. arrived via ambulance stretcher . Dsg (dressing) to R (right) hip C/D/I (clean dry intact) . There was no documentation of the always asst documented on the admission high risk patient selection form. There was no documentation of the frequent monitoring and assisted with toileting intervention implemented from previous fall. There was no high risk resident follow-up form completed by the facility per fall prevention program. Resident #161's 6/22/13 fall resulted in a fractured right hip injury and a hematoma to the head. A post falls nursing assessment dated [DATE] at 9:45 PM documented, Found patient on the floor beside bed in front of bathroom ambulating in room unattended pt. stated he was just going to sit down and his legs gave out and he fell to the floor . safety devices in use: low bed, alarm, fall mat . what immediate interventions were initiated to prevent future falls? The staff documented, evaluate & assess need for prompt & assist toileting program . A post falls investigation dated 7/9/13 documented, .Fall investigation 7/5/13 9:45 PM type of injury Abrasion Rib. There was no high risk resident follow-up form completed per the facility's fall prevention program. There was no documentation of frequent monitoring or always asst being provided. Resident #161's 7/5/13 fall resulted in an abrasion to the rib area. During an interview in the conference room on 7/10/13 at 5:00 PM, the Assistant Director of Nursing (ADON) was asked what was the process the nurses are to do for a fall. The ADON stated, When a resident falls the nurses complete a post falls assessment. They document what happened and they also document the immediate intervention started to prevent future falls. This is put in the computer and then I (ADON) do a post falls investigation . On the first fall he (Resident #161) got up and fell was having diarrhea, and nurses put in place assist with toileting and frequent monitoring due to diarrhea. The ADON was asked to define frequent monitoring. The ADON stated, More often than routine which is every 2 hours. The ADON was asked where this frequent monitoring was documented. The ADON stated, Not documented except in nurses notes. On the second fall the nurses put in place to attend while toileting. Yes, he was left unattended and he was not suppose to be. On the 3rd fall nurses put in place prompt and assist toileting. The ADON was asked what the difference between frequent monitoring and prompt and assist toileting was. The ADON stated, The prompt and assist is documented by the restorative aide and the resident is assessed. He is not yet on the program we are still assessing. The ADON was asked if frequent monitoring was an appropriate intervention. The ADON stated, No. The ADON was asked if frequent monitoring was measurable. The ADON stated, It is not. During an interview on the B hall on 7/10/13 at 6:15 PM, when asked how CNA's find out about residents at risk for falls, CNA #3 stated, The nurses tell us who is at risk for falls. During an interview at the AB nurses' station on 7/10/13 at 6:25 PM, Licensed Practical Nurse (LPN) #2 was asked what procedure is used to assess residents for fall risk? LPN #2 stated, The admitting nurse completes the high risk fall assessment and follows the care path. If it triggers then we put in preventative interventions and send the form to restorative. Interventions include tab alarms, low bed, mats . We do not use falling star (name of a fall prevention program) anymore. During an interview in the conference room on 7/10/13 at 7:00 PM, the Director of Nursing (DON) was asked what procedure is used to assess residents for fall risk? The DON stated, We do not use falling star anymore. We have updated forms and the nurses are using the most current forms. The DON was asked why all assessments were not done per the Fall Prevention Program? The DON stated, (Named Resident #161) did not get walking / wheelchair assessments because he was an always gets assistance. During an interview in the conference room on 7/11/13 at 9:20 AM, CNA #4 was asked how they know what care to provide to a fall risk resident. CNA #4 stated, For resident with behaviors . we have daily assignments. We get report from the nurses and we use the care cards . We know if they (residents) have a fall alarm on and a fall pad. They (residents) are a fall risk if they have those and just the fall risk residents have those . CNA #4 was asked about care provided for Resident #161. CNA #4 stated, We do frequent checks, routine is 1 to (-) 2 hours. For him (Resident #161) we check every 30-40 minutes . On the day (Resident #161) fell he had taken himself to the bathroom, he told us that . During an interview in the conference room on 7/11/13 at 10:30 AM, the Registered Physical Therapist (RPT) was asked the cognitive and physical mobility status of Resident #161. The RPT stated, (Named other RPT) and I take turns taking care of (Resident #161). The RPT was asked what was Resident #161's cognitive status on admission. The RPT stated, On admission he had dementia, confusion, physically he ambulated with front wheel walker, had 3/5 (3 is resident's actual score 5 being highest score of being independent) right weakness, 2/5 left weakness, physical mobility scale of 12/45 (45 indicating independently stable) did not ambulate on eval (evaluation) due to cognition, by 6/12/13 he had improved to 20/45, did walk with minimal assist x (times) 1 with FWW (front wheel walker) for 50 ft (feet) with 25% (percent) verbal cueing. On 6/18/13 he walked 75 ft. with rest breaks with contact guard to minimal assist with 25% verbal cueing was scored 24/45 transfers bed - wheelchair with minimal assist and minimal assist sit to stand. On 6/26/13 Occupational Therapist (OT) documented he was able to follow 1 step commands. OT on 5/29/13 documented he was alert to person with increased instruction time/cueing. OT documented on 6/18/13 education with patient regarding safety with toileting. On 7/2/13 OT documented educated on safety with wheelchair with fair understanding due to confusion and 1- (on) 1 with slow pace . An interview was conducted in the conference room on 7/11/13 beginning at 5:40 PM with the fall team members as follows: Unit Manager (UM), Social Worker (SW), Registered Physical Therapist (RPT), DON, and Falls Prevention Nurse/ADON. The falls team was asked to describe the process staff follow from admission forward concerning residents at risk for falls and having falls? The DON stated, Nurses assess and decide preventions, before the resident is even admitted using the referral information. If a resident has had a hip fracture we will put a prime snap (a personal body alarm) in the room. The DON was asked what training do the nurses receive to be able to determined what interventions are needed? The DON stated, We train our nurses. We use a mentor program. The fall prevention committee members were asked what information is used to train nurses? The fall prevention team gave no answer. The facility was unable to provide a training protocol used to train the staff. The fall prevention committee members were asked to explain how risks and interventions were decided based on the assessment form being used? The UM stated, Nurses do top part (high risk patient selection form), bottom part goes to restorative nurse. We make decisions based on our education and communication . The ADON stated, Nurses screen residents to see if restorative needs to complete the restorative assessment part. The UM stated, Restorative nurse talks with UM. We discuss interventions. The fall committee team was unable to explain how risks and interventions were decided. The fall prevention committee members were asked what does always assist mean? The UM stated, We assist patient in room, physical assist- yes. The ADON stated, Always means always needs assistance. The RPT stated, I would have to assess, is it minimal, maximum, contact. Would do assessment and get physician order. Would do a time up and go test assessment. The DON stated, Always means needs assistance all the time, with adls, mobility, always, every time. The fall prevention committee team was unable to consistently describe the meaning of always assist. The fall prevention committee members were asked how always assist was done and documented? The DON stated, Make rounds every 2 hours and provide what assistance needed. If resident is confused, we keep them out of room, use dementia kit, memory care, keep engaged. If the resident is in isolation for[DIAGNOSES REDACTED], I expect them to make rounds and take to the bathroom. I am having a problem being stuck on the word always . It is not okay for them (residents) to go to the bathroom, transfer, ambulate by themselves. They (staff) know who by nurses report, communication, staff would know. I expect them (staff) to check and toilet. The UM stated, The prime snap and bed alarms help us know when to go assist the resident. The ADON stated, Alarms do not stop falls they just alert us. The UM stated, Prime snap and alarms help us anticipate resident needs. The fall prevention team was unable to consistently describe how always assist was implemented. They were unable to provide any documentation of the always assist. They failed to recognize that when an alarm sounds it is too late for staff to anticipate the residents needs. The fall prevention committee members were asked what is done about residents who remove the alarms? The DON stated, If snaps are taken off then we put the bed alarm or wheelchair pad alarms or move the alarm to a place where they (resident) cannot reach the alarm. The fall prevention committee members were asked, what is an intervention? The DON stated, Something in place to make sure that it (falls) doesn't happen again. The fall prevention committee members were asked if they felt they had done everything possible to keep Resident #161 safe from falls? The ADON stated, We have done everything we can . Frequently means more often than every 2 hours routine. On his first fall he had had a bowel movement. The frequent monitoring was what the staff put in place immediately . The fall prevention committee was unable to consistently describe the interventions that had been put in place for this resident. There was no documentation of the interventions being implemented. The fall prevention committee members were asked about implementation of the new forms. The ADON stated, We changed forms. We recognized a need trying to get more information . The fall prevention committee was unable to provide evidence that the falls had been investigated to determine the root cause. The fall prevention committee members were asked if the fall prevention program information had been read? The ADON stated, No, I have not read the fall program. On his second fall he (Resident #161) had taken himself to the bathroom. The alarm did not sound, had malfunctioned, the prompt/toileting intervention is still being assessed. The fall prevention committee failed to consistently and thoroughly investigate the falls to determine the root cause. There was no documentation that the malfunctioned alarm had been addressed. The fall prevention committee failed to read and consistently implement the fall prevention program the facility was using. The fall prevention committee members were asked, what intervention was put in place after the last fall to keep Resident #161 safe while the prompt/toileting assessment is being done? No answer was received from any of the fall prevention committee members. Observations in Resident #161's room on 7/8/13 at 5:30 PM, revealed Resident #161 seated in a chair with one mat on the floor on the bathroom side of the bed. Observations in Resident #161's room on 7/10/13 at 8:10 AM, revealed Resident #161 in a wheelchair with a mat on the floor on the bathroom side of the bed. Observations in Resident #161's room on 7/11/13 at 8:40 PM, revealed Resident #161 in bed asleep with mats now on both sides of the bed. The resident was currently being monitored by the RPT. Resident #161 sustained three falls with injuries, with one of those falls resulting in a fractured hip. The facility failed to thoroughly and consistently investigate falls to determine the root cause, failed to implement appropriate and measurable interventions addressing falls, and failed to document interventions which resulted in a serious and immediate threat to the health and safety of Resident #161. 3. Medical record review for Resident #146 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The admission MDS dated [DATE] and quarterly assessment dated [DATE] indicating the resident was severely cognitively impaired and falls were checked. The high-risk patient selection form completed on 1/15/13 for admission documented an intervention of always assist on the narrative section of the form. Instructions on the form documented, .For patients who are eligible for the Fall Prevention Program PROCEED WITH SECTION 2 (box checked) . complete the rest of this form . Section 2 documented, .Put a check (symbol for checkmark) in the box beside each assessment that applies to the patient . All patients in the program will need a transfer and mobility assessment, unless they are always assisted (circled with ink) or bed bound . Walking Assessment . (no check in box) . Wheelchair Assessment / Seating Assessment . (no check in box) . NARRATIVE documents always assist . SECTION 2 . BEHAVIOR ASSESSMENT . 1 . ANTIPSYCHOTICS . Zyprexia (is circled) . Seroquel (was not marked) . 2 . UNSAFE BEHAVIOR (is circled) . (listed under) UNSAFE BEHAVIOR . tried to stand, transfer or walk alone unsafely, the box (is checked) . tried to get out of bed alone unsafely (is circled) . walked or paced when too tired to be safe (is checked) . CARE PLAN DECISION: PROCEED (is checked) . (listed [DIAGNOSES REDACTED]. Section 2 of the form was not signed until 1/17/13. The behavior assessment antipsychotics assessment was not completed, nor was the behavior assessment unsafe behavior assessment completed per the facility fall prevention program. The resident's initial care plan dated 1/14/13 and the care plan revised on 5/3/13 documented the resident was identified at risk for falls. Fall interventions of the care plan were low bed, fall mats, keep areas free of clutter, prime snap alarm, and non-skid socks. Review of post falls nursing assessments documented the following: a. .2/28/13 . 3:30 AM . Describe the actual known facts: What was seen or heard: CNA WALKED IN ROOM AND PT (patient) WAS ON THE FLOOR IN FRONT OF BED . Describe task patient attempting at time of fall: Ambulating in room unattended . Safety devices in use: LOW BED . Patient was wearing following devices: FOOTWEAR . What immediate interventions were initiated to prevent future falls? Non-skid shoes/socks . A post falls investigation form for Resident #146 on 2/28/13 documented, NEEDED CARE PLAN CHANGES: non-skid socks/shoes . No new intervention had been put into place for this fall. The care plan was not updated with any new intervention for this fall. b. .3/13/13 . 2:50 PM . Describe the actual known facts: What was seen or heard: TEC (technician) AS GIVING SHOWER TEC SAID PT WENT TO fell SHE TRIED TO CATCH PT BUT COULD'NT (could not) PT fell TO FLOOR ON BOTTOM . Patient was wearing following devices: NONE . What immediate interventions were initiated to prevent future falls? Keep walker/assistive device within reach .A post falls investigation form for 3/13/13 documented, NEEDED CARE PLAN CHANGES: Non-skid shoes/socks . No new intervention had been put into place for this fall. Walker and assistive devices is not an appropriate intervention for a fall in the shower. The care plan was not updated with any new intervention for this fall. c. .3/25/13 . 11:15 AM . Describe the actual known facts: What was seen or heard: No answer in space . Safety devices in use: LOW BED, ALARM . Patient was wearing following devices: FOOTWEAR . What immediate interventions were initiated to prevent future falls? Low bed .A post falls investigation form for 3/25/13 documented, NEEDED CARE PLAN CHANGES: low bed . No new intervention had been put into place for this fall. The care plan was not updated with any new intervention for this fall. d. .3/27/13 . 5:45 PM . Describe the actual known facts: What was seen or heard: PT FOUND ON FLOOR SITTING UPRIGHT ON HER BOTTOM FACING THE AIR CONDITIONER . Safety devices in use: LOW BED, ALARM, FALL MAT . Patient was wearing the following devices: NONE . What immediate interventions were initiated to prevent future falls? fall mat . A post falls investigation form for 3/27/13 documented, NEEDED CARE PLAN CHANGES: Fall mat . No new intervention had been put into place for this fall. The care plan was not updated with any new intervention for this fall. e. .4/13/13 . 10:15 PM . Describe the actual known facts: What was seen or heard: CNA ON 10PM ROUNDS ALERTED NURSE THAT PT WAS SITTING ON BOTTOM IN FLOOR BESIDE BED (written in ink was on fall mat) . Safety devices in use: LOW BED, FALL MAT . Patient was wearing the following devices: NONE . What immediate interventions were initiated to prevent future falls? Use socks with non-skid tread . A post falls investigation form for 4/13/13 documented, NEEDED CARE PLAN CHANGES: no intervention documented . No new interventions had been put in place for this fall. The care plan was not updated with any new intervention for this fall. f. .4/20/13 . 12:30 PM . Describe the actual known facts: What was seen or heard: TEC FOUND PT ON FALL MAT . Safety devices in use: LOW BED, FALL MAT . Patient was wearing the following devices: GLASSES, FOOTWEAR . What immediate interventions were initiated to prevent future falls? MAKE SURE PT SIT FAR ENOUGH BACK WHEN SITS DOWN .A post falls investigation form for 4/20/13 documented, NEEDED CARE PLAN CHANGES: none documented. No new interventions had been put in place for this fall. The suggested intervention on the immediate was not carried over to the post falls investigation form. The form did not list any intervention to be put in place. The care plan was not updated with any new intervention for this fall. g. .4/23/13 . 12:15 am . Describe the actual known facts: What was seen or heard: ALARM SOUNDING ENTERED ROOM TO FIND PT SITTING ON BUTTOCKS BESIDE BED. SMALL CUP OF WATER SPILLED ON THE FLOOR . Safety devices in use: LOW BED, ALARM, FALL MAT . Patient was wearing the following devices: NONE . What immediate interventions were initiated to prevent future falls? Use socks with non-skid tread .A post falls investigation form for 4/23/13 documented, NEEDED CARE PLAN CHANGES: none documented . attached is a Post Falls Assessment . No new interventions had been put in place for this fall. The care plan was not updated with any new intervention for this fall. h. .4/25/13 . 8:10 PM . Describe the actual known facts: What was seen or heard: NURSE HEARD PT YELLING HELLO NURSE ENTERED SHOWER ROOM TO FIND PT SITTING ON BUTTOCKS WITH PANTS OFF AND BM (bowel movement) ON FLOOR . Safety devices in use: LOW BED, ALARM, FALL MAT . Patient was wearing the following devices: footwear, assistive devices (walker) . What immediate interventions were initiated to prevent future falls? Walking Assessment or Wheelchair Assessment .A post falls investigation form on 4/25/13 documented, NEEDED CARE PLAN CHANGES: Restorative to eval (evaluate) for prompt & (and) assist toileting Program . alarm not working (checked in box) . The new intervention of walking assessment or wheelchair assessment was added for this fall, however, there were no documentation addressing the alarm. The walking assessment or wheelchair assessment was not carried over to the post falls investigation. This intervention was not added to the care plan nor was there any documentation that this intervention had been implemented. i. .5/4/13 . 12:30 PM . Describe the actual known facts: What was seen or heard: PT FOUND SITING (sitting) ON FLOOR BESIDE W/C (wheelchair) . Safety devices in use: question not generated on this form . Patient was wearing the following devices: GLASSES, FOOTWEAR . What immediate interventions were initiated to prevent future falls? Chair alarm .A post falls investigation form for 5/4/13 documented, NEEDED CARE PLAN CHANGES: None documented . No new interventions had been put in place for this fall. The care plan was not updated with any new intervention for this fall. j. .5/13/13 . 6:30 PM . Describe the actual known facts: What was seen or heard: PT FALL WAS WITNESSED BY (nurse's name) AND (nurse's name) THIS EVENING, THEY BOTH STATED SHE JUST SLID OUT OF THE WHEEL CHAIR . PT SEEMED TO BE TRYING TO GO TO RESTROOM, ALARMS ARE IN PLACE AND WORKING . Safety devices in use: ALARM . What immediate interventions were initiated to prevent future falls? Chair alarm . A post falls investigation form for 5/4/13 documented, NEEDED CARE PLAN CHANGES: None documented . No new interventions had been put in place for this fall. The care plan was not updated with any new intervention for this fall. k. .6/13/13 . 6:30 AM . Describe the actual known facts: What was seen or heard: PT'S ROOMMATE CAME TO NURSES STATION AND STATED THAT PT WAS ON THE FLOOR . Safety devices in use: LOW BED . Patient was wearing following devices: FOOTWEAR . What immediate interventions were initiated to prevent future falls? alarm applied . A post falls investigation form for 6/13/13 documented, NEEDED CARE PLAN CHANGES: None documented . No new interventions had been put in place for this fall. The care plan was not updated with any new intervention for this fall. Nurse's notes dated 6/28/13 at 5:30 PM documented,",2017-03-01
8913,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2013-07-12,371,F,0,1,5JNA11,"Based on recipe review, observation and interview, it was determined the facility failed to maintain proper kitchen sanitation as evidenced by the door to the dishwasher room and the door to the service hall were propped open, raw beef patties were placed in a pan next to prepared deli meat and partially covered corn bread, cold food was not served at 41 degrees Fahrenheit (F) or below and a visitor entered the kitchen without a hair cover with the potential to contaminate the food served to 79 of 88 residents. The findings included: 1. Observations in the kitchen on 7/10/13 beginning at 11:00 AM, revealed the following: a. The door to the dishwasher room and the door to the service hall were propped open. b. Raw beef patties were being placed in a pan next to prepared deli meat and partially covered corn bread on the prep table. c. A visitor entered the kitchen without a hair cover. During an interview in the kitchen on 7/10/13 at 11:08 AM, the Certified Dietary Manager (CDM) was asked if the raw meat and the prepared deli meat and partially covered corn bread should be placed next to each other. The CDM stated, Should not be . cornbread should be covered . During an interview in the kitchen on 7/10/13 at 12:05 AM, the CDM was asked if visitors were allowed in the kitchen without a hair cover. The CDM stated, .it is corporate policy . During an interview in the dining room on 7/10/12 at 2:35 PM, the Regional Nurse Consultant was asked about the visitor being in the kitchen. The Regional Nurse Consultant stated, .the corporation does this at all the facilities . 2. Review of the facility's Banana Pudding recipe documented, .Ingredients . Milk, Whole . Sour Cream . Hold and serve a 41 (degrees) F or below . Observations in the kitchen on 7/10/13 at 11:30 AM, revealed the temperature of the banana pudding was 60 degrees F. During an interview in the kitchen on 7/10/13 at 11:35 AM, the CDM was asked about the temperature of the banana pudding. The CDM stated, (Banana pudding) just came out of the cooler .",2017-03-01
8914,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2013-07-12,441,F,0,1,5JNA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Material Safety Data Sheet (MSDS), review of a manufacturer's website, observation and interview, it was determined the facility failed to ensure proper infection control practices were followed to prevent the potential spread of infections in the terminal cleaning of the 50 of 50 rooms. The findings included: Review of the Clorox Professional Products Company Material Safety Data Sheet (MSDS) provided by the facility documented the product name used for terminal cleaning of rooms as being Clorox Healthcare Bleach Germicidal cleaner produced by Clorox Professional Products Company. Review of the Clorox Healthcare Bleach Germicidal Cleaner website at - documented, .Bleach Germicidal Cleaner . cleans and disinfects in just one step . it is premixed ready to use . There were two residents with clostridium difficile (C-diff) that were observed in isolation rooms. One resident resided on A hall and one resident resided on B hall. Observations of the spray bottle of Clorox Healthcare Bleach Germicidal spray revealed, the documentation on the label confirming product with a kill time for[DIAGNOSES REDACTED] at 5 minutes contact and is a 1 to 10 solution. During an interview in the conference room on 7/11/13 at 5:30 PM, the Housekeeping Supervisor stated, I mop the floor with germicidal spray (Clorox Healthcare Bleach). I put 1/2 of a bottle in my mop water and mop the floor . The housekeeper diluted the Clorox Healthcare Bleach Germicidal Cleaner when it was added to the mop water, thus reducing the effectiveness of the cleaner.",2017-03-01
8915,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2013-07-12,460,E,0,1,5JNA11,"Based on observations and interview, it was determined the facility failed to maintain full visual privacy for residents in 11 of 50 (Rooms #103 B, 104 B, 105 B, 106 B, 107 B, 123 B, 124 B, 126 B, 126 C, 153 B and 158 B) resident rooms. The findings included: 1. Review of the facility's PRIVACY policy documented, .In your accommodations you will be afforded at least visual privacy. Privacy is also maintained during toileting, bathing and other activities of personal hygiene, except when assistance is needed for your safety and well being . 2. Observations in room 103 B 7/8/13 beginninng at 10:30 AM, revealed the privacy curtain did not provide full visual privacy. 3. Observations in room 104 B on 7/12/13 at 4:45 PM, revealed the privacy curtain did not provide full visual privacy. During an interview in room 104 B on 7/12/13 at 4:50 PM, Nurse #1 verified the privacy curtain did not provide full visual privacy for the resident in bed B. 4. Observations in room 105 B on 7/8/13 beginninng at 10:30 AM, revealed the privacy curtain did not provide full visual privacy. 5. Observations in room 106 B on 7/8/13 beginninng at 10:30 AM, revealed the privacy curtain did not provide full visual privacy. 6. Observations in room 107 B on 7/8/13 beginninng at 10:30 AM, revealed the privacy curtain did not provide full visual privacy. 7. Observations in room 123 B on 7/8/13 beginning at 11:30 AM, revealed the privacy curtain did not provide full visual privacy. 8. Observations in room 124 B on 7/8/13 beginning at 11:30 AM, revealed the privacy curtain did not provide full visual privacy. 9. Observations in room 126 B on 7/8/13 beginning at 11:30 AM, revealed the privacy curtain did not provide full visual privacy. 10. Observations in room 126 C on 7/8/13 beginning at 11:30 AM, revealed the privacy curtain did not provide full visual privacy. 11. Observations in room 153 B on 7/9/13 beginning at 11:00 AM, revealed the privacy curtain did not provide full visual privacy. 12. Observations in room 158 B on 7/10/13 at 5:10 PM, revealed the privacy curtain did not provide full visual privacy.",2017-03-01
8916,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2013-07-12,490,J,0,1,5JNA11,"Based on review of the fall prevention program, contract review, review of a Material Safety Data Sheet (MSDS), review of a manufacturer's website, policy review, medical record review, observation and interview, it was determined the facility failed to be administered in a manner to ensure the environment was safe and free of accident hazards, failed to ensure each resident received complete and accurate assessments and failed to implement appropriate and measurable interventions to prevent potential injuries for 2 of 6 (Residents #161 and 146) residents with falls. The administrator failed to ensure the staff accurately and completely assessed residents with falls, implemented appropriate interventions and provided supervision to ensure the environment was safe and free of accident hazards which placed Resident #161 and Resident #146 in immediate jeopardy (IJ). The administrator failed to ensure the abuse prevention policy and procedure was implemented to ensure an injury of unknown origin was thoroughly investigated and reported to the state survey agency within 5 working days of the injury for 1 of 2 (Resident #66) residents reviewed with injuries. The administrator failed to ensure proper infection control practices were followed to prevent the potential spread of infections in the terminal cleaning of 50 of 50 resident rooms. In the conference room on 7/11/13 at 7:10 PM, the Administrator, the Director of Nursing (DON), and the Regional Nurse Consultant were informed of the IJ. This IJ was removed on 7/12/13. The findings included: 1. The Administrator failed to ensure the environment was safe and free of accident hazards, residents received complete and accurate assessments and implemented appropriate and measurable interventions to prevent serious injuries from falls for 2 of 6 (Residents #161 and 146) residents with falls. The facility failed to accurately and completely assess residents with falls, implement appropriate interventions and provide supervision to ensure the environment was safe and free of accident hazards which placed Resident #161 and Resident #146 in immediate jeopardy. The facility's failure to consistently follow a systemic process of assessing residents at risk for falls, failure to develop and implement appropriate interventions to prevent falls and injury, failure to develop new approaches to protect residents when current interventions were ineffective and the failure to ensure direct care staff were trained to consistently follow the facility fall prevention program placed Residents #161 and 146 in immediate jeopardy. Refer to F323. The facility was cited with an Immediate Jeopardy (IJ) at F323, F490, F501 and F520 all with a scope and severity of a J. The facility failed to ensure the environment was safe and free of accident hazards, residents received complete and accurate assessments and implemented appropriate and measurable interventions after each fall to prevent injuries from falls. The facility failed to accurately and completely assess residents with falls, implement appropriate interventions and provide supervision to ensure the environment was safe and free of accident hazards which placed Resident #161 and Resident #146 in immediate jeopardy. The IJ was effective 6/4/13 through 7/11/13. An acceptable AOC, which removed the immediacy of the jeopardy, was received on 7/12/13 and actions were validated onsite by the survey team on 7/12/13. An allegation of compliance (AOC) was received on 7/11/13 and documented, As this plan is being developed, partner (staff member) has been assigned to sit with patient (Resident #161) . until potential implementation of plan in place . Patient will be asked for need to void every 2 hours while awake and given . assistance with regard to all transfers by CNA's (certified nursing assistants) and licensed nurses. While asleep, CNA or licensed nurse staff will round every 1 hour to ensure that the following fall interventions are in place: fall mat on both sides of the bed, bed pan alarm in place, prime snap attached to alarm, urinal within reach and sight. If patient is awake during hourly rounds, patient will be asked for need to void at that time by licensed nurse or CNA. Alarm will be monitored every 12 hours to ensure in working order by licensed nurse . All 1 and 2 hour checks will be logged onto form to measure compliance. Night shift . will be immediately in-serviced with regard to fall interventions and then all other partners (staff) by 7/12/13. DON (Director of Nursing) will monitor daily until substantial compliance is achieved. On 7/12/13 the Administrator presented additional information for the AOC as followed 7/12/13 . in-service training began for licensed nursing staff and CNA's on 7/12/13 of the center's policies related to falls risk prevention. Specific attention was given to the expectation that interventions are put in immediately . any partners on leave or otherwise unavailable will be in-serviced prior to their next shift worked . Beginning 7/12/13 . 5 licensed nurses and 5 CNAs will be interviewed weekly x (times) 6 weeks for their understanding of the need to put falls risk interventions in place immediately and their role in monitoring the fall interventions . The surveyors verified the AOC was in place by the following: a. Observations in Resident #161's room on 7/11/13 at 8:40 PM, revealed Resident #161 was in bed with the bed in low position, fall mats were in place on both sides of the bed, 1/2 side rails were up times 2, bed pad alarm and prime snap alarm were in place, call light was within reach and a staff member at bedside. Observations in Resident #146's room on 7/12/13 at 4:10 PM, revealed fall mats were in place on both sides of the bed. Observations in the front lobby on 7/12/13 at 4:12 PM, revealed Resident #146 had on appropriate footwear sitting on the settee with prime snap alarm and sensor pad alarm attached and urinal within reach and sight. Restorative Nurse beside Resident #146 adjusting the wheelchair. b. On 7/12/13 the surveyors reviewed the inservices of all the staff that were working. No staff will begin work until inserviced. The monitoring forms were reviewed with documented compliance with the 1 hour, 2 hour and 12 hour checks. Non-compliance of the IJ continues at a scope and severity of a D level for F490 for monitoring of corrective actions. The facility is required to submit a plan of correction for all tags. 2. The Administrator failed to ensure the Quality Assurance Committee established a method to identify an ineffective fall prevention program. Refer to F520. 3. The Administrator failed to ensure the abuse prevention policy and procedure was implemented to ensure a complete and thorough investigation was completed for an injury of unknown origin or report the incident to the state survey certification agency within 5 working days of the injury for 1 of 2 (Resident #66) residents with injuries. Refer to F225 and F226. 4. The Administrator failed to ensure the facility had an effective infection control program that prevented the potential spread of infections in the facility by failing to ensure the correct method of terminal cleaning was performed. Refer to F441.",2017-03-01
8917,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2013-07-12,501,J,0,1,5JNA11,"Based on contract review, review of the fall prevention program, policy review, medical record review, observation and interview, it was determined the facility failed to ensure the Medical Director assisted the facility with identifying, evaluating and addressing clinical concerns, failed to coordinate the medical care and provide clinical guidance and oversight regarding the implementation of resident care policies and procedures that reflect the current standards of practice for residents residing in the facility. The Medical Director failed to ensure the staff accurately and completely assessed residents with falls, implemented appropriate measurable interventions to prevent potential serious injuries for 3 of 6 (Residents #161, 146 and 66) residents with falls or injury of an unknown origin. This placed Resident #161 and Resident #146 in immediate jeopardy (IJ). The Medical Director failed to ensure the abuse prevention policy and procedure was implemented to ensure an injury of unknown origin was thoroughly investigated and reported to the state survey agency within 5 working days of the injury for 1 of 2 (Resident #66) residents with injuries. In the conference room on 7/11/13 at 7:10 PM, the Administrator, the Director of Nursing (DON), and the Regional Nurse Consultant were informed of the IJ. This IJ was removed on 7/12/13. The findings included: 1. Review of the Medical Director's contract dated 4/19/12 documented, .3.3 Physician shall be responsible and accountable for the coordination of medical care of all residents in the Center. Physician shall help the Center obtain and maintain timely and appropriate medical care that supports the healthcare needs of the patients, is consistent with current standards of practice and helps the Center meet its regulatory requirements. Physician shall address issues related to the coordination of medical care identified through the Center's Quality Improvement Committee and program and other activities related to the coordination of care . 2. The Medical Director failed to ensure the environment was safe and free of accident hazards, residents received complete and accurate assessments and implemented appropriate and measurable interventions to prevent falls and injuries of unknown origin for 3 of 6 (Residents #161, 146 and 66) residents with falls or injury of unknown origin. The Medical Director failed to ensure the staff accurately and completely assessed residents with falls, implemented appropriate and measurable interventions which placed Resident #161 and Resident #146 in immediate jeopardy (IJ). The facility's failure to consistently follow a systemic process of assessing residents at risk for falls, failure to develop and implement appropriate interventions to prevent falls and injury, failure to develop new approaches to protect residents when current interventions were ineffective and the failure to ensure direct care staff were trained to consistently follow the facility fall prevention program placed Residents #161 and 146 in immediate jeopardy. Refer to F323. The IJ was effective 6/4/13 through 7/11/13. An acceptable AOC, which removed the immediacy of the jeopardy, was received on 7/12/13 and actions were validated onsite by the survey team on 7/12/13. An allegation of compliance (AOC) was received on 7/11/13 and documented, As this plan is being developed, partner (staff member) has been assigned to sit with patient (Resident #161) . until potential implementation of plan in place . Patient will be asked for need to void every 2 hours while awake and given . assistance with regard to all transfers by CNA's (certified nursing assistants) and licensed nurses. While asleep, CNA or licensed nurse staff will round every 1 hour to ensure that the following fall interventions are in place: fall mat on both sides of the bed, bed pan alarm in place, prime snap attached to alarm, urinal within reach and sight. If patient is awake during hourly rounds, patient will be asked for need to void at that time by licensed nurse or CNA. Alarm will be monitored every 12 hours to ensure in working order by licensed nurse . All 1 and 2 hour checks will be logged onto form to measure compliance. Night shift . will be immediately in-serviced with regard to fall interventions and then all other partners (staff) by 7/12/13. DON (Director of Nursing) will monitor daily until substantial compliance is achieved. On 7/12/13 the Administrator presented additional information for the AOC as followed 7/12/13 . in-service training began for licensed nursing staff and CNA's on 7/12/13 of the center's policies related to falls risk prevention. Specific attention was given to the expectation that interventions are put in immediately . any partners on leave or otherwise unavailable will be in-serviced prior to their next shift worked . Beginning 7/12/13 . 5 licensed nurses and 5 CNAs will be interviewed weekly x (times) 6 weeks for their understanding of the need to put falls risk interventions in place immediately and their role in monitoring the fall interventions . The surveyors verified the AOC was in place by the following: a. Observations in Resident #161's room on 7/11/13 at 8:40 PM, revealed Resident #161 was in bed with the bed in low position, fall mats were in place on both sides of the bed, 1/2 side rails were up times 2, bed pad alarm and prime snap alarm were in place, call light was within reach and a staff member at bedside. Observations in Resident #146's room on 7/12/13 at 4:10 PM, revealed fall mats were in place on both sides of the bed. Observations in the front lobby on 7/12/13 at 4:12 PM, revealed Resident #146 had on appropriate footwear sitting on the settee with prime snap alarm and sensor pad alarm attached and urinal within reach and sight. Restorative Nurse beside Resident #146 adjusting the wheelchair. b. On 7/12/13 the surveyors reviewed the inservices of all the staff that were working. No staff will begin work until inserviced. The monitoring forms were reviewed with documented compliance with the 1 hour, 2 hour and 12 hour checks. Non-compliance of the IJ continues at a scope and severity of a D level for F501 for monitoring of corrective actions. The facility is required to submit a plan of correction for all tags. 3. The Medical Director failed to ensure the abuse prevention policy and procedure was implemented to ensure an injury of unknown origin was thoroughly investigated and reported to the state survey agency within 5 working days of the injury for 1 of 2 (Resident #66) residents with injuries. Refer to F225 and F226. 4. During an interview in the conference room on 7/9/13 at 5:23 PM, the Medical Director stated, .falls are obviously important . physicians have Quality Assurance one monthly with DON, ADON (Assistant Director of Nursing), PT (Physical Therapy) and Administrator . a 2 part meeting first is monitoring issues and review . second utilization of what needs to be done . During an interview in the medical records office on 7/12/13 at 10:30 AM, the Health Information Manager (HIM) stated, .the QAA (Quality Assurance and Assessment) committee meets once a month and members are HIM, administrator, DON, ADON, Social Services, Rehab and Medical Director . chart audits done monthly and admission reviews are done within 72 hrs of admission . once the action plan is in place we adapt adopt or abandon which is discussed in the meetings . at present action plans in place we are always working on . weights, infection control, falls, customer satisfaction, incidents and accidents we work on continuously . tracking and trending for falls shows chart that breaks down into shifts, times and location . put interventions in place, report back if it worked or if we need to add or change interventions . The facility was unable to provide any documentation for an action plan developed on falls. Refer to F520.",2017-03-01
8918,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2013-07-12,514,D,0,1,5JNA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to ensure the medical record was complete and addressed all of the resident ' s behaviors for 1 of 2 (Resident #119) residents of the 31 sampled residents included in the stage 2 review. The findings included: Medical record review for Resident #119 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Nurses' notes documented the following: a. 12/28/12 - 1a (AM) Pt. (patient) found wandering the hallways . b. 12/30/12 - 10p (PM) .wandering hallways trying to go in other pts rooms . c. 1/1/13 - 10p .Pt. wandering the halls. redirect multiple times from pts rooms . d. 1/9/13 - 10:30p .Pt conts to wander hallways into other patients rooms slight agitation when redirected by staff . e. 1/17/13 - 2a .Pt wandering halls into patient room. found attempting to remove a painting from the wall & (and) almost dropping painting on himself & techs (technicians) . 1/17/13 - 7AM .Pt was flipping over dining room tables and chairs. Pt got stuck in one of the chair . Pt got combative Took 4 staff members to get pt out of chair . Social service notified of pts agitation. f. 2/8/13 - 10p .Pt. wanders into other pts rooms c (with) redirection x (times) 4 . g. 2/11/13 - 10:40 p .pt wandering and pacing halls multiple attempts to redirect also attempted to urinate on wall in hallway and going in other patients rooms . h. 2/12/13 - 730-Pt wandering into other pts room Inappropriate behavior (trying to get in a bed in another room) noted, staff intervened. Social services notified . The 14 day Minimum Data Set ((MDS) dated [DATE] and the 30 day MDS dated [DATE] documented the resident with severe impaired cognition with behaviors. A Physician's facility follow-up dated 2/15/13 documented, Assessment / Plan: [MEDICAL CONDITION]. He was put on [MEDICATION NAME] 10 mg (milligrams) q. (every) day . During an interview in the conference room on 7/11/13 at 8:00 AM, the Social Worker (SW) stated, I monitor behaviors. On (named Resident #119) I called the caregiver . The SW was asked about the inappropriate incident of the resident trying to get in a bed in another room. The SW stated, I called the Behavior Health Clinic to come and evaluate him . I would document what I did in social services notes. No, I can't find anything in chart . During an interview in the conference room on 7/11/13 at 8:25 AM, the Director of Nursing (DON) was asked about the inappropriate behavior situation. The DON stated, Yes, it should have been documented. The social worker was brand new and we told her to document it . Yes, it should be in the notes. (Named Resident #119) was one that wandered worse at night . he would go in other resident rooms especially at night he had to be watched closely . The comprehensive care plan did not address [MEDICAL CONDITION] or combativeness and did not include any interventions provided by the Social Worker.",2017-03-01
8919,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2013-07-12,520,J,0,1,5JNA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the fall prevention program, review of the Material Safety Data Sheet (MSDS), review of a manufacturer's website, policy review, medical record review, observation and interview, it was determined the facility's Quality Assurance and Assessment (QAA) committee failed to identify and address quality of care issues such as failure to ensure appropriate and measurable interventions were developed to manage and prevent potential serious injuries for 2 of 6 (Resident #161 and 146) residents of the 31 sampled residents included in the stage 2 review. The failure of the QAA committee to ensure appropriate and measurable interventions were developed placed Resident #161 and 146 in Immediate Jeopardy (IJ) as evidenced by actual serious injury to Resident #161 and potential serious injury to Resident #146. The QAA committee failed to ensure the abuse prevention policy and procedure was implemented to ensure an injury of unknown origin was thoroughly investigated and reported to the state survey agency within 5 working days of the injury for 1 of 2 (Resident #66) residents reviewed with injuries. The QAA committee failed to ensure proper infection control practices were followed to prevent the potential spread of infections in the terminal cleaning of the 50 of 50 rooms. In the conference room on 7/11/13 at 7:10 PM, the Administrator, the Director of Nursing (DON), and the Regional Nurse Consultant were informed of the immediate jeopardy (IJ). This IJ was removed on 7/12/13. The findings included: 1. During an interview in the medical records office on 7/12/13 at 10:30 AM, the Health Information Manager (HIM) was asked if the facility had a QAA committee. The HIM stated, Yes, we meet once a month. The members are HIM, Administrator, Director of Nursing, Assistant Director of Nursing, Social Services, Rehabilitation and the Medical Director. The HIM was then asked how they identify issues. The HIM stated, We do chart audits monthly and admission reviews . The HIM was asked how they respond to identified issues. The HIM stated, We do an action plan . When asked for an action plan for falls, the HIM was unable to provide an action plan for falls. The facility's failure to consistently follow a systemic process of assessing residents at risk for falls, failure to develop and implement appropriate interventions to prevent falls and injury, failure to develop new approaches to protect residents when current interventions were ineffective and the failure to ensure direct care staff were trained to consistently follow the facility fall prevention program placed Residents #161 and 146 in immediate jeopardy. Refer to F323. The IJ was effective 6/4/13 through 7/11/13. An acceptable AOC, which removed the immediacy of the jeopardy, was received on 7/12/13 and actions were validated onsite by the survey team on 7/12/13. An allegation of compliance (AOC) was received on 7/11/13 and documented, As this plan is being developed, partner (staff member) has been assigned to sit with patient (Resident #161) . until potential implementation of plan in place . Patient will be asked for need to void every 2 hours while awake and given . assistance with regard to all transfers by CNA's (certified nursing assistants) and licensed nurses. While asleep, CNA or licensed nurse staff will round every 1 hour to ensure that the following fall interventions are in place: fall mat on both sides of the bed, bed pan alarm in place, prime snap attached to alarm, urinal within reach and sight. If patient is awake during hourly rounds, patient will be asked for need to void at that time by licensed nurse or CNA. Alarm will be monitored every 12 hours to ensure in working order by licensed nurse . All 1 and 2 hour checks will be logged onto form to measure compliance. Night shift . will be immediately in-serviced with regard to fall interventions and then all other partners by 7/12/13. DON (Director of Nursing) will monitor daily until substantial compliance is achieved. On 7/12/13 the Administrator presented additional information for the AOC as followed 7/12/13 . in-service training began for licensed nursing staff and CNA's on 7/12/13 of the center's policies related to falls risk prevention. Specific attention was given to the expectation that interventions are put in immediately . any partners on leave or otherwise unavailable will be in-serviced prior to their next shift worked . Beginning 7/12/13 . 5 licensed nurses and 5 CNAs will be interviewed weekly x (times) 6 weeks for their understanding of the need to put falls risk interventions in place immediately and their role in monitoring the fall interventions . The surveyors verified the AOC was in place by the following: a. Observations in Resident #161's room on 7/11/13 at 8:40 PM, revealed Resident #161 was in bed with the bed in low position, fall mats were in place on both sides of the bed, 1/2 side rails were up times 2, bed pad alarm and prime snap alarm were in place, call light was within reach and a staff member at bedside. Observations in Resident #146's room on 7/12/13 at 4:10 PM, revealed fall mats were in place on both sides of the bed. Observations in the front lobby on 7/12/13 at 4:12 PM, revealed Resident #146 had on appropriate footwear sitting on the settee with prime snap alarm and sensor pad alarm attached and urinal within reach and sight. Restorative Nurse beside Resident #146 adjusting the wheelchair. b. On 7/12/13 the surveyors reviewed the inservices of all the staff that were working. No staff will begin work until inserviced. The monitoring forms were reviewed with documented compliance with the 1 hour, 2 hour and 12 hour checks. Non-compliance of the IJ continues at a scope and severity of a D level for F520 for monitoring of corrective actions. The facility is required to submit a plan of correction for all tags. 2. The QAA Committee failed to ensure the abuse prevention policy and procedure was implemented to ensure an injury of unknown origin was thoroughly investigated and reported to the state survey agency within 5 working days of the injury for 1 of 2 (Resident #66) residents reviewed with injuries. Refer to F225 and F226. 3. The The QAA Committee failed to ensure proper infection control practices were followed to prevent the potential spread of infections as evidenced by the method for terminal cleaning for 50 of 50 rooms. Two residents with [MEDICAL CONDITIONS] were observed in isolation rooms. One resident resided on A hall and one resident resided on B hall. Refer to F441.",2017-03-01
10819,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2011-06-15,241,D,0,1,HH7Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined 1 of 15 Certified Nursing Assistants (CNA #5) failed to knock on the door or gain permission prior to entering residents' rooms. The findings included: Observations on the B hall on 6/14/11, revealed CNA #5 entered the following rooms without knocking or gaining permission to enter: a. room [ROOM NUMBER] at 7:45 AM with a meal tray. b. room [ROOM NUMBER] at 7:48 AM with a meal tray. c. room [ROOM NUMBER] at 7:50 AM with a cup of coffee. d. room [ROOM NUMBER] at 7:53 AM with a cup of coffee. e. room [ROOM NUMBER] at 7:58 AM with a meal tray. f. room [ROOM NUMBER] at 8:10 AM with a meal tray. During an interview in the B hall on 6/14/11 at 8:15 AM, CNA #5 was asked if she knocked before entering each room. CNA #5 stated, No. During an interview at nurses' station #1 on 6/15/11 at 9:05 AM, the Director of Nursing confirmed that she would expect the CNAs to knock before entering resident rooms.",2016-04-01
10820,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2011-06-15,278,D,0,1,HH7Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, it was determined the facility failed to ensure the Minimum Data Set (MDS) was accurately coded for oxygen and the cognition status for 2 of 20 (Residents #7 and 16) sampled residents. The findings included: 1. Medical record review for Resident #7 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] did not reflect that Resident #7 used oxygen. Observations in Resident #7's room on 6/13/11 at 11:30 AM, 3:20 PM, 5:45 PM, on 6/14/11 at 4:45 PM and on 6/15/11 at 7:35 AM, revealed Resident #7 was receiving oxygen (O2) at 3.0 liters per minute (LPM) per binasal cannula (BNC). Observations in Resident #7's room on 6/14/11 at 7:30 AM, revealed Resident #7 receiving O2 at 2.5 LPM BNC. Resident #7 asked if her O2 was on 3. CNA #7 confirmed it was on 2.5 LPM and adjusted the rate to 3.0 LPM. Observations in the dining room on 6/14/11 at 9:30 AM and 11:30 AM, revealed Resident #7 was receiving O2 at 3.0 LPM BNC. During an interview in the conference room on 6/15/11 at 10:30 AM, Nurse #3 confirmed the oxygen was not on the MDS. 2. Medical record review for Resident #16 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] section C revealed the cognitive pattern was not assessed. During an interview in the conference room on 6/15/11 at 9:05 AM, Nurse #3 confirmed the cognitive status was not assessed for Resident #16. Nurse #3 stated, .I didn't get the information from Social Services coded. It didn't get coded .",2016-04-01
10821,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2011-06-15,280,D,0,1,HH7Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, it was determined the facility failed to revise the comprehensive care plan for [MEDICAL CONDITION] activity, oxygen, interventions for fall, polypharmacy or wound care interventions for 4 of 20 (Residents #3, 7, 9 and 13) sampled residents. The findings included: 1. Review of the facility's Care Plan Development policy documented, .9. Problems are patient conditions, need, or weaknesses which currently do, or potentially could, prevent the patient from achieving or maintaining the highest practicable level of well-being. Approaches: Care Plan Approaches are specific, individualized steps partners and patients will take together to assist the patient to achieve the goal. a. Approaches serve as instructions for patient care and provide for continuity of care by all partners . 2. Medical record review for Resident #3 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the POS [REDACTED].Transition to Memory Care . and Post Falls Investigation for 6/6/11 documented, .Redirect Pt.(patient) Offer Snack keep up at nursing area . Review of the weekly skin assessment progress notes for 6/7/11 documented, Blister noted to L (left) knee .Skin prep applied to bilateral heels. Heels floated. Review of physician's orders [REDACTED].To L (left) knee open circular blister p (after) cleansing with ADLs (Activities of Daily Living) Apply Skin Around Blister cover with non-stick [MEDICATION NAME] daily -prn (as needed) dislodgement daily until healed . The care plan dated 4/8/11 had not been updated for the fall interventions or the wound on the left knee. 3. Medical record review for Resident #7 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 5/31/11 documented no interventions for oxygen therapy. Observations in Resident #7's room on 6/13/11 at 11:30 AM, 3:20 PM and 5:45 PM, on 6/14/11 at 4:45 PM and on 6/15/11 at 7:35 AM, revealed Resident #7 was receiving oxygen (O2) at 3.0 liters per minute (LPM) per binasal cannula (BNC). Observations in Resident #7's room on 6/14/11 at 7:30 AM, revealed Resident #7 receiving O2 at 2.5 LPM BNC. Resident #7 asked if her O2 was on 3. CNA #7 confirmed it was on 2.5 LPM and adjusted the rate to 3.0 LPM. Observations in the dining room on 6/14/11 at 9:30 AM and 11:30 AM, revealed Resident #7 was receiving O2 at 3.0 LPM BNC. During an interview in the conference room on 6/15/11 at 10:30 AM, Nurse #3 confirmed the care plan did not have interventions for oxygen therapy. 4. Medical record review for Resident #9 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive care plan dated 3/14/11 documented, .Obs (observe) for S*S (sign and symptoms) [MEDICAL CONDITION] activity . The care plan did not address safety measures to be put in place for [MEDICAL CONDITION] activity. During an interview at the nurses' station #2 on 6/14/11 at 2:15 PM, the Assistant Director of Nurses (ADON) reviewed the care plan. The ADON stated, .keeping the patient safe during [MEDICAL CONDITION] is not on the care plan . 5. Medical record review for Resident #13 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's recertification orders dated 6/7/11 documented, .[MEDICATION NAME] .[MEDICATION NAME] .[MEDICATION NAME] .[MEDICATION NAME] .[MEDICATION NAME] .[MEDICATION NAME] .[MEDICATION NAME] .[MEDICATION NAME] .Levetiracetam .[MEDICATION NAME] .Humalog .[MEDICATION NAME] . Review of the comprehensive care plan dated 5/12/11 documented, .At risk for [MEDICAL CONDITION] disorder - [MEDICAL CONDITION] activity 5-5-11 . The care plan did not address safety measures to be put in place for [MEDICAL CONDITION] activity. The care plan did not address monitoring the resident for polypharmacy. During an interview in the conference room on 6/15/11 at 10:45 AM, Nurse #3 was asked if the care plan addressed polypharmacy. Nurse #3 stated, .No, I don't do care plans for nine plus meds (medications) . During an interview in the conference room on 6/15/11 at 10:45 AM, the ADON was asked to review the care plan for Resident #13. The ADON stated, .I see no safety approaches for [MEDICAL CONDITION] and nothing for 9 plus meds .",2016-04-01
10822,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2011-06-15,282,D,0,1,HH7Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, it was determined the facility failed to follow the plan of care for palm protectors for 1 of 17 (Resident #2) sampled residents. The findings included: Medical record review for Resident #2 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 4/8/11 documented, Approaches .Attempt to place palm protectors or wash cloths in both hands daily. Observations in room [ROOM NUMBER] on 6/14/11 at 10:15 AM, revealed Resident #2 seated in a high back wheelchair and no hand rolls or palm protectors were in place. During an interview in room [ROOM NUMBER] on 6/14/11 at 10:15 AM, Nurse #4 stated, We don't use the hand rolls because it hurts her so bad. She (Resident #2) don't like it and it hurts her, so we don't use them.",2016-04-01
10823,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2011-06-15,283,E,0,1,HH7Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to ensure each resident discharged from the facility had a recapitulation of the resident's stay for 3 of 3 (Residents #18, 19 and 20) discharged residents reviewed. The findings included: 1. Medical record review for Resident #18 documented an admission date of [DATE] and a discharge date of [DATE]. Review of the Transfer/Discharge/Death Summary form documented no recapitulation of the resident's stay. 2. Medical record review for Resident #19 documented an admission date of [DATE] and a discharge date of [DATE]. Review of the Transfer/Discharge/Death Summary form documented no recapitulation of the resident's stay. 3. Medical record review for Resident #20 documented an admission date of [DATE] and a discharge date of [DATE]. Review of the Transfer/Discharge/Death Summary form documented no recapitulation of the resident's stay. 4. During an interview in the conference room on 6/15/11 at 8:30 AM, the Assistant Director of Nursing (ADON) was asked if the facility completed a recapitulation of the resident's stay. The ADON stated, All there is for the recap (recapitulation) is a summary at discharge and the MDS (Minimum Data Set). There is no full recap.",2016-04-01
10824,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2011-06-15,309,D,0,1,HH7Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to accurately assess, document weekly skin assessments or follow physician's orders [REDACTED].#18) sampled residents. The findings included: Medical record review for Resident #18 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's telephone orders dated 5/24/10 documented, To (L) (left) ankle open area: clean c (with) NS (normal saline) & (and) pat dry then cover c dry drsg (dressing). (Symbol for change) QOD (every other day) & PRN (as needed) displacement. The facility was unable to provide documentation the treatments were performed every other day as ordered from 6/1/10 to 6/20/10. Review of the Weekly Skin Assessment Record dated 5/25/10 documented Y (Key : Y = yes) for the Alteration in Skin Integrity section of the record. The Weekly Skin Assessment Progress Notes section of the record dated 5/25/10 documented, Skin tears noted LLE (Left Lower Extremity) & RUE (Right Upper Extremity). Cleaned & dry Dsg (Dressing) intact. Review of theWeekly Skin Assessment Record dated 6/1/10 documented N (Key: N = no) for the Alteration in Skin Integrity section of the record. There was no documentation dated 6/1/10 found in the Weekly Skin Assessment Progress Notes section of the record. Review of the Weekly Skin Assessment Record dated 6/8/10 documented Y for the Alteration in Skin Integrity section of the record. There was no documentation dated 6/8/10 found in the Weekly Skin Assessment Progress Notes section of the record. Instructions on the record documented, Narrative Note is required if answered yes. Review of the Weekly Skin Assessment Record dated 6/15/10 revealed no documentation a weekly skin assessment was performed. The Alteration in Skin Integrity section of the record was left blank and there was no documentation dated 6/15/10 found in the Weekly Skin Assessment Progress Notes section of the record. Review of Resident #18's hospital History and Physical dated 6/20/10 documented, .There are two bandages, one across the lateral ankle on the left and one on the shin. These both show excoriated, chronic appearing wounds with jelly-like substance across and mild erthroderma that appears chronic about the size of my hand on the dorsum of his foot and a bit streakier on the shin. There is no bony step off or obvious bony abnormality . During an interview in the conference room on 5/14/11 at 4:15 PM, the Assistant Director of Nursing confirmed the facility was unable to locate the requested documentation for the treatments were performed every other day as ordered from 6/1/10 to 6/20/10.",2016-04-01
10825,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2011-06-15,322,D,0,1,HH7Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, it was determined the facility failed to ensure only nurses operated the Percutaneous Endoscopy Gastrostomy (PEG) tube pump. the findings included: Medical record review for Resident #9 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].@ (at) 85 ML (milliliters) / (per) HR (hour) X (times) 18 HRS / DAY (ALLOW 2 HR DISCONNECT @ BREAKFAST, LUNCH, DINNER) . Observations in room [ROOM NUMBER] on 6/14/11 at 8:18 AM, revealed Certified Nursing Assistant (CNA #4) pushed the peg tube feeding pump hold button and stopped the tube feeding. During an interview in the conference room on 6/15/11 at 8:05 AM, Nursing Assistant (NA #1) was asked what she would do when caring for a resident with a PEG tube. NA #1 stated, .if we lay a patient on their back, we put (PEG tube pump) on hold . During an interview in the conference room on 6/15/11 at 8:24 AM, the CNA instructor was asked what should the CNAs do with a PEG pump when caring for a resident with a pump. The CNA instructor stated, Let the nurse know when they are ready to go in so the nurse can put them (PEG pump) on hold .",2016-04-01
10826,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2011-06-15,325,D,0,1,HH7Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, it was determined the facility failed to monitor weights monthly for 3 of 20 (Residents #6, 9 and 16) sampled residents. The findings included: 1. Review of the facility's Weight Monitoring policy documented, 1 .If weights are stable, patients will then be weighed monthly according to center policy . 2. Medical record review for Resident #6 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Weight Record documented no monthly weights for January, February, March and April 2011. 3. Medical record review for Resident #9 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Weight Record documented no weights for January, March and April 2011. 4. Medical record review for Resident #16 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Weight Record documented no monthly weights for January, February and March 2011. 5. During an interview at the nurses' station #2 on 6/14/11 at 1:35 PM, the Registered Dietician (RD) stated, We were having trouble getting weights. I didn't find any for the first of the year (2011) . The RD was asked how often a resident should be weighed. The RD stated, It depends, but at least monthly. 6. During an interview in the conference room on 6/14/11 at 5:15 PM, Nurse #1 was asked how often the residents were expected to be weighed. Nurse #1 stated, .expected to weigh (the residents) monthly.",2016-04-01
10827,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2011-06-15,328,D,0,1,HH7Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, it was determined the facility failed to ensure a resident received proper treatment for [REDACTED]. The findings included: Medical record review for Resident #7 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's recertification orders dated 6/7/11 documented no order for oxygen. Observations in Resident #7's room on 6/13/11 at 11:30 AM, 3:20 PM and 5:45 PM, on 6/14/11 at 4:45 PM and on 6/15/11 at 7:35 AM, revealed Resident #7 was receiving oxygen (O2) at 3.0 liters per minute (LPM) per binasal cannula (BNC). Observations in Resident #7's room on 6/14/11 at 7:30 AM, revealed Resident #7 receiving O2 at 2.5 LPM BNC. Resident #7 asked if her O2 was on 3. CNA #7 confirmed it was on 2.5 LPM and adjusted the rate to 3.0 LPM. Observations in the dining room on 6/14/11 at 9:30 AM and 11:30 AM, revealed Resident #7 was receiving O2 at 3.0 LPM BNC. During an interview at nurses station #1 on 6/14/11 at 2:50 PM, CNA #7 confirmed that she adjusted the oxygen rate on Resident #7. CNA #7 was asked if she should adjust resident's oxygen rates. CNA #7 stated, .I haven't been told not to . During an interview in the medical records office on 6/15/11 at 9:10 AM, the Director of Nursing (DON) was asked who she would expect to make adjustments to oxygen rates. The DON stated, .I would expect the nurse to adjust it (oxygen rate) . The DON confirmed that Certified Nurses Assistants should not adjust oxygen rate.",2016-04-01
10828,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2011-06-15,371,F,0,1,HH7Y11,"Based on policy review, observation and interview, it was determined the facility failed to ensure food was stored and prepared under sanitary conditions as evidenced by expired buttermilk, opened and not dated food, condensation dripping on clean cereal bowls, flies in the kitchen, food particles on the equipment stored in the clean area, handling food in an unsanitary way and chemical concentration of three compartment sink on 3 of 3 (6/13/11, 6/14/11, and 6/15/11) days of the survey. The findings included: 1. Observations in the kitchen on 6/13/11 at 10:50 AM, on 6/14/11 at 9:50 AM and on 6/15/11 at 12:50 PM, revealed a 1/2 gallon carton of buttermilk with sell by date 6/13/11 stored in the walk in refrigerator. During an interview in the kitchen on 6/15/11 at 12:50 PM, the Dietary Manager (DM) was asked if the buttermilk should be used. The DM looked at the date and stated, .No, shouldn't be (used) . 2. Review of the facility's Safety & (and) Sanitation Best Practice Guidelines, SANITATION, REFRIGERATOR AND FREEZER STORAGE guideline documented, .9. Foods will be stored in their original container or .wrapped tightly in moisture-proof film, foil, .Clearly labeled . Observations in the kitchen on 6/13/11 at 10:45 AM, revealed an opened box of hamburger patties uncovered and not labeled with open date stored in the walk in freezer. Observations in the kitchen on 6/13/11 at 6:30 PM, revealed open and uncovered cream cheese and a box of sausage patties open and uncovered stored in the walk in refrigerator. Observations in the kitchen on 6/14/11 at 9:50 AM, revealed opened boxes of turkey bacon, hamburger patties and waffles stored in the walk in freezer with no date when they were opened. During an interview in the kitchen on 6/13/11 at 6:30 PM, the DM stated, .yes, it (cream cheese) is open and not covered on the end . yes the sausage patties are not covered . boxes should be dated when opened . During an interview in the kitchen on 6/14/11 at 1:00 PM, the DM stated, .food should be covered with parchment paper and bags should have been pulled (tight), boxes should be dated when opened, frozen items should be covered . 3. Observations in the kitchen on 6/14/11 at 10:00 AM, revealed Dietary Staff (DS) #1 was wearing a black zip up hooded jacket preparing the meat. DS #1 placed the meat in a large stock pot on the stove top, placed her left arm elbow deep into the stock pot and broke up the meat with her bare hand then pulled her sleeved arm out revealing a red food substance on the sleeve at the elbow. During an interview in the dry storage room on 6/14/11 at 1:00 PM, the DM stated, (staff) not supposed to put arm in the pan . 4. Review of the facility's Safety & Sanitation Best Practice Guidelines, SANITATION, MANUAL WAREWASHING guideline documented, .4. Sanitize in the third sink, by immersing items in . b. A chemical sanitizing solution at the proper concentration and at the correct temperature for the sanitizer used. Test the solution with a test kit to assure adequate concentration of chemical and record . Observations in the kitchen on 6/13/11 at 10:45 AM and 6:30 PM, on 6/14/11 at 1:00 PM and on 6/15/11 at 12:45 PM, revealed the PHydroin papers Quaternary (QT) - 40 measured below 200 parts per million (PPM) when the sanitizer compartment of the three compartment sink was tested . During an interview in the kitchen on 6/13/11 at 10:45 AM, the DM stated, It (sanitizer) was right earlier. I will redo. During an interview in the kitchen on 6/13/11 at 6:30 PM, the DM stated, It (sanitizer) was right earlier. I will redo. During an interview in the kitchen on 6/14/11 at 1:00 PM, the DM stated, It (sanitizer) was right earlier. I will redo. During an interview in the kitchen on 6/15/11 at 12:45 PM, the DM stated, I had to adjust it (sanitizer) earlier to get it right. I'll adjust it again. 5. Observations in the kitchen on 6/13/11 at 6:30 PM, revealed condensation dripping down from the air vent onto the clean storage area of the cereal bowls. During an interview in the kitchen on 6/13/11 at 6:30 PM, the DM stated, probably the air conditioning unit dripping. 6. Review of the facility's Safety & Sanitation Best Practice Guidelines, CLEANING PROCEDURES, SLICER guideline documented, 1. After each use . 2. Wash all removable parts in detergent solution in pot and pan sink. Rinse in clear water and sanitize in sanitizing solution . Observations in the kitchen on 6/13/11 at 6:30 PM, revealed the tomato slicer located in the clean storage area with 6 black/green colored substances and one large red tomato piece in the slicer blades. The lemon slicer was stored in the clean storage area with a medium piece of lemon pulp in the blade. Another tomato slicer was located in the clean storage area with dried green/black hard material in the slicer. During an interview in the kitchen on 6/13/11 at 6:30 PM, the DM stated, .We had tomatoes today but did not use this slicer . It looks like tomato left in the slicer . yes, it (tomato slicer) was cleaned and on the clean rack . During an interview in the kitchen on 6/13/11 at 6:55 PM, the DM stated, .It is lemon in the slicer . yes, it had been cleaned already . that is an old tomato slicer we have not used in two years, yes there is a substance in the old tomato slicer . 7. Observations in the kitchen on 6/13/11 at 10:45 AM and on 6/14/11 at 9:50 AM, revealed multiple flies in the kitchen preparation area. During an interview in the kitchen on 6/13/11 at 10:45 AM, the DM stated, Yes, I see the flies. During the group interview on 6/14/11 at 10:00 AM, the residents attending the group interview were asked Do you ever see insects or rodents here? Resident #7 stated, .sometimes see flies .",2016-04-01
10829,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2011-06-15,441,E,0,1,HH7Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, it was determined 5 of 15 Certified Nurses Assistants (CNA #2, 5, 6, 7 and 8) failed to ensure infection control practices were used to prevent the potential spread of infection by not using sanitary hand hygiene or by not using appropriate personal protective equipment and failed to ensure [DEVICE] (vac) tubing was not touching the floor. The findings included: 1. Review of the facility's handwashing policy documented, .Wash hands before and after contact with each patient . 2. Observations during meal pass on A Hall on 6/13/11 revealed the following: a. CNA #2 entered room [ROOM NUMBER] at 5:15 PM, applied gloves moved a urinal from a overbed table, then opened the food plate, drink, ice cream and straw with the gloves she used to remove the urinal. CNA #2 entered room [ROOM NUMBER] at 5:30 PM, placed the meal tray on a desk, applied gloves, placed trash in the can, moved a urinal from the overbed table, removed gloves, set the meal tray on the overbed table, and put the overbed table across the residents bed. CNA #2 did not wash her hands after removing gloves and handling the meal tray or clean the overbed table where the urinal had sat. 3. Observations in the B hall on 6/14/11 between 7:45 AM and 8:10 AM revealed the following: CNA #5 entered room [ROOM NUMBER] at 7:45 AM, placed the tray on the table, set up the tray and adjusted the resident's pillow. CNA #5 entered room [ROOM NUMBER] at 7:48 AM, placed the tray on the table, assisted the resident up in the bed and set up tray the tray. CNA #5 entered room [ROOM NUMBER] at 7:50 AM, placed the tray on the table and set up the tray. CNA #5 entered room [ROOM NUMBER] at 7:53 AM, placed the tray on the table, used the hand control to raise the head of the bed, went out of the room to room [ROOM NUMBER] to assist CNA #6 with pulling a resident up in bed at 7:54 AM. CNA #5 went to the coffee cart in B hall and poured a cup of coffee and returned to room [ROOM NUMBER] at 7:56 AM and placed the coffee on the resident's tray. CNA #5 entered room [ROOM NUMBER] at 7:58 AM and placed the tray on the table. CNA #5 entered room [ROOM NUMBER]B at 8:00 AM and placed the tray on the table. CNA #5 did not wash her hands or use hand sanitizer between any of the residents. During an interview in the B hall on 6/14/11 at 8:15 AM, CNA #5 confirmed she did not wash her hands or use hand sanitizer between residents. 4. Observations in the B hall on 6/14/11 between 7:45 AM and 8:10 AM revealed the following: CNA #6 entered room [ROOM NUMBER]A at 8:02 AM, placed the tray on the table, adjusted a pillow behind the resident and set up the tray. CNA #6 entered room [ROOM NUMBER] at 8:03 AM, placed the tray on the table of resident 158A, assisted resident 158B up in the bed with the assistance of CNA #5, assisted resident 158A up in the bed with the assistance of CNA #5, the set up the tray. CNA #5 entered room [ROOM NUMBER] at 8:04 AM, placed the tray on the table, assisted resident in 158B up in the bed with the assistance of CNA #6, then set up the tray. CNA #6 did not wash his hands or use hand sanitizer between any of the residents. During an interview in the B hall on 6/14/11 at 8:12 AM, CNA #6 confirmed he did not wash his hands or use hand sanitizer between residents. During an interview at nurses station #1 on 6/15/11 at 9:05 AM, the Director of Nursing (DON) confirmed that hand hygiene should be performed between residents. 5. Review of the facility's .TRANSMISSION - BASED PROCEDURES . policy documented, .1) Wear a gown if the patient is incontinent or has diarrhea . Medical record review for Resident #5 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].CONTACT PRECAUTIONS FOR[DIAGNOSES REDACTED] (clostridium difficile) . COCCYX . APPLY WOUND VAC . L (left) GLUTEAL FOLD . APPLY WOUND VAC . Review of the Minimum (MDS) data set [DATE] documented, .H0400. Bowel Continence . this section was coded 3 which indicated Resident #5 was always incontinent of bowel. Observations in Resident #5's room on 6/13/11 at 3:15 PM, CNA #7 and #8 assisted Resident #5 up in the bed without wearing a gown. Observations in Resident #5's room on 6/13/11 at 3:15 PM and 6:00 PM, on 6/14/11 at 9:25 AM, 11:00 AM, 2:30 PM and 4:00 PM and on 6/15/11 at 7:25 AM and 8:55 AM, revealed Resident #5's wound vac tubing was touching the floor. During an interview at nurses station #1 on 6/14/11 at 2:50 PM, CNA #7 confirmed she had direct resident contact without wearing a gown. During an interview in Resident #5's room on 6/15/11 at 8:55 PM, the DON confirmed the wound vac tubing was touching the floor. The DON stated, .I would expect it (wound vac tubing) not to be on the floor .",2016-04-01
10830,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2011-06-15,469,D,0,1,HH7Y11,"Based on observation and interview, it was determined the facility failed to keep the facility free of pests as evidenced by the presence of flies in 5 of 69 resident rooms (rooms 119, 122, 128, 145 and 156), 1 of 4 halls (D hall) and nurses' station number 2. The findings included: 1. Observations in room 119 on 6/13/11 at 11:45 AM, revealed a fly in the room. 2. Observations in room 122 on 6/13/11 at 4:50 PM, revealed 6 flies in the room. Observations in room 122 on 6/14/11 at 7:18 AM, revealed a fly in the room. 3. Observations in room 128 on 6/13/11 at 11:05 AM, revealed a fly in the room. 4. Observations in room 145 on 6/14/11 at 10:16 AM, revealed a fly crawling on the residents left arm. 5. Observations in room 156 on 6/13/11 at 11:06 AM, revealed a fly on the side rail of the bed. 6. Observations in D hall on 6/13/11 at 11:45 AM, revealed a fly in the hall outside room 119. 7. Observations in nurses' station number 2 on 6/13/11 at 3:30 PM, revealed a fly in the station. 8. During the group interview conducted in the conference room on 6/14/11 at 10:00 AM, Resident #7 stated, .sometimes sees flies .",2016-04-01
10831,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2011-06-15,504,D,0,1,HH7Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, it was determined blood samples were obtained without a physician's order for 4 of 20 (Residents #5, 7, 9 and 13) sampled residents. The findings included: 1. Review of the facility's laboratory services policy documented, .obtained only upon the written order of the patient's physician . 2. Medical record review for Resident #5 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's order dated 4/10/11 had no order documented to obtain [MEDICATION NAME] peak and trough levels. Review of the laboratory results documented a [MEDICATION NAME] peak and trough levels were drawn on 4/16/11, 4/19/11, 4/20/11, 4/21/11, 4/22/11, 4/23/11, 4/24/11 and 4/27/11. During an interview at nurses' station #1 on 6/15/11 at 7:55 AM, the Assistant Director of Nursing (ADON) was asked about orders for the [MEDICATION NAME] peak and trough levels. The ADON stated, .Did because he was on the vanc. ([MEDICATION NAME]), but he (physician) didn't write an order . 3. Medical record review for Resident #7 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's recertification orders for 4/1/11 through 4/30/11 had no orders documented for a comprehensive metabolic panel (CMP), Glycosolated hemaglobin (HGBA1C), complete blood count (CBC) and a renal laboratory test. Review of the laboratory results documented a CMP, HgbA1C and CBC on 4/21/11 and a Renal laboratory test on 4/27/11. During an interview at the post acute nurses' station on 6/14/11 at 4:35 PM, Nurse #2 confirmed there was no order for the labs obtained as noted above. 4. Medical record review for Resident #9 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's recertification orders dated 4/12/11 and the physician's recertification orders dated 5/3/11 documented, .HGBA1C EVERY 3 MONTHS . Review of laboratory test results for Resident #9 documented a HGBA1C was obtained 5/11/11. The facility was unable to provide documentation of a physician's order for the HGBA1C obtained on 5/11/11. During an interview at the nurses' station #2 on 6/14/11 at 2:15 PM, the Assistant Director of Nurses (ADON) reviewed the chart and stated, .Don't know why did HgbA1C in May (2011) see no order . 5. Medical record review for Resident #13 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's recertification orders dated 1/3/11, 2/2/11, 4/12/11, 5/3/11 and 6/7/11 had no order documented to obtain a CBC. Review of the laboratory test results for Resident #13 documented a CBC was obtained on 1/7/11, 2/8/11, 3/8/11, 4/8/11 and 6/8/11. During an interview in the conference room on 6/15/11 at 10:30 AM, the ADON reviewed the chart and stated, .The lab (laboratory) was drawn here and I don't see an order for [REDACTED].>",2016-04-01
10832,"NHC HEALTHCARE, COLUMBIA",445109,101 WALNUT LANE,COLUMBIA,TN,38401,2011-06-15,514,D,0,1,HH7Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility failed to ensure medical records were complete and accurate for 2 of 20 (Residents #3 and 11) sampled residents. The findings included: 1. Medical record review for Resident #3 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].HUMALOG SSI (sliding scale insulin) SUBQ (subcutaneous) 150- (to) 200 = (amount of insulin to be administered) 2 UNITS, 201-250 = 4 UNITS, 251-300 = 6 UNITS, 301-350 = 8 UNITS, 341-400 = 10 UNITS, OVER 400 - CALL MD (medical doctor) . The original order date 3/18/11 documented, .Humalog SQ (subcutaneous): 150-200 = 2 units 201-250 = 4 units, 250-300 = 6 units 301-350 = 8 units 351-400 = 10 units > (greater than) 400 = call MD . The facility failed to correct the physician's orders [REDACTED].= 8 units and 341-400 = 10 units with overlap from 341-350. During an interview in the Director of Nursing's (DON) office on 6/15/11 at 8:45 AM, the DON was asked who should have caught the overlapping sliding scale insulin order. The DON stated, .Who ever checks orders should have caught it (overlapping sliding scale insulin). The nurses check off their own (orders) . 2. Medical record review for Resident #11 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].D/C (discontinue) [MEDICATION NAME] 5/500 Give [MEDICATION NAME] 10/500 1 (one) po (by mouth) Q (every) 4 hours PRN (as needed) pain. Review of physician's orders [REDACTED]. Review of physician's orders [REDACTED].D/C [MEDICATION NAME] . Review of the physician orders [REDACTED].Therapeutic VIT (vitamin) / (with) MIN (mineral) TAB (tablet) ONE (1) PO DAILY . [MEDICATION NAME] 25 MG (milligram) TABLET ONE (1) PO Q 6 HRS (HOURS) .[MEDICATION NAME] 5/500 TABLET ONE (1) TO TWO (2) PO Q 6 HRS PRN FOR Pain . The facility failed to DC the Therapeutic Vit/Min, [MEDICATION NAME] and [MEDICATION NAME] 5/500 and give [MEDICATION NAME] 10/500 Q 4 hours prn pain on the recertification orders. During an interview in the medical records office on 6/15/11 at 9:10 AM, the DON was asked about the [MEDICATION NAME] and vitamin orders. The DON stated, It should have been changed on the certification orders .",2016-04-01
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
3630,"NHC HEALTHCARE, COOKEVILLE",445110,815 SOUTH WALNUT AVENUE,COOKEVILLE,TN,38501,2017-03-15,248,D,0,1,69GY11,"**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 activities based on the resident's preferences for 2 residents (#88, #85) of 5 residents reviewed for activities, of 25 residents reviewed. The findings included: Review of the facility policy Group Activities revised 9/1/14 revealed .activities should be suited to the needs, abilities, and interests of patients . Medical record review revealed Resident #88 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Staff Assessment of Daily Activity Preferences dated 10/23/16 revealed .Listening to music yes-all music .Keeping up with the news yes on TV .Spending time outdoors yes, sometimes when weather is nice . Medical record review of the Recreation Assessment Report dated 10/24/16 revealed Plan for involvement . individual 1 on 1 . staff will try talking to her, doing her nails, and grooming her .while here she enjoys watching out her window listening to music, visiting with her daughter, listening to tv and sometimes getting her nails done. staff will offer 1 on 1 visits and offer to help groom and do her nails . Medical record review of the Recreation Notes dated 1/26/17 revealed .Quarterly Note .Pt (Patient) enjoys snacks, listening to music, one-on-one visits, and family visits . Medical record review of the (MONTH) (YEAR) Activity Calendar revealed the resident was provided 2 activities (Visitors) out of 31 days. Medical record review of the (MONTH) (YEAR) Activity Calendar revealed the resident was provided 3 activities (talking/reminiscing, TV, Visitors) out of 28 days. Medical record review of the (MONTH) (YEAR) Activity Calendar revealed the resident was provided 2 activities (singing, visitors) out of 31 days. Medical record review of the (MONTH) (YEAR) Activity Calendar revealed the resident was provided 2 activities (visitors) out of 31 days. Medical record review of the (MONTH) (YEAR) Activity Calendar revealed no documentation the resident was provided any activities. Observation on 3/14/17 at 1:45 PM and 3:30 PM revealed the resident lying in bed. Continued observation revealed the TV was not on and there was no music playing. Observation on 3/15/17 at 7:25 AM revealed the resident seated in a reclining back wc (wheelchair) in the resident's room. Continued observation revealed no TV or music on, and fingernails not painted. Observation on 3/15/17 at 1:00 PM revealed the resident seated in a reclining back wc in the resident's room with the TV on a soap opera program. Interview with the Recreation Director on 3/15/17 at 8:30 AM in the conference room confirmed the facility had not provided Resident #88 activities based on the resident's preferences. Medical record review revealed Resident #85 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) of 99 (resident unable to complete interview, indicating severe cognitive impairment), behaviors included physical (occurred 1 to 3 times), other behavioral symptoms not directed at others (occurred 4 to 6 days but less than daily), and required extensive assistance for completion of Activities of Daily Living. Medical record review of the Recreation Plan of Care dated 4/22/16 and Updated/Reviewed on 1/16/17 through 4/16/17 revealed .Pt (patient) may need one-on-one .or materials to support independent recreation or to provide social stimulation and opportunity for recreation participation .one-on-one visits 2 times per week . volunteers with similar interests/hobbies . Medical record review of the monthly 1:1 Independent Activity Participation Log revealed the following documentation: 11/2016: 5 activities 12/2016: 5 activities 1/2017: 1 activity 2/2017: 3 activities 3/2017: 2 activities Further review revealed the activities included talking/reminiscing, pet visits, TV, newspapers/delivered/read, and 1 attendance of a singing group. Observation of Resident #85 on 3/15/17 at various times of the day in the resident's room revealed the resident in the bed, the TV on with the remote not in reach of the resident. Interview with the Recreation Director on 3/15/17 at 9:50 AM, in the Conference Room confirmed personalized preferences for 1 on 1 activities had not been done for Resident #85 .haven't had time .I'm weak on documenting 1 on 1 activities . Continued interview confirmed Resident #85 did not receive the newspaper but she said hello to him when she delivered the newspaper to his roommate. Further interview confirmed it is her responsibility to plan, coordinate, and document individual activities for the residents. Interview with the Administrator on 3/15/17 at 12:35 PM, in the Conference Room confirmed the facility failed to provide personalized 1 on 1 activities twice a week for Resident #85.",2020-04-01
5470,"NHC HEALTHCARE, COOKEVILLE",445110,815 SOUTH WALNUT AVENUE,COOKEVILLE,TN,38501,2016-03-09,371,F,0,1,MY6H11,"Based on facility policy review, observation, and interview, the facility failed to ensure pans used to serve food for the residents were dry when stored, ensure the mixer and food preparation areas used to prepare food for the residents were clean, ensure scoops in food bins were not stored in the food, and failed to ensure 1 of 3 ice machines in use for the residents was clean and sanitary. The findings included: Review of facility policy Safety & Sanitation Best Practice Guidelines revised 1/2011 revealed, .Air-dry all items. Make sure all items are completely dry before stacking to prevent wet-nesting . Observation on 3/7/16, at 8:45 AM, of the facility kitchen area with the Nutritionist revealed: 4 of 4 6 inch pans stored wet; 2 of 3 1/2 pans stored wet; debris on the mixer/beater and cage; the drawer in the food preparation table had food crumbs with the spoons and ladles used to serve food for the residents; the shelf below the food preparation table was wet and had whitish debris; and the cornmeal and sugar bins had scoops lying in the food. Interview with the Nutritionist on 3/7/16 at 9:10 AM, in the kitchen confirmed the facility failed to ensure equipment and utensils used to prepare and serve food for the residents was sanitary. Observation and interview with Registered Nurse #1, of the ice machine in the 100 hallway Hydration room on 3/7/16, at 9:30 AM, confirmed the ice machine had brown/black debris on the inside right side wall. Observation and interview with Licensed Practical Nurse #2 of the ice machine in the 100 hallway Hydration room on 3/9/16, at 11:15 AM, confirmed the ice machine had brown/black debris on the inside right side wall. Interview with the Administrator on 3/9/16, at 11:25 AM, outside of the conference room, revealed the ice machines are .cleaned semi-annually due to they grow algae maybe we need to do it more often .",2019-02-01
6604,"NHC HEALTHCARE, COOKEVILLE",445110,815 SOUTH WALNUT AVENUE,COOKEVILLE,TN,38501,2015-03-11,280,D,0,1,ES0811,"**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 one resident (#134) of thirty sampled residents. The findings included: Resident #134 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a laboratory report dated March 8, 2015, revealed, Specimen: Stool .Report Final: 03/08/2015 (7:29 p.m.) .C. diff ([MEDICAL CONDITION]) .positive. Medical record review of a physician's orders [REDACTED]. Medical record review of a physician's orders [REDACTED].related to [MEDICAL CONDITION]. Medical record review of the resident's current care plan, effective through March 19, 2015, revealed no documentation regarding infectious disease and/or isolation. Interview with the Assistant Director of Nursing (ADON) on March 10, 2015, at 3:12 p.m, at the 400 wing nurse's station, revealed the ADON was responsible for revising the resident's care plan. Continued interview confirmed the facility failed to revise the care plan to address the resident's infectious disease and isolation.",2018-05-01
6605,"NHC HEALTHCARE, COOKEVILLE",445110,815 SOUTH WALNUT AVENUE,COOKEVILLE,TN,38501,2015-03-11,371,F,0,1,ES0811,"Based on observation, facility policy review, review of manufacturer's recommendations, and interview, the facility failed to ensure dishes and utensils were cleaned under sanitary conditions in the dietary department. The findings included: Observation on March 10, 2015, at 8:41 a.m., in the kitchen, revealed dietary employee #1 washed kitchen utensils using the three compartment sink. Continued observation revealed the dietary employee washed a large skillet, food scoop, and two quarter pans by dipping the kitchen items in the chemical sanitizer and then immediately placing them on a rack. Review of the facility policy Chemical Sanitizing, revised January 2011, revealed .4. Chemical sanitizing may be accomplished .by immersing a clean object in a specific concentration of sanitizing solution for a required period of contact time . Review of the chemical product manufacturer's recommendations and interview with the dietary manager on March 10, 2015, at 3:56 p.m., in the dietary office, confirmed a 1 minute contact time was needed for chemical sanitizing, and the facility policy and manufacturer's recommendations were not followed for chemical sanitizing.",2018-05-01
8745,"NHC HEALTHCARE, COOKEVILLE",445110,815 SOUTH WALNUT AVENUE,COOKEVILLE,TN,38501,2014-01-23,280,D,0,1,S0XG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility investigation reports, observation, and interview, the facility failed to revise the care plan following a resident incident for one resident (#11) and for current medication interventions for one resident (#19) of thirty residents reviewed. The findings included: Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) Significant Change dated September 23, 2013, revealed the resident required extensive assistance of two persons for transfers, bathing, dressing, grooming, and toileting; required extensive assistance of one person for eating; was always continent of bowel and frequently incontinent of bladder. Review of the facility's investigation dated September 28, 2013, revealed at 7:25 p.m., the resident received a cut to the left lower leg during a transfer in the resident's room. Further review of the facility's investigation documentation revealed the Certified Nursing Assistant (CNA) was transferring the resident from the chair to the bed. Continued review of the facility's investigation documentation revealed the question, .How much assistance does the patient require in transfer? . with the response, .2 person or mechanical lift . Medical record review of the Quarterly MDS dated [DATE], revealed the resident required extensive assistance of two people for bathing, dressing, grooming, transfers, and toileting; extensive assistance of one person for eating; was always incontinent of bowel and frequently incontinent of bladder. Medical record review of the care plan dated October 3, 2013, and revised on December 31, 2013, revealed no documentation of the amount and type of assistance the resident required with transfers and Activities of Daily Living. Continued medical record review of the care plan revealed no documentation the front lower bars on the wheelchair were to be padded and wrapped with ace wraps. Further medical record review of the care plan revealed no documentation the side rails were removed from the bed and were not to be reapplied. Observation of the resident on January 23, 2014, at 1:25 p.m., in the resident's room, revealed the resident was sitting in a rock-n-go chair with an alarm in place, support bars on the bilateral from wheelchair bars were wrapped with cotton batting and covered with wraps. Observation of the resident's bed revealed the bed rails had been removed from the bed. Interview with CNA #1 on January 23, 2014, at 2:10 p.m., at the 400 hall nursing station, confirmed the resident required use of a stand-up lift or two people for transfers, the side rails were removed from the bed after the accident, and the wheelchair front bars were padded to prevent skin injuries. Interview with the Director of Nursing (DON) on January 23, 2014, at 9:40 a.m., in the conference room, confirmed the care plan did not address the assistance required for transfers nor the fact the wheelchair bars were to remain padded. Resident #19 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Clinical Pharmacy Review dated September 3, 2013, revealed the resident had been readmitted with physician's orders [REDACTED]. Review of the Physicians Recapitulation Orders dated January 2014, revealed, the resident received [MEDICATION NAME] and [MEDICATION NAME] daily. Review of the Care Plan dated November 5, 2013, revealed care plan interventions for [MEDICATION NAME] (antidepressant) and no interventions for [MEDICATION NAME] or [MEDICATION NAME]. Interview with the Assistant Director of Nursing on January 23, 2014, at 9:40 a.m., at the 100/200 hall nurse's station, confirmed the care plan had not been revised to reflect the resident's current medication regimen. COMPLAINT #",2017-04-01
8746,"NHC HEALTHCARE, COOKEVILLE",445110,815 SOUTH WALNUT AVENUE,COOKEVILLE,TN,38501,2014-01-23,323,G,0,1,S0XG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility investigation, observation, and interview, the facility failed to ensure staff transferred a resident in a manner to prevent accidents for one resident (#11) of three residents reviewed for accidents. The facility's failure to transfer the resident according to the resident's assessment resulted in harm to resident #11. The findings included: Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the ADL 31 Day Look-back dated August 30 through September 30, 2013, revealed the resident required one to two persons for transfers. Medical record review of the Monthly Nursing Summary Report dated September 3, 2013, revealed, .Current Modes of Transfer: Lifted manually Lifted mechanically . Medical record review of the Minimum Data Set (MDS) Significant Change dated September 23, 2013, revealed the resident required extensive assistance of two persons for transfers. Medical record review of the nurse's notes for September 2013, revealed, 9/4/13 1:55 p (p.m.) (up) dly (daily) in rock-n-go w/c (wheelchair). Requires ext (extensive) assist (assistance) (with) locomotion. Non-amb (non-ambulatory), 0 (no) walking occurred in room/corridor. Requires ext. assist (with) ADLs (Activities of Daily Living) .Requires ext assist (with) meals .9/18/13 @ (at) 6:48 p (p.m.) .Assist x 2 (two people) for transfers .9/25/13 11:15 A (up) dly in rock-n-go w.c. Requires ext assist (with) locomotion. Non-amb. Ext assist (with) ADL's .Requires ext assist (with) meals . Review of an Investigation of Incident dated September 28, 2013, revealed, at 7:25 p.m., the resident received a cut to the left lower leg during a transfer in the resident's room. Further review of the investigation revealed the Certified Nursing Assistant (CNA) was transferring the resident from the chair to the bed. Continued review of the investigation revealed the question, .How much assistance does the patient require in transfer? . with the response, .2 person or mechanical lift . Further review of the investigation revealed one CNA was transferring the resident. Review of a statement written by CNA #3 dated September 28, 2013, revealed, .When I transferred .(named resident #11) from .wheelchair to .bed .became combative with me while holding .When I laid .down I noticed blood on my gloves and arm. That is when I realized the skin tear on .left leg. It had gotten caught on the bottom of .bed rail . Review of a statement written by CNA #4 dated September 28, 2013, revealed, .When I was getting my resident ready for bed I heard my coworker, (named CNA #3), saying that .has blood on .gloves and arm. I came around the corner to see if I could help. That's when I noticed the skin tear on .left leg. I asked .how .did .get that skin tear .said it had gotten caught on the bottom part of the rail. After that we went and got the nurse . Review of the Emergency Department (ED) report dated September 28, 2013, revealed the resident presented to the ED by ambulance with complaints of leg injury. Continued review of the ED record revealed, .EMS (Emergency Medical Services) state resident was being moved .skin became caught on a foreign object, and was subsequently torn. The resident presents with a laceration 9 cm (centimeters), clean, irregular L shaped tear on anterolateral leg .Positive for laceration, pain, of the lateral aspect of the left calf, 10 cm laceration in L shape on lateral leg . Continued review of the ED record Physician Documentation revealed, .noted in the lateral aspect of left calf: laceration 8 cm laceration in L pattern, L (left) anterolateral leg . Further review of the ED record revealed, wound repair of .8 cm full thickness laceration to lateral aspect of calf, irregularly shaped. Wound cleansed, irrigated, and explored. Subcutaneous tissue closed with 7 sutures and skin closed with 8 sutures . Review of a staff in-service Transfers and Mechanical Lifts dated October 1, 2013, revealed, Every Resident under your care must be transferred as care planned no exceptions. If your resident is a two person transfer you must have two people to transfer this resident every time. All Manual Transfers require the use of a gait belt, no exceptions. If your resident requires the use of a lift for transfers you must use the appropriate lift to transfer this resident every time .Improper transferring of the resident can and does cause serious injury to our residents . Observation of the resident on January 23, 2014, at 8:30 a.m., in the resident's room, revealed the resident seated in a chair with the lower bars padded. Continued observation revealed the resident did not respond to questions. Observation of the resident on January 23, 2014, at 11:10 a.m., revealed the CNA taking the resident to the bathroom, cleaning the resident, and taking the resident to lunch. Interview with CNA #1 on January 24, 2013, at 1:30 p.m., at the 300/400 hall nursing station, revealed staff used a stand-up lift or two people to transfer the resident. Continued interview with CNA #1 revealed two people were usually present even if the lift was used. Interview with CNA #2 on January 23, 2014, at 4:15 p.m., at the 300/400 hall nursing station, revealed the resident was transferred with two people or using a lift. Continued interview with CNA #2 revealed staff used the lift more often since the resident can become combative with transfers. Interview with the Director of Nursing (DON) on January 23, 2014, at 9:40 a.m., in the conference room, revealed in-services were begun the day of the incident on September 28, 2013, for all staff regarding Transfers and Mechanical Lifts. Further interview confirmed when the resident sustained [REDACTED]. c/o #",2017-04-01
8747,"NHC HEALTHCARE, COOKEVILLE",445110,815 SOUTH WALNUT AVENUE,COOKEVILLE,TN,38501,2014-01-23,371,F,0,1,S0XG11,"Based on observation and interview, the facility dietary department failed to prevent cross contamination while processing the dishes in the dish room. The findings included: Observation and interview with the morning cook on January 21, 2014, at 9:35 a.m., in the dietary department dish room, revealed the dish machine was in operation. Further observation revealed the dietary staff member operating the dish machine pushed a rack containing dirty dishes into the rack of clean dishes inside the dish machine in two consecutive operations of the dish machine, thereby cross contaminating the cleaned dishes. Further interview with the cook confirmed the dietary staff member failed to properly process the dishes by having the dirty dishes come in contact with the clean dishes.",2017-04-01
8748,"NHC HEALTHCARE, COOKEVILLE",445110,815 SOUTH WALNUT AVENUE,COOKEVILLE,TN,38501,2014-01-23,431,D,0,1,S0XG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure expired items were discarded and food items were correctly labeled in two of two medication rooms observed. The findings included: Observation of the medication room for the ,[DATE] hall on [DATE], at 1:50 p.m., revealed a 1000 ml (milliliter) container of Glucerna 1.5 calories (used for tube feedings) sitting on the shelf next to other containers of tube feeding. Continued observation revealed the container had 600 ml remaining in it but there was no resident name on it nor was there a date when the container was opened. Interview with LPN (Licensed Practical Nurse) #1 on [DATE], at 2:00 p.m., in the medication room, confirmed the container of tube feeding was undated, unlabeled, and available for resident use. Observation of the medication room for the ,[DATE] hall on [DATE], at 2:15 p.m., revealed a partial bottle of wine in the refrigerator used for resident nutrition. Continued observation of the refrigerator revealed there was no name on the bottle nor was there a date when it was opened. Interview with LPN #2 on [DATE], at 2:40 p.m., in the medication room, confirmed the wine bottle belonged to one of the residents but it was not labeled with the resident's name or the date of opening.",2017-04-01
8749,"NHC HEALTHCARE, COOKEVILLE",445110,815 SOUTH WALNUT AVENUE,COOKEVILLE,TN,38501,2014-01-23,494,C,0,1,S0XG11,"Based on review of the CFR Title 42, Volumn 3, PART 483 Requirements for States and Long Term Care Facilities (Nurse Aide Training Programs) and interview, the facility failed to ensure no nurse aide was charged for any portion of the program. The findings included: Review of the Requirements for States and Long Term Care (LTC) Nurse Aide Training Requirements revealed, .Sec.483.152(c) Prohibition of charges. (1) No nurse aide who is employed by, or who has received an offer of employment from, a facility on the date on which the aide begins a nurse aide training and competency evaluation program may be charged for any portion of the program . Interviews with three Nurse Aide Trainees (NAT) currently enrolled in the NAT class provided by the facility on January 23, 2014, from 10:05 a.m., to 10:10 a.m., in the conference room, revealed each trainee had been required to pay $225.00 for class materials and training. Interview with the Staff Education Coordinator on January 23, 2014, at 10:10 a.m., in the Staff Education Coordinator's office, confirmed the NAT students were not employed during the training, and the charge for the class was $225.00 for the training and materials. Continued interview confirmed the Staff Education Coordinator had no knowledge of persons who had been hired by the facility after completing the class being reimbursed for the cost of the class. Interview with NAT #1 on January 23, 2014, at 10:40 a.m., in the conference room, confirmed the nurse aide had been enrolled in the class that started October 7, 2013, and was hired by the facility on October 30, 2013. Continued interview confirmed NAT #1 had not been reimbursed by the facility for the NAT class. Interview with the Administrator in the Administrator's office on January 23, 2014, at 10:45 a.m., confirmed the facility had not reimbursed nurse aides for the cost of the class after the nurse aides completed the class and were employed by the facility.",2017-04-01
8750,"NHC HEALTHCARE, COOKEVILLE",445110,815 SOUTH WALNUT AVENUE,COOKEVILLE,TN,38501,2014-01-23,514,D,0,1,S0XG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to maintain a complete medical record for one resident (#78) of thirty residents reviewed. The findings included: Resident #78 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the medical record revealed the last monthly recapitulation orders signed by the physician were dated October 2 and 3, 2013. Interview with the Assistant Director of Nursing on January 21, 2014, at 2:10 p.m., at the 300/400 hall nursing station, confirmed the record for resident #78 did not contain current monthly recapitulation orders signed by the physician. Interview with the Director of Nursing, on January 21, 2014, at 2:50 p.m., in the conference room, confirmed the facility failed to have current physician orders [REDACTED].#78, and the signed orders were to be completed in December 2013.",2017-04-01
13166,"NHC HEALTHCARE, COOKEVILLE",445110,815 SOUTH WALNUT AVENUE,COOKEVILLE,TN,38501,2011-06-22,441,F,0,1,9ITU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain a sanitary clean room in the laundry; and failed to maintain resident equipment in a sanitary manner. The findings included: Observation on June 20, 2011, at 9:50 a.m., of the clean room in the laundry, revealed a wall mounted fan blowing directly onto the folding table with several stacks of clean folded linen. Further observation revealed the fan blowing onto clean clothes hanging on racks. Further observation revealed the fan blades had a heavy accumulation of blackened debris and the fan grate had debris hanging off the grate. Interview on June 20, 2011, at 9:50 a.m., with laundry staff #1, present during the observation confirmed the fan blade and grate had debris accumulation and was blowing directly onto the folding table with stacks of clean linen and onto the racks with clean clothes, therefore contaminating the clean linen and clothes. Observations on June 20, 2011, at 10:23 a.m., and June 22, 2011, at 9:30 a.m., of the bathroom shared by the residents in rooms [ROOM NUMBERS] revealed an extender commode seat directly on the bathroom floor. Interview with Certified Nurse Aide #1 on June 20, 2011, at 10:25 a.m., and Licensed Practical Nurse #1 on June 22, 2011, at 9:30 a.m., in the bathroom shared by the residents in rooms [ROOM NUMBERS], confirmed the extender commode seat was not to be stored on the floor.",2015-04-01
13167,"NHC HEALTHCARE, COOKEVILLE",445110,815 SOUTH WALNUT AVENUE,COOKEVILLE,TN,38501,2011-06-22,323,D,0,1,9ITU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, review of facility investigation, and interview, the facility failed to maintain a secure central supply room containing potentially hazardous items; and failed to provide two person physical assistance for transfers and toileting to prevent falls for one resident (#4) of nineteen residents reviewed. The findings included: Observation on June 20, 2011, from 10:00-10:07 a.m., revealed the central supply door was open to the 200 hall and unattended by facility staff. Further observation of the shelves directly inside the door revealed the potentially hazardous items of safety pins, peri-wash, hand sanitizer, nail clippers, and wound cleanser. Observation revealed no residents were in the hall during the observation period. Further observation revealed a Licensed Practical Nurse walked by the open central supply room; a Certified Nurse Aide and a student nurse passing ice in the hall across from the open central supply room; and a housekeeper in the hall across from the open central supply room. Observation revealed a facility staff member pushing a cart into the central supply room at 10:07 a.m., on June 20, 2011. Interview with the facility staff person pushing the cart into the central supply room on June 20, 2011, at 10:07 a.m., revealed the person was the Central Supply Director. Further interview with the Central Supply Director confirmed the central supply door was unlocked, open to the 200 hall and no facility staff was in attendance in the room. Further interview confirmed the central supply room contained potentially hazardous items and the door was to be closed and locked when unattended. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Sets dated June 30, 2010; and September 13, 2010 revealed the resident was short and long term memory impaired, had severely impaired cognition, and required extensive assistance with two plus staff member physical assistance for bed mobility, transfers, and toileting. Medical record review of the Fall Risk Assessments dated July 15, 2010; August 11, 2010; September 11, 2010 and September 13, 2010, revealed the resident was at high risk for falls. Medical record review of the Nursing Summary Report dated August 12, 2010, and September 13, 2010, revealed the resident's memory was ""...not able to recall after 5 minutes. Unable to recall long past..."" Further review revealed the resident had moderately impaired cognitive skills for decision making. Further review revealed the resident required two plus person physical assist for toileting and transfers. Review of the care plan initiated on July 8, 2010, and updated on September 30, 2010, revealed the resident problem of needing ""...ext (extensive) to total assist of 1-2 (staff) with bed mobility and toileting; ext to total assist of 2 (staff) with transfers..."" Review of a facility investigation revealed resident #4 fell on [DATE], at 8:00 a.m., ""...while exiting commode unattended...c/o (complained of) pain LLE (left lower extremity) knee region..."" Further review of the facility investigation revealed the immediate intervention initiated to prevent future falls was ""attend while toileting."" Review of the left knee x-ray report dated August 2, 2010, revealed ""...Arthritic disease to knee. No acute skeletal injury..."" Review of a facility investigation revealed the resident fell on [DATE], at 10:30 a.m., after one Certified Nurse Aide (CNA) had transferred the resident from the bedside commode onto the wheelchair and the resident moved forward in the wheelchair seat onto the floor. Review of a written statement by the CNA attending the resident during the fall revealed ""...I had just transferred (resident) to (resident) w/c (wheelchair) from BSC (bedside commode). (Resident) was sitting on edge of w/c I told (resident) to help me scoot (resident) back in the chair. Instead of going back (resident) went forward. I tried to get (resident) back in (resident) chair but had to lower (resident) to floor..."" Further review of the facility investigation revealed ""What was done to prevent reoccurrences?...staff instructed to use 2 CNA for all transfers..."" Further review revealed the immediate intervention initiated to prevent future falls was ""...teach (resident) to rise slowly from seated/lying position..."" Further review revealed the resident sustained [REDACTED]. Interview with the Director of Nursing, on June 21, 2011, beginning at 2:40 p.m., in the conference room, confirmed the facility had not provided two plus staff physical assistance for toileting and transfers as assessed by the MDS which resulted in two falls without injury.",2015-04-01
13168,"NHC HEALTHCARE, COOKEVILLE",445110,815 SOUTH WALNUT AVENUE,COOKEVILLE,TN,38501,2011-06-22,246,D,0,1,9ITU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure call lights were answered timely for one resident (#19) of nineteen residents reviewed. The findings included: Resident #19 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident scored 12 out of 15 on the BIMS (Brief Interview for Mental Status-moderately impaired cognitive status.) Observation on June 22, 2011, at 7:55 a.m., revealed the resident's call light was turned on (sounding). Continued observation revealed two CNAs (certified nursing assistant) were in the hallway passing out breakfast trays, one student CNA was in the hallway, one Registered Nurse was in the hallway standing at the medication cart, and one nurse was at the nurse's station. Further observation revealed the call light was not answered untill 8:10 a.m. (15 minutes). Interview with the Director of Nursing (DON) on June 22, 2011, at 8:15 a.m., in the DON's office, confirmed the call light was not answered timely.",2015-04-01
13169,"NHC HEALTHCARE, COOKEVILLE",445110,815 SOUTH WALNUT AVENUE,COOKEVILLE,TN,38501,2011-06-22,221,D,0,1,9ITU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to assess one resident (#15) of nineteen residents reviewed for the use of a click release seatbelt. The findings included: Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident to be cognitively intact, with a score of 15 (out of a possible total of 15), on the ""Brief Interview for Mental Status."" Continued review revealed the resident to be non-ambulatory and required extensive assistance for transfers, bed mobility, and most activities of daily living. Further review revealed the resident used an electric wheelchair as a mobility device. Medical record review of the resident's record revealed no documentation of an assessment for the use of a click release seatbelt when in the wheelchair. Observation of the resident on June 21, 2011, at 2:30 p.m., and June 22, 2011, at 8:30 and 9:20 a.m., revealed the resident sitting in an electric wheelchair with a click release seatbelt over the upper thigh waist area. Interview with the DON (Director of Nursing) on June 22, 2011, at 9:25 a.m., in the 400 Hall confirmed the facility failed to assess the resident for the use of the click release seatbelt.",2015-04-01
14174,"NHC HEALTHCARE, COOKEVILLE",445110,815 SOUTH WALNUT AVENUE,COOKEVILLE,TN,38501,2014-01-23,246,D,,,S0XG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to maintain the bathroom call light cords within reach for two residents (#78, #93) of thirty residents reviewed. The findings included: Resident #78 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set, dated dated dated [DATE], revealed the resident was independent in ambulation and required extensive assistance with one person physical assistance for toileting. Observation on January 21, 2014, at 2:17 p.m., revealed the resident's shared bathroom had a call light located behind the toilet, mounted high on the wall, and the pull cord was wrapped around the rail attached to the wall near the toilet tank. Interview with Licensed Practical Nurse (LPN) #2 on January 22, 2014, at 10:24 a.m., at the 300/400 hall nursing station, confirmed resident #78 was capable of ambulating and toileting independently. Resident #93, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data Set, dated dated dated [DATE], revealed the resident was independent with ambulation and required extensive assistance with one person for toileting. Observation in the resident's room on January 22, 2014, at 9:11 a.m., revealed resident #93 entered the room using a rolling walker. Continued observation revealed resident #93 entered and exited the shared bathroom independently. Interview with LPN #2 on January 22, 2014, at 3:00 p.m., at the 300/400 nursing station, confirmed resident #93 was capable of independently ambulating and toileting. Interview with Certified Nurse Aide #1 on January 21, 2014, at 2:30 p.m., in the shared bathroom, confirmed the call light pull cord was not within reach of the residents.",2014-03-01
14262,"NHC HEALTHCARE, COOKEVILLE",445110,815 SOUTH WALNUT AVENUE,COOKEVILLE,TN,38501,2010-05-26,431,D,,,F3R311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure medications were dated when opened and failed to ensure expired biologicals were not available for resident use for one of four medication carts and one of two medication rooms. The findings included: Observation of the medication cart on the 300 hall on [DATE], at 8:00 a.m., with LPN #1 (Licensed Practical Nurse) revealed a drawer containing the following multiple stock medications, not dated when opened: Aspirin 325 mg 125 tablets, ,[DATE] full; Colace Stool Softener 100 tablets, ,[DATE] full; Tussin DM Sugar Free Cough medicine 4 ounces, ,[DATE] full; Aspirin 325 mg 100 tablets, ? full; Enulose one pint, ,[DATE] full; Pepto 8 ounces, ? full; Liquid Acetaminophen 16 ounces more than ? full; Docusate 16 ounces, more than ? full. Observation of a drawer on the cart revealed a glucometer kit (to check blood sugar) containing glucometer strips with an expiration date of March, 2010, and dated as opened [DATE]. Interview with LPN #1 on [DATE], at 8:00 a.m., on the 300 hall confirmed the stock medications had not been dated when opened and the glucometer strips were expired and had been used for a resident's blood sugar checks. Observation of the medication room on the 300 and 400 hall on [DATE], at 8:15 a.m., revealed the following expired biologicals and undated medications: Glucometer strips with an expiration date of March, 2010; Stomahesive (for ostomy bag changes) one ounce expired September, 2009; Hemoccult (to check for blood in stool) 15 mL expired March, 2009; and, in the refrigerator, one Humulin-R insulin ? full, not dated when opened. Interview with the wound care nurse on [DATE], at 8:15 a.m., in the 300 and 400 hall medication room, confirmed the biologicals had expired and were available for resident use. Interview with the Director of Nursing (DON) on [DATE], at 8:20 a.m., in the 300 and 400 hall medication room, confirmed the insulin had not been dated when opened. Interview with the DON on [DATE], at 8:40 a.m., confirmed stock medications and insulin are to be dated when opened.",2014-02-01
14263,"NHC HEALTHCARE, COOKEVILLE",445110,815 SOUTH WALNUT AVENUE,COOKEVILLE,TN,38501,2010-05-26,246,D,,,F3R311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to place the call light within reach for three residents (#16, #17, #18) of twenty-one residents reviewed. The findings included: Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the comprehensive care plan dated May 22, 2010, revealed ""Risk for Falls"" and ""keep call light within my reach."" Observation on May 24, 2010, at 6:10 p.m., revealed the resident in bed with the call light draped over a reclining chair near the bed and out of reach of the resident. Interview with the Director of Nursing on May 26, 2010, at 9:15 a.m., in the Administrator's office confirmed the call light is to be within reach of the resident. Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the comprehensive care plan dated March 1, 2010, revealed ""ADL's"" (activities of daily living) and ""Please keep my call light within my reach."" Observation on May 24, 2010, at 6:15 p.m., revealed the resident in bed with the call light cord draped across the foot board of the bed and out of the resident's reach. Continued interview with the resident revealed the resident was unable to reach the cord and ask the surveyor to please move the cord near the resident's left side. Interview with the Director of Nursing on May 26, 2010, at 9:15 a.m., in the Administrator's office confirmed the call light is to be positioned within reach of the resident. Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the comprehensive care plan dated February 24, 2010, revealed ""ADL's"" and ""please keep call light within my reach."" Observation on May 24, 2010, at 6:20 p.m., revealed the resident in bed with the call light cord draped across the foot board of the bed and out of the resident's reach. Interview with the Director of Nursing on May 26, 2010, at 9:15 a.m., in the Administrator's office confirmed the call light is to be positioned within reach of the resident.",2014-02-01
14264,"NHC HEALTHCARE, COOKEVILLE",445110,815 SOUTH WALNUT AVENUE,COOKEVILLE,TN,38501,2010-05-26,157,D,,,F3R311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility policy, and interview, the facility failed to notify the physician of low finger stick blood sugar (FSBS) levels and/or high FSBS for three residents (#2, #13, #10) of twenty-one sampled residents. The findings included: Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Physician's Recapitulation Orders For April and May of 2010, revealed, ""...FSBS AC (before meals) and HS (at bedtime) ...Sliding scale insulin with [MEDICATION NAME] SQ (subcutaneous injection) as follows: 400=12 units and call MD..."" Medical record review of the Diabetic Monitoring Log revealed the resident had a FSBS of 44 on April 10, 2010, at 5:30 p.m., a FSBS of 56 on April 11, 2010, at 7:00 a.m., a FSBS of 55 on April 11, 2010, at 5:30 p.m., a FSBS of 54 on April 12, 2010, at 5:30 p.m., and a FSBS of 54 on May 1, 2010 at 11:00 a.m. Resident #13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Physician's Recapitulation Orders for April and May of 2010, revealed ""...FSBS AC (before meals) and HS (at bedtime) ...Sliding scale insulin with [MEDICATION NAME] SQ (subcutaneous injection) as follows: 400=12 units and call MD..."". Medical record review of the Diabetic Monitoring Log revealed the resident had a FSBS of 42 on April 2, 2010, at 4:20 a.m., a FSBS of 44 on April 8, 2010, at 1:20 a.m., and a FSBS of 56 on April 22, 2010, at 7:00 a.m. Review of facility policy Insulin Administration revealed ""...5. Physician to be notified of blood sugars below 60 or above 200 unless there is a specific order addressing blood sugars outside these ranges or directing otherwise..."" Interview with the DON (Director Of Nursing) in the DON office on May 25, 2010, at 3:00 p.m., confirmed the facility had failed to notify the physician of the low blood sugars. Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the resident's March, April and May 2010, Physician Recapitulation Orders revealed, ""FSBS AC & HS (finger stick blood sugars before meals and at bedtime)"" and ""Sliding scale insulin with [MEDICATION NAME] SQ as follows: (greater than) 400 = 10 units."" Medical record review of the resident's Diabetic Log dated April 2010, revealed a low FSBS of 56 on April 18, 2010, at 11:00 a.m. Medical record review of the resident's Diabetic Logs dated March 2010, and April 2010, revealed the following high FSBS: March 26, 2010, at 7:00 a.m., 423 and 11:00 a.m., 477; March 27, 2010, at 11:00 a.m., 471; March 28, 2010, at 8:00 p.m., 415; March 30, 2010, at 11:00 a.m., 484 and 5:00 p.m., 457; April 3, 2010, at 8:00 p.m., 431; April 7, 2010, at 5:00 p.m., 422; and April 22, 2010, at 5:00 p.m., 413. Review of facility policy Insulin Aadministration revealed ""...5. Physician to be notified of blood sugars below 60 or above 200 unless there is a specific order addressing blood sugars outside these ranges or directing otherwise..."" Interview with the DON in the Conference Room on May 25, 2010, at 10:30 a.m., confirmed the facility had failed to notify the physician of the low and high blood sugars.",2014-02-01
14265,"NHC HEALTHCARE, COOKEVILLE",445110,815 SOUTH WALNUT AVENUE,COOKEVILLE,TN,38501,2010-05-26,176,D,,,F3R311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure assessment for self-administration of medications was completed for one resident (#10) of twenty-one residents reviewed. The findings included: Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Observation of a medication pass on May 24, 2010, at 8:20 p.m., with RN #1 (Registered Nurse), revealed the RN entered the resident's room and administered oral medications to the resident, applied an ointment to the resident's cheeks, and left a plastic medicine cup with [MEDICATION NAME] cream 0.01% setting on the resident's over bed table. Interview with RN #1 on May 24, 2010, at 8:40 p.m., on the 200 hall confirmed the [MEDICATION NAME] cream was left on the resident's over bed table for the resident to self-administer when ready. Interview with the Director of Nursing on May 24, 2010, at 9:05 p.m., at the 200 hall nursing station, confirmed the resident had not been assessed for self-administration of medications and medications were not to be left in the resident's room.",2014-02-01
14266,"NHC HEALTHCARE, COOKEVILLE",445110,815 SOUTH WALNUT AVENUE,COOKEVILLE,TN,38501,2010-05-26,323,D,,,F3R311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure a safety alarm was in place for one resident (#3) of twenty-one residents reviewed. The findings included: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had short term memory problems, moderately impaired cognitive skills for daily decision making, and required assistance with most activities of daily living. Medical record review of a Falls Risk assessment dated [DATE], revealed the resident was at high risk for falls. Medical record review of the Care Plan dated March 25, 2010, revealed ""...alarms after supper to remind me to call for help..."" Medical record review of a Post Falls Nursing assessment dated [DATE], 8:00 p.m., revealed ""...Patient was found sitting on floor with call light in hand by bedside...was reaching for lotion on the bedside table when...slipped from bed to floor..."" Review of a facility fall investigation form dated May 17, 2010, revealed ""...no alarms on when the incident occurred..."" Observation on May 24, 2010, at 8:15 p.m. revealed the resident in bed, the bed in the lowest position, pressure pad alarm on the bed and activated. Interview with LPN (Licensed Practical Nurse) #1, on May 26, 2010, at 10:25 a.m., confirmed the resident did not have the pressure pad alarm in place at the time of the fall on May 17, 2010.",2014-02-01
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
3752,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2017-02-15,151,D,1,0,C72111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of review of facility policy, medical record review, review of a facility investigation, and interview, the facility failed to ensure resident rights were honored without interference for 1 resident (#6) of 3 residents review for resident rights of 8 sampled residents. Review of the facility policy Patients' Rights, undated, revealed .Privacy-Knock on doors before entering, do not enter while you are knocking, wait for response . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimal (MDS) data set [DATE] revealed Resident #6's Brief Interview Mental Status (BIMS) score was 15 (cognitively intact). Review of a facility investigation dated 2/6/17 at 11:20 AM revealed Resident #6 reported Licensed Practical Nurse (LPN) #5 violated his personal rights by entering his room after he told the LPN to wait. Interview with Registered Nurse (RN) #5 on 2/14/17 at 2:25 PM, in the conference room, revealed LPN #5 came to her (RN #5) office on 2/6/17 and reported .she (LPN #5) had just walked in on the resident and his girlfriend having sex .asked (LPN #5) if she had knocked before entering .she said she had and the resident replied hold on a minute .asked (LPN #5) if she had waited before she (LPN #5) entered the room and she replied no . Further interview revealed RN #5 informed LPN #5 the resident . did have the right to privacy . Interview with Resident #6 on 2/14/17 at 2:45 PM, in his room, revealed .I do not know what her (LPN #5) deal was .I told her to hold on a minute .I knew I had rights . Interview with the Risk Manager on 2/15/17 at 11:45 AM, in the conference room, confirmed Resident #6's rights were violated and the facility failed to follow facility policy.",2020-02-01
3753,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2017-02-15,164,D,1,0,C72111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of review of facility policy, medical record review, review of a facility investigation, and interview, the facility failed to ensure personal privacy was maintained for 1 resident (#6) of 8 residents reviewed. Review of the facility policy Patients' Rights, undated, revealed .Privacy-Knock on doors before entering, do not enter while you are knocking, wait for response . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimal (MDS) data set [DATE] revealed Resident #6's Brief Interview Mental Status (BIMS) score was 15 (cognitively intact). Review of a facility investigation dated 2/6/17 at 11:20 AM revealed Resident #6 reported Licensed Practical Nurse (LPN) #5 violated his right to privacy by entering his room after he told the LPN to wait. Interview with Registered Nurse (RN) #5 on 2/14/17 at 2:25 PM, in the conference room, revealed LPN #5 came to her (RN #5) office on 2/6/17 and reported .she (LPN #5) had just walked in on the resident and his girlfriend having sex .asked (LPN #5) if she had knocked before entering .she said she had and the resident replied hold on a minute .asked (LPN #5) if she had waited before she (LPN #5) entered the room and she replied no . Further interview revealed RN #5 informed LPN #5 the resident . did have the right to privacy . Interview with Resident #6 on 2/14/17 at 2:45 PM, in his room, revealed the resident's girlfriend was in his room for a visit. Continued interviewed revealed .(LPN #5) grabbed and pulled the curtain back .I do not know what her (LPN #5) deal was .I told her to hold on a minute . Interview with the Risk Manager on 2/15/17 at 11:45 AM, in the conference room, confirmed Resident #6's privacy was not maintained and the facility failed to follow facility policy.",2020-02-01
3754,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2017-02-15,224,D,1,0,C72111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of review of facility policy, medical record review, review of a facility investigation, and interview, the facility failed to ensure 1 resident (#6) was free from verbal abuse of 7 residents review for abuse of 8 sampled residents. Review of the facility policy Abuse, undated, revealed .each resident has the right to be free from abuse .mistreatment .abuse is defined as .verbal .mental . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimal (MDS) data set [DATE] revealed Resident #6's Brief Interview Mental Status (BIMS) score was 15 (cognitively intact). Review of a facility investigation dated 2/6/17 at 11:20 AM revealed while Resident #6 was in his room with his girlfriend, Licensed Practical Nurse (LPN) #5 entered Resident #6's room after the resident told the LPN to wait. Continued review revealed LPN #5 was verbally abusive to the resident and stated .this is not a (expletive) motel . Further review revealed LPN #5 called Resident #5 .a (expletive) piece of (expletive) . Interview with Registered Nurse (RN) #5 on 2/14/17 at 2:25 PM, in the conference room, revealed LPN #5 came to her (RN #5) office on 2/6/17 and reported .she (LPN #5) had just walked in on the resident and his girlfriend having sex . Interview with Resident #6 on 2/14/17 at 2:45 PM, in his room, revealed .I do not know what her (LPN #5) deal was . Interview with the Risk Manager on 2/15/17 at 11:45 AM, in the conference room, confirmed the facility failed to protect Resident #6 from verbal abuse and the facility failed to follow facility policy.",2020-02-01
3755,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2017-02-15,225,D,1,0,C72111,"**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 alleged incident of abuse for 1 resident (#4) of 7 residents reviewed for abuse of 8 sampled residents. Review of facility policy Abuse, undated, revealed .Any partner having either direct or indirect knowledge of any event that might constitute abuse must report the event immediately . Medical record review revealed Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Admission Minimum (MDS) data set [DATE] revealed Resident #4 had a Brief Interview Mental Status score of 12 (cognitively intact). Continued review revealed the resident was totally dependent for transfers, dressing and personal hygiene with 1-2 person assist. Further review revealed the resident was always incontinent of bowel and bladder. Review of a facility investigation dated 1/30/17 at 12:40 PM revealed Resident #4 reported to the Social Worker (SW) he had called Licensed Practical Nurse (LPN) #4 a (expletive) as she was walking out of his room at 9:30 AM the morning of 1/30/17 (3 hours earlier). Continued review revealed LPN #4 re-entered Resident #4's room and stated say it to my face. Further interview revealed the SW reported the incident immediately to the Risk Manager (RM). Interview with LPN #3 on 2/13/17 at 2:50 PM, in the Risk Manager's (RM) office revealed .I was outside of the door .heard (Resident #4) call (LPN #4) a (expletive) .she (LPN #4) goes back into his room and says say it to my face . Continued interview revealed LPN #3 did not report the incident. Interview with the RM on 2/13/17 at 3:00 PM, in her office revealed .I was notified by the Social Worker immediately after she spoke with Resident #4. I sent (LPN #4) to my office to wait while we began interviews . Continued interview revealed the RM interviewed the resident at 12:50 PM and the resident reported the incident occurred around 9:30 AM. Further interview with the RM confirmed LPN #3 did not immediately report the incident and the facility failed to follow facility policy.",2020-02-01
3756,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2017-02-15,241,D,1,0,C72111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of a facility investigation, and interview, the facility failed to treat one resident (#6) with dignity and respect of 8 residents reviewed. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimal (MDS) data set [DATE] revealed Resident #6's Brief Interview Mental Status (BIMS) score was 15 (cognitively intact). Review of a facility investigation dated 2/6/17 at 11:20 AM revealed Resident #6 reported Licensed Practical Nurse (LPN) #5 entered his room after he told the LPN to wait. Interview with Registered Nurse (RN) #5 on 2/14/17 at 2:25 PM, in the conference room, revealed LPN #5 came to her (RN #5) office on 2/6/17 and reported .she (LPN #5) had just walked in on the resident and his girlfriend having sex .asked (LPN #5) if she had knocked before entering .she said she had and the resident replied hold on a minute .asked (LPN #5) if she had waited before she (LPN #5) entered the room and she replied no . Further interview revealed .(LPN #5) told the resident 'this is not a (expletive) motel . Interview with Resident #6 on 2/14/17 at 2:45 PM, in his room, revealed the resident's girlfriend was in his room for a visit. Continued interviewed revealed .(LPN #5) grabbed and pulled the curtain back .I do not know what her (LPN #5) deal was .I told her to hold on a minute . Interview with the Risk Manager on 2/15/17 at 11:45 AM, in the conference room, confirmed the facility failed to respect the dignity of Resident #6.",2020-02-01
6326,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2015-08-05,157,D,0,1,4H7P11,"**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 was notified of the use of a splint device for 1 resident (#140), of 35 residents reviewed. The findings included: Review of the facility policy for Splinting Interventions revealed .Document assessments .and medical staff and departmental communication . Medical record review revealed Resident #140 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physicians telephone order dated 3/31/15 revealed .therapy eval (evaluation) for bracing bilateral hand contractures . Observation of Resident #140 on 8/3/15, at 3:20 PM, in the resident's room, revealed the resident resting in bed with the hand splints noted on the residents bookshelf. Interview with restorative aide #1 on 8/5/15 at 8:12 AM, in the Unit manager's office, revealed restorative had been seeing the resident since 12/25/14 for splinting. Interview with the unit manager on 8/5/15 at 8:19 AM, in the Unit manager's office, confirmed the facility failed to notify the physician of the splinting Interview and review of restorative notes with the Unit manager on 8/5/15 at 1:20 PM, in the Unit manager's office, confirmed the resident had been seen by restorative since 12/25/14 for splinting. Continued interview revealed therapy was responsible for physician notification, obtaining the physicain order, and ensuring the information was placed in the electronic system. Continued interview confirmed the resident did not have an order in place for splinting . .",2018-08-01
6327,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2015-08-05,241,D,0,1,4H7P11,"Based on facility policy review, the facility Food and Nutrition Service Tray Delivery Schedule review, observation and interview, the facility failed to provide dignity during dining in 1 of 4 dining areas observed. The findings included: Review of the facility policy, Tray Delivery and Monitoring the Resident During Meal Times, revised date 04/14 revealed .Residents will be provided nourishment to meet their daily nutritional and special dietary needs. Each resident is provided services to maintain or improve eating skills and provide a dining experience that enhances the resident's quality of life .Trays being delivered to a dining table on a unit will be served when all residents seated at the table can be served and assisted . Review of the facility Food & Nutrition Service Tray Delivery Schedule, revised 12/29/11, revealed .Lunch . Cart 1 12:15 PM, Cart 2 12:50 PM . Observation on 8/4/15, from 12:15 PM to 12:55 PM, at the 2nd East Nurses Station revealed 4 residents seated around a table in the hallway. Continued observation revealed 2 of the residents were being fed by staff members that were standing, and 2 residents who had not been served. Continued observation revealed 3 residents seated at the nurses station, 1 with a bedside table in front of him, feeding himself, 1 resident being fed by a seated staff member from the tray placed on the counter above her head, and 1 resident who had not been served. Continued observation revealed 4 residents in the day room, 2 residents feeding themselves and 2 residents who had not been served. Continued observation revealed additional trays were brought to the residents at various times with the last resident being served at12:55 PM (35 minutes later). Interview with Certified Nursing Assistant #1 on 8/4/15 at 8:15 AM, in the 2nd East nurses station revealed .sometimes we sit, sometimes we stand .we get 4 dining carts . Continued interview revealed the food trays come to the floor .by room number . at different times. Interview with the Assistant Director of Nursing #1 on 8/4/15, at 9:15 AM in her office, confirmed the facility had failed to ensure dignity during dining for the residents in the 2nd East dining area.",2018-08-01
6328,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2015-08-05,279,D,0,1,4H7P11,"**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 care plan was developed to address a splint device for 1 resident (#140) of 35 residents reviewed. The findings included: Review of the facility policy for Splinting Interventions revealed .Document assessments .and medical staff and departmental communication . Medical record review revealed Resident #140 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physicians telephone order dated 3/31/15 revealed .therapy eval (evaluation) for bracing bilateral hand contractures . Observation of Resident #140 on 8/3/15 at 3:20 PM, in the resident's room, revealed the resident resting in bed with hand splints noted on the resident's bookshelf. Interview with the unit manager on 8/5/15 at 8:19 AM, in the Unit manager's office, revealed the plan of care last updated 7/15/15, with no documentation to address the residents bilateral splints. Continued interview revealed the resident had been seen by restorative since 12/25/14, for splinting as tolerated. Interview with the unit manager on 8/5/15, at 1:20 PM, in the Unit manager's office, confirmed the facility failed to develop a care plan to address the splints.",2018-08-01
6329,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2015-08-05,281,D,0,1,4H7P11,"**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 eye medications were administered at least 5 minutes apart for 1 resident (#35) of 2 residents reviewed for eye medication administration of 35 residents sampled. The findings included: Review of the facility policy Medication Administration: Eye Drops revised 4/24/14, revealed .Wait at least 5 minutes .before applying additional medication to the eye . Medical record review revealed Resident #36 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Physician's Recapitulation Orders dated (MONTH) (YEAR), revealed .Artificial Tears 1.4 % Solution apply 1 drop .give in both eyes .[MEDICATION NAME] (antibiotic) 5mg (milligram)/gm (gram) apply 1 application .in both eyes .Dx:(diagnosis) [MEDICAL CONDITION] (inflammation of the inner eye) . Medical record review of Progress Notes dated 3/12/15, and 5/11/15, revealed .Recurrent Blepharitis (infection of the eyelid) .Recurrent [MEDICAL CONDITION] (dry eye syndrome) . Observation on 8/4/15, from 9:56 AM to 10:01 AM, in the resident's room, revealed Licensed Practical Nurse (LPN) #1 administered the Artificial Tears to the left eye at 9:56 AM and the right eye at 9:58 AM. Continued observation revealed the LPN then administered the [MEDICATION NAME] ointment to the left eye at 9:58 AM and the right eye at 10:00 AM. Interview on 8/4/15 at 10:05 AM, in the 100 East 1 Hall with LPN #1 confirmed LPN #1 failed to wait 5 minutes between the administration of the eye medication in both eyes. Interview on 8/5/15 at 8:15 AM, at the East 1 100 Nurse's Station, with Assistant Director Of Nursing #2 (responsible for staff education) confirmed the facility failed to follow the policy for eye medication administration.",2018-08-01
6330,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2015-08-05,425,D,0,1,4H7P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to ensure eye medication was available for 1 resident (#36) of 6 residents reviewed for medication administration, of 35 residents sampled. The findings included: Medical record review revealed Resident #36 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Physician's Recapitulation Orders dated (MONTH) (YEAR), revealed .Erythromycin (antibiotic) 5mg (milligram)/gm (gram) apply 1 application .in both eyes .Dx: (diagnosis) Conjunctivitis (inflammation of the inner eye) . Medical record review of a Medication Administration Record [REDACTED]. Medical record review of a document Meds Not Given dated (MONTH) (YEAR) revealed the Erythromycin Ointment was not in stock for 7 days. Observation on 8/5/15 at 9:30 AM in the East 1 100 Hallway revealed Licensed Practical Nurse (LPN) #1 prepared Resident #36's medication. Continued observation revealed the resident asked LPN #1 if the nurse had the eye drops and stated You usually don't have them. Interview with LPN #1 on 8/5/15 at 9:50 AM in the East 1 100 Hallway, confirmed the Resident #36's Erythromycin Ointment had not been available on several occasions (unsure of exact dates). Interview with the Assistant Director of Nursing #2 on 8/5/15, at 2:15 PM, in the lobby, confirmed the facility had failed to ensure the eye medication had been available for Resident #36 from the pharmacy.",2018-08-01
6331,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2015-08-05,431,D,0,1,4H7P11,"Based on review of facility policy, medical record review, observation and interview, the facility failed to ensure controlled substance logs were accurate and controlled substances were secured for 1 medication cart, of 10 medication carts reviewed, of 22 medication carts available. The findings included: Review of the facility policy Medication Administration revised 4/24/14 revealed .controlled substance/narcotic log is kept in order to assure controlled substance/narcotic accountability . Medical record review of a Controlled Substance Record dated (MONTH) (YEAR) revealed Percocet (controlled substance) 2.5-325 mg (milligram) available 11. Observation on 8/4/15 at 9:27 AM, in the 100 East 1 Hall, during a random observation, revealed the East 1 Medication Cart with (2) 5 cc (cubic centimeter) medication cups on top of the medication cart with 3 pills in 1 cup and 1.5 pills in the second cup. Continued observation revealed the medication cart was unattended. Observation and interview on 8/4/15 at 9:30 AM, in the 100 East 1 Hall with Licensed Practical Nurse (LPN) #1 revealed cup #1 contained 3 Tylenol (pain) caplets and cup #2 contained 1 Percocet 2.5/325mg and 1/2 of an Aricept (medication for Dementia). Interview at this time confirmed the LPN had left the medication cart unattended and the controlled medication and Tylenol were not secured. Observation with LPN #1 on 8/4/15 at 9:40 AM, in the 100 East 1 Hall, of a controlled substance record on East 100 Hall Medication Cart 1, revealed Percocet 2.5-325 mg available 10. Interview with LPN #1 on 8/4/15, at 9:40 AM, in the 100 East 1 Hall, confirmed LPN #1 failed to sign out the Percocet 2.5-325 mg on the narcotic log at the time the nurse removed the controlled substance from the medication cart. Interview with the Assistant Director Of Nursing (ADON) #2 on 8/5/15 at 9:26 AM in the East 100 Head Nurse Office, confirmed all controlled substances should be signed out on the narcotic log at the time of removal. Continued interview confirmed all medications should be secured in the medication cart, and controlled substances placed under 2 locks.",2018-08-01
6332,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2015-08-05,441,D,0,1,4H7P11,"**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 eye medication was not contaminated during administration to both eyes for 1 Resident (#36) of 2 residents reviewed of 35 residents sampled and failed to ensure good infection control practices during dining, in 1 of 4 Dining Rooms observed. The findings included: Review of the facility policy Medication Administration: Eye Drops, revised 4/24/14, revealed .hold the tip over the eye taking care to avoid touching the eye or eyelid . Medical record review revealed Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician's Recapitulation Orders dated (MONTH) (YEAR) revealed .Artificial Tears 1.4 % Solution apply 1 drop .give in both eyes .[MEDICATION NAME] (antibiotic) 5mg (milligram)/gm (gram) apply 1 application .in both eyes .Dx:(diagnosis) Conjunctivitis (inflammation of the inner eye) . Medical record review of Progress Notes dated 3/12/15 and 5/11/15 revealed .Recurrent Blepharitis (infection of the eyelid) .Recurrent Keratoconjunctivitis (dry eye syndrome) . Observation on 8/4/15, from 9:56 AM to 10:01 AM, in the resident's room, revealed Licensed Practical Nurse (LPN) #1 placed the tip of an [MEDICATION NAME] Ointment tube in the right eyelid and administered 1 application of ointment to the right eyelid. Continued observation revealed the LPN used the same tube of ointment, placed the tip in the left eyelid, administered 1 application of the ointment to the left eyelid, and returned the ointment to the medication cart available for resident use. Interview on 8/4/15 at 10:05 AM, in the 100 East Hall, with LPN #1 confirmed the LPN had touched the tip of the tube to both eyelids during the administration of the ointment and placed the ointment in the medication cart available for use by the next nurse. Interview on 8/5/15 at 8:15 AM, in the East 1 100 Nurse's Station, with ADON #2 (responsible for education) confirmed the licensed staff were in-serviced and monitored during medication administration to avoid touching the eye or eyelids when eye medications were administered. Continued interview confirmed touching the eyelid contaminated the eye medication and the nurses were instructed to dispose of the medication and reorder if contaminated. Review of facility policy, Infection Control: Resident Meal Preparation, dated 7/19/12 revealed .The Health Center at Standifer Place staff will serve and prepare a resident meal tray, snack, and beverage in a manner that will help prevent cross contamination . Observation of Dietary Technician (DT) #1 on 8/3/15, at 11:50 AM, in(NAME)main dining room revealed the DT held a residents hand with gloved hands, continued to the next table, filled a beverage cup with ice, and placed the ice scoop directly on the ice available for resident use. Continued observation revealed the DT served 3 more residents ice and beverages in the dining room before changing gloves or washing the hands. Interview with DT #1 on 8/3/15 at 12:10 PM, in the(NAME)main dining room confirmed DT #1 should have changed gloves after touching the resident and should have placed the ice scoop in the holder, not in the ice chest, and the facility failed to ensure good infection control practices during dining,",2018-08-01
6333,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2015-08-05,464,D,0,1,4H7P11,"Based on observation and interview, the facility failed to provide sufficient space to accommodate all dining activities in 1 of 4 dining areas observed. Observation on 8/4/15 at 12:15 PM, at the 2nd East Nurses Station revealed 4 residents seated around a table that had been pushed up against the wall in the hallway (2 residents were being fed by staff, 2 had not been served). Continued observation revealed 3 residents were seated at the nurses station. 1 resident with a bedside table in front of him, feeding himself, 1 resident being fed by a staff member from the tray placed on the counter above the residents head, and 1 resident had not been served. 4 residents were in the day room, 4 residents were seated at a small table, 2 feeding themselves, and 2 residents had not been served. Further observation revealed additional food trays were brought to the residents at various times with the last resident being served at 12:55 PM. Interview with Certified Nursing Assistant #1 on 8/4/15 at 8:10 AM, in the 2nd East Nurses Station revealed .that table has always been there. We call it our mini dining room . Continued interview revealed .he eats where ever we have a spot . Interview with Assistant Director of Nursing #1 on 8/4/15, at 9:15 AM, confirmed the dining area had insufficient space for dining.",2018-08-01
8054,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2014-08-13,280,G,1,0,DZTF11,"**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 to include effective fall prevention measures for one resident (#2) of six sampled residents, resulting in a fall and fractured pelvis (Harm) for Resident #2. The findings included: Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of Resident #2's Interim Care Plan dated May 29, 2014, revealed, .at risk for falls d/t (due to) decreased mobility and [DIAGNOSES REDACTED].dementia .[MEDICAL CONDITION] .will be maintained in a safe environment .Remind to call for assistance as needed, Bed/chair sensor pad for 2 weeks, if no problems then may be d/c'd (discontinued) .Assist with all transfers and ambulation .Monitor for steadiness, balance, and coordination . Medical record review of a Physical Therapy (PT) Plan of Care dated May 30, 2014, revealed, .[MEDICAL CONDITION] residual L (left) sided weakness .alert and oriented to person and place .Safety Awareness: Fair (to) Poor . Medical record review of a nurse's note dated June 2, 2014, at 10:30 a.m., revealed, .up to therapy this (morning) .conf (confused) and tries to get out of bed. Total care by staff for ADLs (Activities of Daily Living), transfers . Medical record review of the Admission Minimum Data Set, dated dated dated [DATE], revealed the resident was severely impaired with decision-making skills, sometimes able to understand others, and sometimes able to express needs and wants. Continued review revealed the resident required extensive assistance of two persons for bed mobility, transfers and toileting; and extensive assistance of one person for ambulation in the resident's room. Continued review revealed the resident had impaired balance during transitions and walking and a history of falls. Medical record review of a nurse's note dated June 9, 2014, at 3:00 p.m., revealed, pt (patient) attempting transfers without assistance, unsteady .will monitor for safety. Medical record review of a nurse's note dated June 14, 2014, at 11:00 a.m., revealed, .O (oriented) to self .attempts to ambulate without assistance d/t dementia .confusion . Medical record review of the care plan dated June 18, 2014, revealed, .at risk for falls due to decreased mobility, unsteady gait, and weakness .at risk for injury if a fall does occur due to a [DIAGNOSES REDACTED].does occur .Remind to call for assistance as needed .Call light within reach .Assist with all transfers and ambulation as needed .Monitor for steadiness, balance, and coordination . Medical record review of a nurse's note dated June 19, 2014, at 11:00 a.m., revealed, .cont (continue) to monitor for safety d/t pt ambulating without assistance . Medical record review of a nurse's note dated June 22, 2014, at 4:50 a.m., revealed, .found in BR (bathroom) by CNA (Certified Nursing Assistant) pt up OOB (out of bed) without asst (assistance). Alarm sounding .Confused diff (difficult) to re-direct. c/o (complained of) pain with Lt. LE (Left Lower Extremity) and back .sent to (Hospital) per family request . Medical record review of a physician's orders [REDACTED].Send to (Hospital) .as per family's request. Medical record review of an emergency room record dated June 22, 2014, revealed, .fall, unknown etiology, occurred last night. C/O generalized pain, localized to right knee. Unable to provide further (history secondary to) dementia lower extremity exam (examination) .abnormal, ecchymosis (bruising) to R (right) knee .chronic bilateral foot contractures .L (left) sup/inf (superior/inferior) rami (pelvis) fx (fracture) .pt w (with) significant pain . Continued review of the emergency room record revealed, .[DIAGNOSES REDACTED].advanced dementia .Disposition Home (Facility) . Medical record review of a nurse's note dated June 22, 2014, at 11:30 a.m., revealed the resident returned to the facility. Interview with Registered Nurse (RN) #1 on July 21, 2014, at 11:45 a.m., in a conference room, revealed .judgment was impaired right from the start .moments of clarity . Interview with Physical Therapist Assistant (PTA) #1 on July 21, 2014, at 1:40 p.m., in a conference room, revealed PTA #1 treated the resident in therapy; the resident was unable to retain reminders and was impulsive. Continued interview revealed there was difficulty improving the resident's safety awareness; PTA #1 had observed the resident get out of the wheelchair numerous times in therapy and PTA #1 reported the unsafe behavior to nursing staff. Telephone interview with Certified Nursing Assistant (CNA) #1 on August 11, 2014, at 12:10 p.m., revealed the resident was confused and the resident quickly walked and/or ran after getting up unassisted. CNA #1 stated, .(resident) got so (resident would) try to get up on (resident's) own without using (a) call light. We'd try to catch (resident) to prevent (resident) falling .(Resident would) try to get out of bed and wheelchair .We constantly explained to (resident) to ask for assistance and to use the call light .had to be right on (resident) due to (resident's) quickness. We had to hurry .wouldn't always use the light and couldn't remember .accurate to say use of a call light was unreliable. Telephone interview with RN #1 on August 11, 2014, at 12:20 p.m., revealed the resident was increasingly confused following admission to the facility, and the resident would not use the call light for assistance. Continued interview revealed the resident ambulated and/or ran unassisted at times, the resident's gait was not always steady, and RN #1 stated, .We couldn't anticipate when/if (resident would) use call light .observed (resident) running we'd have to run right after (resident) . Telephone interview with Care Plan Coordinator #1 on August 11, 2014, at 2:10 p.m., revealed the care plan dated June 18, 2014, did not reflect the resident's inability to retain reminders for safety or inconsistent use of a call light. Continued interview revealed the use of reminders and a call light were ineffective interventions and confirmed the facility failed to revise the care plan to address the needs of Resident #2 prior to the fall on June 22, 2014. C/O: #",2017-08-01
8055,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2014-08-13,323,G,1,0,DZTF11,"**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 provide effective supervision of a resident with Dementia/fall risk for one resident (#2) of four residents reviewed, resulting in a fall and fractured pelvis with pain and functional decline (Harm) for Resident #2. The findings included: Resident (#2) was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #2 expired on [DATE]. Medical record review of the resident's fall risk assessment dated [DATE], revealed the resident was at risk for falls. Medical record review of a physician's orders [REDACTED].Therapy to Evaluate and Treat . Medical record review of an Interim Care Plan dated [DATE], revealed, .at risk for falls d/t (due to) decreased mobility and [DIAGNOSES REDACTED].dementia .vertigo .will be maintained in a safe environment .Remind to call for assistance as needed, Bed/chair sensor pad for 2 weeks, if no problems then may be d/c'd (discontinued) .Assist with all transfers and ambulation .Monitor for steadiness, balance, and coordination . Medical record review of a Physical Therapy (PT) Plan of Care dated [DATE], revealed, .Safety Awareness: Fair (to) Poor .Coordination: Impaired L (left) side worse than R (right) .Current Level of Function .demonstrates .total balance and gait score of ,[DATE], which relates to the high .fall risk category .demonstrates balance instabilities during gait, evidenced by intermittently veering off path .impaired bed mobility .functional deficit with rolling side to side, transferring .and ambulating . Medical record review of a nurse's note dated [DATE], at 10:30 a.m., revealed, .up to therapy this (morning) .conf (confused) and tries to get out of bed. Total care by staff for ADLs (Activities of Daily Living), transfers . Medical record review of an untimed nurse's note dated [DATE], revealed, PA (Physician's Assistant) in and reviewed pt (patient) meds (medications) d/t (due to) fall risk, impulsiveness in getting out of chair and decreased B/P (blood pressure) and pulse. Medical record review of the Admission Minimum Data Set, dated dated dated [DATE], revealed the resident was severely impaired with decision-making skills, sometimes able to understand others, and sometimes able to express needs and wants. Continued review revealed the resident required extensive assistance of two persons for bed mobility, transfers and toileting; and extensive assistance of one person for ambulation in the resident's room. Continued review revealed the resident had impaired balance during transitions and walking and had a history of [REDACTED]. Medical record review of a nurse's note dated [DATE], at 10:45 a.m., revealed, Pt .continuously trying to ambulate without assist. Extensive assist with ADLs (activities of daily living), transfers, and bed mobility . Medical record review of a nurse's note dated [DATE], at 3:00 p.m., revealed, pt attempting transfers without assistance, unsteady .will monitor for safety. Medical record review of a nurse's note dated [DATE], at 11:00 a.m., revealed, .O (oriented) to self .attempts to ambulate without assistance d/t dementia .confusion . Medical record review of a nurse's note dated [DATE], at 2:00 p.m., revealed, Pt continues to attempt ambulation without assistance .Pt placed at NS (nurse's station) in WC (wheelchair) when OOB (out of bed) for observation. This is to be done at all times that pt is OOB . Medical record review of resident #2's care plan dated [DATE], revealed, .at risk for falls due to decreased mobility, unsteady gait, and weakness .at risk for injury if a fall does occur due to a [DIAGNOSES REDACTED].does occur .Remind to call for assistance as needed .Call light within reach .Assist with all transfers and ambulation as needed .Monitor for steadiness, balance, and coordination .Two upper side rails raised for bed mobility .Document all behaviors . Medical record review of a nurse's note dated [DATE], at 11:00 a.m., revealed, .cont (continue) to monitor for safety d/t pt ambulating without assistance . Medical record review of a nurse's note dated [DATE], at 4:50 a.m., revealed, .found in BR (bathroom) by CNA (Certified Nursing Assistant) pt up OOB (out of bed) without asst (assistance). Alarm sounding .Confused diff (difficult) to re-direct. c/o (complained of) pain with Lt. LE (Left Lower Extremity) and back .sent to (Hospital) per family request . Medical record review of a Post Fall Nursing assessment dated [DATE], revealed, .time of incident .5:25 a.m .Describe the actual known facts .(Resident) got OOB to BR (bathroom) and locked BR door. Bed sensor pad in place and alarming. When CNA entered room, the BR door was locked and CNA had to go to other resident's room to enter BR .was found in the BR floor, crying .stated .left hip and back was hurting as (resident) is unable to clearly answer at times .placed on blanket .carried to bed .pain med was given per nurse .Call light in room was within reach .did not call for assist .Bathroom call light was within reach .did not call for assist .Describe task patient attempting at time of fall: Exiting commode while unattended .Safety devices in use: ALARM . Continued review revealed, What was patient's statement regarding the fall .is confused, but did state .left hip was hurting and back .(resident) was unable to tell me if (resident) hit (resident's) head . Medical record review of a physician's orders [REDACTED].Send to (Hospital) .as per family's request. Medical record review of an emergency room record dated [DATE], revealed, .fall, unknown etiology, occurred last night. C/O (complains of) generalized pain, localized to right knee. Unable to provide further (history secondary to) dementia .lower extremity exam (examination) .abnormal, ecchymosis (bruising) to R (right) knee .chronic bilateral foot contractures .L (left) sup/inf (superior/inferior) rami (pelvis) fx (fracture) .pt w (with) significant pain . Continued review of the emergency room record revealed, .[DIAGNOSES REDACTED].advanced dementia .Disposition Home (Facility) . Medical record review of a nurse's note dated [DATE], at 11:30 a.m., revealed the resident returned to the facility. Review of a facility investigation dated [DATE], (regarding the resident's fall on [DATE]) revealed, .experienced a fall while ambulating unattended in (resident's) room .Got OOB without assistance - Why? Got OOB without req (requesting) assistance and took .self to BR .unable to complete BIMS (Brief Interview for Mental Status) test for cognition d/t level of confusion .Should we try or add a different approach .NA (Not Applicable) .Staff were unable to redirect resident and (resident) fell off balance .was unavoidable because the patient was ambulating in the room and fell . Staff responded to .sounding alarm .did not request assistance, did not use call light .has osteoporosis . Medical record review of a Physical Therapy progress note dated [DATE], revealed, .The patient unable to ambulate following fall on [DATE] secondary to pelvic fracture . Interview with Registered Nurse (RN) #1 on [DATE], at 11:45 a.m., in a conference room, revealed the resident was oriented to self, ambulated with assistance, and RN #1 stated, .judgment was impaired right from the start .moments of clarity . Interview with Physical Therapist Assistant (PTA) #1 on [DATE], at 1:40 p.m., in a conference room, revealed PTA #1 treated the resident in therapy; the resident was unable to retain reminders and was impulsive. Continued interview revealed there had been difficulty improving the resident's safety awareness; PTA #1 had observed the resident get out of the wheelchair numerous times in therapy, and PTA #1 reported the unsafe behavior to nursing staff. Telephone interview with Certified Nursing Assistant (CNA) #1 on [DATE], at 12:10 p.m., revealed the resident was confused and the resident quickly walked and/or ran after getting up unassisted. CNA #1 stated, .(resident) got so (resident would) try to get up on (resident's) own without using (a) call light. We'd try to catch (resident) to prevent (resident) falling .(Resident would) try to get out of bed and wheelchair .We constantly explained to (resident) to ask for assistance and to use the call light .had to be right on (resident) due to (resident's) quickness. We had to hurry .wouldn't always use the light and couldn't remember .accurate to say use of a call light was unreliable. Telephone interview with RN #1 (Head Nurse) on [DATE], at 12:20 p.m., revealed the resident became increasingly confused following admission to the facility, and as confusion increased, the resident less frequently used the call light for assistance. Continued interview revealed the resident ambulated and/or ran unassisted at times, the resident's gait was not always steady, and RN #1 stated, .We couldn't anticipate when/if (resident would) use call light .observed (resident) running we'd have to run right after (resident) . Telephone interview with Physician Assistant (PA) #1 on [DATE], at 12:37 p.m., revealed the resident required subcutaneous administration of pain medication for pain management following the fall and pelvic fracture on [DATE]. Continued interview confirmed it was reasonable to conclude the resident's increased pain resulted from the pelvis fracture on [DATE]. Telephone interview with the Assistant Director of Nursing (ADON) on [DATE], at 2:30 p.m., revealed the fall prevention measures implemented by the facility were ineffective interventions for Resident #2. Continued interview revealed the facility had not increased the frequency of rounds for the resident with recurrent unsafe behaviors and confirmed the facility failed to provide adequate supervision to prevent a fall with pelvic fracture for Resident #2. The ADON stated, .with (resident's) physical capabilities we did the best we could. With this particular patient .was extra challenging with (resident's) dementia .no way to prevent (resident) from falling . Telephone interview with the Director of Nursing on [DATE], at 2:32 p.m., revealed the facility utilized alarms as a constant monitor to prevent the resident from falling, and stated, There is nothing I would have done differently for (resident). In summary, the facility failed to identify an intervention of a call light with reminders to call for assistance before transferring or ambulating was inappropriate for the cognitively impaired resident. Additionally, the facility failed to increase supervision for a resident who was known to be impulsive, relying on alarms instead of increased supervision, resulting in a fractured pelvis (Harm) for resident #6. C/O: #",2017-08-01
8214,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2014-04-30,156,E,0,1,CRSS11,"Based on review of facility termination of services notifications and interview, the facility failed to provide timely notification to beneficiaries of the decision to terminate covered services no later than two days before the proposed end of services for one resident (#105) and failed to notify of change in services for one resident (#169) of three residents reviewed for notification of services. The findings included: Review of the facility termination of services notification for resident #105 dated March 3, 2014, revealed, .On 3/3/14, our Utilization Review Committee reviewed (resident #105's) medical information and found the services furnished to (resident #105) no longer qualified for payment by Medicare beginning on 3/4/14 . Review of the facility termination of services notification for resident #169 dated February 1, 2014, revealed, .This letter is to notify you that on 01/31/14 (resident #169) exhausted all 100 days of (the resident's) Medicare coverage. As a result, Medicare will no longer pay for (resident #169) continued stay after this date . Interview with the Administrator of Daily Operations on April 30, 2014, at 3:45 p.m., in the conference room, confirmed the facility failed to provide notification of the decision to terminate services under Medicare prior to termination of services for resident #105 and resident #169.",2017-07-01
8215,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2014-04-30,160,D,0,1,CRSS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of Expired Patient Report, review of Patient Trust Fund Statements, and interview, the facility failed to return deceased residents' personal funds to their families and provide final accounting of deceased residents' personal funds from their Resident Trust Fund Accounts for seven residents (#190, #67, #182, #267, and #18) of thirty-five deceased residents reviewed. The findings included: Review of the Patient Trust Fund Statement, showing balances as of [DATE], and the facility Expired Patient Report dated [DATE], revealed residents #190, #67, #182, #267, and #18 had expired and the facility was carrying resident fund balances for these residents in the Resident Trust Fund account as follows: 1. Resident #190 expired [DATE], and had a balance of $262.49. 2. Resident #67 expired [DATE], and had a balance of $759.65. 3. Resident #182 expired [DATE], and had a balance of $247.68. 4. Resident #267 expired [DATE], and had a balance of $38.74. 5. Resident #18 expired [DATE], and had a balance of $1239.39. Interview with the Business Office Manager and review of the current balances in the Trust Fund Accounts on [DATE], at 2:30 p.m., in the business office, confimed the balances in the accounts of residents #190, #67, #182, #267, and #18 had not changed from the [DATE], statement and all 5 residents still had monies in the account. Continued interview confirmed the proceeds of the deceased residents' Trust Fund accounts, managed by the facility, had not been returned to the residents' families or to the probate officers for their estates, within the thirty day time requirement.",2017-07-01
8216,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2014-04-30,372,D,0,1,CRSS11,"Based on observation and interview, the facility failed to maintain the Dalton Towers garbage storage area in a clean manner, free of debris, for one of two kitchen dumpster areas reviewed. The findings included: Observation with the Certified Dietary Manager (CDM) #1, on April 28, 2014, at 10:50 a.m., at the Dalton Towers dumpster site, revealed multiple used vinyl gloves and other refuse strewn on the ground from the building exit to the dumpster area. Interview with CDM #1, on April 28, 2014, at 10:52 a.m., confirmed the dumpster area was not clean.",2017-07-01
8920,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2014-03-10,225,D,1,0,H24U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, review of facility investigation, review of employee files, review of facility policy and procedures, and interview, the facility failed to report an allegation of abuse to local law enforcement for one resident (#9) of sixteen residents reviewed. The findings included: Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's cognition was moderately impaired and was totally dependent for all Activities of Daily Living (ADL's). Observation of the resident on February 18, 2014, at approximately 5:10 p.m., in the resident's room, revealed the resident was lying quietly on the bed, with eyes closed. Review of a facility investigation revealed on August 22, 2013, at approximately 11:00 a.m., three (3) Certified Nursing Assistants (CNA's) were assisting the resident with bathing. The resident was lying on the bed and raised both arms upward, then back down toward (resident's) abdomen. Continued review revealed as the resident lowered (resident's) arms, CNA #1 slapped the resident's left side of (resident's) face with (CNA #1's) opened right hand. CNA #2 instructed CNA #1 to stop and remained with CNA #1 while CNA #3 immediately reported the alleged abuse to the Nursing Supervisor. The Nursing Supervisor responded immediately and removed CNA #1. Continued review revealed the Nursing Supervisor assessed the resident and was without injury. Continued review revealed CNA #1 was immediately suspended pending investigation; the investigation was concluded and CNA #1 was terminated on August 26, 2013. Further review of the investigation revealed no documentation of local law enforcement (Police) being notified of the alleged abuse. Review of CNA #1's Separation Notice dated August 26, 2013, in CNA #1's employee file, revealed, .If other than lack of work, explain the circumstances of this separation: Patient Abuse . Review of facility policy, Reporting Reasonable Suspicion of a Crime, (no date) revealed, .If you have reasonable suspicion that a crime has occurred against a resident .at this facility, Federal law requires that you report your suspicion directly to .law enforcement .How do I report .Contact the following .regarding a suspicion of crime .(local) Police Department: 911 . Interview with CNA #1 on February 18, 2014, in the Conference Room, confirmed CNA #1 witnessed CNA #3 open-handedly slap the resident on the left side of the resident's face. Continued interview confirmed the resident did not provoke CNA #3 and the alleged abuse was not out of reflex. CNA #1 stated, I was standing beside of (CNA #3) .(resident), without intentional movement, raised both of (resident's) arms, then began to lower them. As (resident) was lowering them (arms), CNA #3 took (CNA #3's) right open hand and slapped (resident) on the left side of (resident's) face. (Resident) began cursing loudly. (Resident) had not touched or hit (CNA #3) in any manner .nothing happened .(Resident) did nothing to cause (CNA #3) to respond in a reactionary manner .(CNA #3) just slapped (resident) and slapped (resident) hard . Continued interview confirmed when CNA #3 slapped the resident, CNA #1 and CNA #3 were standing and facing the resident's right side of the bed, with CNA #3 positioned near the resident's head and CNA #1 near the resident's abdomen. Further interview confirmed CNA #2 was standing on the resident's left side of the bed, straight across from and facing CNA #1 and CNA #3. Telephone interview with CNA #2 on February 26, 2014, at approximately 1:43 p.m., confirmed CNA #2 witnessed CNA #3 open-handedly slap the resident on the left side of the resident's face. Continued interview confirmed the resident did not provoke CNA #3 and the alleged abuse was not out of reflex. CNA #2 stated, It was completely unprovoked .once (CNA #3) hit (resident) (CNA #3) acted like (CNA #3) didn't even care. I was extremely upset. I didn't deal well with that. When (CNA #3) hit (resident), (resident) wasn't doing anything to (CNA #3). (Resident) had raised (resident's) arms ups and was lowering them down .(resident) wasn't being aggressive at all. I have no idea why (CNA #3) hit (resident) .there's no excuse for it .(CNA #3) slapped (resident) hard. As hard as (CNA #3) slapped (resident), I'm surprised (CNA #3's) whole hand print wasn't on (resident's) face. (Resident) was not in (resident's) right mind and was unable to defend (resident's) self. (CNA #3) abused (resident) and (CNA #3) needs to be stopped from ever working with these old frail people ever again. Continued interview confirmed when CNA #3 slapped the resident, CNA #2 was standing and facing the resident's left side of the bed, straight across from CNA #1 and CNA #3, who were standing on the resident's right side of the bed, with CNA #3 near the resident's head and CNA #1 near the resident's abdomen. Telephone interview with CNA #3 on February 26, 2014, at approximately 2:23 p.m., confirmed CNA #3 stated, I grabbed (resident's hands .(resident) hit me across the ribs .I said, 'Stop, (resident), stop.' I held (resident's hands, but (resident) was too strong. I've never had a problem with (resident) before. I really don't know what happened. I was (resident's) usual aide (CNA). I've been doing this a long time .I know what abuse is .I know even if the resident hits me, I can't hit them back. I did not hit (resident). Interview with the Administrator of Daily Operations (ADO) on February 19, 2014, at approximately 4:50 p.m., in the Conference Room, confirmed the ADO was aware of the reporting requirements of reporting a reasonable suspicion of a crime to local law enforcement. Continued interview confirmed CNA #3 was terminated for abusing the resident. Continued interview confirmed the facility had failed to ensure local law enforcement were notified of CNA #3 allegedly abusing the resident. C/O #",2017-03-01
10133,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2013-04-03,272,D,0,1,W34Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to accurately assess the dental status for one (#8) of forty-one residents sampled. The findings included: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation and interview with resident #8 confirmed, on April 1, 2013, at 3:57 p.m., in the resident's room, revealed the resident had missing and broken teeth. Further interview confirmed the resident had no difficulty with chewing or eating and had no complaints of mouth pain. Observation on April 3, 2013, from 8:45 - 9:15 a.m., in the resident's room, revealed the resident self feeding a biscuit, bacon, potato wedges, and beverages. Further observations revealed the intake was greater than 25% (percent) during that time frame. Medical record review of the Nutritional Assessment Report signed by the Registered Dietitian, on August 9, 2012, revealed the resident had chewing problems and broken, loose, carious teeth. Review of the Annual Minimum Data Set (MDS) dated [DATE], revealed the resident had no dental issues. Interview with Certified Nurse Aide #1 on April 3, 2013, at 9:05 a.m., at the East 2 nursing station, confirmed the resident had missing and broken teeth. Further interview revealed the resident had no problems eating or chewing and had not complained of mouth pain. Further interview revealed the resident usually ate 25-50% of meals and got a supplement if ate less than 50% of the meal. Interview with Licensed Practical Nurse #3, a MDS Coordinator, on April 3, 2013, at 9:21 a.m., at the East 2 nursing station, revealed the resident had refused to allow an oral inspection at the time of the Annual MDS dated [DATE]. Further interview confirmed the oral status section of the MDS included the option of .G. Unable to examine . Further interview confirmed the MDS failed to accurately assess the dental status of the resident.",2016-07-01
10134,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2013-04-03,279,D,0,1,W34Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide an accurate care plan for one resident, (#455), of forty-one residents reviewed. The findings included: Resident #455 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the nurses notes dated January 12, 2013, at Midnight revealed .refused BP (blood pressure), hitting at nurse, physically aggressive .; at 11:05 a.m., on January 12, 2013, .very combative /c (with) care, also striking out at nurse trying to ck (check) O2 (oxygen) sat (saturation level) and giving txs (treatments) .; at 1:35 p.m., on January 12, 2013, .jerked it out and threw it at writer .; at 10:15 a.m., January 13, 2013, .combative when writer tried to ck (check) .O2 sat (oxygen saturation level) .taking off finger and throwing it . Medical record review of the care plan dated March 7, 2013, revealed no care planning for behaviors. The care plan dated March 7, 2013, revealed a care plan for .risk for adverse effects and drug interactions d/t (due to) use of multiple medication and/or [MEDICAL CONDITION] medications d/t dementia and depression .patient wanders at night, staff has to redirect patient back to bed .nursing to administer medications as ordered .[MEDICATION NAME] 0.5mg po (by mouth) q8h (every 8 hours) prn (as needed) agitation/anxiety . Interview with Nurse Manager (NM) #2, on April 3, 2013, at 10:00 a.m., in the NM office, revealed the care plan for .risk for adverse effects and drug interactions . was the care plan for the behaviors. Further interview confirmed the combative behaviors were not specifically addressed on the care plan.",2016-07-01
10135,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2013-04-03,281,D,0,1,W34Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility policy, and interview, the facility failed to follow professional standards of practice and facility policy for labeling and dating Intravenous (IV) fluid bag and administration set tubing for one resident. The findings included: Observation during initial tour on April 1, 2013, at 11:00 a.m., in resident room [ROOM NUMBER], revealed an Intravenous bag of Sodium Chloride 0.9 percent hanging on an Intravenous (IV) pole with administration set tubing attached to the bag, but not the resident. Continued observation, at that time, revealed the IV bag of fluid and the IV administration set tubing were not labeled or dated. Review of facility policy titled Intravenous Therapy revealed .Administration sets will be labeled with initials, date, and time initiated . Further review of facility policy revealed .IV fluid bags are changed at least every 24 hours or as indicated . Interview with Registered Nurse (RN #1) on April 1, 2013, at 11:05 a.m., in the resident's room, confirmed the IV fluid bag and the IV administration set tubing were not labeled or dated. Continued interview with RN #1, at that time, confirmed the RN had not followed facility policy regarding the labeling and dating of IV fluids and administration set tubing.",2016-07-01
10136,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2013-04-03,323,D,0,1,W34Z11,"Based on observation and interview the facility failed to maintain a safe environment on two halls of seven halls in the Hamilton building. The findings included: Observation of the facility on the initial tour April 1, 2013, at 10:50 a.m., revealed on the 900 hall an entrance to the staff lounge and through the staff lounge an entrance to the clean linen closet with the door standing wide open. The clean linen closet door inside the room was unlocked and shut. Observation revealed several personal items of employees, including purses and backpacks, in the staff lounge that were unsecured and accessible to wandering residents. Continued observation revealed one resident sitting in a wheelchair, in the hallway outside the open door. Licensed Practical Nurse (LPN) #2, confirmed the staff lounge door is to be shut and locked because do have wanderers on the hall. Repeat observation of 900 hall staff lounge/clean linen closet on April 2, 2013, at 11:00 a.m., revealed the door was shut and locked. Observation of the facility on the initial tour April 1, 2013, at 11:15 a.m., revealed the door to the Treatment Room in the 800 hall was unlocked and the door pushed open very easily. Observation inside the room revealed nineteen 4.5 ounce bottles of Lantiseptic skin protector, seven 8 ounce bottles of aloe vista skin protector, thirty-five bottles of Get Fresh liquid, eight packages of ten-pack single blade razors. Interview with Nurse Manager (NM) # 1, April 1, 2013, at 11:34 a.m., in the hallway outside the treatment room, confirmed the door was unlocked and items labeled Keep out of reach of children were present and accessible in the room. Continued interview with NM #1 confirmed the door was to be locked. Repeat observation on April 3, 2013, at 12:15 p.m., revealed the door to the Treatment Room on the 800 hall had a hand written sign make sure door latches. Observation revealed the door was unlocked, and easily opened. Interview with Licensed Practical Nurse (LPN) #1, on April 3, 2013, at 12:18 p.m., in the 800 hall outside the treatment room confirmed the treatment room was unlocked and accessible. Continued interview with LPN #1 confirmed the door was to be locked.",2016-07-01
11914,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2012-10-16,201,D,1,0,BOYV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide a discharge necessary for the resident's welfare and/or for which the facility could not meet needs for one resident (#12) of three residents reviewed. The findings included: Resident #12 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Minimum Data Set, dated dated dated [DATE], revealed the resident was severely impaired with decision-making skills, free of behavior problems, and totally dependent on staff for activities of daily living. Medical record review of a nurse's note dated September 21, 2012, at 8:15 p.m., revealed, made allegation of inappropriate sexual conduct by employee. Medical record review of a nurse's note dated September 22, 2012, revealed the resident was transported to a hospital for evaluation. Medical record review of social service note dated September 22, 2012, at 12:10 p.m., revealed, .admitted to (hospital).Writer informed (hospice social worker) (facility) would not be able to receive (resident) back and alternate placement should be found per adm (administrator's) request. Medical record review of a Discharge Summary dated September 28, 2012, revealed, .rec (received) hospice care. On 9-22-12 patient stated (resident) had been assaulted.transported to local ER (emergency room ) for further eval (evaluation).no plans for patient to return. Medical record review revealed no documentation regarding risks to the resident's welfare due to residing in the facility or how the facility was unable to meet the resident's needs. Medical record review revealed the resident did not return to the facility. Interview with the Administrator of Daily Operations on October 15, 2012, at 12:21 p.m., in a conference room and the presence of the Administrator, revealed the resident's spouse expressed the desire to return the resident to the facility. He stated, .I felt it was not (in resident's) best interest for (resident) to return with help (employee) here (resident) alleged had raped (resident). Interview with the Administrator on October 15, 2012, at 12:25 p.m., in a conference room and the presence of the Administrator of Daily Operations, confirmed the facility involuntarily discharged Resident #12.",2015-10-01
11915,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2012-10-16,203,D,1,0,BOYV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide a thirty day notice prior to discharge for one resident (#12) of three residents reviewed. The findings included: Resident #12 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Minimum Data Set, dated dated dated [DATE], revealed the resident was severely impaired with decision-making skills, free of behavior problems, and totally dependent on staff for activities of daily living. Medical record review of a nurse's note dated September 21, 2012, at 8:15 p.m., revealed, made allegation of inappropriate sexual conduct by employee. Medical record review of a nurse's note dated September 22, 2012, revealed the resident was transported to a hospital for evaluation. Medical record review of social service note dated September 22, 2012, at 12:10 p.m., revealed, .admitted to (hospital).Writer informed (hospice social worker) (facility) would not be able to receive (resident) back and alternate placement should be found per adm (administrator's) request. Medical record review of a Discharge Summary dated September 28, 2012, revealed, .rec (received) hospice care. On 9-22-12 patient stated (resident) had been assaulted.transported to local ER (emergency room ) for further eval (evaluation).no plans for patient to return. Medical record review revealed the resident did not return to the facility. Medical record review revealed no documentation regarding the reasons for the resident's discharge. Interview with the Administrator on October 15, 2012, at 12:25 p.m., in a conference room and the presence of the Administrator of Daily Operations, confirmed the facility failed to provide a thirty day notice prior to discharge for Resident #12.",2015-10-01
12378,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2011-07-13,322,D,0,1,60TM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure a tube feeding was administered as ordered for one (#3) of thirty-four residents reviewed. The findings included: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Observation on July 11, 2011, at 10:30 a.m. with RN (Registered Nurse) #1, and LPN (Licensed Practical Nurse) #4 revealed the resident seated in a reclined wheelchair, in the resident's room, with the tube feeding connected to the resident and the tube feeding not infusing. Continued observation revealed the tube feeding bottle was dated July 11, 2011, 12:30 a.m., with 1500 milliters of [MEDICATION NAME] 1.2 in the bottle. Continued observation revealed the tube feeding pump displayed a feed error. Interview on July 11, 2011, at 10:30 a.m., with RN #1 and LPN #4, in the resident's room, confirmed the resident had not received the tube feeding as ordered.",2015-08-01
12379,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2011-07-13,160,D,0,1,60TM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of resident trust accounts, facility policy review, and interview, the facility failed to refund the balance of the resident trust accounts,within 30 days, after the discharge or death for two (#32, #33) of five closed records reviewed. The findings included: Medical record review of the nursing notes revealed resident #32 was discharged to the hospital on [DATE]. Review of resident #32's trust account revealed a balance of $1,860.11 on [DATE]. Medical record review of the nursing notes revealed resident #33 expired on [DATE]. Review of resident #33's trust account revealed a balance of $1,876.72 on [DATE]. Review of the facility's policy Patient Trust revealed ""The balance remaining for a patient's trust fund account should be refunded as soon as all transactions are fully accounted for after a patient is discharged or deceased ...The funds should be refunded within 30 days of death or discharge..."" Interview on [DATE], at 8:35 a.m., with the bookkeeper, in the bookkeeper's office, confirmed the balance of resident #32 and #33's trust accounts had not been refunded to the residents' estate.",2015-08-01
12380,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2011-07-13,167,C,0,1,60TM11,"Based on observation, and interview, the facility failed to make available the survey results in one of the two facility buildings. The findings included: Observation on July 13, 2011, at 10:50 a.m., with a Registered Nurse (RN #3) for the East 200 hall, revealed a sign posted in the main lobby of the Dalton Building which stated the latest survey results could be located in the main lobby of the Hamilton building and the main lobby of the Dalton building. Continued observation revealed the survey results were not located in the main lobby of the Dalton building. Interview with the Registered Nurse (RN #3) on July 13, 2011, at 10:50 a.m., in the main lobby of the Dalton building, confirmed the survey results were not available in the main lobby the Dalton building as directed by the sign.",2015-08-01
12381,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2011-07-13,513,D,0,1,60TM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to insure the results of a Doppler Study was included in the medical record for one (#11) of thirty-four residents reviewed. The findings included: Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed an order dated March 7, 2011, ""...Doppler Study (L) (left) leg/ (L) foot - Dx. (diagnoses) of /DM (Diabetes Mellitus) Type II and [MEDICAL CONDITION]"" Medical record review revealed no documentation of the results for the Doppler Study. Interview with Registered Nurse (RN # 3) on July 13, 2011, at 10:30 a.m., in the Dalton building conference room, confirmed the results of the Doppler Study were not made available in the resident's medical record.",2015-08-01
12382,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2011-07-13,226,D,0,1,60TM11,"Based on facility policy review, and interview, the facility failed to ensure the Abuse policy revealed all allegations of abuse, substainated or not, were to be reported to the state agency. The findings included: Review of the facility Abuse policy revealed, ""...Any investigation that substantiates abuse or neglect will be reported immediately to the administrator or his designated representative and to other officials in accordance with State Law within 5 working days of the event. A report is filed with the state survey and certification agency, and any other required agencies..."" Interview on July 13, 2011, at 8:30 a.m., with the Assistant Director of Nursing, in the Social Worker's office, confirmed the abuse policy did not reveal all allegations of abuse, substainated or not, were to be reported to the state agency, and confirmed the abuse policy did not correspond with the federal regulations.",2015-08-01
12383,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2011-07-13,514,D,0,1,60TM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview and policy review, the facility failed to have documentation of the ordered blood pressure for one resident (#9); and failed to have documentation of interventions for asymptomatic episodes of blood sugars below 70 for one resident (#14) of thirty-four residents reviewed. The findings included: Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the June 2011, Current Physician order [REDACTED]. (systolic) outside 80 to 200 dias.(diastolic) outside 50 to 100 Start date 5/26/10...."" Medical record review of the 2011, April, May, June, and July Medication Administration Records, the vital sign record, and the nursing notes revealed no documentation for eleven of fourteen opportunities to document the blood pressure on Sundays. Interview with Licensed Practical Nurse #2, on July 13, 2011, at 7:30 a.m., at the 800 hall nursing station, confirmed the 2011, April, May, June and July Medication Administration Records, nursing notes and the vital sign record did not contain documentation of the blood pressures. Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician orders [REDACTED].< (less than) 70 AND SYMPTOMATIC - GIVE [MEDICATION NAME], 1 MG (MILLIGRAM) SUBQ (subcutaneously); IF ASYMPTOMATIC - MAY GIVE JUICE...Start Date: 10/25/2010..."" Medical record review of the 2011 April Medication Administration Record [REDACTED]. Medical record review of the 2011 May MAR indicated [REDACTED]. Medical record review of the nursing notes revealed no documentation of any interventions addressing the low blood glucose. Review of the facility document ""MD Standing Order"" revealed ""...[DIAGNOSES REDACTED]...If BG <70, may give juice or sugar equivalent if patient able to swallow or if feeding tube in place...Document all treatments and results in Nurse's notes..."" Interview with the Director of Nursing on July 12, 2011, at 10:35 a.m., by the 900 nursing station, confirmed on April 4, and 13, 2011; and May 1 and 5, 2011, the nursing notes did not contain documentation of intervention administered for BG less than 70 as ordered.",2015-08-01
12384,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2011-07-13,159,F,0,1,60TM11,"Based on review of resident trust accounts and interview, the facility failed to notify the responsible party of three residents who received Medicaid benefits when the amount in the resident accounts was within $200.00 of the SSI resource limit ($2,000.00), and failed to credit interest to 303 of 303 resident accounts reviewed. The findings included: Review of three resident trust accounts revealed the following balances: account #1 on June 3, 2011=$1,935.77, July 1, 2011=$2,825.77, and July 13, 2011=$1,925.77; account #2 on May 6, 2011=$1,844.99, June 6, 2011=$1,894.99, and July 13, 2011=$1,944.99; account #3 on May 6, 2011=$1,809.79, June 6, 2011=$1,860.19, and on July 3, 2011=$1,910.59. Review of 303 resident trust accounts revealed a balance of $154,375.01 on July 13, 2011. Continued review of the 303 resident trust accounts revealed no interest was applied to the accounts from January 1, 2011, through June 30, 2011. Interview on July 13, 2011, at 8:35 a.m., with the bookkeeper, in the bookkeeper's office, revealed the social worker was to be notified when resident's receiving Medicaid benefits trust accounts approached $2,000.00, to notify the resident or the responsible party. Continued interview with the bookkeeper confirmed there was no interest applied to the resident trust accounts from January 1, 2011, through June 30, 2011. Interview on July 13, 2011, at 9:50 a.m., with social workers #1 and #2, in the conference room, confirmed the resident or responsible party of the three Medicaid residents with account balances within $200.00 of the SSI resource limits had not been notified.",2015-08-01
12385,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2011-07-13,431,F,0,1,60TM11,"Based on facility record review, facility policy review, and interview, the facility failed to ensure a system of reconciliation of narcotic medication patches in place on residents for a continual seventy-two hour period for 15 of 18 residents who used narcotic patches. The findings included: Medical record review with the Director of Nursing (DON) in the lobby area on July 12, 2011, at 9:30 a.m., of the facility's Medication Administration Records (MAR), for 15 of the 18 residents who require the use of narcotic patches for a continual seventy-two hour period, revealed there was no documentation to ensure continued presence and integrity of the narcotic patches during the continual seventy-two hour period the narcotic patch was on any the 15 residents. Interview with the Director of Nursing (DON) in the lobby area on July 12, 2011, at 9:30 a.m., confirmed there was no documentation of reconciliation of the narcotic patches during the continual seventy-two hour period the narcotic patchs were utilized by the 15 residents. Review of the facility policy Controlled Medication Storage, undated and unnumbered, revealed ""...at each shift change, a physical inventory of all controlled medications is conducted by two licensed nurses and the controlled substance accountability record...controlled medication storage, records and expiration dates are routinely monitor by (the consultant pharmacist during medication storage inspection)..."" Interview with the facility's pharmacy consultant by phone on July 12, 2011, at 4:20 p.m., revealed the facility had ""...not experienced any issues loss or discrepancies on seventy-two hour narcotic patches...pain control pumps containing narcotics are in use on residents within the facility...are maintained in resident room...are reconciled each shift..."" Interview with the DON in the conference room on July 13, 2011, at 10:15 a.m., confirmed narcotic patches in use on a resident for a continual seventy-two hour period need to be reconciled as a seventy-two hour period is too long to wait to ensure the accountability and integrity of the narcotic patch. Continued interview confirmed 15 of the facility's 18 residents who were on continual seventy-two hour narcotic patches had not been monitored to ensure continued presence and integrity of the narcotic patches during the continual seventy-two hour period the patches were on the residents.",2015-08-01
12386,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2011-07-13,441,D,0,1,60TM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, facility policy review, and interview, the facility failed to ensure infection control practices were maintained to prevent contamination of resident supplies for one resident (#31) of thirty-four residents reviewed. The findings included: Medical record review revealed resident #31 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated [DATE], revealed the resident was alert but in a persistent vegetative state; was totally dependent on staff for all activities of daily living, had all nutrition needs met by a feeding tube; and required the use of tracheostomy for breathing. Observation in the resident's room with the Respiratory Unit Manager and the Assistant Director of Nursing on July 11, 2011, at 10:30 a.m., revealed a note taped to the resident's feeding tube pump. Continued observation revealed the tape on the note discolored around the edges. Continued observation revealed ""Use bottled water for tube feeding...family request..."" Continued observation revealed five 1 gallon bottles of commercially packaged water stored on the floor in front of the sink. Continued observation revealed four of the bottles of water were unopened and one was ? empty. Review of the Physician's order, dated May 31, 2011, no time noted, revealed ""...flush (feeding tube) with 60 ml (milliliters) of water Q (every) hour..."" Review of the facility policy Infection Control (number X-11, dated December, 1998) revealed ""...Respiratory...Bedside Equipment...Items are used for an individual patient as long as the product remains intact and sanitary..."" Interview on July 11, 2011, at 10:30 a.m., in the resident's room with the Respiratory Unit Manager and the Assistant Director of Nursing confirmed the bottled water stored on the floor in front of the sink was intended for patient use. Continued interview confirmed in order to prevent contamination and the spread of infection, patient supplies are not to be stored on the floor. Continued interview confirmed the bottled water stored on the floor was not in accordance with infection control practices.",2015-08-01
12387,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2011-07-13,278,D,0,1,60TM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure accuracy of the Minimum Data Set (MDS) for two residents (#34 and #14) of thirty-four residents reviewed. The findings included: Medical record review of a nursing note dated March 25, 2011, revealed resident #34 experienced a fall without injury on March 24, 2011. Medical record review of the MDS dated [DATE] did not indicate resident #34 had experienced a fall without injury. Interview with the MDS Coordinator, LPN #6, on July 13, 2011 at 11:05 a.m., in the Hamilton building conference room, confirmed resident #34's Minimum Data Set was inaccurate regarding the number of falls since admission or since the prior MDS assessment. Medical record review of resident #14 of the nursing note dated April 13, 2011, 4:50 p.m. revealed ""...Resident was being assisted to bed. PT (patient) sat on side of bed before CNA (Certified Nurse Aide) could reposition backwards PT shifted and slid to floor...No injury noted..."" Review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had not sustained a fall since the prior assessment dated [DATE]. Interview with the Minimum Data Set Coordinator (LPN #6) on July 13, 2011, at 10:40 a.m., in the lobby, confirmed the May 2011 MDS failed to address the fall sustained on April 13, 2011.",2015-08-01
12388,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2011-07-13,246,D,0,1,60TM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to place the call light within reach for one (#10) of thirty-four residents reviewed. The findings included: Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident was able to make self understood and did not walk. Observation on July 11, 2011, at 9:58 a.m., revealed resident #10 sitting in the wheelchair, beside the resident's bed. Continued observation revealed the resident stated ""I'm about to faint,"" wanted to be assisted to bed, and was unable to locate the call light. Continued observation revealed the call light cord extended under a blanket to a side rail behind the resident's wheelchair. Observation and interview on July 11, 2011, at 10:01 a.m., with Licensed Practical Nurse (LPN) #3, in the resident's room, confirmed the call light was not within the resident's reach.",2015-08-01
12389,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2011-07-13,371,F,0,1,60TM11,"Based on observation and interview, the facility dietary department failed to maintain sanitary dietary equipment; and failed to maintain an ice machine lid in good repair. The findings included: Observation of the Hamilton dietary department on July 11, 2011, beginning at 10:00 a.m., with the Director of Operations present, revealed the following: 1.) Eight stacks of crates containing individual milk cartons, gallons of milk and five pound containers of yogurt were directly stored on the walk-in refrigerator #2 floor. 2.) A plastic covered large floor mixer. After removal of the plastic cover, the underside of the beater arm, base and bowl arm had multi-colored dried splattered debris present. 3.) A plastic covered mid-size floor mixer. After removal of the plastic cover, white dried debris splatters were present on the underside of the beater arm. 4.) A wall mounted fan by the trayline blowing directly onto a staff member rolling clean silverware in napkins and another staff member placing food into the steam table. Observation of the trayline fan grate and blades revealed an accumulation of blackened debris present. 5.) A wall mounted fan was blowing from the soiled side of the three compartment sink toward the clean side of the compartment sink and toward the clean side of the dish machine. Observation revealed soiled pots and utensils were stacked to be cleaned; clean dishes were coming out of the dish machine and clean utensils and pans were drying on the drying board of the three compartment sink. Observation of the dish room fan grate and blades revealed an accumulation of blackened debris present. Interview in the Hamilton dietary department on July 11, 2011, beginning at 10:00 a.m., with the Director of Operations, present during the observations, confirmed the crates containing individual milk, gallons of milk and yogurt were stored directly onto the floor of the walk-in refrigerator. Further interview confirmed the plastic covered large and small mixers had dried splattered debris present. Further interview revealed the plastic cover meant the equipment was clean and ready for use. Further interview confirmed the wall mounted fans were blowing into clean areas and the fan grate and blades were not clean. Observation on July 12, 2011, at 8:15 a.m. of the Dalton dietary department, with the Director of Operations present, revealed an ice machine in the entry area of the department. Further observation revealed the ice machine lid was broken exposing the insulation. Interview with the Director of Operations on July 12, 2011, at 8:15 a.m., revealed the entry area of the dietary department contained an ice machine used by nursing. Further interview confirmed the ice machine lid was broken exposing the insulation.",2015-08-01
12390,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2011-07-13,253,D,0,1,60TM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure resident care equipment was in good repair for one (#16) of thirty-four residents reviewed. The findings included: Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Safety/Positioning/Protective Equipment Documentation dated June 1, 2011, revealed, ""...Side rails with pads... pads which protect skin integrity for residents with movement disorders or neurological diseases...pt (patient) moves in bed (and) hits extremities on rails..."" Observation on July 12, 2011, at 7:50 a.m., with Registered Nurse #2, revealed the resident lying on the bed with rail pads in place. Continued observation revealed the rail pad on the resident's left side torn at the top with the pressed board exposed. Interview on July 12, 2011, at 7:50 a.m., with Registered Nurse #2, in the resident's room, confirmed the rail pad was in need of repair.",2015-08-01
13857,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2011-04-15,172,D,1,0,LH9911,"Based on observation and interview, the facility failed to ensure residents' visitation rights were protected for one hall (700 hall which is a respiratory unit) of eleven halls. The findings included: Observation on April 5, 2011 at 8:30 a.m., with the Assistant Director of Nursing (ADON) outside the entrance door to the 700 hall revealed a sign stating ""Visiting Hours: Monday - Friday 10:00 a.m. to 2:00 p.m. and 5:00 p.m. to 8:00 p.m.; Saturday and Sunday 10:00 a.m. to 8:00 p.m."" Interview on April 5, 2011 at 8:30 a.m., with the ADON outside the entrance door to the 700 hall confirmed the sign indicated restricted visiting hours "" ...but family are only encouraged to not visit during those hours so respiratory and nursing staff can provide care ...some family have access cards ...some families visit during those times ..."" Interview on April 5, 2011 at 8:35 a.m., with a resident's family member on the 700 hall confirmed the staff had provided an access card to the unit and the family member enters the unit without problems. Interview on April 5, 2011 at 8:35 a.m., with a Respiratory Therapist on the 700 hall confirmed some family member are present on the unit outside the time the sign indicates for visiting and the staff and family members ""work together"". Interview on April 5, 2011 at 10:30 a.m., with the Administrator of Daily Operations in the conference room confirmed the sign will need to be changed as it restricts visiting hours for the residents. C/O #",2014-08-01
14078,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2010-06-15,323,D,,,4BZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure a safety device was in place for one (#20) resident of thirty-one residents reviewed. The findings included: Resident #20 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had short/long term memory problems, moderately impaired cognitive skills for daily decision making, and required extensive assistance for transfers. Medical record review of the High Risk Patient Selection Form dated March 11, 2010, and May 27, 2010, revealed the resident had fallen in the past 30 days and the past 31-180 days. Medical record review of the post falls nursing assessment dated [DATE], revealed, ""...fell from wheelchair...on floor with WC (wheelchair) on top of (resident) safety belt still hooked to (resident) ...What immediate interventions were initiated to prevent future falls?...Anti Tipper Bars to WC..."" Medical record review of the post falls investigation dated April 19, 2010, revealed, ""...Type of injury: Bruise Head...Anti Tip Bars ordered for w/c..."" Observation with LPN #1 (Licensed Practical Nurse), in the resident's room, on June 15, 2010, at 9:25 a.m., revealed the resident seated in the wheelchair without the antitipper bars on the wheelchair. Interview with LPN #1, on June 15, 2010, at 9:30 a.m., in the nursing station, confirmed the anti tippers are to be on the wheelchair.",2014-04-01
14079,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2010-06-15,425,D,,,4BZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the pharmacy delivery record and interview, the facility failed to ensure medication was available to meet the needs for one (#4) resident and failed to document the administration of three doses of a narcotic for one resident (#15) of thirty-one residents reviewed. The findings included: Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's progress note dated April 21, 2010, revealed, "" ...recurrent cystitis...resistant pseudomonas...Tx (treat) (with) Aztreonam (antibiotic) 1 gram IM (intramuscular) q (every) 12 (hours) x 7 days..."" Medical record review of a physician's orders [REDACTED]. Medical record review of the MAR (Medication Administration Record) dated April 2010, revealed the Aztreonam was circled as not administered on April 22, 2010, at 9 a.m., and 9 p.m., April 23, 2010, at 9:00 a.m., April 24, 2010, at 9:00 a.m., and 9:00 p.m., April 29, 2010, at 9:00 p.m., and April 30, 2010, at 9:00 p.m. Medical record review of the Nurse's Medication Notes (back of MAR) revealed, ""...4/22/10 9 p Aztreonam 1 g IM (not) available from pharmacy...4/23/10 9 A Aztreonam...(not) available from pharmacy ...4/24/10 9 pm Aztreonam...(not) available from pharmacy...4/29/10 9 pm Aztreonam...not available...4/30/10 9 pm Aztreonam...not available ..."" Review of the pharmacy delivery record dated April 24, 2010, revealed the Aztreonam 1 Gram was delivered on April 24, 2010. Interview on June 14, 2010, with RN #1 (Registered Nurse) at 10:30 a.m., in the Charge Nurse's office, confirmed the medication was not available for the resident. Review of the Narcotic Tracking/Destruction Log for June 2010, for resident #15, revealed four doses of Oxycodone 5 mg. was signed out for June 6, 2010. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. signed out on June 6, 2010. Interview with head nurse #2 on June 15, 2010, at 9:00 a.m., in the Head Nurse's office, confirmed the documentation showed the resident did not receive three of the four doses of Oxycodone as documented.",2014-04-01
14080,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2010-06-15,322,D,,,4BZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to properly position the head of bed for resident (#7); failed to provide nutritional support as ordered for resident (#27); and failed to ensure assigned responsible staff administered nutritional support for resident (#9) of thirty one residents reviewed. The findings included: Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Physician's Recapitulation Orders dated June 1, 2010, to June 30, 2010, revealed, ""...GLUCERNA 1.5...75ML/HR (milliliters per hour) X (times)21 HRS...OFF AT 1PM - ON AT 4PM...ASPIRATION PRECAUTIONS: HOB (head of bed) > (greater than) 30 DEGREES WHILE TF (tube feeding) IN PROGRESS..."" Observation in the resident's room on June 13, 2010, at 10:15 a.m., revealed the resident lying on a Clinitron bed with the tube feeding in progress and the head of the bed elevated 20 degrees. Continued observation on June 14, 2010, at 8:40 a.m., revealed the resident lying on the Clinitron bed with the tube feeding in progress and the head of the bed elevated 19 degrees. Interview with Registered Nurse (RN) #2 in the resident's room on June 14, 2010, at 9:00 a.m., confirmed the facility failed to properly elevate the head of the bed greater than 30 degrees as ordered. Resident #27 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Physician's Recapitulation Orders dated June 1, 2010, to June 30, 2010, revealed, ""[MEDICATION NAME] 1.5 @ (at) 70ML/HR X 20 HR...(OFF 10AM-2PM)..."" Observation in the resident's room on June 14, 2010, at 3:05 p.m., and 3:50 p.m., revealed the resident sitting in a recliner with the tube feeding pump positioned directly behind the resident and was not turned on. Interview with RN #2 in the resident's room on June 14, 2010, at 3:50 p.m., confirmed the facility failed to ensure the feeding pump was turned on as ordered. Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had persistent vegetative state, was dependant for activities of daily living and required tube feed for nutritional support. Observation on June 13, 2010, at 10:00 a.m., revealed CNA #1 (Certified Nursing Assistant) had provided bath care. Continued observation revealed the feeding tube was disconnected and the pump was in the hold position. Further observation revealed the CNA connected the tube and started the feeding pump at the rate to be delivered. Interview with the CNA at the time of observation confirmed had reconnected the tubing and started the pump at the prescribed rate. Continued interview revealed the CNA's practice was to place feeding pump on hold and to disconnect prior to providing care. Review of the Nurse Aid Handbook for the State of Tennessee, Version 4.5, October 1, 2009, revealed no evidence of training for operation and safety or regulating flow rates of the tube feeding pumps. Interview with the DON (Director of Nursing) on June 14, 2010, at 4:15 p.m., in the DON's office, confirmed the CNA's are not to disconnect the feeding tube or to start the feeding pumps.",2014-04-01
14081,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2010-06-15,250,D,,,4BZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure resident's needs were met by providing social services for one resident (#6) of thirty one residents reviewed. The findings included: Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the hospital discharge summary dated November 19, 2009, revealed the resident was fifty years old, had a bilateral below the knee amputation. Continued review revealed the resident had left hand digit amputation (2-5), and on April 28, 2010, had a revision of the bilateral above the knee revision. Observation of the resident on June 13, 2010, at 3:25 p.m., revealed the resident sitting. Interview with the resident at the time of observation revealed the resident explained the removal of both legs, and partial removal of the digits on both hands. Medical record review of the social services notes revealed no documentation the social services had addressed the loss of the lower extremities and the digits (fingers). Interview with the Master Social Worker on June 14, 2010, at 11:30 a.m., in the unit manager's office, confirmed the issue of the amputations had not been addressed. .",2014-04-01
14082,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2010-06-15,280,D,,,4BZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to develop a care plan that addressed the psychosocial needs for one resident (#6) of thirty one residents reviewed. The findings included: Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the hospital discharge summary dated November 19, 2009, revealed the resident was fifty years old, had a bilateral [MEDICAL CONDITION]. Continued review revealed the resident had left hand digit amputation (2-5), and on April 28, 2010, had a revision of the bilateral above the knee revision. Observation of the resident on June 13, 2010, at 3:25 p.m., revealed the resident sitting in a wheel chair. Interview with the resident at time of observation revealed the resident explaining the removal of both legs, and partial removal of the digits on both hands. Medical record review of the care plan dated May 5, 2010, revealed the psychosocial needs following amputations had not been addressed. Interview with the Unit Manager of 500 Hall, on June 14, 2010, at 11:30 a.m., confirmed the care plan had not addressed the psychosocial needs of the resident have bilateral leg amputation and partial removal of fingers on both hands.",2014-04-01
14083,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2010-06-15,281,D,,,4BZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to provide medication requested by one (hospice) resident (#15), of thirty-one residents reviewed. The findings included: Resident #15 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had difficulty with long and short term memory, moderate difficulty with decision making skills, usually understood, and usually understands verbal information content. Continued review of the MDS revealed the resident had [MEDICAL CONDITION]/change in usual sleep pattern, no verbal or social behaviors, no difficulty with perception or awareness of surroundings, and no problems with mental function over the course of the day. Continued review of the MDS revealed the resident required assistance of staff with all activities of daily living Interview with the resident on June 14, 2010, at 9:15 a.m., in the resident's room, revealed the resident alert and oriented x three (person, place and time), responded appropriately to questions and statements. Continued interview with the resident revealed a request was made at approximately 10:00 p.m., on June 13, 2010, for an [MEDICATION NAME], for complaints of anxiety/anxiousness. Continued interview revealed the resident stated, ""I felt awful, I thought I would come out of my skin, and I woke up hurting."" When asked if the resident received it, stated ""no, I never received it all night."" When asked if the resident received an explanation why it was not given then or later, the resident stated, ""no"". Continued interview with the resident revealed the understanding the night medication had been given earlier; however, the resident stated was having anxiety/anxiousness. Medical record review revealed physician's orders [REDACTED]. by mouth every 2 hours as needed for severe anxiety"". Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Continued review of the MAR indicated [REDACTED]. Review of the nurse's notes revealed no documentation the resident received the PRN [MEDICATION NAME], or that the resident was having difficulty with anxiety. Interview with Head Nurse #2 on June 14, 2010, at 9:00 a.m., in the Head Nurse's office, confirmed the resident was able to make needs known, and could communicate appropriately. Continued interview with the Head Nurse confirmed the resident did not receive the [MEDICATION NAME] as requested; confirmed no explanation was given to the resident, and confirmed no alternate treatment or support was given.",2014-04-01
14084,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2010-06-15,221,D,,,4BZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and interview, the facility failed to assess for the use of a restraint for one (#8) resident, and failed to ensure the restraint for one (#20) resident was secured according to the manufacturer's recommendation, of thirty-one residents reviewed. The findings included: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had difficulty with long and short term memory and difficulty with decision making skills. Continued review of the MDS revealed the resident was dependent on staff for all activities of daily living, including feeding. Observation on June 13, 2010, at 2:45, and 4:00 p.m., revealed the resident in the day room, on 2-E, seated in a Geri Chair with a lap tray attached. Observation on June 13, 2010, at 3:30 p.m., revealed the resident at the Nurses Station on 2-E, seated in a Geri Chair with a lap tray attached. Medical record review of the physician's orders [REDACTED]. Pt. (patient) non-ambulatory. Check q (every) 30 min. Release. Reposition q 2hrs. and toilet as needed."" Review of the Physical Therapy notes dated June 2, and June 9, 2010, revealed the resident continues to receive Therapy, noting the resident was able to ambulate 300 - 800 feet with minimal to moderate assist and three sit and rests. Interview with Physical Therapy Assistant #1 on June 15, 2010, at 10:10 a.m., by phone, revealed the resident received Physical Therapy and confirmed the resident is transported to and from the Therapy Department by Geri Chair with the lap tray attached. Interview with Head Nurse #2, on June 14, 2010, at 8:55 a.m., in the resident's room, confirmed the resident's Geri Chair was used because the resident attempted to get out of the Geri Chair and confirmed the lap tray had not been assessed for use as a restraint. Resident #20 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had impairment with long and short term memory, and moderately impaired decision making skills. Continued review of the MDS revealed the resident was non ambulatory, and had a history of [REDACTED]. Review of the physician's orders [REDACTED]. Check q (every) 30 m. (minutes). Release, toilet and reposition q 2 hrs & PRN (as needed)."" Observation on June 13, 2010, at 2:40 p.m., revealed the resident in the day room on 2-West, seated in a wheel chair, with a soft belt restraint applied across the resident's abdomen, and the ties draped around the back of the wheel chair. (Not down the sides and crossed at the lower back of the wheelchair). Interview with Licensed Practical Nurse #3at this time confirmed the restraint was not secured correctly. Observation on June 13, 2010, at 3:25 p.m., in the resident's room with Head Nurse #1 revealed the resident's soft belt restraint was applied across the resident's upper body (breast area) and under the arms, with the ties attached to the loops and tied straight across the upper part, of the back of the wheel chair. Continued observation and interview at 3:27 p.m., revealed the Head Nurse retied the restraint with the soft belt across the lap down the sides of the wheel chair, crossed behind the wheel chair and tied to the kick spurs, and confirmed the restraint had not been tied correctly. Review of the Manufacturer's Instructions for Application of the Soft Belt revealed the following: Position the patient as far back in the seat as possible, with the buttocks against the back of the chair...Lay the lap belt across the patient's thighs with the foam facing in...Bring the ends of the connecting straps down at a 45 degree angle between the seat and the wheel chair sides...Criss-cross the straps behind the chair and draw them around the opposite side kick spurs...There is a risk of chest compression or suffocation if the patient's body weight is suspended off the...chair seat...STOP USE AT ONCE: If the patient has a tendency to slide forward or down in the device; or is able to self-release."" Interview with Head Nurse #1 on June 13, 2010, at 3:30 p.m., in the resident's room, confirmed the restraint was not secured according to manufacturer's instructions.",2014-04-01
14085,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2010-06-15,514,D,,,4BZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to maintain documentation of services provided for one resident (#30); and ensure accurate sliding scale orders were obtained for one resident (#19) of thirty one residents reviewed. The findings included: Resident #30 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the medical record revealed no documentation resident had received a shower three times per week as per care plan. Interview with the DON (Director of Nursing) on June 14, 2010, at 10:20 a.m., in the conference room, confirmed no documentation to show resident received a shower as planned. Resident # 19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the referring facility's physician's orders [REDACTED]. (patient) from...(referring facility) to (current facility)...Continue current MAR (Medication Administration Record) see Discharge MAR. Check BG (blood glucose) AC (before meals) & HS (at bedtime). Pt is on [MEDICATION NAME] Sliding (sliding scale insulin) see MAR..."" Review of the referring facility's Medication Status record dated May 29, 2010, and faxed to the facility June 1, 2010 at 1:47 p.m., revealed, ""[MEDICATION NAME] Subcutaneous Solution 100 Units/ML (milliliter) SS (sliding scale) coverage unit qid (four times per day) subcut.(subcutaneously). [MEDICATION NAME] per sliding scale: BG 111-150 I unit, BG 151-200 2 units, BG 201-250 3 units, BG 251-300 4 units, BG 301-350 6 units, BG 351-400 9 units, BG >(greater than) 400 9 units and call hospice MD; <(less than) 70 call hospice MD and titrate hypoglycemic protocol..."" Review of the physician's orders [REDACTED].S. BID (two times per day): 111-150= 1U (unit); 151-200=2U; 201-250=3U; 251-300=4U; 301-350=6U; 351-400=9U; >400=9U and call MD..."" Review of the facility Medication Record for June, 2010, revealed, ""[MEDICATION NAME] 100U/1 ML Vial for Humalog-[MEDICATION NAME] Insulin S.S. BID (two times per day): 111-150= 1U (unit); 151-200=2U; 201-250=3U; 251-300=4U; 301-350=6U; 351-400=9U; >400=9U and call MD..."" Review of the Sliding Scale Diabetic Monitoring Log dated June, 2010 revealed the blood glucose being checked and recorded four times per day. Interview with Head Nurse #2, on June 15, 2010, at 9:30 a.m., in the 3 West Head Nurse's office, confirmed the June 1, 2010, Admission Orders were inaccurately transcribed to the resident's June 2010, physician's orders [REDACTED]. Complaint #",2014-04-01
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
5214,TREVECCA CENTER FOR REHABILITATION AND HEALING LLC,445112,329 MURFREESBORO RD,NASHVILLE,TN,37210,2016-01-19,280,D,0,1,L8FU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to revise the approaches of a care plan addressing the behaviors for 1 (Resident #27) of 3 residents reviewed for behaviors. The findings included: Medical record review revealed Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #27 was severely cognitively impaired in daily decision making, rejection of care occurred 1-3 days, had moderate difficulty hearing, clear speech, usually could make self understood, and could understand others. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #27 was severely cognitively impaired in daily decision making, had 1-3 days of physical, verbal and other behaviors; wandered 4-6 days of the review period, had moderately impaired hearing, clear speech, vision was adequate, usually could make self understood, and could understand others. Medical record review of the care plan with the onset date of 9/4/15, revealed Resident #27 was at risk for combination of behaviors related to Dementia, Hx (history) Confusion. Further review revealed the approaches included Nurses: Supervise direct care staff. Medication as ordered. Notify MD (Medical Doctor) of any comlications (complications) and treat as ordered. Observe for cause of behavior-UTI (Urinary Tract Infection), pain, worsening of disease process. Observe environmental influences such as temperature, lighting and noise levels to reduce stress of resident as needed. Watch for signs of increased anxiety. Watch for increased signs of increasing agitation. Establish routines. Adhere to routines. Further care plan review revealed approaches for the Nurse Aides: Watch for signs of increasing anxiety. Watch for signs of increasing agitation. Allow resident to vent. Keep voice soft and calm. Further review of the 9/4/15 care plan revealed the following inclusions to the problem: 1. On 9/17/15 the problem included .Resists Eating Assistance at Times, Resists taking Medication at Times . with no changes to the approaches. 2. On 10/7/15 the problem included .Episodes of Slapping/Kicking at Staff, Declines Turning/Repositioning at Times . with no changes to the approaches. 3. On 10/12/15 the problem was changed to Altered behavior pattern and the related to included .Combative Towards Staff at Times . with no changes to the approaches. 4. On 10/21/15 the problem included .Pushing, Scratching, Delusional, Withdrawn . with no changes to the approaches. 5. On 10/26/15 the problem included .Unassisted Transfers . with no changes to the approaches. 6. On 10/27/15 the problem included .Delusional at Times (although already addressed on 10/21/15), Propels Without Purpose . with no changes to the approaches. 7. On 11/2/15 the problem included .Combative Toward Staff at Times During ADL (Activities of Daily Living) Care: scratching, pushing, Declines Turning and Repositioning at Times, Resists Eating Assistance at Times . with no changes to the approaches. 8. On 11/16/15 the problem included .Episodes of Wandering into Wrong Room, Rummages, Difficult to Please . with no changes to the approaches. 9. On 11/18/15 the problem included .Delusional (already addressed on 10/21/15 and 10/27/15)/Disoriented . with no changes to the approaches. 10. On 11/23/15 the problem included .Uncooperative . with no changes to the approaches. 11. On 11/27/15 the problem included .Resist Going to Bed . with no changes to the approaches. 12. On 11/30/15 the problem included .Resident demonstrates inappropriate behaviors: threatens staff at Times .Verbally aggressive Physically aggressive . with no changes to the approaches. 13. On 12/3/15 the problem included .Fidgety, Restless, Resists Eating Assistance (already addressed on 9/17/15) .grabbing . with no changes to the approaches. 14. On 12/4/15 the problem included .[MEDICAL CONDITION] . Demanding/Difficult to Please . with no changes to the approaches. 15. On 12/7/15 the problem included .[MEDICAL CONDITION] (although already addressed on 12/4/15) . with no changes to the approaches. 16. On 12/9/15 the problem included .Aimlessly Wandering . with no changes to the approaches. 17. On 12/16/15 the problem included .Attempting Biting Staff . with no changes to the approaches. 18. On 12/21/15 the problem included .Resist/Refuses Taking Medication/PO (by mouth) at Times .Smearing Feces . with no changes to the approaches. 19. On 12/29/15 the problem included .spitting . with no changes to the approaches. 20. On the current care plan dated 1/12/16 the problem included .Delusional AEB (As Evidenced By) thinks she is being poisoned . with no changes to the approaches. Interview with MDS Coordinator #1, #2, #3 and #4, on 1/14/16 at 3:00 PM in the MDS office, after reviewing the comprehensive care plan from onset 9/4/15 through 1/12/16, confirmed the facility failed to revise the approaches of the care plan after the revision to the problems for Resident #27.",2019-04-01
5215,TREVECCA CENTER FOR REHABILITATION AND HEALING LLC,445112,329 MURFREESBORO RD,NASHVILLE,TN,37210,2016-01-19,319,D,0,1,L8FU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, correspondence protocol review, and interview, the facility failed to assess and provide psychiatric services timely for the psychotic behaviors displayed by 1 (Resident #27) of 3 residents reviewed for behaviors. The findings included: Medical record review revealed Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #27 was severely cognitively impaired in daily decision making, rejected care 1-3 days, moderate difficulty hearing, clear speech, usually could make self understood, and could understand others. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #27 was severely cognitively impaired in daily decision making, had 1-3 days of physical, verbal and other behaviors; wandering occurred 4-6 days during the review period, had moderately impaired hearing, clear speech, vision adequate, usually made self understood, and understood others. Medical record review of the physician orders [REDACTED]. 1. On 10/10/15 [MEDICATION NAME] (anti-anxiety medication) 1 mg (milligram) injection intramuscular x (times) 1 dose 6:00 PM for Agitation; 2. On 10/10/15 [MEDICATION NAME] ([MEDICATION NAME]-anti-depressant) 10 mg tablet po HS (by mouth at bedtime) 9:00 PM for Dementia Related [MEDICAL CONDITION]; 3. On 10/13/15 [MEDICATION NAME] (anti-psychotic medication) 25 mg tablet po daily 3:00 PM for Dementia Related [MEDICAL CONDITION]; 4. On 10/21/15 [MEDICATION NAME] and [MEDICATION NAME] were discontinued; 5. On 11/22/15 [MEDICATION NAME] 1 mg injection intramuscular x 1 dose STAT (immediately) 5:30 AM for feeling anxious; 6. On 11/27/15 [MEDICATION NAME] 1 ml (milliliter) injection intramuscular x 1 dose 7:30 PM (may repeat in one hour if needed) for Anxious Mood; 7. On 12/18/15 [MEDICATION NAME] (Mood stabilizer medication) 125 mg po bid (two times daily) 10:00 AM 10:00 PM for Mood Stabilization; 8. On 12/18/15 [MEDICATION NAME] 0.5 mg po bid prn (as needed) x 2 weeks for Agitation/Combativeness, last date 1/1/16; 9. On 12/18/15 Psychiatric Consult combative aggressive; 10. On 1/8/16 Increase [MEDICATION NAME] to 250 mg po bid 10:00 AM 10:00 PM for Mood Stabilization. Medical record review of the Behavior/Mood Notes revealed the following: 1. On 10/4/15 Interacts with others, easy going and friendly, cheerful and cooperative. 2. On 10/6/15 No behaviors. 3. On 10/7/15 Physical Behaviors: hitting, kicking, pushing, grabbing. 4. On 10/8/15 Will not call for assistance, gets up without calling for help, uncooperative, resists ADL (Activities of Daily Living) assistance. 5. On 10/9/15 hitting, will not call for assistance, gets up without calling for help, uncooperative, resists taking medications; S/S (Signs/Symptoms) of Anxiety: [MEDICAL CONDITION], appears fidgity/restless. 6. On 10/10/15 No behaviors noted at 1:34 AM and 2:23 AM. 7. On 10/11/15 No behaviors noted at 1:40 AM. At 11:25 AM Resistance of Care: will not call for assistance, gets up without calling for help, Wanders: propelling in w/c (wheelchair) without purpose. 8. On 10/12/15 Physical Behaviors: hitting, pushing, scratching, grabbing; Verbal Behaviors: curses; Resistance to Care: gets up without calling for help, uncooperative, resists ADL assistance; Wanders: moves with no purpose, propelling w/c without purpose; S/S [MEDICAL CONDITION]: appears suspicious, delusional to place time; S/S Depression: withdrawn; S/S Anxiety: unpleasant mood; Anger: anger at NH (Nursing Home) placement, easily annoyed/short tempered. 9. On 10/13/15 Hitting, scratching, will not call for assistance, gets up without calling for help, uncooperative, resists taking medications; Wanders: propelling in w/c without purpose; S/S Anxiety: [MEDICAL CONDITION], appears fidgity/restless, unpleasant mood. 10. On 10/14/15 No behaviors at 2:56 AM, 10:06 AM. 11. On 10/15/15 Wanders: propelling in w/c without purpose at 2:08 AM; No Behaviors at 11:41 AM. 12. On 10/16/15 No behaviors at 1:52 AM; at 2:27 PM Resistance of Care: will not call for assistance, uncooperative, refuses to turn or reposition, refuses to go to bed, refuses to get out of bed, resists taking medication, resists ADL assistance, non-compliance with medical care. 13. On 10/17/15 Wanders: propelling in w/c without purpose at 2:43 AM; No behaviors noted at 2:55 AM; Resistance in Care: will not call for assistance, gets up without calling for help at 10:55 AM. Late Entry dated 10/21/15 for 10/13/15: Physical Behaviors: pushing, scratching; S/S [MEDICAL CONDITION]: Delusional person place; S/S Depression: withdrawn. 14. On 10/18/15 Wanders: propelling in w/c without purpose at 3:29 AM; at 3:41 PM Verbal Behaviors: repetitive verbalizations, easy going, friendly, calm, wandering in w/c in hallways without purpose. 15. On 10/19/15 No behaviors noted at 1:39 AM and 3:12 PM. 16. On 10/20/15 No behaviors noted at 2:56 AM and 11:20 AM. 17. On 10/21/15 S/S Anxiety: appears fidgity/restless, unpleasant mood, demanding, difficult to please at 3:37 AM; S/S Depression: withdrawn; S/S [MEDICAL CONDITION]: delusional person place time. Interacts with others, easy going and friendly. The resident continued to display behaviors from 10/21/15 to 1/15/16 including: hitting, kicking, pushing, grabbing, attempting to bite staff/others/self, spitting, screaming, slapped (staff) in face, scratching, curses, calling out, will not call for assistance, gets up without calling for help, uncooperative, threatens, resists taking medications, [MEDICAL CONDITION], appears fidgity/restless, resists ADL assistance; moves with no purpose, propelling w/c without purpose, withdrawn, unpleasant mood, anger at NH placement, easily annoyed/short tempered, refuses to turn or reposition, refuses to go to bed, refuses to get out of bed, demanding, sleeping much of the day, non-compliance with medical care. Continued review of the Behavior/Mood Notes revealed Resident #27 displayed the following behaviors in addition to the above mentioned behaviors: 1. On 10/26/15 at 11:47 AM, 10/27/15 at 11:37 AM, 10/30/15 at 1:20 PM, 10/31/15 at 12:28 PM, 11/1/15 at 11:30 AM, 11/14/15 at 10:36 AM and 6:42 PM, 11/15/15 at 11:04 AM,11/18/15 at 1:37 PM, 11/19/15 at 11:37 AM, 11/23/15 at 11:22 AM, 12/18/15 at 2:30 PM, 1/11/16 at 12:33 AM and 9:24 PM, S/S [MEDICAL CONDITION]: delusional to person and/or place and/or time. 2. On 11/02/15 at 9:33 AM, 11/19/15 at 11:37 AM, 11/22/15 at 3:28 PM, 11/231/5 11:22 AM, 11/28/15 at 1:03 AM, 1/11/16 at 12:33 AM and 9:24 PM S/S [MEDICAL CONDITION]: appears suspicious and/or accusatory and/or paranoid. 3. On 11/14/15 at 10:36 AM, 11/15/15 at 11:04 AM, 11/19/15 at 11:37 AM, 11/20/15 at 6:51 PM, 11/26/15 11:39 PM, 12/16/15 at 11:54 PM, 12/25/15 at 7:27 PM, 1/7/16 at 7:56 AM enters other resident's rooms and/or bathrooms and/or wander into other resident's rooms. 4. On 11/14/15 at 6:42 PM, 11/18/15 at 1:37 PM, 11/19/15 at 11:37 AM, 11/26/15 at 4:06 PM, 1/12/16 at 12:11 PM rummages thru others' belongings and/or taking items from others without permission. 5. On 11/16/15 at 11:31 AM .S/S [MEDICAL CONDITION]: Hallucinates, delusional, wanders into several other resident's rooms, on a daily basis .she states she just got off the bus, doesn't know anyone here, doesn't know where she is supposed to be, people are in her bed . 6. On 11/19/15 at 11:37 AM, 11/22/15 at 3:28 PM S/S [MEDICAL CONDITION]: paranoid, states others are talking about her. 7. On 11/24/15 at 1:35 PM, 11/30/15 at 3:35 PM, 12/2/15 at 1:47 PM, .continues to be followed by psych (psychiatric) . although no psychiatric consult was ordered until 12/18/15 and the resident was not seen by psychiatric services until 1/14/16. 8. On 12/6/15 at 4:02 PM, 12/14/15 at 3:50 PM, 12/16/15 at 2:48 PM, 12/18/15 at 1:22 PM, 12/28/15 at 1:25 PM, 1/11/16 9:24 PM repetitive verbalizations. 9. On 12/13/15 at 6:28 AM, 12/17/15 at 5:38 AM, 12/19/15 at 2:31 PM, 1/12/16 at 12:11 PM, 1/13/16 at 11:51 AM disrobes in public, and/or spits at staff at times. 10. On 12/18/15 at 5:16 PM, refused to eat/drink and/or by mouth fluid poor this shift. Psych consult requested. 11. On 12/19/15 at 2:31 PM makes disruptive sounds, smearing feces. 12. On 12/28/15 at 3:40 AM digging trash can to get food. 13. On 1/7/16 at 7:55 AM .S/S [MEDICAL CONDITION] .accusatory, paranoia, delusional get me knife so I can cut my foot off . 14. On 1/9/16 at 3:25 AM .S/S [MEDICAL CONDITION]: paranoia, thinks people are trying to poison her . Medical record review revealed Resident #27 was seen by Psych-Services on 1/14/16, 28 days after the referral although the resident had displayed delusional, and/or paranoid and/or hallucinatory behaviors since 10/12/15. Review of the Psychiatric provider's undated correspondence to the facility Administrator revealed .our protocol .is to see routine patients within 30 days, if not sooner. Urgent patients will be seen within one week from referral .However, if there is a change of status, we will rely on staff notifying our practitioner . was signed by Nurse Practioner (NP) #2. Interview with the Director of Nursing (DON) on 1/14/16 at 10:22 AM in the Administrator's office revealed she had just called NP#3, from psychiatric services, to remind her of the 12/18/15 order and she's coming today. She came only once in (MONTH) due to the holidays and all . Interview with the DON on 1/14/16 at 12:38 PM in the Administrative area hallway, when asked if the referral to psychiatric services had been carried out timely stated No. When asked if she would consider that a delay in treatment the DON stated Yes. Telephone interview with NP#2 on 1/14/16 at 2:11 PM, when asked how long the undated protocol had been effective, stated since 12/2013. When asked to define what routine patient meant, she stated the resident was stable, not psychotic, and not in distress. When asked to define distress, she stated not suicidal, hallucinating or disruptive. When asked to define disruptive, she stated yelling, hitting, bothering others. When asked if yelling, kicking, getting into other resident's room and getting in their bed, and smearing feces was disruptive, she stated yes. Further interview with NP#2 revealed the resident should have been classified as urgent and confirmed the resident should have been seen 1 week from the referral. Interview with NP#1 on 1/14/16 at 3:55 PM in the conference room revealed .the resident had no delay in treatment since the resident was seen by the NP and Medical Doctor with medication intervention. When asked what the facility staff had determined the cause was for the behavior, NP#1 stated she .didn't know . When asked what interventions were implemented before the [MEDICAL CONDITION] medications, she stated .did not know .",2019-04-01
5216,TREVECCA CENTER FOR REHABILITATION AND HEALING LLC,445112,329 MURFREESBORO RD,NASHVILLE,TN,37210,2016-01-19,371,D,0,1,L8FU11,"Based on observation and interview, the facility failed to serve food under sanitary conditions on 1/11/16 on 1 out of 4 floors; the facility dietary department failed to serve hot food at or greater than 135 degrees Fahrenheit (F) and cold food at or less than 40 degrees F; and failed to use utensils to serve the food for the resident morning meal trayline on 1/12/16 for 1 of 8 resident delivery carts. The findings included: Observation on 1/11/16 at 5:55 PM on the 5th floor revealed the Certified Nurse Aide (CNA) #3 carrying a tray of individual coffee cups filled with coffee down the hall with no lids on the cups and setting it on top of the food cart for delivery to the residents. The uncovered coffee cups were then carried down the hall to the individual residents rooms. Interview with the CNA#3 on 1/11/16 at 6:00 PM on the 5th floor revealed the floor had run out of coffee cup lids and she would have to get more from downstairs. Interview with the Dietary Manager on 1/11/16 at 6:05 PM on the 1st floor confirmed the coffee cups should not have been delivered to the residents without lids. Observation on 1/12/16 at 7:15 AM in the facility dietary department, with the Registered Dietitian (RD) present, revealed the resident morning meal trayline was in progress. Further observation of the trayline revealed the sausage patties were 122 degrees F. Further observation revealed 3 individual serving dishes containing cottage cheese were on a tray which was stored on top of another tray containing cartons of juice on the trayline. Further observation revealed the cottage cheese was 47 degrees F. Further observation revealed no serving utensils available for the sausage, bacon, toast, pancake and biscuits. Further observation revealed the server touched the bacon, sausage and toast with the same gloved hands therefore potentially contaminating the food. Interview with the RD on 1/12/16 at 7:15 AM, at the resident morning meal trayline in the dietary department, confirmed the facility failed to serve the hot food at or greater than 135 degrees F and the cold food at or less than 40 degrees F. Further interview confirmed several food items lacked serving utensils and the server touched multiple foods with the same gloved hand.",2019-04-01
5217,TREVECCA CENTER FOR REHABILITATION AND HEALING LLC,445112,329 MURFREESBORO RD,NASHVILLE,TN,37210,2016-01-19,514,D,0,1,L8FU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview the facility failed to maintain accurate clinical records of NP/MD documentation for 1 (Resident #245) of 46 residents reviewed. The findings included: Medical record review revealed Resident #245 was admitted to facility on 5/7/15 with [DIAGNOSES REDACTED]. Medical record review of a Wound Team assessment dated [DATE] revealed a newly acquired Stage 2 pressure ulcer to the sacral/coccyx area. Continued review revealed on 6/2/15 the wound had become unstageable due to the presence of slough and eschar. Continued review revealed on 7/14/15 the pressure ulcer had developed into a Stage 4. Medical record review of the Nurse Practitioner/Medical Doctor (NP/MD) notes dated 5/8/15-12/29/15 documented Resident #245's skin was .warm and dry, no wounds . Continued review revealed there was no mention in the History, Assessment, or Plan of the NP/MD notes the resident had developed a pressure ulcer to her coccyx that went from a Stage 2, to unstageable to a Stage 4. Interview with the NP #1 on 1/19/16 at 8:40 AM in the NP's office stated, when asked if the NP #1 documented any notes concerning Resident # 245's pressure ulcer stated, .The wound team handles the wounds, unless there is a concern, and then they pull us in . When asked if the NP would expect there to be documentation by the NP or Physician if the resident developed a pressure ulcer and it developed into a Stage 4, the NP stated, .yes, we do that . NP #1 then began looking at her progress notes in the computer. When NP #1 was asked if the documentation stating the resident's skin was warm and dry with no wounds was accurate the NP stated, .Well, no it's obviously not accurate, but this resident had so much going on that documenting about the wounds just wasn't a priority . NP #1 confirmed the facility failed to maintain accurate clinical records for Resident #245.",2019-04-01
10945,TREVECCA HEALTH CARE CENTER,445112,329 MURFREESBORO RD,NASHVILLE,TN,37210,2013-03-19,225,D,1,0,Q0H211,"Based on review of the facility's abuse policy , review of facility documentation, review of grievance/concern reports and interview, the facility failed to report allegations of abuse for three residents (#1, #2 and #5) of six residents reviewed. The findings included: Review of the facility's Abuse Policy effective October 01, 2007 revealed under Policy Statement All suspected violations and substantiated incidents of abuse will be promptly reported to appropriate state agencies and other entities or individuals as may be required by law. Record review of an incident involving Resident #1 revealed Certified Nurse Technician (CNT) #1 signed a statement that documented On Thursday January 3, 2013 at about 4:15(a.m.) .(Resident #1) was on the floor .(Resident #1) was pushing on the over the bed table and there was a glass of water and a water pitcher on it. (Named CNT #2) came into the room and I had asked her to take it off (glass of water) and she took the glass of water and stuck her finger in it and flung water on (Resident #1). He was agitated enough . Review of a Grievance/Concern Report dated January 5, 2013 revealed resident #2 complained CNT#2 was Fighting with her; squeezed her hand causing injury. Review of a Grievance/Concern Report dated December 6, 2012 revealed resident #5 stated she was slapped. Review of facility incident reports revealed the facility investigated the complaints but there was no documentation the allegations were reported to the State Agency. Interview with the Administrator on March 12, 2013 at 4:58 p.m. in the Administrator's office revealed the Administrator stated I thought we only had to report abuse to the State if it was substantiated by us. I thought that was in our policy. C/O #",2016-03-01
11177,TREVECCA HEALTH CARE CENTER,445112,329 MURFREESBORO RD,NASHVILLE,TN,37210,2012-10-03,371,F,0,1,ZF4H11,"Based on observation and interview, the facility failed to provide sanitary storage of food and equipment. The findings included: Observation of the dietary department on October 1, 2012, from 10:35 a.m. until 11:30 a.m., revealed the following: 1. One measuring cup stored in a container of thickener and available for use; 2. The food processor was wet and had water standing in the bottom of the mixing bowl and available for use; 3. Twenty-six of twenty-six sheet pans were wet and available for use; 4. The floor in the main dietary department was wet with a slippery substance without a Wet Floor Sign present; 5. Thirteen of thirteen two inch steam table pans were stored wet and available for use; 6. One large container of Peanut Butter in the dry storage area had a loose cracked lid on it and available for use; 7. Four of four, four inch steam table pans were stored wet and available for use; 8. Seven scoops were stored wet with standing water in the bottom of the scoop and available for use; 9. Fifteen one-half steam table pans were stored wet and available for use; 10. Thirteen sliced banana pieces, undated in the walk in refrigerator and available for use; 11. One pan of rolls in the dry storage area, undated and available for use; 12. The following items were open, undated, and available for use, in the reach in refrigerator: a. Cottage Cheese, three six ounce serving cups; b. Applesauce, one six ounce serving cup; c. Grapes, three six ounce serving cups; d. Two - Tomato Juice in small cups; 13. The following items were open, undated, and available for use in the salad prep area: a. Yellow food coloring, 32 ounce container; b. Red food coloring, 32 ounce container; c. Two - Lemon extract, 16 ounce containers; d. Blue food coloring, 32 ounce container; e. Salt, 26 ounce container; f. Food sprinkles, 207 gram container; g. Chocolate syrup, 24 ounce container; 14. Lettuce and tomatoes were being prepped on the end of the three compartment sink on a cutting board with wash and sanitizer water in the compartments next to the food; 15. A thirty gallon trash can had 6 ounce serving bowls in it that were wet and stored open side up, and available for use; 16. A thirty gallon trash can was full of wet bowls with standing water in some of them and available for use; Continued observation on October 1, 2012, at 10:35 a.m., in the dietary department food preparation area revealed a 5.5 pound container of onion power, a 5.5 pound container of ground black pepper, and an 8 pound container of beef base all opened, undated, and available for use. Interview with the Dietary Manager on October 1, 2012, at 10:37 a.m., in the food preparation area, confirmed the containers were to have been dated and labeled upon being opened, and made available for use. Continued observation on October 1, 2012, at 10:50 a.m. in the dietary department dry storage area, revealed dented cans stored in the canned food storage rack available for use; a 115 ounce can of Tomato Soup, a 108 ounce can of black eyed peas, a 105 ounce can of diced potatoes, and a 110 ounce can containing cut yams. Interview with the Dietary Manager on October 1, 2012, at 10:51 a.m., in the dry storage room, confirmed the cans were improperly stored and were available for use. Interview with the Dietary Manager on October 1, 2012, at 11:30 a.m., in the dietary department, confirmed dented cans were to be removed from stock, there needed to be a Wet Floor Sign in the kitchen area, the pans needed to be dried prior to being stored for use, all items stored in the walk in refrigerator, dry storage area, and spice storage area were to be labeled with the date once they were opened, no scoops or measuring cups were to be stored in the thickener, the food processor was to be dried prior to storage, all food items with broken lids were to be disposed of and not placed back on the shelf, bowls were to be dried prior to use, and food was not to be prepped or plated directly on the three compartment sink.",2016-02-01
13441,TREVECCA HEALTH CARE CENTER,445112,329 MURFREESBORO RD,NASHVILLE,TN,37210,2011-01-27,312,D,0,1,3B7711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, facility policy and procedure review, and interview, the facility failed to provide nail care for two residents (#5, #10) of thirty-four residents reviewed. The findings included: Resident #5 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 assistance with all activities of daily living. Observation and interview with Registered Nurse (RN) #1 on January 26, 2011 at 4:25 p.m., in the resident's room revealed the resident had long toenails on both feet. Continued observation revealed all five toenails on the left foot were 1/4 - 1/2 centimeter (cm) long. Continued observation revealed the right foot fifth toenail had a sharp edge and the remaining four toenails were 1/ 4 - 1/2 cm long. Interview with RN #1 at that time confirmed the toenails needed to be trimmed. Interview with resident #5 on January 26, 2011 at 4:30 p.m., in the resident's room revealed the resident had requested the toenails to be trimmed the week prior. Resident #10 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE] revealed the resident required assistance with all activities of daily living. Observation on January 25, 2011 at 9:45 a.m., and on January 26, 2011 at 8:25 a.m., in the resident's room revealed the resident with dark debris under the tips of the fingernail . Observation on January 27, 2011 at 7:35 a.m., in the resident's room revealed Certified Nursing Technician (CNT) #3 assisted the resident to prepare for breakfast; washed the resident's face with a wet washcloth but did not wash the resident's hands. Observation on January 27, 2011, at 7:50 a.m., in the resident's room revealed the resident ate a piece of boiled egg with the un-washed hands. Observation on January 27, 2010, at 8:05 a.m., with the Licensed Practical Nurse (LPN) Weekend Supervisor, in the resident's room revealed the resident with dark debris under the tips of the finger nails , and in the cuticles. Continued observation of the resident's right foot revealed all five toenails were 1- 1.5 cm long and three were curled under. Review of the facility's Policy 007 Foot and Nail Care revealed ""...Nail care will be given at least weekly and as needed...If the resident is diabetic, toenails will be trimmed by the licensed nurse..."" Interview with the LPN Weekend Supervisor on January 27, 2011 at 8:08 a.m., in the resident's room revealed the resident frequently refused to allow the Podiatrist to trim the toenails. Continued interview confirmed the resident's fingernails were in need of cleaning. Observation and interview with the LPN Weekend Supervisor on January 27, 2011 at 9:25 a.m., in the resident's room confirmed the resident's right foot toenails had been trimmed by the nursing staff.",2014-12-01
13442,TREVECCA HEALTH CARE CENTER,445112,329 MURFREESBORO RD,NASHVILLE,TN,37210,2011-01-27,315,D,0,1,3B7711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, facility policy review, and interview, the facility failed to provide perineal/catheter care in a sanitary manner for one resident (#5) of thirty-four residents reviewed. The findings included: Resident #5 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 assistance with all activities of daily living and required a urinary catheter. Observation on January 26, 2011 at 4:00 p.m., in the resident's room revealed Certified Nursing Technician (CNT) #1 and CNT #2 provided the resident with a bed bath. Continued observation revealed the resident had a small amount of feces in the anal area; CNT #2 wet the washcloth with water from a basin; washed the anal area and tip of the penis/catheter in a back and forth motion with the feces contaminated wash cloth four times. Review of the facility's Foley Catheter Care policy revealed ""...The catheter will be cleaned using soap and warm water or periwash at the urethral meatus opening..."" Interview with CNT #2 on January 26, 2011, at 4:20 p.m., outside of the resident's room, confirmed the perineal/catheter care was not completed in a sanitary manner.",2014-12-01
13443,TREVECCA HEALTH CARE CENTER,445112,329 MURFREESBORO RD,NASHVILLE,TN,37210,2011-01-27,226,D,0,1,3B7711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, review of facility policy, review of facility investigation, review of personnel time records, and interview, the facility failed to prevent further potential abuse during the investigation of an allegation of abuse of one resident (#34) of thirty four residents reviewed and based on interview the facility failed to report the allegation of abuse to the State. The findings included: Observation on January 25, 2011, at 9:50 a.m., revealed resident #34 in a wheelchair in the resident's room. Interview and observation at that time with the resident revealed the resident was alert, oriented, and friendly; and stated had been a resident in the facility for many years and was very pleased with the care received at the facility. Interview on January 26, 2011, at 2:00 p.m., with a family member of resident #34, revealed a staff member had called resident #34 a ""son of a [***] ."" Review of the facility investigation revealed a handwritten note dated September 15, 2010 written by Certified Nursing Technician (CNT #6) which described an observation of resident #34 as ""acting down"" (depressed) when taken to the therapy department. The note read, ""Several of us asked in PT (Physical Therapy) what was wrong. (Patient #34) stated that someone had been cursing (patient #34). We asked who but...would not tell us. I went to (unit manager #3) and asked (unit manager #3) to go speak with (resident #34)."" Review of the facility investigation revealed the Unit Manager #3 (UM #3) signed a form titled ""Grievance/Concern Report"" and dated it September 15, 2010 which read patient #34 stated a rehab (rehabilitation) staff had called the resident a ""SOB."" Review of the report revealed the Director of Nursing (DON) dated the grievance/concern as resolved on September 20, 2010. Review of the facility investigation revealed a statement by the named rehab staff (RS #1) which read, ""I categorically Deny any supposed statements I made toward anyone that would portray me in a negative or unprofessional manner..."" The statement by RS #1 was signed and not dated. Review of the facility investigation included two witness statements by Physical Therapists; one was handwritten and one was typed, and both were dated September 20, 2010. Both statements did not support the allegation of verbal abuse. Review of the facility investigation revealed a physician's order dated September 20, 2010 received from the Geriatric Nurse Practitioner for a urine dip test for resident #34. (The order included to send the urine for culture and sensitivity if positive. Medical record review revealed antibiotics were started on September 20, 2010 for the treatment of [REDACTED].) Review of the facility investigation revealed a handwritten Social Services Note dated September 20, 2010 and signed by the Director of Social Services which read, ""Social Services spoke (with) resident 9/20/10 regarding situation reported earlier to DON."" Review of the investigation revealed a summation note signed by the Director of Nursing and dated September 20, 2010 that the allegation of abuse was resolved and not substantiated. Interview in the conference room on January 27, 2011 at 12:05 p.m., revealed the CNT #6 informed UM #3 of the observation and concerns of verbal abuse ""before lunch"" on September 15, 2010. Interview in the conference room with the UM #3 on January 27, 2011 at 12:05 p.m., revealed resident #34 was interviewed ""after lunch"" on September 15, 2010. Review of the Time Detail (actual hours worked by an employee) revealed RS #1 was on duty as usual schedule on September 15, 16, 17, and 20, 2010 and completed a regularly scheduled day, reporting in on or before 9:00 a.m., and clocking out varying from 4:03-5:17 p.m. Interview in the conference room on January 27, 2011 at 8:55 a.m., revealed rehab staff #1 was informed ""by a tech (a certified nursing tech) a few days later"" (after 9/15/10) that the resident #34 had reported the verbal abuse and named RS #1. Continued interview revealed RS #1 continued to work September 15-20, 2010 as scheduled providing direct patient care as usual with the exception of instruction not to care for resident #34 without supervision. Continued interview verified RS #1 did continue to provide direct patient care to residents during the investigation of the allegation of abuse; was not reassigned other duties; and was not removed from providing patient care. Review of the facility policy titled Abuse Policy and Procedures (there is no date or number on the policy) under section Protection of Residents During Abuse Investigations reads, ""Employees accused of participating in the alleged abuse will be immediately reassigned to duties that do not involve resident contact or will be suspended without pay until the findings of the investigation have been reviewed by the Administrator..."" Interview with the Director of Social Services (who is designated as the Abuse Coordinator) in the Social Services office on January 27, 2011 at 10:45 a.m., verified RS #1 was not removed from providing direct patient care or reassigned during the investigation; confirmed the facility policy was not followed; and confirmed the facility failed to prevent further potential abuse during the investigation of the allegation of abuse. Interview with the Director of Nursing and Administrator in the Administrator's office on January 27, 2011 at 12:35 p.m., confirmed the allegation of verbal abuse was not reported to the State.",2014-12-01
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
4438,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2016-10-06,241,D,0,1,S63D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation and interview, the facility failed to promote dignity by providing urinary covers for 1 resident (#192) of 32 residents observed. The findings included: Medical record review of the facility policy Catheter Care, Urinary, revised 9/14 revealed .check .(urinary drainage) bag .placed in a dignity bag . Medical record review revealed Resident #192 was admitted on [DATE] with [DIAGNOSES REDACTED]. Observation of Resident #192 on 10/4/16 at 9:00 AM from the 300 Hallway revealed the resident lying on the bed, with the urinary drainage bag clipped to the side of the bed. The urinary drainage bag containing yellow fluid was visible from the hallway. Interview and observation with the Director of Nursing on 10/4/16 at 9:15 AM on the 300 Hallway outside Resident #192's room, confirmed the facility failed to provide a urinary drainage bag cover for the resident to ensure the dignity of the resident.",2019-09-01